Inspection visit

InspectionFebruary 2, 2023

ASBURY GARDENS NSG & REHABCMS #14617014 citations on this visit

14 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/1/23 at 9:18 AM, R26 was sitting in his wheelchair propelling himself in the hall. At 9:33 AM, R26 was assisted to bed by V5 CNA (Certified Nursing Assistant) to provide catheter care. R26 had a dressing in place to his coccyx. Residents Affected - Few The Nurse's Note dated 1/4/23 for R26 showed, Resident has a new skin open on coccyx or sacrum, dressing applied The Weekly Wound Documentation dated 1/5/23 for showed R26 had a facility acquired pressure ulcer that was identified on 1/4/23 and was a stage III when it was identified. The sacral pressure ulcer had a large amount of pink granulation tissue present and was 1.5 cm x 1.5 cm x 1 cm in size. The peri wound had maceration. This was documented as the initial assessment and was completed by the wound nurse practitioner. On 2/2/23 at 11:16 AM, V6 RN (Registered Nurse) stated, The nurses and aides monitor residents skin. The nurses are supposed to do skin assessments every week. Aides monitor the resident's skin with every shower and monitor the perineal area every time they change the resident. They are to notify us immediately if there is any skin problem. On 2/2/23 at 11:25 AM, V2 DON (Director of Nursing) stated that R26 is a resident that is usually up in his wheelchair and doesn't have any behaviors. V2 reviewed R26's electronic medical record and stated, On 1/4/23 he had a new open area to coccyx. On 1/5/23 the wound nurse practitioner staged it as a stage 3. V2 stated R26's wound should not have become a stage III before it was found. V2 stated pressure injuries are to be identified at a stage 1. V2 stated she did not know why R26 developed the pressure injury and the only thing she could think of is that R26 had COVID and was in bed more. R26's admission Record printed on 2/2/23 showed diagnoses including dementia, COVID-19, metabolic encephalopathy, type 2 diabetes mellitus, hypertension, hyperlipidemia, long term use of anticoagulants, and gastrointestinal hemorrhage. R26's MDS (Minimum Data Set) dated 1/18/23 showed severe cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The facility's Pressure Injury Prevention and Management policy (10/2022) showed, The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying interventions as appropriate. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 146170 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have pressure injury present. Basic or routine care interventions could include but are not limited to: redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.). Based on observation, interview, and record review, the facility failed to implement pressure relieving interventions for a resident at risk for pressure and failed to identify pressure injuries prior to becoming unstageable for 2 of 5 residents (R15, R26) reviewed for pressure in the sample of 15. The findings include: 1. R15's face sheet showed a [AGE] year-old female with diagnosis of dementia, chronic kidney disease, hypertension, and (12/10/22) palliative care. On 1/31/23 at 12:07 PM, R15 was in the dining room in a high back reclining chair. R15's feet were dangling unsupported, and her heels were resting against the chair's footrest. R15 had lilac-colored socks on and no heel/foot protectors. At 02:31 PM, R15 was lying supine in bed. R15 had white booty socks on, and her heels and feet were in contact with the mattress. There was a foot cradle at the foot of R15's bed. R15's sheet and blanket were under the cradle allowing the linens to rest directly on the resident. R15 was not wearing any pressure relieving devices to her feet. On 02/02/23 at 12:48 PM, V2 Director of Nursing (DON) said the foot cradle should have the blankets and covers over the top and not on the feet. She (R15) should have boots on and not have heels on the bed. In the high back reclining chair, she should still have her boots on to protect her feet. The bottom of the chair is only a leather strap and bars. I cannot really say how she acquired the 5 wounds at the same time. I do not know why they were identified like that; she did have weekly skin checks. R15's 1/31/23 skin check note showed right heel had a new opening sore and the left big toe had darkened marks on the tip of the toes. R15's 12/21/22 3:08 AM note showed her skin was intact with darkness marks on tip of the toes noted. R15's 12/21/22 9:30 PM nurse note showed five areas of unblanchable erythema noted. The left heel area measured 1.7 centimeters (cm) X 1.5 cm. The first toe on left foot wound measured 0.7 cm X 0.8 cm. The second toe on the left foot wound measured 0.4 