Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ashton Memorial Living Center during CMS and state inspections, most recent first.
A resident with CHF and CKD was transferred to the hospital and later returned, but the facility did not complete the bed-hold agreement at the time of transfer. The document was completed only after the resident came back, and the billing clerk stated she completed bed-hold agreements when residents returned from the hospital.
A resident with sepsis and a UTI had an order for PRN O2 at 2-3 LPM to keep SpO2 above 88%, but the record showed repeated low SpO2 readings on RA and on 2 LPM with no documented nursing interventions. The DNS stated staff failed to document the low SpO2 interventions and should have.
A facility failed to ensure a CNA's annual performance review was completed within the required 12-month interval. Review of the CNA's personnel file showed no documentation of an annual performance review, and the HR Director stated the annual competencies were believed to satisfy that requirement.
A resident with HF and DM had a medication cup with several pills left on her bedside table after a nurse brought in her meds, and the resident said she removed her thyroid med and was waiting to take the rest with food. RN stated she was not ordered or care-planned for self-administration. In a separate finding, a medication cart was observed unlocked and unattended, and the DNS stated it should have been locked.
Food Storage and Labeling Deficiencies: Surveyors observed improperly stored and labeled dry food items in the kitchen, including opened molasses, Nesquik chocolate, and confectionary sugar without required open or use-by dates. The Dietary Supervisor acknowledged that the opened items should have been correctly labeled.
Infection control practices were not maintained when an LPN's personal mug and water bottle were observed on top of a treatment cart, and an RN placed a glucometer back into storage after checking a resident's blood sugar without cleaning it first. The facility's policy directed staff to clean and disinfect glucometers after each use, and the DNS confirmed they should have been cleaned after each use.
The facility was found to have improperly stored food items in the walk-in refrigerator, with several items lacking proper date marking as required by the FDA 2022 Food Code. Loose tomatoes and open containers of dressings were not dated, posing a risk of food contamination. The Food Service Manager confirmed the oversight.
The facility failed to provide the required 12 hours of in-service education for three CNAs and did not complete annual performance reviews for three CNAs. The HR Director and DNS acknowledged that these requirements were not met since COVID-19 in 2020.
The facility failed to maintain infection control practices by not encouraging hand hygiene before meals and not cleaning glucometers after use. CNAs did not prompt residents to perform hand hygiene before eating, and an RN did not disinfect a glucometer after use, believing it was unnecessary for personal devices. The DNS confirmed these practices were not in line with facility policies.
The facility did not provide Advance Beneficiary Notices (ABNs) to three residents, failing to inform them of their potential financial liability when Medicare Part A benefits ended. A resident with chronic kidney disease and sepsis, another with dementia and hypertension, and a third with Parkinson's disease and a lumbar fracture were affected. The DNS confirmed the absence of ABNs, highlighting a compliance issue with beneficiary protection notifications.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in recorded heights and missing documentation of a PASARR Level II evaluation. These inaccuracies were confirmed by the DNS and could potentially result in negative outcomes if residents are not properly assessed or monitored.
A facility failed to refer a resident with developmental delay for a PASARR Level II evaluation, as required by their admission criteria policy. Despite the resident's multiple diagnoses, including heart failure and hypertension, the necessary evaluation was not completed, as confirmed by the DNS.
A facility failed to follow its wound care protocol by not dating and initialing wound dressings for a resident, as required by their policy. This oversight was confirmed by the DNS and posed a risk for infection and skin breakdown.
The facility did not post a completed daily staffing sheet as required. Observations on a specific morning showed the sheet was blank at 8:00 AM and remained so by 9:25 AM, despite the DNS stating it should be completed by the start of the shift at 6:00 AM.
A resident with chronic respiratory failure and hypoxia was using an oxygen concentrator without a physician's order. The resident's care plan indicated the need for oxygen to maintain saturation levels, but the medical record lacked a formal order. The DNS confirmed the absence of a physician's order since admission.
The facility failed to store medications appropriately, as the emergency narcotic kit containing Ativan was found in an unlocked refrigerator, contrary to the policy requiring double locking. An LPN and the DNS confirmed the requirement for double locking controlled substances.
Bed Hold Notice Not Provided at Time of Hospital Transfer
Penalty
Summary
The facility failed to ensure that a bed hold notice was provided to residents or their representatives at the time of transfer to the hospital. This was identified for 1 of 2 residents reviewed for transfers, Resident #6, who was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic heart failure and chronic kidney disease. The medical record showed Resident #6 was transferred to a hospital on 8/12/25 and returned on 8/15/25, but a bed-hold agreement was not completed when she was discharged to the hospital. The bed-hold agreement was completed only after her return to the facility on 8/15/25. On 12/9/25 at 2:40 PM, the facility billing clerk stated she completed the bed-hold agreement when the resident returned from the hospital stay, as she had done for all residents.
