Afton Oaks Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Afton Oaks Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF580Oct 27, 2025

  Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 13 residents (Resident#2) reviewed for resident rights. 1. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 2. […]

• Immediate jeopardy, patternF600Oct 27, 2025

  Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from neglect for 2 of 13 residents (CR#1 and Resident #2) reviewed for neglect.1. The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE].2. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.3. […]

• Immediate jeopardy, patternF686Oct 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, a residents with pressure ulcers received necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 13 residents (CR #1 and Resident #2) reviewed for pressure ulcers. -The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE]/2025. 2.--The facility failed to identify and treat the wounds of Resident #2 from admission on [DATE]-[DATE]. An Immediate Jeopardy (IJ) situation was identified on 10/11/2025. […]

• Immediate jeopardy, patternF697Oct 27, 2025

  Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (Resident #2) reviewed for pain. -The facility failed to ensure that pain management was provided for Resident #2, who was crying in pain, during the treatment of her 14 individual wounds. -The facility failed to assess Resident #2 accurately and appropriately, for pain prior to Resident #2 receiving wound care treatments for 14 separate wounds. […]

• Immediate jeopardy, patternF698Oct 27, 2025

  Based on interview and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 4 residents (Resident #2). The facility to ensure that Resident #2 received hemodialysis as ordered on 10/03/2025, which resulted in her not receiving any hemodialysis for a total of four days. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 PM. While the Immediacy was removed on 10/16/2025 at 7:43 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. […]