Ashford Hall

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of one maintenance room reviewed for accidents and hazards. The facility failed to ensure the door to the maintenance room located outside by the smoking area, which contained plugged power tools, harmful chemicals, and sharp tools, was secured. This failure placed residents at risk for injuries due to having access to an unsecured maintenance room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's one of one kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure food items, placed in the dry storage areas, were sealed and kept off the floor. 2. The facility failed to ensure food items placed in the refrigerator and/or freezer were dated, sealed and labeled appropriately. 3. The facility failed to ensure garbage receptacles in the kitchen had lids on them, when trash was in the containers, not being used. These failures could place residents at risk for food-borne illnesses.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 7 residents (Resident #3 and Resident #4) reviewed for resident assessments. The facility failed to accurately assess Resident #3's anticoagulant medication status. The facility failed to accurately assess Resident #4's anticoagulant medication status. These failures could place residents at risk of having an inaccurate care plans and inappropriate identification of care needs.

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, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #11) reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan to address Resident #11's nicotine dependence. This failure could place residents at risk of not receiving services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure at the time each resident was admitted , the facility had physician orders for the resident's immediate care for 1 of 7 residents (Resident #12) review for physician orders upon admit. The facility failed to ensure Resident #12's hospital discharge order were followed. This failure could place residents at risk of not receiving care to meet the physical, mental, and psychosocial needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from abuse for three (Resident #2, Resident #3, and Resident #4) of five residents reviewed for abuse, in that: 1.) On 03/01/26 the facility failed to ensure that Resident #2 did not have her hair pulled by Resident # 1, resulting in Resident #2 screaming loudly in what sounded to facility staff like pain.2.) On 03/05/26 the facility failed to ensure that Resident #3 was not scratched on the face by Resident #1 resulting in redness.3.) On 03/10/26 the facility failed to ensure that Resident #4 was not verbally threatened, grabbed by the throat and her hair pulled by Resident #1 with no resulting injury. These failures could result in resident abuse and injuries.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop or revise care plan interventions for Resident #1 following three episodes of aggression towards other residents on 03/01/26, 03/05/26, and 03/10/26. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on interview and record review the facility failed to implement the facility's own written abuse and neglect prevention policy and procedure for one (Resident # 1) of thirteen residents reviewed for abuse and neglect. The facility did not immediately notify Resident #1's representative of an allegation of sexual abuse by The Maintenance Director on 02/19/26, causing the family to learn of the allegation when Resident #1 called to tell them that the police were at the facility, attempting to speak with her about the allegation on 02/20/26. This failure could place residents at risk of their responsible parties not having knowledge of allegations of abuse or neglect, thereby not having the emotional or logistical support of their responsible parties during an investigation.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from abuse for two (Resident #2 and Resident #3) of 5 residents reviewed for abuse, in that: 1.) On 11/03/25 the facility failed to ensure that Resident #2 did not have coffee thrown on him by Resident #4 resulting in redness to the face and chest which faded quickly and resolved without need for treatment. The nursing assessment completed the same day revealed no injury and no redness or other changes in skin assessment from baseline.2.) On 12/03/25 the facility failed to ensure that Resident #3 was not hit on the left side of the face/jaw with a closed fist by Resident #4 resulting in no injury. These failures could result in resident abuse and injuries.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide pharmaceutical services, including procedures that assured the accurate accountability of controlled narcotic drugs for 1 of 2 Residents (Resident #350) reviewed for pharmacy services. The facility failed to ensure that narcotic count sheet records were consistent with the remaining amount of narcotics. The facility failed to ensure that nursing staff signatures required for the narcotic count sheet were obtained and consistent with documentation of narcotics administered to Resident #350. These failures could place residents at risk for medication errors, potentially leading to overdose of narcotic pain medications, or diversion of narcotic pain medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure notification and receipt of Medicare Provider Non-Coverage letters (CMS 10123 or CMS 10055) which included information about their right to appeal were reviewed for Medicare Beneficiary Notification Review (Residents #71 and Resident #95). The facility failed to provide the Medicare Provider Non-Coverage letters to Resident #71 and Resident #95. This failure could place residents who receive Medicare Part A benefits at risk of not being fully informed of their right to appeal.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of one residents (Resident #350) reviewed for nephrostomy care. The facility failed to ensure staff kept Resident #350's nephrostomy (tube placed in the back that drains urine from the kidney) bag below the kidney while the resident was in bed. This failure could place residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services for one (Resident #10) of four resident's observed for checking g-tube for placement. The facility failed to verify that placement of the feeding tube for Resident #10 was confirmed by x-ray (Imaging that is taken with electromagnetic waves to show pictures of the inside of your body) upon initial insertion and that the tube length was marked and documented before it was flushed with water, medications were given, and bolus feedings were administered on 01/22/25. These failures could place residents with g-tubes at risk of aspiration pneumonia, infection, discomfort, malnutrition, and a decline in the residents' health.

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure that licensed nurses had the specific competencies, and skill sets necessary to replace a g-tube and to follow g-tube verification of placement procedure, as identified through the physician orders and facility policy for one of four residents (Resident #10) reviewed for nursing services in that: 1. The facility failed to ensure LVN A had a competency validation course before replacing Resident #10's g-tube on 01/21/25. 2. The facility failed to provide training for RN B and LVN C regarding when it was safe to feed a resident or give medications via g-tube. RN B and LVN used Resident #10's G-tube before placement was verified via x-ray or CT scan. These failures could place residents at risk of being cared for by insufficiently trained staff, resulting in serious injury or infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete and accurate smoking assessments for one (Resident #26) of two residents' records reviewed for smoking assessments. The facility failed to ensure Resident #26's smoking assessments were done quarterly, and that his smoking assessments were accurate. This failure could affect residents who smoke by placing them at risk of inaccurate information, resulting in a lack of appropriate safety interventions when smoking.

