Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspen Ridge West Transitional Rehab during CMS and state inspections, most recent first.
Infection prevention and control was not maintained when EBP was inconsistently implemented for residents with PICC lines, an NG tube, a chronic wound, and an indwelling catheter. Staff were observed using gloves without gowns, one RN exited a room without hand hygiene after handling a PICC line, and there was no EBP signage for some residents. Clean linens were also observed on the laundry room floor.
A resident kept an unlabeled bottle of white tablets in the room, identified by the resident as digestive enzymes taken throughout the day, but there was no nursing assessment or MD order authorizing self-administration. Staff, including an LPN, NM, and DON, stated that a resident needed an assessment and order before medications could be stored in the room, and the resident’s record did not contain either document.
A resident with fractures and CKD missed multiple doses of ordered meds because the pharmacy did not have eszopiclone and dronabinol in stock. The MAR showed several consecutive days of non-administration for both meds due to unavailability. Interviews with an LPN, NM, and DON showed staff expected the floor nurse to contact the pharmacy and physician, but the NM was not aware the resident’s meds were unavailable.
Failure to Document Pneumococcal Immunization Offer or Declination: The facility did not document that two residents were offered the pneumococcal vaccine or that they refused it. One resident’s USIIS record showed no pneumococcal immunizations, and another resident’s USIIS record showed prior pneumococcal vaccines but indicated a current dose was due. Staff interviews confirmed that the admission nurse was responsible for reviewing immunizations, but the records did not show a declination or documentation of vaccine status for either resident.
A resident reported feeling threatened and scared for her safety due to a CNA's angry behavior during assistance with her bedtime routine. The facility did not report this allegation of mistreatment to the appropriate authorities, as required, instead treating it as a customer service issue.
A resident reported feeling threatened and unsafe due to a CNA's angry and rough behavior, but the facility did not conduct a thorough investigation into the abuse allegation as required by policy, instead treating the incident as poor customer service.
The facility failed to ensure safe self-administration of medications for two residents. One resident, with multiple diagnoses, had medications left at the bedside without authorization for self-administration. Another resident, with cognitive impairment and tremors, also had medications left unattended, despite lacking a self-administration assessment. Interviews revealed that leaving medications at the bedside was against facility policy.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During the initial tour, surveyors noted there was no Enhanced Barrier Precautions (EBP) signage for residents 3, 15, and 17. The Director of Nursing stated that residents requiring EBP should have a sign on their door and that gowns and gloves should be worn when staff spent over 15 minutes in a resident’s room, but the observations and interviews showed that this was not consistently occurring. Resident 15 had diagnoses that included sepsis and a cutaneous abscess of the buttock and had a physician order for EBP due to a right upper extremity PICC line. The resident was observed with the PICC line in place, stated that staff had only worn gloves when providing care, and there were no gowns in the room or EBP sign on the door. Later, two CNAs were observed weighing the resident with a Hoyer lift while wearing gloves and no gowns. Resident 55 had diagnoses that included osteomyelitis and left third toe resection and had an order for EBP due to a PICC line. The resident was observed receiving IV antibiotics through the PICC line, and the RN handling the line wore gloves but no gown and exited the room without performing hand hygiene. Resident 17 had diagnoses that included a left below-knee amputation and a stage 2 sacral pressure ulcer and was observed receiving NG tube feeding and having an indwelling catheter with a drainage bag. A physician order was created for EBP due to an NG tube and chronic wound to the left stump. Although an EBP sign and gowns were later observed in the room, staff interviews showed inconsistent understanding of EBP, with one CNA stating gowns were only for residents in isolation and an RN stating gowns were only needed for respiratory infections or not needed for PICC lines. In the laundry room, clean linens were observed on tables, with a blanket hanging off a table and touching the floor, and a pillowcase and towel on the floor; the housekeeper stated the items were clean and just needed to be folded.
Unapproved Self-Administration of Medications
Penalty
Summary
The facility did not ensure the right to self-administer medications when clinically appropriate because Resident 2 had medications kept in the room without a nursing assessment or physician order authorizing self-administration. Resident 2 was admitted with diagnoses including displaced transverse fracture of the shaft of the right fibula, displaced fracture of the lateral malleolus of the left fibula, age-related osteoarthritis, and diverticulitis of the large intestine. During an interview and observations, surveyors found an unlabeled prescription bottle containing white tablets on the resident’s bedside table, and the resident stated the tablets were digestive enzymes taken throughout the day. A later observation again found an unlabeled medication bottle on the bedside table, halfway filled with white tablets. Staff interviews confirmed that medications in a resident’s room required a nursing assessment and a physician’s order for self-administration. A CNA stated she would notify the nurse if she saw medications in a room and was not aware of any residents currently keeping medications in their rooms. An LPN stated that if a resident requested to self-administer medications, the admissions nurse would assess the resident and obtain a physician order before medications could be stored in the room, and she acknowledged that Resident 2 kept medication in the room. The NM and DON both stated that a resident needed a nursing assessment and physician order before medications could be kept in the room, and both were unable to locate either document in Resident 2’s record.
