Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ashby Care Center during CMS and state inspections, most recent first.
The facility failed to honor residents’ rights to organize and participate in resident/family groups by not holding regular Resident Council meetings for all residents. The ADM could not locate Resident Council minutes and instead provided a list of names that was later identified by a CNA/AS as attendance for bingo, not council meetings. The CNA/AS reported that Resident Council meetings had not been held for several months and that no meeting minutes were present in the designated binder. Review of the facility’s Resident Council P&P showed that monthly meetings with recorded minutes and attendance were required but not implemented, limiting residents’ opportunity to voice concerns and participate in decisions affecting their quality of life.
Surveyors found that the facility failed to implement individualized activities consistent with residents’ documented preferences and its own activity policy. Several cognitively intact residents with depression and other conditions reported boredom, lack of meaningful activities, and infrequent assistance to go outdoors, despite MDS assessments showing interests in music, news, hobbies, outdoor time, and religious practices. The posted activity calendar was not followed, such as a scheduled baking session that did not occur, and residents were left in the activity room watching TV after activity staff left, including on weekends when no activity staff were present. The ADM and DON acknowledged missing activity care plans and lack of activity progress notes in some residents’ charts, and staff interviews showed they were unaware of certain residents’ specific activity interests, such as playing musical instruments.
Surveyors found that controlled drug records and MARs for three residents did not match, with discrepancies in the documentation of morphine and hydrocodone/APAP administration and inventory. Nursing staff and the DON confirmed the inconsistencies, and the Consultant Pharmacist failed to identify these issues during routine reviews, despite facility policy requiring accurate reconciliation of controlled substances.
Surveyors identified that several residents with complex medical conditions were not offered assistance with advance directives, and the facility failed to ensure these documents were present in their medical records as required by policy. Staff confirmed that neither paper nor electronic records consistently contained advance directives, nor were residents properly informed or assisted in completing them.
The facility did not complete required quarterly MDS assessments for five residents, as identified during a record review and staff interview. Several residents either lacked a quarterly assessment or had assessments completed late, with the staff member responsible acknowledging the delays. This failure was identified through direct review of records and staff acknowledgment.
The facility did not conduct or document annual performance reviews for its nurse aide staff, as required by policy. During a review of personnel files and an interview with the ADM/MDSC, it was confirmed that no records of these reviews existed for any nurse aide.
The facility did not employ a full-time Certified Dietary Manager, with the DM only working part-time on weekends and the Registered Dietitian serving as a consultant for less than eight hours per week. This resulted in insufficient oversight of food and nutrition services for 24 residents, as confirmed by staff interviews, payroll records, and facility policies.
Surveyors found that food items, including cereals and frozen goods, were not properly labeled or dated after opening, and some were not stored in their original packaging. The dietary staff member on duty, who was new to the facility, confirmed that labeling and date checks had not been consistently performed. The DON/IP also stated that opened food should be labeled and dated per facility policy to ensure food safety. Review of facility policies confirmed these requirements, but observations showed they were not followed for all sampled residents' nourishment.
Staff failed to clean blood pressure cuffs and medication carts between use on multiple residents, and a housekeeper wore a contaminated laundry gown in resident areas. The housekeeper had not received proper in-service training on environmental cleaning and used ineffective wipes for disinfecting high-touch surfaces. Clean linens were stored in a dirty laundry area and some were contaminated by contact with the floor, all in violation of facility infection control policies.
A resident with multiple medical conditions, including cognitive impairment and generalized weakness, was placed in a Geri chair with a hard tray that prevented independent movement. Staff confirmed the resident could not remove the tray or exit the chair without assistance, and the care plan lacked alternative interventions for fall risk. Facility policy defined the Geri chair as a restraint and required documentation of alternatives, which was not found in the resident's records.
The facility did not ensure that the DON and ADM, both designated as Infection Preventionists, had completed specialized infection prevention and control training, as confirmed during interviews and record review.
Six multi-bed rooms were found to provide less than 80 sq. ft. per resident, with measurements ranging from 73.32 to 74.9 sq. ft. per bed. Staff and a resident reported that care and mobility were not hindered, and the ADM/MDSC confirmed no changes in room sizes and acknowledged the deficiency.