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect the confidentiality of personal and medical records for one (RN E) of three staff observed for confidentiality of records. The facility failed to ensure RN E locked and closed the laptop during the medication pass exposing residents on the secured unit's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents in the locked memory care unit were free from involuntary seclusion for one (Resident #1) of six residents reviewed for involuntary seclusion. The facility failed to obtain a physician order, documenting the clinical criteria met for placement in the secured/locked, prior to Resident #1's move to the secured unit on 11/21/24. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning, and injury.

Inspectors wroteBased on observation, record review, and interviews the facility failed to assure that medications were stored in locked compartments under proper temperature controls and inaccessible to unauthorized staff and residents for one (Secured Unit Cart) of four medication carts reviewed for medication storage. The facility failed to ensure the Secured Unit medication cart was locked when left unattended by RN E. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion.

Inspectors wroteBased on interviews and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 1 resident (Resident #1) reviewed for discharge requirements. The facility failed to ensure Resident #1 was readmitted from the hospital she was transferred to for treatment. The facility failed to provide Resident #1 a discharge notice. There was no documentation from the physician indicating the facility could not meet the Resident's needs. This failure could place residents at risk of unnecessary transfer or discharge causing their needs to go unmet.

Inspectors wroteBased on, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #2) of 6 residents reviewed for quality of care. The facility failed to identify and treat a wound to Resident #2's left great toe, prior to his visit to a local hospital on [DATE], where Resident #2 was found to have wound to his left great toe with osteomyelitis . Resident #2's left great toe was amputated on 06/18/24. An Immediate Jeopardy (IJ) situation was identified on 08/09/24. While the IJ was removed on 08/10/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the personal privacy rights of the resident during medical treatment for 1 (Resident #1) of 6 residents observed for dignity. The facility failed to ensure ADON A provided Resident #1 with privacy during wound care on 08/09/24. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased 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 prevent complications from enteral feeding for 1 of 2 residents (Resident #1) reviewed for enteral feeds. The facility failed to follow physician's order on 7/02/24 in accordance with the care plan for Resident #1's positioning during G-tube feeding. This failure could place residents with G-tubes at risk for aspiration and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (Station 100) reviewed for pharmacy services. The facility failed to ensure LVN B ensured Medication Cart was locked when unattended in Station 100 hallway on 7/02/24 at 10:43 AM. This failure could cause accidental ingestion of medication by a resident not prescribed the medication and could cause access, loss, and diversion of medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 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 5 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A sanitized or washed her hands and changed gloves while providing incontinent care for Resident #1. This failure could place residents at risk for cross-contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge process that focuses on the resident's discharge goals and effectively transition them to post discharge care for 1 of 1 (Resident #1) resident reviewed for an effective discharge process. The facility failed to ensure Resident #1 was not discharged pending a discharge appeal. This failure could place residents who discharge at risk of improper discharge, unmet needs, and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for 2 of 8 residents (Resident #1) reviewed for Quality of Care. Cumulative effects of LVN A's and MA V's individual failures to provide oversight of care delivery on 03/25/24, Resident #1 had an unwitnessed fall and sustained bruising, swelling, and an abrasion to the frontal scalp. The facility failed to implement interventions for Resident #1 identified as a fall risk on 12/05/22 to observe frequently and place in supervised area when out of bed (Start date 12/23/22). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for residents identified as a fall risk. Resident #1 sustained a skin tear to the right inner wrist on 03/14/24, a skin tear on the left inner wrist on 03/23/24, and sustained head trauma from an unwitnessed fall on 03/25/24. Resident #2 sustained blunt head trauma and a laceration above the left eyebrow from an unwitnessed fall on 03/09/24. The facility failed to implement effective care plan interventions for residents identified as a fall risk. An Immediate Jeopardy (IJ) was identified on 04/01/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents 1 of 14 residents (Resident #1) were free from neglect. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility neglected Resident #1 daily wound care treatment and wound care management by physician services. These failures could place residents at risk for neglect due to facility not providing needed care and services. An Immediate Jeopardy (IJ) was identified on 3/20/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care according to professional standards of care and the care plan to prevent pressure ulcers or develop new ulcers for 1 of 14 residents (Resident #1) reviewed for pressure ulcers. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility failed to add the resident to wound care physicians list of patients for pressure ulcers. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure that resident who is unable to carry out activities of daily living (ADLs) receives the necessary service to maintain good nutrition, grooming, and personal and oral hygiene for three (Residents #11, #58, #79) of nine residents reviewed for ADL care in that: Facility failed to ensure Resident # 79, #11, and #58 were provided a shower for 2 weeks as scheduled. Facility failed to ensure Residents # 11, #58, and #79 were provided timely incontinent care as scheduled. These failures could place residents at risk of not receiving personal care services, having decreased quality of life, and skin breakdown.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for one (Resident # 99) of nine residents reviewed for medication administration. The facility failed to ensure Resident #99 received the correct medication as ordered which resulted in Resident #99 receiving Furosemide (diuretic) prior to going to dialysis, which the resident should not have received. This failure could place residents at risk of health and safety.

Inspectors wroteBased on observation, interview, the facility failed to ensure that the daily nurse staffing was posted as required each day for one (11/17/23) of one days reviewed for nursing services and postings. The facility failed to update the daily staffing information posting on 11/17/23. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for one (Resident #1) of 13 residents reviewed for reporting of alleged allegations. The facility failed to report Resident #1's unwitnessed fall that incurred a rib fracture. This failure could place residents at risk of not having incidents reported as/when required.