Failure to Document Interventions for Low Oxygen Saturation
Penalty
Summary
Failure to provide respiratory services as ordered by the physician occurred for one resident who was admitted and later readmitted with diagnoses including sepsis and urinary tract infection. The resident had a physician order for oxygen PRN at 2-3 LPM to keep oxygen saturation above 88%, with the order starting on 11/4/25. The medical record documented multiple low SpO2 readings, including 86% on room air, 88% on room air, and 88% on 2 LPM, but on 12/9/25 there was no documentation of nursing interventions for the low oxygen saturation readings. The DNS stated that nursing staff had failed to document any low SpO2 interventions for the resident and should have.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure that each CNA's annual performance review was completed at least once every 12 months for CNA #1, whose personnel record was reviewed for sufficient and competent staffing. Review of CNA #1's employee file on 12/9/25 at 2:57 PM showed an initial hire date of 10/13/20, but there was no documentation that an annual performance review had been completed. During an interview on 12/9/25 at 3:47 PM, the HR Director stated the CNAs' annual performance reviews had not been done because she believed the annual competencies met the requirement for the annual performance review.
Medication Storage and Security Lapses
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted professional principles when a medication cup with several pills was observed on Resident #17’s bedside table. Resident #17, who was admitted with diagnoses including heart failure and diabetes, stated that a nurse had brought her medication into the room and left it on the table, and that she had removed her thyroid medication and was waiting to take the other pills with food. RN #1 stated that Resident #17 did not have an order to self-administer medications and it was not documented in her care plan for self-administration, so the medications should not have been left in her room. In a separate observation, the medication cart outside the dining room was found unlocked and unattended, and the DNS stated the cart should have been locked.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to appropriately store, distribute, and label foods in the kitchen. During a tour of the dry food storage area with the Dietary Supervisor, surveyors observed a 1 gallon container of molasses that had been opened on 12/22/23 with a use-by date of 8/17/25, along with 2 other gallons of molasses that were unopened but past their use-by dates. Surveyors also observed an opened container of Nesquik chocolate with no opened date or use-by date and an opened bag of confectionary sugar with no open or used-by dates. The Dietary Supervisor stated that the opened food items should have been correctly labeled and were not.
Infection Control Lapses With Personal Drinks on Treatment Cart and Uncleaned Glucometer
Penalty
Summary
The facility failed to maintain infection control prevention practices to provide a safe and sanitary environment. During observation, a treatment cart in the hallway by a resident room had a pink mug and a bottle of water on top of it, and an LPN stated the personal drinks were hers and should not have been on top of the treatment cart. In a separate observation, an RN used a glucometer to check Resident #20's blood sugar, brought the glucometer to the medication cart, and placed it in the storage box without cleaning it first. The facility's Glucometer Cleaning Policy directed staff to clean and disinfect glucometers after each use, and the DNS stated the glucometers should have been cleaned after each use.
Improper Food Storage and Date Marking
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as observed during an inspection of the kitchen. In the walk-in refrigerator, several items were found without proper date marking, which is required by the FDA 2022 Food Code. Loose tomatoes were on the shelf without received or use-by dates, and an open container of Ranch dressing lacked an open or use-by date. Additionally, a container of Italian dressing had an open date of 7/23/24 but no use-by date, and a container of Caesar dressing had an open date of 9/24/24 with no use-by date. The Food Service Manager acknowledged that the tomatoes should have been in a container and dated, and the open dressings should have been dated.
Deficiency in CNA In-Service Education and Performance Reviews
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of in-service education per year for three Certified Nursing Assistants (CNAs) whose personnel records were reviewed. Specifically, CNA #4 and CNA #5 had no documented in-service hours for 2023 or 2024, while CNA #7 had only 1.25 hours documented for the same period. This lack of in-service education was acknowledged by the HR Director, who confirmed that the CNAs should have completed the 12 hours of annual in-service education. Additionally, the facility did not complete annual performance reviews for three CNAs as required. CNA #2 had no documented annual evaluation since her hire date in 2020, CNA #4's last evaluation was in 2020, and CNA #5 had no evaluation since her hire in 2019. The HR Director and the Director of Nursing Services (DNS) both stated that staff evaluations had not been performed since the onset of COVID-19 in 2020, although they acknowledged that these evaluations should have been conducted.
Infection Control and Prevention Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as observed during meal delivery and medical equipment cleaning. Specifically, staff members did not encourage or offer hand hygiene to residents before meals served in their rooms. On multiple occasions, CNAs did not prompt residents to perform hand hygiene before eating, and they acknowledged this oversight during interviews. The Director of Nursing Services (DNS) confirmed that CNAs should have offered hand hygiene to residents receiving meals in their rooms. Additionally, the facility did not adhere to its policy regarding the cleaning of glucometers. An RN used a glucometer to check a resident's blood sugar and returned it to the storage box without disinfecting it. The RN believed that since the glucometer was the resident's personal device, it did not require cleaning after each use. However, the DNS stated that glucometers should be cleaned after every use, indicating a failure to follow established cleaning protocols.
