Asbury Gardens NSG & Rehab

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 11, 2025

  Based on interview and record review, the facility failed to safely transfer a resident.This failure resulted in R1 sustaining a right leg laceration requiring stitches when V4 (CNA/Certified Nursing Assistant) transferred R1 without a gait belt.This applies to 1 of 3 residents (R1) reviewed for resident injury in the sample of 3.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, epilepsy, asthma, aphasia, and cellulitis of right lower limb. R1's MDS (Minimum Data Set) dated October 9, 2025, showed R1 was cognitively intact. […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2024

  Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents the total census was 64 residents. On [DATE] at 11:06 AM, V12 (Dietary Manager) 63 residents eat from the facility kitchen. On [DATE] starting at 10:13 AM, the facility kitchen was toured in the presence of V12 (Dietary Manager) and V13 (Dietary Manager-in-Training). The following was found: Walk-in refrigerator: 1. […]

• No harm, potential for more than minimal, widespreadF882Jan 26, 2024

  Based on interview and record review, the facility failed to have a designated certified Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP). This affects all 64 residents in the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/23/24 documents the total census was 64 residents. On 01/24/24 at 12:10 PM, V2 DON (Director of Nurses) said the facility no longer has an IP. V2 said she believed that the IP quit around the end of September 2023 and the facility has not hired anyone to fill the position since. V2 said she does some of the ICPC along with the facility's nurse consultant. […]

• No harm, potential for more than minimal, widespreadF908Jan 26, 2024

  Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition. This applies to all residents residing in the facility, and all staff and visitors that come to the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/23/24 documents that the total census was 64 residents. On 1/23/24 at 10:59 AM, the hotbox electrical cord in the kitchen was observed frayed/damaged at both ends with wires exposed. The end of the cord that attached to the electrical plug was frayed, and the end of the cord that attached to the hot box was also frayed, exposing wires underneath at both ends. […]

• No harm, potential for more than minimal, widespreadF921Jan 26, 2024

  Based on observation, interview and record review, the facility failed to ensure lint was removed from the facility's dryers, posing a fire hazard. This applies to all residents residing in the facility, all staff, and visitors that come to the facility. The findings include: On 01/24/24 at 10:26 AM, all four clothes dryers were observed with clothes in them and with lint on the screens, from about an eighth to a half inch thick. Each dryer had a front panel at the bottom of the dryer, and when removed, two piles of lint were noted inside each dryer. The sizes of the piles all ranged from six to eighteen inches across, four to six inches high, and three to six inches deep. V20 (Director of Housekeeping) said all the dryers were fire hazards because of the lint in them. […]