Aspen Meadows Health And Rehabilitation Center
ASPEN MEADOWS HEALTH AND REHABILITATION CENTER in BILLINGS, MT — inspection on March 26, 2026.
Found 8 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.
Inspection Findings
she had been an employee of the facility approximately four years ago and was terminated due to an allegation of abuse towards a resident.
During an interview on 3/26/26 at 8:48 a.m., NF2 stated he knew the facility was not allowing NF1 to visit resident #53. NF2 stated he was aware of the abuse allegation and was not worried about NF1 abusing resident #53. NF2 stated he wanted NF1 to be allowed to visit resident #53. NF2 stated the facility did not offer supervised visits or visits in a common area of the facility. NF2 was hesitant to bring up the visitation issue because he was concerned it might change the way resident #53 was treated by the facility.
During an interview on 3/26/26 at 12:05 p.m., staff member B stated when an employee was terminated due to an abuse allegation, the employee was not allowed to return to the building for any reason.
Staff member B stated the restriction was to protect all residents from abuse.
Staff member B stated the facility did not consider the resident's history with the visitor when deciding to deny visitation.
Review of the facility's policy titled, Visitation, dated March of 2025, showed residents have the right to receive visitors of their choice and at a time of their choosing.
The policy also showed, The CENTER PROVIDES REASONABLE ACCOMMODATION FOR VISITATION . LIMITATIONS MAY INCLUDE BUT ARE NOT LIMITED TO: . 4.
Denying access or providing limited and supervised access to an individual if that individual is suspected of abusing, exploiting, or coercing a resident until an investigation into the allegation has been completed or has been found to be abusing, exploiting, or coercing a resident.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
275140 03/26/2026
Aspen Meadows Health and Rehabilitation Center 3155 Ave C Billings, MT 59102
Review of resident #22's Annual MDS Assessment, with an ARD of 10/14/25, showed the resident had impaired mobility to both upper and lower extremities.
The assessment also showed the resident was dependent for all ADLs except eating.
The resident required partial or moderate assistance with eating.
Review of a facility policy, titled Grievance Procedure Policy, dated 11/16, showed, . 6.
Grievances are resolved immediately, when possible, by the individual receiving the grievance.
The individual receiving the grievance fills out a Grievance Form. 8. If the grievance involves abuse, neglect, exploitation, or misappropriation . an investigation begins .
275140 03/26/2026
Aspen Meadows Health and Rehabilitation Center 3155 Ave C Billings, MT 59102
help with the resident's edema.3.
Grievance Process: Please see F-F585 - Grievances for details on grievance concerns and the grievance system.
During an interview on 3/25/26 at 11:22 a.m., staff member C stated a grievance should be made if a resident brought up a concern of neglect of care, ADLs not being done, or long call light wait times.
Staff member C stated if there were any concerns brought forward by a resident or family member, a grievance would be filed.
Staff member C stated they were unaware of any concerns brought forward from resident #47 or NF6, specifically.
Review of resident #47's Care Conference, dated 2/24/26, showed, (Resident #47) reports that at night they are making him sign refusal sheets.
Reports waiting 20-40 minutes for call light to be answered, and in the mean time he reports having an accident and when they come, they want him to go to bathroom, and he expresses that he is already wet so they can clean him when standing up.
This issue is only at night per (resident #47). (Resident #47) reports that when he refuses to go to the bathroom they make him sign a refusal paper and he does not understand why.
This document was signed by staff member C.
Although staff member C signed the document showing the neglect of care concerns, a grievance was not filed and the neglect was not reported and investigated.
During an interview on 3/25/26 at 4:15 p.m., resident #47 stated he told staff member C about the neglect and long call lights, and sitting in a soiled brief for hours and staff member C had brought this issue up to management. Resident #47 stated when NF7 was taking care of him, he had not felt safe as he would go for hours without being checked (12:00 a.m. to 4:00 a.m.), or his call light not answered in that time. Resident #47 stated, Oh boy, yes, that he was irritable and anxious, every time NF7 walked into the room. Resident #47 stated he waited as long as possible to push his call button if he knew NF7 was working that night. Resident #47 stated no staff members had asked him if he felt safe, what had happened those nights with NF7, what happened on nights without NF7, and how his concerns related to neglect of care impacted him physically, mentally, or psychosocially.
During an interview on 3/26/26 at 9:19 a.m., staff member B stated no concerns from family or the resident were brought to their attention.
Staff member B stated they did not report or investigate the alleged abuse or neglect for resident #47.
275140 03/26/2026
Aspen Meadows Health and Rehabilitation Center 3155 Ave C Billings, MT 59102
encourage resident #47 to sign refusal of care form. Resident #47 stated NF7 would then want resident #47 to ambulate to the restroom, but resident #47 stated he had already gone in his brief.