Surveyors found that medication storage practices were not followed, including an unlocked medication refrigerator containing an emergency kit, incomplete temperature logs, non-medication food items stored in a medication-only refrigerator without proper labeling, and a staff clothing item stored in the medication room. The DON and ADM confirmed these practices did not meet facility policy.
Multiple infection control lapses were identified, including an open bin with used gowns placed next to clean PPE, a bag of adult briefs stored on the floor, a resident water container stored near chemicals in the medication room, and an unlocked biohazard room containing used needles. Both the LVN and DON acknowledged these practices did not meet infection control standards.
A resident with dementia and receiving hospice services experienced unnecessary pain during wound dressing changes due to the facility's failure to administer prescribed Morphine. Despite orders and notifications from hospice staff, the resident was not pre-medicated on multiple occasions, leading to significant distress.
Failure to Hold and Document Required Resident Council Meetings
Penalty
Summary
The facility failed to honor residents’ rights to organize and participate in resident/family groups by not providing regular Resident Council meetings for a census of 27 residents. During an interview, the Administrator stated she was unaware of the location of Resident Council meeting minutes and produced a two-page list of resident names from the past two months, which she identified as attendance for past Resident Council meetings. In a subsequent interview, a CNA/Activity Staff member reported that Resident Council meetings had not occurred since November 2025, confirmed that the facility needed to consistently hold these monthly meetings, and stated there were no records of meeting minutes in the binder and that the list provided by the Administrator only reflected residents who attended bingo. Review of the facility’s undated Resident Council Policy and Procedure showed that the facility supports a Resident Council with monthly meetings, with minutes and attendance to be recorded and maintained, which was not followed. This failure had the potential to result in the inability of residents to voice their concerns or contribute to improving facility operations impacting their dignity and overall quality of life.
Failure to Provide Individualized, Implemented Activity Program for Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide activities designed to meet the interests and the physical, mental, and psychosocial well-being of four cognitively intact residents. One resident with major depressive disorder and a BIMS score of 14 reported wanting to transfer due to boredom and lack of activities, stating it felt as though residents were sent there to die. This resident’s MDS activity preference interview documented that listening to music, staying informed, and doing favorite activities were important, and that going outside in good weather and participating in religious activities were somewhat important, yet these preferences were not reflected in meaningful, individualized activities. Another resident with major depressive disorder, delirium, and unspecified dementia, and a BIMS score of 13, had documented preferences for listening to preferred music, staying updated on news, engaging in favorite activities, and spending time outdoors. The Administrator acknowledged that this resident’s chart did not contain an activity care plan or activity staff progress notes, and also stated the resident preferred independence and enjoyed watching cars in the parking lot. This resident reported that the posted activity calendar was not followed, that activities were advertised but not held, and expressed interest in performing music for other residents, but noted there were no opportunities to do so. The CNA/Activity Staff later stated she did not know this resident loved to play violin and piano. Surveyors observed that a baking activity scheduled on the posted calendar for a Wednesday at 2 p.m. did not occur; only a few residents in wheelchairs were present in the activity room, and the activity staff had already left. One resident stated they did not bake that day, that activity staff had left, and that CNAs only helped with coffee before dinner, also noting residents did not go out to the patio even when the weather was good. Another resident with a BIMS score of 15, whose MDS showed preferences for music, news, group activities, favorite hobbies, outdoor time, and religious services, reported going outside for fresh air only when a friend visited, stating staff were usually too busy to assist residents to go outside. The DON confirmed there was no activity care plan or progress notes in this resident’s record. CNA staff reported that on weekends residents sat in the activity room without activities because no activity staff were present, and that CNAs monitored them from outside the room to prevent falls. The facility’s undated Activity Director policy stated that the facility would provide ongoing activities based on assessments and care plans, with posted calendars and documentation of participation and responses, which was not carried out as described in practice for these residents.