cm X 0.4 cm. The right medial foot wound measured 1.5 cm X 1.7 cm. The right heel wound measured 2.5 cm X 1 cm. The facility's current wound document received 1/31/23 showed R15's wounds as: Stage 2 Right toe healed 1/5/23. Acquired 12/21/22. Unstageable left great toe 08. X 0.8 X UTD (unable to determine). Acquired 12/21/22 .Cleanse with NS (normal saline). Apply betadine and leave OTA (open to air) 3 times weekly. DTI (deep tissue injury)- Right medial lateral foot 1.3 X 1 X 0 acquired 12/21/22. Apply skin prep everyday shift 3 times a week. DTI Right heel 2 X 2 X 0 acquired 12/21/22. Apply skin prep everyday shift 3 X weekly. DTI left heel 2.0 X 1.5 X 0 Acquired 12/21/22. Apply skin prep everyday shift 3 X weekly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm R15's skin integrity care plan showed she needs staff assistance for activities of daily living, heel lift suspension boots at all times when in bed, heel lift boots at all times when in bed, and foot cradle to protect feet from pressure from blankets. This care plan showed the following wounds: 2/26/22 unstageable on sacrum-resolved, 12/21/22 right third toe stage 2 (healed), 12/21/22 right medial foot DTI, 12/21/22 right calcaneus heel DTI, 12/21/22 left calcaneus heel DTI, 12/21/22 left great toe unstageable. Residents Affected - Few R15's physician order sheet showed a 10/4/22 order for a foot cradle and a 12/22/22 order for heel lift boots on at all times when in bed for skin protection. R15's 11/7/22 pressure risk assessment showed a high risk for developing a pressure injury. R15's 12/19/22 facility assessment showed R15 had severe cognitive impairment, required extensive assistance of two plus persons physical assist for bed mobility, transfer, dressing, and toilet use. The facility's 10/22/22 Pressure Injury Prevention and Management Policy showed the facility is committed to the prevention of avoidable pressure injuries, provide treatment and services to heal the pressure ulcer/injury, and prevent the development of additional pressure ulcer/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention for prevention and management of pressure injuries with appropriate interventions. Evidence based interventions for prevention will be implemented for all residents who are assessed at risk or who have pressure injury present. The RN unit manager, or designee will review compliance ate least weekly. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include new onset or recurrent pressure injury development and lack of progress towards healing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure preventative measures for falls were in place for a resident with a history of falls for 1 of 3 residents (R44) reviewed for falls in the sample of 15. The findings include: The Nurse's Notes dated 1/18/23 for R44 did not show any documentation of a fall. On 1/20/23 the Nurse's Notes for R44 showed, Resident remains on fall follow up, no new injuries noted, neuro-checks in progress. Left stump dressing clean and intact, no signs/symptoms of infection noted at this time. R44's Care Plan with an initiation date of 12/15/22 showed she is at risk for falls related to her confusion, deconditioning, gait/balance problems, dementia, and a new right below knee amputation. The care plan showed on 1/18/23, R44 had a fall out of her wheelchair in her room. The interventions put in place after the fall were to apply a foot rest to her wheelchair for her left leg use and non-slide material to her wheelchair. The Nurse's Notes dated 1/28/23 for R44 showed, Resident leaned forward in her wheelchair and fell head first onto the floor and rolled onto left side. Laceration above left eye with moderate bleeding. Held pressure until bleeding was staunched to evaluate. Cleansed with normal saline and 3 steri strips were applied to wound with a pressure bandage. Pupils are sluggish and right pupil is elongated. Resident is responsive but has a flat affect and slow to react. 911 was called. R44's Care Plan with an initiation date of 12/15/22 showed she is at risk for falls related to her confusion, deconditioning, gait/balance problems, dementia, and a new right below knee amputation. The care plan showed on 1/28/23 R44 leaned forward in her wheelchair, fell out of the wheelchair onto her right side and sustained a laceration above her left eye. The intervention that was put in place after the fall was to have therapy evaluate her sitting balance. On 1/31/23 at 11:39 AM, R44 was leaning to the left while sitting in a regular wheelchair at the dining room table. R44 did not have a foot rest in place for her left foot and had a right below knee amputation. R44 did not have a grip sock on her left foot. On 2/1/23 at 