Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Ashford Place Health Campus during CMS and state inspections, most recent first.
Inaccurate MDS Coding for Alarm Use: The facility failed to accurately code alarm use on Quarterly MDS assessments for two residents. One resident with dementia had care plan interventions and physician orders for a pull tab alarm and floor mat alarm, but the MDS stated no alarms were used. Another resident with Parkinson’s disease and TBI had an order for a pressure alarm at all times, but the MDS stated bed and/or chair alarms were not used. The MDS Coordinator stated both assessments were coded incorrectly.
A resident with diabetes and psychotic disorder with delusions had a PASRR Level I approval with no Level II required, but after a new psychosis diagnosis, the resident was not referred for a Level II review. The ED stated the resident did not have a Level II, and the SSD stated the resident should have been referred after the change in status. The PASRR SOP indicated Social Services ensures paperwork is submitted for change in status and Level II follow up.
An LPN administered lispro insulin to a resident with type 2 DM after checking a blood sugar of 273, attaching the needle, and dialing up 10 units, but did not prime the flex pen first. The resident had an order for 10 units of lispro before meals, and the DON confirmed pens were to be primed before use; manufacturer instructions also stated to prime before each injection.
A resident with Parkinson's disease and TBI was manually transferred from a recliner to a wheelchair by two CRCA staff without a gait belt, despite needing 2-person assist and gait belt use. Two residents also had personal alarm use documented in their care plans and physician orders, but alarm/restrictive device evaluations were not completed when the alarms were initiated, according to the DNS and NC.
Glucometer Not Disinfected Per Manufacturer Instructions: An LPN obtained a resident’s blood sugar reading using a glucometer, wiped the device with an alcohol wipe before use, and returned it to the med cart without disinfecting it afterward. The LPN stated alcohol wipes were the wrong wipes to use, and the DON later provided the manufacturer’s instructions requiring Clorox Germicidal Wipes to clean and disinfect the meter.
A resident requiring substantial assistance with ADLs did not receive scheduled showers twice weekly as care planned, instead receiving only two showers during her stay, with inconsistent documentation and no evidence of refusal or alternative preference. Staff interviews revealed uncertainty in documentation and lack of awareness of missed bathing.
The facility failed to implement effective fall prevention measures for two residents. One resident, who was lethargic due to medication side effects, fell in the shower and sustained fractures. Another resident, requiring more than limited assistance, was dropped during a transfer due to the staff's failure to use a gait belt. These incidents highlight deficiencies in the facility's fall prevention practices.
A resident with stage 4 chronic kidney disease and a stage 4 pressure ulcer was discharged to the hospital without the required medical and contact information. The facility's DON confirmed the lack of documentation verifying that essential information was sent to the hospital.
The facility failed to timely revise a resident's care plans for depression and shower refusal. The resident's care plan did not reflect her request to discontinue Lexapro or her preference for evening showers and specific caregivers, leading to inconsistencies in her care.
The facility failed to administer medications as ordered for two residents. One resident did not receive prescribed medications due to unavailability, and another did not receive eye drops due to insurance coverage issues. Despite multiple notifications from the pharmacy, the facility did not resolve the issues promptly.
The facility failed to properly label an opened bottle of Timolol eye drops, did not timely destroy medications for an expired resident, and had a controlled medication lock box that was not permanently affixed within the medication refrigerator. The DON was unaware of the broken metal wire that had detached the lock box.
A resident with diabetes and kidney failure reported urinary symptoms, prompting a STAT urinalysis order. The facility failed to send the UA to the lab as required, despite the resident being cognitively intact and the facility's policy mandating timely transport of STAT specimens.
The facility failed to maintain infection control during medication administration for two residents. An RN did not perform hand hygiene before donning gloves and administering eye drops, and an LPN picked up a dropped tablet with bare hands and administered it without performing hand hygiene. Both actions violated the facility's infection prevention and control policy.
The facility failed to timely address a grievance for a resident who was transported to a doctor's appointment without being cleaned after incontinence. The family member discovered the issue and had to clean the resident, while the bus driver returned to the facility for clean clothes. The grievance was not resolved promptly as per the facility's policy.
Inaccurate MDS Coding for Alarm Use
Penalty
Summary
The facility failed to ensure the accuracy of MDS assessments for alarm use for two residents reviewed for falls. One resident with dementia had a fall care plan identifying risk factors including decreased mobility, medication regimen, weakness, incontinent status, and other comorbidities. The care plan included use of a clip alarm when in a wheelchair or chair and a floor mat alarm when in a recliner, and physician orders directed use of a personal pull tab alarm while in the wheelchair every shift and a floor mat alarm every shift. However, the 7/7/25 Quarterly MDS indicated the resident did not use alarms. A second resident with Parkinson's disease and traumatic brain injury had a physician order for a pressure alarm at all times, with the alarm to be moved from the wheelchair to the recliner or bed with the resident. The 7/9/25 Quarterly MDS stated that bed and/or chair alarms had not been used during the assessment period. During interview, the MDS Coordinator stated both Quarterly MDS assessments were coded incorrectly and that the residents were using alarms.
