Asbury Towers Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Jun 14, 2021

  A. Based on observation, interview, and record review, the facility failed to prevent pressure ulcers from worsening, complete follow-up assessments, track wound progression, follow interventions, and notify the physician with worsening of wounds up to and including, infections for 1 of 2 residents reviewed for pressure ulcers resulting in Resident 19's stage II (partial thickness loss of dermis) pressure ulcer progressing to a stage III (full thickness tissue loss where subcutaneous fat may be visible) pressure ulcer and developing [CONDITION(S)] (bone infection) requiring hospitalization and surgical debridement resulting in a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. B. […]

• Actual harm, isolatedF867Jun 14, 2021

  Based on observation, record review, and interview, the facility failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by the severity and number of deficiencies cited and to ensure active quality assessment and performance improvement (QAPI) plans were implemented to prevent deficiencies from re-occurring. This had the potential to affect 30 residents residing in the facility. Findings include: On 6/6/21 at 3:00 p.m., the Director of Nursing (DON) provided and identified a document as the current facility policy, titled Facility QAPI (Quality Assessment and Assurance/Performance Improvement) Plan, dated 2014. […]

• No harm, potential for more than minimal, patternF943Nov 22, 2022

  Based on record review and interview, the facility failed to provide annual education for abuse prevention, and ensure employees had also completed dementia and resident rights training for 3 of 5 randomly selected Healthcare facility employees who had been employed at the facility for greater than one year. This deficient practice had the potential to effect 18 of 18 residents who resided in the facility. Findings include: On 11/21/22 at 1:00 p.m. 10 randomly selected employee files were reviewed, 5 new hires and 5 employees who had worked at the faccility greater than one year. […]

• No harm, potential for more than minimal, patternF725Jun 14, 2021

  Based on observation, interview, and record review, the facility failed to ensure sufficient staffing to accommodate safe transfer when using a lift (Resident 24) for 1 of 1 resident reviewed for lift safety, to ensure timely dining service to 2 residents observed during 1 of 1 dining observation (Residents 10 and 232), to accommodate a resident's preference related to showers for 1of 3 residents reviewed for choices (Resident 30), and to complete Minimum Data Set (MDS) assessments timely and accurately for 6 of 13 residents reviewed for MDS assessment accuracy (Residents 19, 3, 20, 7, and 24). Findings include: During an interview, on 6/11/21 at 2:37 p.m., the Administrator (ADM) indicated the staffing was horrible, and it was hard to hire staff. […]

• No harm, potential for more than minimal, isolatedF550Mar 30, 2026

  Based on record review and interview, the facility failed to ensure the rights and dignity of a resident were maintained for 1 of 3 residents reviewed for resident rights (Resident B). The deficient practice was corrected on 3/19/26, prior to the start of the survey, and was therefore past noncompliance. Findings include:An intake document, dated 3/23/26 at 11:57 a.m., indicated the resident's rights had allegedly been violated when a facility Registered Nurse (RN) had taken a photograph of Resident B's anal area and had sent the photograph to an individual who was not involved with the resident's care and had no connection to the facility.Resident B's record was reviewed on 3/26/26 at 11:26 a.m. […]