Aspen Meadows Health And Rehabilitation Center

F 0554

Allow residents to self-administer drugs if determined clinically appropriate.

Level of Harm - Minimal harm or potential for actual 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]

Residents Affected - Few

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aspen Meadows Health and Rehabilitation Center

3155 Ave C Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

staff member A stated she thought it would take two people to use a lift and stated, I will look for a policy on lifts. 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.

Event ID:

Facility ID:

If continuation sheet