Inaccurate Controlled Drug Records and Inadequate Pharmacist Review
Penalty
Summary
The facility failed to ensure the accuracy of controlled drug records for three residents, as evidenced by discrepancies between the Controlled Drug Record (inventory of scheduled drugs) and the Medication Administration Record (MAR). For one resident, the amount of morphine recorded in the Controlled Drug Record did not match the actual amount in the bottle, and the MAR did not show administration of the medication on dates when the Controlled Drug Record indicated doses were removed. For another resident, the Controlled Drug Record showed removal of hydrocodone/APAP tablets on specific dates, but the MAR did not reflect administration of those tablets on the same dates. A third resident's MAR indicated daily administration of hydrocodone/APAP, but the Controlled Drug Record did not show corresponding removals for each day. These discrepancies were identified during concurrent observations, interviews, and record reviews conducted by surveyors with nursing staff, including an LVN and the Director of Nursing (DON). The DON acknowledged that the Controlled Drug Records and MARs did not match and stated that her expectation was for scheduled medication records to be accurate. The inconsistencies were confirmed through direct inspection of medication bottles, review of Controlled Drug Records, and comparison with MARs. Additionally, the facility's Consultant Pharmacist failed to identify these discrepancies during routine reviews. The Consultant Pharmacist's reports for the previous three months did not mention any issues with the accuracy of controlled medication documentation. The facility's policy required the pharmacist to establish a system for accurate reconciliation of controlled drugs, but the observed practice did not meet this standard.
Failure to Ensure Advance Directives Were Offered and Documented
Penalty
Summary
Surveyors found that the facility failed to offer or ensure that advance directives were on file for six sampled residents. Record reviews showed that while some residents had executed advance directives, these documents were not consistently present in either the paper charts or electronic health records. For several residents, there was no evidence that they had been offered the opportunity to complete an advance directive or that staff had assisted them in locating or completing one. The facility's own policy requires staff to inquire about advance directives during admission, document their existence, and include copies in the medical record, but this process was not followed for the residents reviewed. The residents involved had a range of significant medical conditions, including epilepsy, schizophrenia, stroke, atherosclerosis, traumatic subdural hemorrhage, venous insufficiency, and adult failure to thrive. Despite these complex health needs, the facility did not ensure that advance directives were available or that residents were informed about their right to execute one. During interviews, facility staff acknowledged the importance of having advance directives on file, especially in emergency situations when residents may become incapacitated, but confirmed that the required documentation and offers were not consistently made.
Failure to Complete Quarterly MDS Assessments as Required
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments for five sampled residents as required by regulation. During an interview and record review with the Administrator/Minimum Data Set Coordinator (ADM/MDSC), it was found that several residents did not have their quarterly MDS assessments completed within the required timeframe. Specifically, one resident had no quarterly MDS assessment, another had no quarterly assessment completed for an extended period, and two residents had their last quarterly assessments completed several months prior to the review. The ADM/MDSC acknowledged responsibility for the completion and transmission of all residents' MDS assessments and confirmed that these assessments were late. The review referenced the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, which requires that quarterly assessments be completed at least every 92 days following the previous OBRA assessment. The failure to complete these assessments as scheduled could result in delayed assessment of residents' needs and hinder the ability to monitor residents' progress over time. The findings were based on direct record review and staff interview, with no mention of corrective actions or follow-up steps taken at the time of the report.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for all nurse aide staff, as required by its own policies and procedures. During an interview and record review with the Administrator/Minimum Data Set Coordinator, it was found that there were no records of annual performance reviews in any of the nurse aide personnel files. The Administrator confirmed that the facility did not have documentation of these reviews and acknowledged the importance of conducting them to provide quality care and feedback to staff.
Failure to Employ Full-Time Certified Dietary Manager for Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager (DM) to oversee food and nutrition services for 24 residents, as required by standards of practice. Observations and interviews revealed that the DM was only scheduled to work part-time, specifically on weekends, and was not present during weekdays. Payroll records confirmed that the DM consistently worked only two days per week, with total hours well below the full-time threshold. Other dietary staff also worked limited hours, and the Registered Dietitian (RD) was employed as a consultant, working less than eight hours per week and primarily available by phone. Interviews with staff, including the DON/Infection Preventionist, confirmed that the DM was needed on a full-time basis to ensure proper menu adherence, food sanitation, and the nutritional needs of residents. Facility policies required a qualified supervisor to manage the dietary department and ensure quality food service, but these requirements were not met due to the DM's limited schedule. The lack of full-time dietary management had the potential to impact the safe and sanitary delivery of meals and the overall nutritional care of residents.