During an interview on 3/26/26 at 9:19 a.m., staff member B stated no care concerns from family or the resident were brought to their attention.
Staff member B stated they did not report the alleged abuse or neglect of care.
Refer to F-F600 - Abuse and Neglect on the lack of identification of neglect for the resident. A request was made for documentation for resident #47's interdisciplinary team notes, any root causes identified, reporting, and investigation for any concerns with staff member NF7 and resident #47. No documentation was provided by the end of the survey.
275140 03/26/2026
Aspen Meadows Health and Rehabilitation Center 3155 Ave C Billings, MT 59102
275140 03/26/2026
Aspen Meadows Health and Rehabilitation Center 3155 Ave C Billings, MT 59102
Review of resident #11's electronic health records showed an admission date of 2/19/26. Resident #11 was admitted with diagnoses which included acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, right femur fracture, morbid obesity and muscle weakness.
Review of the nurse progress note dated 2/19/26 at 8:14 p.m., showed resident #11 had wound to coccyx reported stage I open. [sic]Review of resident #11's baseline care plan showed no care plan had been started to direct staff in caring for resident #11's wounds, pain management or caring for chronic medical conditions. A care plan was not initiated until 2/24/26 when advanced directives, oral dental health problems, loneliness, and discharge planning were added to the care plan. b.
Review of resident #78's care plan showed she was admitted on [DATE] with diagnoses which included dysphagia, dementia, behaviors, history of falls and a urinary tract infection.A review of resident #78's nurse progress note dated 1/5/26 at 5:53 p.m., showed the resident had skin issues on the buttocks, both heels, and the right knee.
The baseline care plan initiated on 1/5/29 did not identify pressure wounds or treatment for the wounds. c.
Review of resident #82's physician Office/Clinic Notes showed the resident was admitted to the local hospital on 3/1/26 with a lumbar 4 compression fracture.
The hospital surgically repaired the lumbar fracture.Review of resident #82's admission Nursing Evaluation initiated on 3/9/26 showed resident #82 had a Stage 3 pressure ulcer and the incision on the lower back had intact staples.Review of resident #82's baseline care plan, dated 3/9/26, did not identify wound management interventions. Resident #82's baseline care plan did not include pain management to control post operative pain.
During an interview on 3/24/26 at 4:49 p.m., staff member B said the baseline care plan was triggered when the admitting nurse completed the admission nursing assessment.
The baseline care plan was not completed until the nursing assessment was locked.
When the nursing assessments were not locked the baseline care plan was not done.
Staff member B said the baseline care plans are not always completed on time.
275140 03/26/2026
Aspen Meadows Health and Rehabilitation Center 3155 Ave C Billings, MT 59102
Review of resident #51's EHR showed the task personal hygiene: comb hair, shave, apply makeup,
for resident #51.
During an observation and interview on 3/24/26 at 3:40 p.m., resident #51 stated there were no washcloths available for her to use for the day, yet. No washcloths were observed in resident #51's room.
During an interview on 3/24/26 at 4:12 p.m., staff member O stated resident #51 was able to wash her face, brush her teeth, and comb her hair independently.
Staff member O stated she had never given resident #51 a wash cloth daily as she was generally independent with cares.
275140 03/26/2026
Aspen Meadows Health and Rehabilitation Center 3155 Ave C Billings, MT 59102
Review of a facility policy titled Skin Integrity updated January 2026 showed: .a resident having pressure ulcer/injury receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
- Upon admission, the licensed nurse (LN) establishes a plan of care based on risk factors or
- Ongoing evaluation continues weekly with the LN completing a full body skin audit.
- For new skin impairments identified, the LN completes the following:
presence of wounds.
a.
Documents the skin impairment that includes measurements of location, size, color, presence of odor, exudate and presence of pain associated with the skin impairment. b.
Surgical wounds, pressure injury, burns venous stasis ulcer, arterial ulcer, diabetic ulcers, blanchable redness on a bony prominence, and Moisture-Associated Skin Damage (MASD) is documented on the Weekly Skin Evaluation. are documented on the weekly skin evaluation form. d.
Notifies the medical provider, and if needed, obtains a treatment order and documents on the TAR after order is implemented. e.
Notifies the resident/representative of skin condition and treatment plan. f.
Notifies the facility Registered Dietitian. g.
Implements interventions and documents on the resident's care plan as appropriate.
References
- National Pressure Ulcer Advisory Panel, Prevention and Treatment of Pressure Ulcers: Clinical
Guideline. [NAME], DC: National Pressure Ulcer Advisory Panel; 2009.