Asbury Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 6, 2026

  Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent resident elopement that created an immediate jeopardy situation for one of fourteen residents that were identified as at risk for elopement and did not reside on a secured unit (Resident R84).Findings Include: Review of the facility policy, Wandering and Elopements dated 3/1/26, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the clinical record revealed Resident R84 was admitted to the facility on [DATE]. […]

• Immediate jeopardy, isolatedF689Aug 18, 2021

  Based on review of facility policy, resident clinical records, observations, hospital records, email correspondence, and staff interviews, it was determined the facility failed to provide an environment free from potential or actual accidents and hazards, failed to investigate and implement safety measures to prevent potential accidental medication use by a cognitively impaired resident (Resident R60). The facility failed to provide sufficient staff supervision of residents and effective safety measures, including use of a Wanderguard system (an electronic alarm system designed to prevent memory impaired individuals from elopement), and failed to prevent the elopement of 3 of 14 residents (Resident R97, R206 and R52) with Wanderguard bracelets, resulting in physical harm to 1 resident… […]

• Actual harm, isolatedF760May 18, 2022

  Based upon review of facility policies, medication instructions, employee file, clinical records, facility investigation, resident and staff interview, it was determined that the facility failed to ensure that residents were free from significant medication errors, which resulted in actual harm with the resident experiencing a [CONDITION(S)] and an unresponsive episode requiring hospitalization for one of nine sampled residents (Resident R1). Findings include: The facility Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Admission policy dated 8/8/12, and last reviewed on the 3/23/22, indicated that the referring facility provides all necessary documentation to ensure a safe hand-off for a new admission. […]

• Actual harm, isolatedF600Aug 18, 2021

  Based on review of facility policy, facility clinical records, incident reports, resident interviews, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for two of five residents reviewed (R36 and R86) resulting in acutal harm to one resident who sustained a disclocation of her right shoulder (R36), requiring transfer to the hospital for admission and treatment and another resident (R86) who sustaied a fractured thighbone of the knee, resulting in increased pain and pain medication (Residents R36 and R86). […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2026

  Based on review of facility policies, observations, and staff interview, it determined the facility failed to maintain sanitary conditions in the Main Kitchen, which created the potential for cross contamination and food borne illness.Findings include: During an initial observation of the kitchen from 10:15 a.m., through 10:52 a.m., the following was observed: -leaking water under kettle pan heaters-one of two Ice machine had a drainpipe sitting on floor with a black substance around pipe. […]