Ashford Gardens

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Resident #2, Resident #3, and Resident #4) of 5 residents reviewed for quality of care.- The facility failed to establish wound care services for Resident #2 as ordered for 7/4/26, 07/06/26, 06/29/26, and 05/21/26.- The facility failed to establish wound care services for Resident #3's as ordered for 07/11/26, 06/07/26, 06/14/26, 06/15/26, 06/23/26, 05/21/26, 05/23/26, and 05/31/26.- The facility failed to establish wound care services for Resident #4's as ordered for 6/07/26, 05/21/26, and 05/27/26. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 5 residents (CR #1) reviewed for discharge.-The facility failed to provide CR #1 with a written discharge notice before discharging her on 7/3/26. This failure could place residents at risk of not knowing their discharge rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 (Resident #1) of 5 residents reviewed for quality of life.-The facility failed to ensure Resident #1's brief was changed before becoming full of urine and wetting his bed sheet. This failure could place residents at risk of skin breakdown.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and record review, the facility failed to provide residents access to visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident for 1 of 1 facility's.- The facility failed to allow any visitors in the building after 8pm when the doors locked. This failure could place residents at risk for decreased quality of life, sadness, and depression.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 of 8 medication carts (Hall 2300/2400 Nurse cart and Hall 2100/2200 Med Aide cart) reviewed for pharmacy services.1. The facility failed to ensure expired medications were not stored with current medications on the 2300/2400 Hall Nurse cart.2. The facility failed to ensure expired medications were not stored with current medications on the 2100/2200 Med Aide cart. These failures could place residents at risk for not receiving therapeutic benefits of the medication and/or worsening health concerns.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 4 hallways, (Halls 2400 and Hall 1200), the conference room and Resident #44's room. The facility had live flies, roaches and bed bugs in areas of the facility including Halls 2400, 1200, the conference room and Resident #44's room. This failure could place residents at risk for decreased health, safety and quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Residents #101 and #146) reviewed for comprehensive care plans. -The facility failed to provide Residents #101 and #146 with a comprehensive person-centered care plan to address their diet orders. This failure could place residents at risk of not having personalized plans developed to address their specific care needs.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 (Resident #97) residents reviewed for tube feeding. LVN A failed to check for placement of the G-tube before giving Resident #97 his morning medications on 4/30/26. This failure could place residents at risk for the medications going into the abdominal cavity, pain, infection, and hospitalization.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 18%, based on 5 errors out of 27 opportunities, which involved 2 of 3 residents (Resident #70 and Resident #97) and 2 of 3 staff (MA K and LVN A) observed during medication administration reviewed for medication errors.- MA K failed to give Resident #70 his Supplement Pass (provides protein) 90ml during his morning medication administration on 4/29/26.- MA K failed to give Resident #70 his Aspirin 81mg during his morning medication administration on 4/29/26. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure residents were free from any significant medication errors for 1 of 3 (Resident #97) residents reviewed for pharmacy services.1. LVN A failed to give Resident #97 the correct dose of Valproic Acid (seizure medication) and gave the resident a double dose during his morning medication administration on 4/30/26. 2. LVN A failed to give Resident #97 the correct form of Valproic Acid and gave it in capsule form instead of liquid form during his morning medication administration on 4/30/26.3. LVN A failed to give Resident #97 his Insulin Glargine during his morning medication administration on 4/30/26. These failures could place residents at risk of side effects due to an increase in dosage, toxicity, and overdose.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to establish and 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 for 2 out of 28 resident rooms (Resident #42 and Resident #97) reviewed for infection control. - LVN AB failed to wear appropriate PPE while giving G-tube (tube into stomach for nutrition) medications to Resident #42, when she was on Enhanced Barrier Precautions.- LVN A failed to wear appropriate PPE while giving G-tube medications to Resident #97, when he was on Enhanced Barrier Precautions. These failures could place residents and staff at risk for cross contamination and infection.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure Resident #1 received treatment and care in accordance with professional stands of practice for one (Resident #1). The facility failed to follow Resident #1's physician order to ensure his legs were wrapped on 3/31/2026. This failure could place residents at risk of neglect and not having their care needs met, a decline in physical and psychosocial health, and worsening of the residents' condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 5 of 5 medication carts (MC #1, MC #2, MC #3, OFMC #4, and MC #5) reviewed for drug storage and labeling. The facility failed to ensure MC #1, MC #2, MC #3, MC #4, MC #5, and OFMC #6 were locked, and medications were secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection control 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 and follow accepted national standards. 1. The facility failed to ensure CNA Q followed standard precautions by leaving soiled gloves and gowns in a clear plastic bag and leaving soiled linens on top of the chest of drawers and on the floor in Resident # 6 on enhanced barrier precautions. 2. The facility failed to ensure CNA R followed enhanced barrier precautions when providing assistance with toileting for Resident # 6. These failures could place residents at risk for developing infection from cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms for 1 (Residents #5) of 9 residents reviewed for restraints. The facility failed to ensure that bedrails were not used on the side of Resident #5's bed. This failure could place residents at risk of having physical restraints used that limited their movement without being evaluated for the medical need.