Failure to Provide Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide the required Advance Beneficiary Notice (ABN) to three residents, which is necessary to inform them of their potential financial liability when their Medicare Part A benefits end. Resident #7, who was admitted with chronic kidney disease and sepsis, did not receive an ABN when their Medicare A benefits ended on May 23, 2024. Similarly, Resident #19, admitted with dementia and hypertension, was not given an ABN when their benefits ended on May 28, 2024. Resident #25, with diagnoses including Parkinson's disease and a lumbar vertebra fracture, also did not receive an ABN when their benefits ended on July 21, 2024. The Director of Nursing Services (DNS) confirmed the absence of ABNs for these residents, indicating a lapse in the facility's compliance with beneficiary protection notification requirements.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status, which was identified for three residents. Resident #5's MDS assessments showed inconsistencies in recorded height, with earlier assessments documenting a height of 66 inches and a later assessment recording 69 inches. The Director of Nursing Services (DNS) acknowledged that the height should have been accurately recorded. Similarly, Resident #7's MDS assessments showed discrepancies in height measurements, with one assessment documenting 66 inches and subsequent assessments recording 60 inches. The DNS confirmed that these assessments should have been accurate. Resident #14's case involved a failure to document a PASARR Level II evaluation in the annual MDS assessment, despite having a significant change in status assessment that indicated the need for such an evaluation. The PASARR Level II was completed a year prior, but the annual MDS assessment did not reflect this. The DNS confirmed the omission of the PASARR Level II evaluation in the documentation. These inaccuracies in the MDS assessments could potentially lead to negative outcomes if residents are not properly assessed, cared for, or monitored.
Failure to Conduct PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer residents for further evaluation when diagnosed with a major mental illness, intellectual disability, or a related condition, as required by the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. This deficiency was identified during a review of records, policies, and staff interviews, specifically affecting one resident. The facility's Admission Criteria policy, dated March 2019, mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders. However, a resident admitted with multiple diagnoses, including heart failure, hypertension, and developmental delay, did not receive the necessary PASARR Level II evaluation. This oversight was confirmed by the Director of Nursing Services (DNS), indicating a lapse in the facility's adherence to its own admission criteria and the PASARR process.
Non-compliance with Wound Care Protocol
Penalty
Summary
The facility failed to adhere to professional standards of practice for wound care for a resident, which was identified during a survey. The facility's wound care policy requires that all wound dressings be dated and initialed when changed. However, during an observation, it was noted that the resident's left leg had two undated bandages, indicating non-compliance with the facility's policy. The Director of Nursing Services (DNS) confirmed that it was the facility's expectation for staff to date and initial all wound bandages, which was not followed in this instance. This oversight created the potential for resident harm or adverse outcomes related to infection and skin breakdown.
Failure to Post Daily Staffing Sheet
Penalty
Summary
The facility failed to ensure that a completed daily staffing sheet was posted in the nursing facility, which is a requirement. On the morning of November 4th, it was observed at 8:00 AM that the staffing sheet was left blank. The Director of Nursing Services (DNS) confirmed that the staffing sheet should have been completed at the beginning of the shift, which started at 6:00 AM. Despite this, by 9:25 AM, the staffing sheet remained blank, indicating a failure to comply with the posting requirement.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident who was admitted with multiple diagnoses, including diabetes and chronic respiratory failure with hypoxia. An oxygen concentrator was observed in the resident's room, and the resident reported using oxygen at night and while sleeping in a recliner chair. Despite this, the resident's medical record did not include a physician's order for oxygen therapy. Progress notes documented the resident using oxygen while asleep, and the care plan indicated the use of oxygen to maintain oxygen saturations above 90%. The Director of Nursing Services confirmed that no physician's order for oxygen had been obtained since the resident's admission.
Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure that medications were stored appropriately, as observed during an inspection of the medication storage room. The facility's emergency narcotic kit, which contained Ativan, a controlled substance, was found in a plastic box secured with a plastic zip tie inside an unlocked medication storage refrigerator. This was contrary to the facility's Control Substance policy, which required narcotics to be double locked. During the inspection, an LPN confirmed that the narcotic emergency kit should have been double locked, and the Director of Nursing Services (DNS) reiterated this requirement the following day.
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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.
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Nursing homes near Ashton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Carriage Cove Short Stay Rehabilitation | 24.5 mi | ★★★★★ | 12 | 0 |
| Temple View Transitional Care Center | 25 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.