Federal inspectors found immediate jeopardy violations at Aspen Hills Healthcare Center after discovering that staff who may have caused a resident's fractured clavicle remained on duty from August 17 through August 18, with access to dozens of vulnerable patients.
The fracture was first noticed on August 17 when a licensed practical nurse spotted discoloration on the resident's left collar bone. But no investigation began that day.
Instead, CNA #1 worked three more shifts after the injury was discovered. She clocked in at 2:52 PM on August 17 and didn't finish her final shift until 7:36 AM on August 19 — nearly two full days later. During that time, she had access to the injured resident and 28 others on the nursing unit.
CNA #2 worked two additional shifts after the bruising appeared, clocking out at 3:23 PM on August 18 with the same access to 29 residents.
The investigation didn't start until August 18, when a health aide noticed the resident couldn't raise their arm.
"That's when we decided uh oh! we need to investigate this," the Licensed Nursing Home Administrator told inspectors on October 30. "Until then the bruise was related to combative behavior."
An X-ray on August 18 revealed the resident had suffered a fractured left clavicle.
The Director of Nursing admitted to inspectors that staff should have been suspended immediately on August 17 when the discoloration was first identified. The Assistant Director of Nursing confirmed that an investigation should have begun that same day to rule out abuse.
"The staff should have notified the DON immediately and all staff should have been removed from the schedule until the investigation has been completed and abuse ruled out," the Director of Nursing told inspectors.
She said statements should have been taken from all staff who had cared for the resident in the previous 24 hours, including both nurses and certified nursing assistants.
But that didn't happen until August 18, when CNA #1, CNA #2, and Health Aide #1 were finally suspended.
The nursing leadership acknowledged they only learned about the resident's pain complaints and decreased range of motion on Monday, August 18 — a full day after the visible injury was documented.
The Assistant Director of Nursing conducted a skin assessment as part of the investigation, but not until August 18.
During those critical hours when an investigation should have been underway, CNA #1 worked back-to-back double shifts. She clocked in at 2:52 PM on August 16 and worked continuously until 7:51 AM on August 17. Then she returned that same afternoon at 2:52 PM for another double shift, working through 7:30 AM on August 18.
She came back yet again on August 18 at 10:53 PM for an overnight shift, finally clocking out at 7:36 AM on August 19.
CNA #2 worked a day shift on August 17 from 6:58 AM to 3:23 PM, then returned the next morning for another day shift from 6:59 AM to 3:23 PM on August 18.
The facility completed an incident report on August 17 when the discoloration was first noted. But the formal investigation, physician notification, and X-ray didn't happen until the following day.
State health officials and the Ombudsman were notified on August 18, the same day the staff were finally suspended.
Federal inspectors determined the violations posed immediate jeopardy to resident health and safety. The nursing home is disputing the citation.
On October 30, the facility's Vice President of Clinical Services reviewed the abuse policy with the Administrator, though no changes were made. The VP also re-educated the Director of Nursing and Administrator on abuse policy and investigation procedures.
Facility-wide education on abuse and neglect policies began October 30. Unit managers and nursing supervisors received additional training on October 31 about reporting requirements and the obligation to suspend staff pending investigation outcomes.
Inspectors verified the facility's corrective action plan and determined the immediate jeopardy was removed at 1:35 PM on October 31.
The case highlights a fundamental breakdown in nursing home safety protocols. When staff discover unexplained injuries on vulnerable residents, immediate investigation and precautionary suspension of potentially responsible caregivers is required to protect other patients.
The 24-hour delay meant two nursing assistants continued providing direct care to dozens of residents while a potential abuse case went uninvestigated. The injured resident endured a full day with an undiagnosed broken collarbone before receiving proper medical attention.
The facility's initial assumption that the bruising resulted from "combative behavior" delayed recognition that the resident had suffered a serious fracture requiring immediate medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aspen Hills Healthcare Center from 2025-10-31 including all violations, facility responses, and corrective action plans.
Additional Resources
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