12:49 PM, V5 CNA (Certified Nursing Assistant) stated she is sure fall interventions for resident's are written somewhere. V5 stated the resident has a [NAME] in the electronic medical record and the fall interventions should be on the [NAME]. V5 stated staff have access to the [NAME]. On 2/1/23 at 12:59 PM, V2 DON (Director of Nursing) stated on 1/18/23, R44 had a fall so a nonskid mat was added to her chair and a foot rest for her left leg. V2 stated on 1/28/23, R44 fell out of her wheelchair because R44's sitting balance was off due to her recent right below knee amputation. V2 stated she asked therapy to evaluate R44 and they recommended changing her wheelchair to a high-backed wheelchair. V2 stated the interventions should be in place for R44 including the foot rest and high-backed wheelchair. V2 stated interventions are documented in a book and on the resident's [NAME]. V2 stated the [NAME] is in the resident's electronic medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm The facility's Fall Prevention Program policy (10/22/22) showed, When any resident experiences a fall, the facility will: Review the resident's care plan and update as indicated. Document all assessments and actions. Each residents risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review the facility failed to ensure the residents catheter tubing was anchored and kept off the floor for 2 of 2 residents (R26, R44) reviewed for catheters in the sample of 15. The findings include: 1. On 1/31/23 at 11:39 AM, R44 was leaning to the left while sitting in a regular wheelchair at the dining room table. R44 had an indwelling urinary catheter with a drainage bag with a dignity cover around it. The drainage bag was partially on the floor. R44's catheter tubing was on the floor and her left foot was touching the top of the tubing. On 2/1/23 at 12:59 PM, V2 DON (Director of Nursing) stated catheter tubing should not be on the floor because it is an infection control issue. The Physician Orders for R44 showed an order dated 1/23/23 to do a bladder scan every 6 hours and if the post void residual is > 250 ml then straight catheter x 1. If the second post void residual is > 250 ml, the catheter is to be re-inserted. On 2/2/23 at 9:56 AM, V2 DON stated, R44 came to us with a catheter from the hospital after a right below knee amputation. V2 stated there was an order placed on 1/23/23 for R44 to have her indwelling urinary catheter discontinued and for post void residuals to be done. V2 stated the nurse practitioner noticed the order but did not schedule the order so it was not completed until the order was changed. V2 stated R44's catheter should have been discontinued on 1/23/23. V2 stated she had to change the order and enter an order for the catheter to be discontinued on 1/30/23. V2 stated R44's care plan was never updated to show she had an indwelling urinary catheter and it should have been updated. The facility's Catheter Care policy (10/20/22) showed leg drainage bags are to be placed on a resident during the day and straps are to be snug but not tight. There were no procedures in the policy for keeping catheter tubing off the floor or ensuring the tubing was free of any obstruction. R44's admission Record printed on 2/1/23 showed diagnoses including dementia, cognitive communication deficit, retention of urine, and need for assistance with personal care. R44's MDS (Minimum Data Set) dated 1/22/23 showed severe cognitive impairment; extensive assistance needed for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. 2. On 2/1/23 at 9:18 AM, R26 was propelling his wheelchair in the hall. R26 had an indwelling urinary catheter and some of the tubing was dragging on the floor under his wheelchair. The observation was pointed out to V5 CNA (Certified Nursing Assistant) who agreed R26's catheter tubing should not be on the floor. On 2/1/23 at 9:33 AM, R26 was taken to his room by V5 CNA for catheter care. R26 transferred to bed and V5 took the drainage bag from the dignity bag and laid it on the resident's bed. V5 pulled R26's pants down and R26 had a hook and loop strap to his right leg with the catheter tubing attached to it. The hook and loop strap was extremely loose and not anchoring the catheter tubing. V5 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R26's dressing to the suprapubic catheter site is changed by the nurse. V5 stated the hook and loop strap around R26's right leg was too loose and the catheter tubing was pulling. V5 stated R26 walks sometimes and it is important that the catheter tubing is secured because if it is not done right the tubing will tug. On 2/1/23 at 12:59 PM, V2 DON (Director of Nursing) stated catheter tubing should not be on the floor because