Ashford Gardens

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that the resident had to have a doctor's order for the bed rails before using the rails. She said Resident #5 did not have an order for bed rails. She said the facility started using two bed rails on Resident #5's bed about a month ago. She said the rails were used on Resident #5 to keep her in the bed. She said the bed rails were not a restraint because the facility did not use all four rails. She said Resident #5 did not have a decline due to the bed rails being used. She said Resident #5 could advocate for herself. During an

interview on 10/24/2025 at 1:03 p.m., RN O revealed she was trained on restraints. She said the facility had

a procedure for the bed rails. She said the procedure was staff could use the rails for four hours at a time.

She said the facility had to have a doctor's order to use the bed rails. She said the risk of using the bed rails was that the resident could get hurt. She said the benefits were that the resident could not get out of bed and fall. She said she was not sure who monitored to ensure the resident's had a doctor's order for the bed rails. She said she did not know when the staff started using the bed rails for Resident #5. She said she did not know why the bed rails were being used for Resident #5 without a doctor's order. During an interview with the DON on 10/25/2025 at 12:45 p.m., she said she and staff were trained on resident rights. She said

the policy for bed rails was staff were to do an assessment on the resident, and if the facility was going to use bed rails staff needed to get a doctor's order. She said the facility did not utilize full bed rails. She said

the facility used assist rails, and staff needed to get consent from the resident and the RP. She said she was not sure when staff started using the bed rails on Resident #5. She said for the half bed rails the facility needed a doctor's order. She said the nurse was responsible for monitoring to ensure the facility had orders for the half bed rails. She said a resident could get hurt if staff misused the bed rails. She said if the bed rails were used for the intended purpose, the resident could not get hurt. She said the bed rails assisted the resident and the staff. She said that Resident #5 required extensive assistance with her functional ability.

She also said she dd not know how long the bed rails stayed up on Resident #5. She said she did not know why staff were using the bed rails on Resident #5. She said she thought the bed rails were used on Resident #5's bed so that Resident #5 could assist staff when rolling. Record Review of Restraint Free Environment Policy, dated 8/1/2025, revealed, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner unless the resident has previously made a valid refusal of the treatment in question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashford Gardens

7210 Northline Dr Houston, TX 77076

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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

when they returned to the facility. She said that when the residents were going to sign out the resident was to notify the nurse. She also said the residents would have their medication sent with them. She said several things could happen. She also said the residents could have issues if they did not have their medication. She said the nurse was responsible for ensuring the resident signed out and the resident had their medication when they left. She said she did not know who monitored to ensure the signing out policy was being followed. She said she thought that Resident #1 left before the nurse was notified. She said she thought he was safe and functional. She also said she felt that Resident #1 needed his medication. Record

review of Resident #1's progress notes from the SW dated 10/22/2025 revealed Resident #1 walked up to SW while I was standing at the Nursing station and asked why he was being held prisoner. SW explained that he is not being held prisoner. Resident #1 asked why he could not leave. SW explained that Resident #1 has the right to leave but SW would like to assist him with finding a safe location. Resident #1stated that

he did not need the SW help and that he could return to his last place. Resident #1 then stated that he has money in the bank and did not need my help. Resident #1 then went to the BOM's office and said that he was leaving. The BOM tried to convince Resident #1 to stay and get some help finding a place and Resident #1 started yelling that he did not need any help and we did not have a reason to keep him here.

Resident #1 then left out the front door. SW, Nurse Manager, Psychologist & BOM tried to convince resident to return the facility, but he refused. Although Resident #1has a right to leave with a BIMS of 14, SW will contact the non-emergency line to [NAME] (be on the lookout), for resident in case he needs assistance. Resident #1 has not done anything wrong, just wanted to ensure resident's safety.Record

review of Signing Residents Out policy dated 8/2006 revealed that Each resident leaving the premises (excluding transfers/discharges) must be signed out. A sign-out register is located at each nurses' station.

Registers must indicate the resident's expected time of return. Unless otherwise prohibited by law, medications that must be administered while the resident is out will be given to the resident/person signing

the resident out. Written and/or oral instructions on when and how to administer the medication will be provided to the resident or to the person signing the resident out. Only medications that must be administered while the resident is out will be issued.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashford Gardens

7210 Northline Dr Houston, TX 77076

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

adjusted on the back of the medication carts. He said staff were trained on how to replace the batteries and how to check them. He said the nursing staff should have known how to check the batteries. During an

interview on 10/22/2025 at 4:14 PM, CMA BB revealed the medication carts were to always be locked unless the nurse or CMA was dispensing medications. She said MC #1 was not locking. She said there was

a code staff needed to enter to unlock MC #1. She also said only the nurses knew the code for MC #1. She said she did not remember if she had reported to anyone the medication cart was not locking. She said she was responsibility to ensure the medication cart was locked and secured. She said if a resident had accessed the medication cart the resident could have overdosed, taken the wrong medication, had an allergic reaction, and possibly could have been admitted to the hospital. She said MC #1 contained residents' prescription medication. Interview on 10/22/2025 at 4:29 PM, CMA CC revealed MC #2 did not lock. She said MC #2 looked like it was locked but it would not lock. She said she did not recall who she told about the medication cart not remaining locked. She said all medication carts were to be locked except when a nurse or CMA was dispensing medications from the cart to give to a resident. She said anytime a nurse or CMA walked away from the medication cart they were to ensure it was locked. She said if a resident opened the medication cart and took some medications there was a possibility of an allergic reaction to someone else's medication. She said a resident could become severely sick such as decrease

in blood pressure if the resident ingested another resident's blood pressure medication. She said there was

a possibility a resident could die from taking medications not prescribed by their physician. CMA CC said there were all types of medications in the medication cart. She stated the narcotics were locked and the nurses were the only staff with access to the narcotics. During an attempted interview on 10/23/2025 at 7:43 AM, LVN F revealed she did not know why MC #3 and OFMC #4 was unlocked. She said OFMC #4 was not in use. She would not answer any questions and walked away from surveyor. During an interview

on 10/24/2025 at 9:30 AM, the DON revealed the OFMC #4 that was found unlocked on 10/23/2025 was an extra cart the facility used when there was an increase of census. She said at this time that medication cart should not have been in use. She said the medication in the cart belonged to a resident who was no longer at the facility. She said the OFMC #4 was expected to be locked. She also said she was investigating why it was unlocked and had medication in the cart. She said in-services were given prior to all nursing staff on locking medication carts. She said she in serviced all CMA and nurses this week on locking medication carts and reporting when medication cart would not lock. Record review of Medication Labeling and Storage Policy, dated 02/2023, revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashford Gardens

7210 Northline Dr Houston, TX 77076

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident's room. She stated there was a potential of spread of infection. The Director of Nurses stated staff was immediately to place the garbage in appropriate trash container and place the soiled linen in the portion of the laundry room where soiled clothes and linen were stored until laundry staff washed them.

She stated it was not the proper protocol to take dirty linens in a bag and garbage to another resident's room and place it on the floor. The Director of Nurses stated there was a potential to transfer infection from one resident to another resident. She stated the staff had been in serviced on infection control and enhanced barrier precautions. The Director of Nurses stated she did not recall the date of the in-service.

Record review of the Facility Policy on Enhanced Barrier Precautions, dated August 2022, reflected.

Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b.

Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing. b. bathing/showering. c. transferring. d. providing hygiene. e. changing linens. f. changing briefs or assisting with toileting. g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. (and similar things); and h. wound care (any skin opening requiring a dressing).

Event ID:

Facility ID:

If continuation sheet