Ashford Place Health Campus

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 11, 2023

  Based on interview and record review, the facility failed to protect the residents' right to be free from sexual abuse by not appropriately determining their capacity to consent to sexual interactions and implementing an effective plan to address the sexual activity between 2 residents for 2 of 2 resident's reviewed for abuse. (Resident 14 and Resident 28). The Immediate Jeopardy started on 5/5/22 when two cognitively impaired residents engaged in a sexual activity. Resident 14 and 28 continued to have sexual encounters after the 5/5/22 incident; resulting in increased falls, initiation of a prophylactic antibiotic, increase in antidepressant medication, initiation of a medication used to suppress sexual desire and emotional distress. […]

• Actual harm, isolatedF689Aug 14, 2024

  Based on interview and record review, the facility failed to ensure interventions to prevent falls were effectively implemented when Resident C exhibited signs and symptoms of lethargy, drowsiness, and sedation and failed to ensure staff used a gait belt during the transfer of a Resident D who required more than limited assistance with transfers for 2 of 3 residents reviewed for falls. This deficient practice resulted in Resident C falling in the shower and sustaining fractures to the left shoulder blade, the left second rib, and the endplate of the third lumbar spinal disc. (Resident C and Resident D) Findings include: 1. The clinical record for Resident C was reviewed on 8/14/24 at 8:30 a.m. The diagnoses included, but were not limited to, dementia, osteoporosis, and insomnia. […]

• Actual harm, isolatedF689Mar 23, 2022

  Based on observation, interview and record review, the facility failed to transfer a resident with a mechanical lift as care planned, resulting in the resident having a fall with a fractured femur and one rib for 1 of 3 residents reviewed for falls. (Resident C) Findings include: The clinical record of Resident C was reviewed on 3-21-22 at 1:32 p.m. Her diagnoses included, but were not limited to, a displaced supracondylar fracture without intracondylar extension of lower end of right femur (fracture of the thigh bone, near the knee), fracture of the 9th rib on the left side, [CONDITION(S)], [CONDITION(S)], heart disease, [CONDITION(S)], age-related [CONDITION(S)], unspecified pain, body mass index (BMI) less than 19.9 or less, history of recent Covid-19, general muscle weakness and an… […]

• No harm, potential for more than minimal, isolatedF641Aug 13, 2025

  Based on interview and record review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for alarm use for 2 of 2 residents reviewed for falls. (Resident 17 and Resident 25)Findings include: 1. The clinical record for Resident 17 was reviewed on 8/11/25 at 11:30 a.m. The diagnoses included, but were not limited to, dementia. A fall care plan, dated 1/16/24, indicated Resident (17) is at risk for falling r/t [related to] decreased mobility, medication regimen, weakness, incontinent status and other comorbidities. The interventions included but were not limited to: the resident's usage of a clip alarm when in wc/chair [wheelchair] with a start date of 3/6/25, and usage of a floor mat alarm when in recliner with a start date of 11/14/24. […]

• No harm, potential for more than minimal, isolatedF644Aug 13, 2025

  Based on interview and record review, the facility failed to timely refer a resident for a level II evaluation for 1 of 1 resident reviewed for Preadmission Screening and Resident Review (PASRR). (Resident 19)Findings include: The clinical record for Resident 19 was reviewed on 8/8/25 at 3:17 p.m. The diagnoses included, but were not limited to, diabetes and psychotic disorder with delusions. A PASRR Level I evaluation, dated 8/10/23, indicated Resident 19 was approved with no Level II required. On 6/1/24, Resident 19 received a new diagnosis of psychotic disorder with delusions. During an interview on 8/8/25 at 2:59 p.m., the Executive Director (ED) indicated Resident 19 did not have a Level II. […]