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Complaint Investigation

Aspen Meadows Health And Rehabilitation Center

September 10, 2025 · Billings, MT · 3155 Ave C
Citations 2
CMS Rating 2/5
Beds 90
Provider ID 275140
Healthcare Facility
Aspen Meadows Health And Rehabilitation Center
Billings, MT  ·  View full profile →
Inspection Summary

ASPEN MEADOWS HEALTH AND REHABILITATION CENTER in BILLINGS, MT — inspection on September 10, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0554
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Based on observation, interview, and record review, the facility failed to ensure a resident who had medications left at bedside was assessed, and a physician's order was obtained for the safe self-administration of medications, for 1 (#5) of 7 sampled residents.

Findings include:During an observation and interview, on 9/9/25 at 7:14 a.m., staff member E prepared resident #5's medication and put them into a medication cup.

Staff member E opened resident #5's door and placed the medications in the resident's room on the bedside table.

Staff member E stated, She's (resident #5) sleeping, I leave them in there for her to take when she wakes up, most of the time she won't take them in front of me and says she will take them when she is ready to take them.

During an interview on 9/9/25 at 9:20 a.m., resident #5 stated, Staff often leave my medication in my room for me to take when I'm ready to take them.

Sometimes they will watch me take them, but not always.

During an interview on 9/9/25 at 3:25 p.m., staff member A stated it was not okay to leave medications at the bedside for residents unless they had been assessed for the self-administration of medications.Review of resident #5's electronic medical record failed to show a physician's order for the self-administration of medications and failed to show that a safety assessment had been completed to determine if resident #5 was safe to self-administer her own medications.Review of a facility document titled Medication Administration: Self-Administration by Resident, dated January 2023, showed: Policy: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration.Procedures: 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. [sic]

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Aspen Meadows Health and Rehabilitation Center

3155 Ave C Billings, MT 59102

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 9/10/25 at 7:24 a.m., staff member A stated, I cannot find a policy on lifts and have reviewed the manuals and cannot find where it says how many people it should take to use them.

Staff member A said she had watched a video about the lift they have, and in the video, it showed one person using the Hoyer lift.

Staff member A stated she would still require two people to use the Hoyer lifts as she feels it is safest. A facility policy on lift use was requested on 9/8/25 at 3:52 p.m., and no lift use policy was received from the facility by the end of the survey.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BILLINGS, MT, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ASPEN MEADOWS HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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