Inspectors wroteBased on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 resident (Resident #1) of 5 residents reviewed for transfer/discharge. The facility failed to ensure Resident #1, was given his medication when he went out on pass. Resident #1 had behavior and mental illness issue that required medication. This failure could place residents at risk for serious injury, harm, and/or death due to lack of appropriate supervision.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and 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 for 1 of 1 facility and 2 of 16 residents (Resident #217 and Resident #218) reviewed for infection control. 1. The facility failed to establish and provide documentation for a water management program as part of the infection control program. 2. The facility failed to ensure Housekeeper L wore the appropriate PPE for contact precautions when she was cleaning the room for Resident #217. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments for 2 of 8 residents (Resident #72 and #105) reviewed for care plans. The facility failed to care plan Resident #105's gastrostomy status nor tube feeding. The facility failed to care plan Resident #72s allegation that a car ran over his foot while out of the facility. This failure could place residents at risk of not receiving individualized care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was a change in residents health status for 1 of 8 residents (Resident #72) reviewed for notification of changes. LVN A failed to notify Resident #72's physician when he reported to him that a car ran over his foot while out of the facility on an unknown date. This failure could place residents at risk of injury, hospitalization, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #92) reviewed for accident hazards. The facility failed to ensure Resident #92 was supervised while smoking outside on the back patio on 1/8/25. These failures could place residents at risk for injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 6% based on 2 errors out of 29 opportunities which involved 2 of 8 residents (Resident #47 and #105) and 2 of 8 staff (MA D and LVN R) reviewed for medication administration. MA D handed Resident #47 (who did not self-administer) his eye drops, and the resident administered the wrong dose per physician orders on 1/8/25. MA D did not provide Resident #47 with instructions. LVN R crushed and administered Lansoprazole DR ODT (a delayed release medication used to treat heartburn and certain other conditions caused by too much acid in the stomach) to Resident #105 via PEG tube on 1/8/25. Delayed Release formulations should not be crushed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete for 1 of 8 residents (Resident #72) reviewed for medical records. LVN A failed to document in Resident #72's medical record the allegation made that a car ran over his foot while out of the facility and the assessment he conducted on the resident on an unknown date. This failure could place residents at risk of injury, hospitalization, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and ensure that residents received the necessary treatment and services, to promote healing and prevent infection for 2 of 9 residents (CR#1 and Resident #2) reviewed for pressure ulcer in that: -The facility failed to identify and treat pressure sore on CR#1's penis, left foot 5th toe, Right Toe Digit 1, great -The facility failed to provide CR#1 with an air mattress for 20 days with multiple diagnoses of Stage 4 pressure ulcers. -The facility failed to initiate precautions for pressure sores when an order was not obtained for air mattress. -The facility failed to prevent progression of the CR#1's Stage 4 Sacral Pressure Ulcer that was not getting better and enlarged from 6x6.2x0.4 cm on 2/27/24 to 10.7x8.9x0.4 cm on 4/15/24, had odor and exhibited signs of infection. [...]

Inspectors wroteBased on interview, record review and observation, the facility failed to ensure each resident was provided with food prepared by methods that conserve nutritive value, flavor, and appearance and is nourishing, palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchens in the facility. -The facility failed to ensure the dessert cook prepared food according to the recipe and utilized all ingredients in the specified amounts which resulted in residents receiving food that did not have nutritive value and flavor. This failure had the potential to affect all facility residents who consumed food from the facility's kitchen.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable for two of seven residents (Resident #3 and Resident #41) reviewed for PASRR. -Resident #3 and Resident #41 had a diagnosis of mental illness while living at the facility, and the facility did not coordinate with the appropriate, State-designated authority. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide or obtain from an outside source routine dental service to meet 1 of 8 residents (Resident #34) reviewed for dental services. The facility failed to provide dental services for Resident #34 who had loose teeth and a diagnosis of periodontal disease. This failure placed resident at risk for infection and unwanted hospitalization.