it is an infection control issue. V2 stated there are a lot of germs on the floor. V2 stated catheter tubing should be secured so the tubing doesn't have any pulling that can cause damage to the urethra. The Physician Narrative Progress Note dated 12/27/22 for R26 showed he had been sick with MRSA (methicillin resistant staphylococcus aureus) urinary tract infection in October 2022. R26's MDS (Minimum Data Set) dated 1/18/23 showed severe cognitive impairment; extensive assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The Physician Narrative Progress Note dated 1/23/23 for R26 showed diagnoses including dementia, chronic kidney disease stage II, type 2 diabetes, metabolic encephalopathy, obstructive and reflux uropathy. R26's Care Plan dated 1/26/23 showed, R26 has a supra-pubic catheter with a diagnosis of obstructive uropathy. The care plan did not have any interventions in place for keeping the catheter tubing off of the floor and keeping the catheter tubing secured. The facility's Catheter Care policy (10/20/22) showed leg drainage bags are to be placed on a resident during the day and straps are to be snug but not tight. There were no procedures in the policy for keeping catheter tubing off the floor, keeping the drainage bag off the bed/contact surfaces, and anchoring of the catheter tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asbury Gardens Nsg & Rehab 212 Airport Road North Aurora, IL 60542 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer oxygen to a resident as ordered for 1 of 1 resident (R48) reviewed for oxygen in the sample of 15. Residents Affected - Few The findings include: R48's face sheet showed an [AGE] year-old female admitted to the facility on [DATE]. R48's diagnosis included chronic obstructive pulmonary disease, need for assistance with personal care, fractured right femur, and polyarthritis. On 01/31/23 at 11:34 AM, V3 Registered Nurse (RN) and V4 wound nurse practitioner provided wound care for R48. V3 and V4 were in the room for at least 15 minutes and did not notice R48's oxygen was not on. R48's unlabeled oxygen tubing was on the floor. After wound care was provided, R48 asked V3 to get her another nasal cannula (nc) as hers was on the floor. At 12:00 PM, this surveyor went to check on R48. R48 had a nc in her nostrils but the end of the tubing was not connected to the oxygen concentrator. On 2/1/23, R48 was in her room in a wheelchair. R48 was sitting on her unlabeled oxygen tubing and the portable oxygen tank attached to the chair was empty. R48 said she was exhausted and didn't want to go to therapy today. V8, therapy entered the room and confirmed the oxygen tank was empty. On 02/02/23 at 12:48 PM, V2 Director of Nursing (DON) said I would expect someone with a continuous order for oxygen to have it on all the time. If the nasal cannula (nc) is on the floor it should be changed out and dated. All tubing should be dated and changed every Sunday on the night shift. As far as tanks and portable oxygen, it is the nurse's responsibility to change them when empty. The tanks should be checked by the aides as well to ensure they are not in the red and close to empty. R48's physician order sheet showed a 1/20/23 order for oxygen 2-4 liters per nc continuously. R48's care plan had no mention of oxygen administration. R48's 1/11/23 facility assessment showed she was cognitively intact and required extensive assistance of one-person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. This surveyor requested a copy of the assessment regarding oxygen and that page was not received. The facility's 12/2022 Oxygen Administration Policy showed oxygen is administered to residents who need it, consistent with professional standards of practice. Oxygen is administered under orders of a physician. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146170 If continuation sheet Page 8 of 8

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Citations

14 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
0161GeneralS&S Epotential for harm
Use approved construction type or materials.
0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
0324GeneralS&S Cno actual harm
Provide properly protected cooking facilities.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
0920GeneralS&S Epotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
0923GeneralS&S Epotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the February 2, 2023 survey of ASBURY GARDENS NSG & REHAB?

This was a inspection survey of ASBURY GARDENS NSG & REHAB on February 2, 2023. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ASBURY GARDENS NSG & REHAB on February 2, 2023?

Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·February 2, 2023