Asbury Health and Rehabilitation Center

Inspectors wroteBased on observations, record review, and resident, staff and Medical Director interviews, the facility failed to provide safe transfers using a mechanical lift. Resident #79 was dependent on staff and required the use of a mechanical lift for transfers. On 8/30/25 Nursing Assistant (NA) #1 transferred the resident twice. Resident #79 complained of left leg pain with notable swelling to her left leg and knee. X-rays obtained in the facility indicated Resident #79 had a fracture of the left distal femur (lower thigh bone near the knee joint) and she was transferred to the emergency department (ED) for further evaluation. An x-ray and computed tomography (CT) scan obtained in the ED revealed Resident #79 had an acute comminuted (broken in multiple pieces) mildly displaced (misaligned) and impacted (the broken ends of the bone jam together) fracture of the left distal femur. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to promote a dignified dining experience for 2 of 3 residents who required assistance with meals (Resident #17 and Resident #92). Nurse Aide #5 was observed standing at a table beside Resident #17 and across the table from Resident #92 while providing the residents with assistance with eating. A reasonable person expects to be treated with dignity and would not want staff to stand over them while assisting them with eating.

Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to implement their abuse policy and procedure in the areas of reporting to Adult Protective Services (APS) and thoroughly investigating an injury of unknown source for a dependent resident who sustained an acute comminuted (broken in multiple pieces), mildly displaced (misaligned) and impacted (the ends of the broken bone jam together) left femur (thigh bone) fracture for 1 of 3 residents reviewed for accidents (Resident #79).

Inspectors wroteBased on record reviews, observations, and resident and staff interviews, the facility failed to store lidded containers of prescription topical medicated cream and medicated powder in a secure locked storage area for 2 of 3 residents observed with medicated cream and medicated powder at the bedside and bathroom (Resident #69 and Resident #21).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure scoops were stored without the potential for cross-contamination, discard outdated prepared food items stored for use and utilize a facial hair covering while in the food preparation area. These practices occurred in the reach-in coolers (reach-in coolers # 4 and #5) and food preparation area in 1 of 2 kitchens (Kitchen #2) and the food preparation service line (Household #4) in 1 of 2 Households and had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to have systems in place to ensure Nurse #1 received the most recent training provided by the facility for blood glucose monitors. In addition, Nurse #1 failed to demonstrate competency in following the manufacturer's instructions for the cleaning and disinfection of a shared blood glucose meter between two residents. Nurse #1 stated she knew she was supposed to use the disinfectant wipes to disinfect the blood glucose meters between residents but had just gotten nervous and forgotten. The interview with Nurse #1 further revealed she did not know the wet time, or dry time for cleaning/disinfecting the glucometer using the disinfectant wipe. The deficient practice occurred for 1 of 3 nursing staff reviewed for competent nursing staff (Nurse #1). [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility staff failed to follow the manufacturer's instructions for cleaning and disinfection of a shared blood glucose meter between resident usage for 2 of 4 residents whose blood sugar levels were checked (Resident #95, Resident #207). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. There were no residents with a bloodborne pathogen in the facility at the time of the investigation. [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to label and date leftover food items stored for use in the dry goods storage area and walk-in cooler and failed to ensure residents' leftover food items stored in nourishment room refrigerators were labeled and dated for 2 of 6 common area refrigerators (400 and 300 Hall nourishment rooms). These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review and staff and resident interviews the facility failed to invite a resident to participate in the planning of the resident's care for 1 of 4 residents reviewed for participation in care plan meetings (Resident # 9).

Inspectors wroteBased on staff interviews and record review, the facility failed to have a Centers for Medicare and Medicaid Services (CMS)-10123 Notice of Medicare Non-Coverage letter (NOMNC) signed prior to discharge from Medicare part A services with benefit days remaining to 1 of 3 residents reviewed for SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review (Resident #307).

Inspectors wroteBased on record review and staff interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD), which was the last day of the assessment period for 1 of 4 residents reviewed for resident assessment (Resident #8).

Inspectors wroteBased on observations and staff interviews, the facility failed to remove expired medications available for use from the refrigerator of a medication storage room in 1 of 3 medication rooms reviewed for medication storage (Windsor medication room).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to discard expired food items in the 2 of 2 freezers, 1 of 4 refrigerators, 1 of 1 dry storage room of satellite kitchen #1 and satellite kitchen #2 used to prepare resident meals. This practice had the potential to affect food served to residents.

Inspectors wroteBased on record review, resident interviews and staff interviews the facility failed to resolve group grievances that were brought to resident council meetings for 4 consecutive months (February, March, April, and May 2023).

Inspectors wroteBased on record review and resident and staff interviews the facility failed to develop comprehensive care plans in the areas of anticoagulant (blood thinning) medication (Resident #63 and Resident #79) and communication (Resident #4). This deficient practice was for 3 of 5 residents whose comprehensive care plans were reviewed.

Inspectors wroteBased on observations, staff interviews, and record reviews the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor the interventions the committee put in place following the Focused Infection Control Survey conducted on 02/25/2021. The deficiency was in the area of Food Procurement, Store/Prepare/Serve. This deficiency was cited again on the annual recertification survey on 06/08/2023. The continued failure of the facility during two consecutive recertification surveys showed a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on record review, observations, resident, family and staff interviews the facility failed to provide communication to a resident in a language that she could understand for 1 of 1 non-English speaking residents (Resident #4) reviewed for resident rights.

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to accurately code the admission Minimum Data Set (MDS) assessment in communicatio for 1 of 1 resident reviewed for MDS accuracy (Resident #4).

Inspectors wroteBased on record review, observations, family interview and staff interviews, the facility failed to obtain and honor a resident's dietary preferences for 1 of 1 resident (Resident #4) reviewed for accommodation of needs.