Failure to Properly Store and Label Food Items in Kitchen and Storage Areas
Penalty
Summary
The facility failed to properly store and label food items in the kitchen and storage areas, as observed during a survey. Specifically, Corn Flakes cereal was found not in its original box and labeled with a date from two years prior, Bran Raisin packages were opened without an opened date, and oatmeal was in its original packaging but lacked an opened date. Additionally, opened food items in the freezer were not labeled with an opened date. The Dietary staff member on duty, who had only recently started working at the facility, confirmed that food packaging had not been thoroughly checked for use-by or opened dates since his employment began. He also acknowledged that it was facility policy to label food immediately after opening due to shelf life considerations. Interviews with the Dietary staff and the DON/Infection Preventionist confirmed that opened food items should be labeled and dated according to facility policy to ensure food safety and prevent serving expired food. Review of the facility's policies and procedures further supported the requirement for labeling and dating opened dry goods and other food items, specifying maximum storage periods and the need for proper inspection and storage of food deliveries. The failure to follow these procedures was observed for all sampled residents' nourishment, indicating a systemic issue in food storage and labeling practices.
Infection Control Failures in Medication Administration and Environmental Cleaning
Penalty
Summary
Staff failed to follow infection prevention and control practices during medication administration and environmental cleaning. Licensed Vocational Nurses (LVNs) were observed using blood pressure cuffs on multiple residents without cleaning the equipment between uses. The BP cuffs were placed on the medication cart, which was also not cleaned between residents. This practice was observed with six residents, and the Director of Nursing (DON) confirmed that the facility's policy required equipment to be cleaned between residents, which was not followed. Housekeeping staff also failed to adhere to infection control protocols. One housekeeper wore a protective gown used for laundry services outside the laundry room, including in resident areas such as the dining room and hallway. The DON stated that the gown was considered contaminated and should not have been worn outside the laundry area, as it could spread infection. Additionally, the housekeeper had not received in-service training on environmental cleaning since being hired and was unaware of the correct disinfectants to use for high-touch surfaces, instead using adult wipes not effective for disinfection. Further deficiencies were observed in the laundry area, where clean linens were stored in the dirty section of the laundry room near where soiled articles were rinsed. Some clean linens were covered with sheet protectors that touched the floor, leading to contamination. The DON acknowledged that these practices did not comply with facility policies, which require precautions to prevent cross-contamination and regular in-service training for housekeeping and laundry staff.
Failure to Ensure Resident Remained Free from Physical Restraints
Penalty
Summary
Facility staff failed to ensure that a resident was free from physical restraints, as required, by placing the resident in a Geri chair with a hard table cover that prevented the resident from moving freely or getting in and out of the chair independently. The resident, who had diagnoses including essential primary hypertension, nontraumatic intracerebral hemorrhage, and mild cognitive impairment, was unable to remove the tray or exit the chair without staff assistance. Staff interviews confirmed that the Geri chair was used to prevent falls due to the resident's generalized weakness and high fall risk, and that the resident could not get out of the chair on his own once placed in it. Record review showed that the resident's care plan only referenced the use of the Geri chair for safety, comfort, and mobility support, but did not include other interventions for fall risk or muscle weakness. Observations on multiple occasions confirmed the resident was restrained in the Geri chair with a tray, and staff acknowledged that the resident could not remove the tray or leave the chair independently. Facility policy identified the Geri chair as a restraint and required documentation of all measures tried prior to restraint use, but such documentation and alternative interventions were not present in the resident's care plan.
