Ashford Hall

In the surveyor’s words

From the most serious findings on record at Ashford Hall, in the surveyor’s own words.

• Immediate jeopardy, patternF684Aug 10, 2024

  Based on, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #2) of 6 residents reviewed for quality of care. The facility failed to identify and treat a wound to Resident #2's left great toe, prior to his visit to a local hospital on 06/13/24, where Resident #2 was found to have wound to his left great toe with osteomyelitis . Resident #2's left great toe was amputated on 06/18/24. An Immediate Jeopardy (IJ) situation was identified on 08/09/24. […]

• Immediate jeopardy, patternF684Apr 4, 2024

  Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for 2 of 8 residents (Resident #1) reviewed for Quality of Care. Cumulative effects of LVN A's and MA V's individual failures to provide oversight of care delivery on 03/25/24, Resident #1 had an unwitnessed fall and sustained bruising, swelling, and an abrasion to the frontal scalp. The facility failed to implement interventions for Resident #1 identified as a fall risk on 12/05/22 to observe frequently and place in supervised area when out of bed (Start date 12/23/22). […]

• Immediate jeopardy, patternF689Apr 4, 2024

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for residents identified as a fall risk. Resident #1 sustained a skin tear to the right inner wrist on 03/14/24, a skin tear on the left inner wrist on 03/23/24, and sustained head trauma from an unwitnessed fall on 03/25/24. […]

• Immediate jeopardy, patternF600Mar 22, 2024

  Based on interview and record review, the facility failed to ensure residents 1 of 14 residents (Resident #1) were free from neglect. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. Resident was admitted to the hospital ICU as septic, had fluid overload with shortness of breath. The facility neglected Resident #1 daily wound care treatment and wound care management by physician services. These failures could place residents at risk for neglect due to facility not providing needed care and services. […]

• Immediate jeopardy, patternF686Mar 22, 2024

  Based on interview and record review, the facility failed to ensure residents received treatment and care according to professional standards of care and the care plan to prevent pressure ulcers or develop new ulcers for 1 of 14 residents (Resident #1) reviewed for pressure ulcers. The facility failed to provide adequate wound care monitored by a physician for 30 days for Resident #1 with a Stage IV pressure sacral ulcer, skin tear of right knee, and pressure ulcer of left foot. The resident was sent to the hospital by the facility after with symptoms of lethargy, disoriented, anorexia and hypotensive. […]