Unavailability of Ordered Medications
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to meet resident needs when Resident 3 did not receive multiple ordered medications because they were out of stock and unavailable from the pharmacy. Resident 3 was admitted with diagnoses including fracture of the first lumbar vertebra, nondisplaced zone II fracture of the sacrum, and chronic kidney disease. A physician’s order for eszopiclone at bedtime was started on 12/12/25, but the December 2025 MAR showed the medication was not administered on 12/12/25, 12/13/25, 12/14/25, and 12/15/25 because it was unavailable. A physician’s order for dronabinol once daily was started on 12/24/25, and the MAR showed it was not administered on 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25, and 12/30/25 because it was unavailable. Staff interviews showed that an LPN would contact the pharmacy and notify the NM if a medication was unavailable, and the NM stated he would contact the pharmacy, family, and physician if needed, but he was not made aware that Resident 3 had unavailable medications. The DON stated that the floor nurse was expected to contact the pharmacy and inform the physician, and that a resident’s medication should not be unavailable for any period of time, especially more than a day or longer.
Failure to Document Pneumococcal Immunization Offer or Declination
Penalty
Summary
The facility did not ensure that residents were offered the pneumococcal immunization and that the medical record documented either receipt of the vaccine or a valid reason for not receiving it, such as medical contraindication or refusal. For 2 of 5 sampled residents, Resident 15 and Resident 55, there was no documentation that the pneumococcal immunization was offered or declined. Resident 15’s record contained a PNA/FLU/COVID/RSV Immunizations, Medication Consent form signed on 12/30/25, and a USIIS record showing no pneumococcal immunizations, but the record did not show that she was offered or declined the vaccine. Resident 55’s record contained a similar signed immunization consent form and a USIIS record showing prior pneumococcal vaccines, including PCV-13 on 8/7/17 and PPSV 23 on 10/13/97 and 1/1/06. The USIIS record indicated that Resident 55 was due for a pneumococcal immunization and required PCV 20 or PCV 21 per CDC timing, but the medical record did not show that she was offered or declined the immunization. During interviews, the Nurse Manager stated he reviewed USIIS for new admissions, notified the DON when residents were not current, and documented refusals in a progress note, while the DON stated the admission nurse was responsible for discussing immunizations but did not have access to USIIS and should have verified immunization status and documented either administration or declination.
Failure to Report Resident Allegation of Threatening Behavior by CNA
Penalty
Summary
The facility failed to report an allegation of abuse, neglect, exploitation, or mistreatment as required. A resident submitted a grievance stating that a CNA appeared angry while assisting her with her bedtime routine, threw her belongings onto a chair, and made her feel threatened and scared for her safety. The resident requested a different CNA, but her request was denied, and the CNA continued to act angrily when asked to assist further. The resident documented her fear and sense of being threatened in the grievance report. The Administrator reviewed the grievance the following day and spoke with the resident, who described the CNA as angry and rude. The Administrator determined that the incident was a matter of poor customer service rather than abuse, and did not report the allegation to the appropriate authorities. The facility's failure to report the resident's allegation of feeling threatened and unsafe constituted a deficiency in meeting the requirement to report all allegations of abuse, neglect, exploitation, or mistreatment.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported feeling threatened and unsafe due to the actions and demeanor of a CNA. The resident documented that the CNA appeared upset, was angry when corrected, handled her belongings roughly, and denied her request for another CNA to assist. The resident expressed feeling scared and threatened by the CNA's behavior. The grievance was documented, and the administrator spoke with the resident the following day. Despite the resident's report of feeling threatened and unsafe, the administrator determined the incident was a matter of poor customer service rather than abuse, based on the resident's statement that she did not feel it was abuse. The administrator did not conduct a thorough investigation as required by the facility's abuse policy, which mandates a written summary of findings within five working days. The documentation lacked evidence of a comprehensive investigation into the allegation of abuse.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the right of residents to self-administer medications was clinically appropriate and safe. For Resident 20, who was admitted with multiple diagnoses including a wedge compression fracture and cardiac arrhythmia, medications were left on the bedside table without confirming if the resident was authorized to self-administer. During a morning medication pass, Resident 20 expressed nausea, prompting RN 1 to leave the medication at the bedside, despite not knowing if there were orders permitting self-administration. Resident 27, who had significant cognitive impairment and essential tremors, was also observed with medications left at the bedside. Despite a BIMS score indicating cognitive impairment, RN 1 left medications for Resident 27, who was unable to confirm if she self-administered her medications. The resident's medical records lacked a Self Administration Assessment, and RN 1 acknowledged that Resident 27 sometimes forgot to take her medications or had difficulty due to tremors. Interviews with RN 2 and the Director of Nursing (DON) revealed that leaving medications at the bedside was against facility policy. RN 2 stated that medications should not be left unattended due to the risk of other residents taking them. The DON confirmed that medications should be locked up if a resident refused them, and a self-medication assessment should be conducted before allowing residents to have medications in their rooms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Murray
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Mountain Care - Cottage On Vine | 1.9 mi | ★★★★★ | 1 | 0 |
| Paramount Health And Rehabilitation | 2 mi | ★★★★★ | 1 | 0 |
| Monument Healthcare Millcreek | 2.3 mi | ★★★★★ | 10 | 0 |
| Monument Healthcare Murray Creek | 2.5 mi | ★★★★★ | 2 | 0 |
| Aspen Ridge Transitional Rehab | 2.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.