Infection Preventionists Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that designated Infection Preventionists, specifically the Director of Nursing (DON) and the Administrator (ADM), had completed specialized training in infection prevention and control. During an interview and record review, both the DON and ADM confirmed that they were responsible for the infection prevention and control program but had not completed the required specialized training. This deficiency was identified through direct statements from the DON and ADM during the survey process. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Resident Rooms Below Required Square Footage
Penalty
Summary
Six resident rooms (Rooms 1, 3, 5, 7, 8, and 9) with multiple beds were found to provide less than the required 80 square feet per resident, as determined by direct measurement and observation. The square footage per bed in these rooms ranged from 73.32 to 74.9 square feet, which is below the regulatory standard. During observations and interviews, a CNA and a resident both stated that there was enough space to provide care and for residents using wheelchairs to move about, and the Administrator/Minimum Data Set Coordinator confirmed that there had been no changes to room sizes since the last survey and acknowledged the rooms did not meet the required square footage per resident. This deficiency was identified through observation, interview, and record review, and was based on the physical measurements of the rooms and confirmation from facility staff.
Improper Medication Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals as required. During observations, the medication refrigerator in the medication room was found unlocked and not padlocked, despite containing an emergency kit with medications. Both the Administrator and the Director of Nursing confirmed that the refrigerator should have been secured to prevent unauthorized access. Additionally, the medication room's dry storage temperature log was missing required entries for two consecutive days, and the Director of Nursing acknowledged that this log should be completed by a licensed nurse to ensure temperature requirements are met. Further observations revealed that the medication room refrigerator, labeled for medication use only, contained non-medication food items such as olives, marmalade, honey, and vinaigrette, none of which were labeled with names or dates. The Director of Nursing was unaware of the origin of these items and stated that food items should be labeled, covered, and dated. Additionally, a staff member's clothing item was found hanging on the medication room door, which the Administrator stated was inappropriate for the medication room. The facility's own policy requires medication rooms and supplies to remain locked, temperature logs to be maintained, and food items to be properly segregated and labeled.
Infection Control Lapses in PPE Handling, Storage, and Biohazard Security
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas. An open lid bin containing a used yellow gown was observed outside a resident room, with a container of unused PPE supplies placed next to it. Both the LVN and DON acknowledged that the bin should have been closed to prevent contamination of clean PPE. In the medication room, a bag of adult brief pads was found on the floor, which the DON confirmed was not appropriate for infection control. Additionally, a half-full container of water was discovered under the sink in the medication room, situated next to two containers of chemical agents, including perineal wash. The LVN stated the water was used by residents, and the DON noted that water should not be stored near chemicals due to the risk of accidental ingestion. Furthermore, the biohazard room door was found unlocked, despite containing used needles, and both the LVN and DON stated that the door should have been locked to prevent unauthorized access.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to provide necessary pain medication for a resident requiring wound dressing changes, leading to unnecessary pain and distress. The resident, who had dementia and was receiving hospice services, had orders for Morphine to be administered prior to dressing changes. However, the licensed nursing staff did not administer the required pain medication before the wound care on multiple occasions, as evidenced by the Medication Administration Record (MAR) and Controlled Drug Record reviews. The resident was observed in significant pain during dressing changes, and the hospice staff confirmed that the resident had not been pre-medicated as per the orders. The Director of Nursing (DON) acknowledged that the hospice agency would call ahead to inform the facility of their visits, and the staff were supposed to pre-medicate the resident. Despite this, the records showed that the resident did not receive the prescribed Morphine on several dates, including 11/13/2023, 11/20/2023, and 11/30/2023. The DON confirmed the lack of administration and mentioned alternative pain management methods, such as asking the resident to count down, which were ineffective. The hospice staff expressed concerns about the resident's pain management and the facility's failure to follow the prescribed plan of care. The facility's policy on pain assessment and management emphasized the importance of respecting and supporting every patient's right to optimal pain relief. The Memorandum of Understanding with the hospice agency also required the facility to comply with the hospice patient's plan of care and ensure the patient's comfort. Despite these policies, the facility did not administer the necessary pain medication, resulting in the resident experiencing significant pain during wound dressing changes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,062 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Berkeley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elmwood Care Center | 0.2 mi | ★★★★★ | 8 | 0 |
| Kyakameena Care Center | 0.4 mi | ★★★★★ | 26 | 0 |
| Berkeley Pines Skilled Nursing Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Chaparral House | 1.4 mi | ★★★★★ | 2 | 0 |
| The Rehabilitation Center Of Oakland | 2 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ashby Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.