Asbury Court Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Asbury Court Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 24, 2021

  Based on observation, interview, and record review, the facility failed to monitor and supervise a cognitively impaired resident with a history of known elopement risk; failed to implement interventions to address resident assessment of being at risk of elopement; failed to follow the facility's policy of implementing interventions of having a personal door alarm device; and failed to educate all employees of interventions for elopement prevention and to train all staff on the identification of residents who are at risk for elopement. As a result, a cognitively impaired resident (R1) with a known behavior of wandering exited out of the facility through an unsecured and unmonitored back door with no alarm or video surveillance. […]

• Actual harm, isolatedF689Apr 7, 2026

  Based on interview and record review, the facility failed to follow its safe resident handling and transfer policy by not having two people assist with the transfer of a resident using a mechanical lift. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfer and safety. These failures resulted in R1 falling during the transfer and had to be transferred to local emergency room for head laceration that required 5 staples.The findings include:R1 was admitted on [DATE] with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. […]

• Actual harm, isolatedF689Dec 17, 2024

  Based on interview and record review, the facility failed to ensure one resident (R1) was kept safe from falls and failed to implement effective fall prevention interventions. This failure resulted in R1 falling seven times in one month (11/13/24, 11/15/24, 11/20/24, 11/27/24, 12/1/24, 12/2/24, and 12/6/24) which resulted in R1 sustaining a subdural hematoma and a head laceration that required sutures. Findings include: R1 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to remain in the facility. […]

• Actual harm, isolatedF689Jun 23, 2023

  Based on interview and record review the facility failed to complete a root cause analysis of falls and develop effective interventions to prevent falls and injury for one resident (R49) of six residents reviewed for falls in the sample of 19. This failure resulted in R49 falling and sustaining fractures to the left 6th, 7th, and 8th ribs. Findings include: R49's medical record indicates that he had a fall on 11/27/22. The progress notes of 11/27/22 at 12:48 PM indicates that R49 was found on the bathroom floor in lying position, leaning against the wall. 911 was called and R49 was transferred to a hospital. He returned to the facility on [DATE]. […]

• Actual harm, isolatedF687Oct 26, 2021

  Based on observation, interview, and record review the facility failed to develop a plan of care with interventions to prevent and/or reduce the risk of diabetic complications leading to foot injury, the facility also failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures affect 4 of 4 residents (R3, R4, R5,R6) reviewed for quality of care. This failure resulted in R3 foot becoming decolored, R3 being sent to the local hospital, and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R3 R3 is readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's care plan indicates that she has potential for impairment to skin integrity related to weakness and urinary incontinence. […]