Asbury Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Asbury Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF726Oct 16, 2024

  Based on observations, record review, and staff interviews, the facility failed to have systems in place to ensure Nurse #1 received the most recent training provided by the facility for blood glucose monitors. In addition, Nurse #1 failed to demonstrate competency in following the manufacturer's instructions for the cleaning and disinfection of a shared blood glucose meter between two residents. Nurse #1 stated she knew she was supposed to use the disinfectant wipes to disinfect the blood glucose meters between residents but had just gotten nervous and forgotten. The interview with Nurse #1 further revealed she did not know the wet time, or dry time for cleaning/disinfecting the glucometer using the disinfectant wipe. […]

• Immediate jeopardy, isolatedF880Oct 16, 2024

  Based on observations, record review and staff interviews, the facility staff failed to follow the manufacturer's instructions for cleaning and disinfection of a shared blood glucose meter between resident usage for 2 of 4 residents whose blood sugar levels were checked (Resident #95, Resident #207). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. There were no residents with a bloodborne pathogen in the facility at the time of the investigation. […]

• Actual harm, isolatedF689Sep 30, 2025

  Based on observations, record review, and resident, staff and Medical Director interviews, the facility failed to provide safe transfers using a mechanical lift. Resident #79 was dependent on staff and required the use of a mechanical lift for transfers. On 8/30/25 Nursing Assistant (NA) #1 transferred the resident twice. Resident #79 complained of left leg pain with notable swelling to her left leg and knee. X-rays obtained in the facility indicated Resident #79 had a fracture of the left distal femur (lower thigh bone near the knee joint) and she was transferred to the emergency department (ED) for further evaluation. […]

• Actual harm, isolatedF550Feb 17, 2022

  Based on record review, observations, staff and resident interviews, the facility failed to honor 1 of 21 resident's rights to maintain dignity by providing showers on the toilet, not providing incontinence care and failed to honor the resident's right to refuse care resulting in the resident feeling belittled, embarrassed and undignified (Resident #43). The findings included: 1. Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's admission/5-day Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact for daily decision making, had no behaviors for refusal of care, required extensive assistance of 2 staff for bathing and toileting and was frequently incontinent of bowel and bladder. […]

• No harm, potential for more than minimal, widespreadF812Jun 8, 2023

  Based on observations, record review, and staff interviews, the facility failed to discard expired food items in the 2 of 2 freezers, 1 of 4 refrigerators, 1 of 1 dry storage room of satellite kitchen #1 and satellite kitchen #2 used to prepare resident meals. This practice had the potential to affect food served to residents. The findings included: An observation on [DATE] during a tour of freezers and refrigerators of satellite kitchen #1 and #2 and the dry storage room with the Culinary Chef and Assistant Culinary Chef, the following concerns were identified: a) One bin of ,d+[DATE] grayish fuzz on turnip vegetables in the freezer of satellite kitchen #2 b) One container of cottage cheese with expiration date of [DATE] in freezer of satellite kitchen #2 c) Two packages of dessert mix… […]