Asbury Place.

“A resident's annual medical evaluation was completed but did not include documentation of whether the resident's needs can be safely met at the personal care home or if the resident is nursing facility clinically eligible (NFCE). This required section was left blank.”

“Poisonous materials were found unlocked and accessible to residents in multiple locations: Super Sani-cloth germicidal wipes under an unlocked cabinet in Brown House kitchen, and an unlocked housekeeping cart with disinfectant cleaners at the end of Meadow Lane hallway. Residents, including resident #1, were not determined to be safe with these poisons.”

“The hand sink in the shower room across from room 307 was clogged and drained very slowly, failing to maintain sanitary conditions.”

“Hot water temperature exceeded the maximum allowable 120°F in two locations: 124.1°F at the kitchenette sink in resident room #233 and 123°F at the sink in the common restroom on Garden Way by room #224.”

“Snow and obstructions impeded egress from multiple exit routes throughout the facility. Snow accumulation ranging from 8-20 inches covered walkways, ramps, and exit pathways in fenced courtyard areas near rooms 311, 333, 216, and 233, and at exits from the great room.”

“Food items in freezers were not properly labeled or dated, violating requirements for leftover food handling. Unsealed, undated bacon strips were found in both Brown House and Green House kitchens, and unsealed, undated breakfast rolls were found in the Green House kitchen freezer.”

“Bathroom sink in resident #1's private bathroom was clogged and not draining properly. This was a repeat violation from 3/18/2024.”

“Resident #1's Nystatin powder pharmacy label indicated to apply twice daily, but the prescribed dosage was to apply to excoriated areas topically every 4 hours as needed for excoriation.”

“Resident #2's March 2025 medication administration record (MAR) does not include the strength (250mg) for Florastor capsule prescribed to give 1 capsule by mouth in the morning.”

“Hot water temperature in areas accessible to residents exceeded the maximum of 120°F. Temperatures measured were 124.3°F at Green House kitchen sink, 123.8°F at Brown House kitchen sink, and 122.1°F at common bathroom sink.”

“The drain at the Green House kitchen sink did not drain properly and appeared clogged, creating a maintenance issue with furniture and equipment not in good repair.”

“Resident #1's bedside lamp was inoperable, failing to provide an operable lamp or other source of lighting that can be turned on at bedside as required.”

“Staff person A did not immediately report suspected abuse of a resident to the Area Agency on Aging. A resident in the Secure Dementia Care Unit wandered into the dining room and grabbed silverware; staff person A yanked items from the resident's hand roughly, shoved the resident away causing them to step backwards, and spoke loudly in an agitated manner. The incident was observed by two staff persons but was not reported to the Area Agency on Aging until hours later.”

“Staff person A was not immediately suspended or placed on a plan of supervision following an allegation of abuse. The staff person continued working their shift until a later time and was not suspended until the next day, in violation of the requirement to immediately develop and implement a supervision plan or suspend the staff person involved in an alleged incident.”

“The home's reportable incident policy was not followed. Two staff members who witnessed an incident of suspected abuse did not report it to the charge nurse on duty, in violation of the policy requiring witnesses to immediately report incidents to the charge nurse/aide, Director of Resident Care, or department supervisor.”

“A resident in the Secure Dementia Care Unit was physically mistreated by staff person A, who yanked items from the resident's hand roughly, shoved the resident away causing them to step backwards, and spoke loudly in an agitated manner, which constitutes abuse and mistreatment in violation of the prohibition against neglect, intimidation, physical or verbal abuse, mistreatment, and corporal punishment.”

“Resident #1's personal property inventory list did not include numerous pieces of jewelry (including a free form ring with four diamonds, a diamond cross-over ring, and a 2.04 carat diamond ring) that were documented as being in the resident's possession upon admission.”