Failure to Refer for PASRR Level II After New Psychosis Diagnosis
Penalty
Summary
The facility failed to timely refer a resident for a PASRR Level II evaluation after the resident received a new diagnosis of psychotic disorder with delusions. The clinical record showed the resident had diagnoses including diabetes and psychotic disorder with delusions, and a PASRR Level I evaluation dated 8/10/23 had approved the resident with no Level II required. After the new psychosis diagnosis on 6/1/24, the resident was not referred for a Level II review. During interviews, the Executive Director stated the resident did not have a Level II, and the Social Services Director stated the resident should have been referred for a Level II with the new diagnosis of psychosis. The current Indiana PASRR Standard Operating Procedure provided by the Nurse Consultant stated that Social Services ensures paperwork is submitted for change in status and Level II follow up.
Insulin Flex Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure an insulin flex pen was primed before the dose was dialed up and administered for a resident with type 2 diabetes mellitus. The resident’s clinical record showed an order for 10 units of lispro insulin with a flex pen before meals, and the diabetic care plan directed staff to administer the medication as ordered. During observation of insulin administration, an LPN obtained the resident’s blood sugar reading of 273, wiped the flex pen with alcohol, attached the needle, dialed up 10 units, and administered the insulin. The LPN was not observed priming the flex pen before giving the dose. The DON stated that insulin flex pens were to be primed prior to administration, and the manufacturer’s instructions indicated the pen should be primed before each injection.
Failure to Use Gait Belt During Transfer and Delay in Alarm Evaluations
Penalty
Summary
The facility failed to ensure a gait belt was used during the manual transfer of Resident 25 and failed to ensure timely evaluation for the use of personal alarms for Resident 25 and Resident 17. Resident 25 had diagnoses including Parkinson's disease and traumatic brain injury. His record showed physician's orders for a pressure alarm that changed over time, and a quarterly MDS indicated he was dependent on staff for chair-to-bed transfers and for moving from sitting to standing. His care plan identified him as at risk for falls and included use of a pressure alarm at all times. An alarm and restrictive device evaluation was dated 8/7/25, but the Nurse Consultant and Director of Nursing stated the alarm evaluations should have been completed when the pressure alarm was initiated. During observation, two CRCA staff manually transferred Resident 25 from a recliner to his wheelchair by lifting him under the arms and holding the back of his pants, and no gait belt was used. The pressure alarm sounded during the transfer and was silenced by another staff member. The Therapy Director stated Resident 25 required two staff members and a gait belt for transfers. Resident 17 had dementia and a fall care plan that included use of a clip alarm in the wheelchair and a floor mat alarm in the recliner. His record also contained physician's orders for a pull-tab alarm in the wheelchair and a floor mat alarm every shift. An alarm and restrictive evaluation dated 8/7/25 documented use of bed, chair, floor, and clipped alarms, and the Nurse Consultant and DNS stated the alarm evaluations should have been completed when the sounding alarms began in November 2024.
Glucometer Not Disinfected Per Manufacturer Instructions
Penalty
Summary
The facility failed to maintain infection control during blood sugar monitoring for a resident with type 2 diabetes mellitus. The resident’s clinical record showed an order for nine units of Novolog insulin before meals, with instructions to hold the insulin if the blood sugar reading was less than 100. During an observation of medication administration, an LPN removed the glucometer from the medication cart, wiped it with an alcohol wipe, and then used it in the resident’s room to obtain a blood sugar reading after pricking the resident’s finger and applying blood to the test strip. After the blood sugar was obtained, the LPN returned the glucometer to the medication cart without disinfecting it. During interview, the LPN stated she had used the wrong wipes and that alcohol wipes were not to be used to disinfect the glucometer. The DON later provided the manufacturer’s instructions, which directed staff to clean and disinfect the meter using Clorox Germicidal Wipes by wiping the entire surface of the meter multiple times with one towelette and then again with a new towelette to remove blood-borne pathogens.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide scheduled bathing to a resident who required substantial to maximal assistance with activities of daily living, including bathing. The resident, who had diagnoses including depression and diabetes and was cognitively intact, was care planned to receive showers twice weekly with staff assistance. Documentation and interviews revealed that the resident did not receive showers as scheduled, receiving only two showers during her stay—one after a delay of about a week and a half following her request, and another following an accident. The Point of Care ADL report showed inconsistent documentation, with most days indicating only partial bed baths and some entries marked as 'other,' which staff could not clearly define. The DON confirmed that residents were scheduled for twice-weekly bathing and was unaware of any refusals or alternative arrangements for the resident in question. CNA staff reported uncertainty in documenting certain types of bathing assistance and did not report any refusals from the resident. The facility's policy required bathing at least twice a week unless otherwise preferred by the resident, but there was no documentation of such a preference or refusal. The deficiency was identified through review of records, interviews with staff and the resident, and comparison with facility policy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to effectively implement interventions to prevent falls for Resident C, who exhibited signs of lethargy, drowsiness, and sedation. Despite being cognitively impaired and dependent on staff for bathing and transfers, Resident C was not provided with additional safety interventions after a change in condition due to medication side effects. This oversight resulted in Resident C falling in the shower and sustaining multiple fractures, including to the left shoulder blade, the left second rib, and the third lumbar spinal disc. Resident C's care plan included various interventions to mitigate fall risk, such as using a silent bed alarm, a fall mat, and a low bed, and assisting with transfers as needed. However, the care plan did not address the resident's increased lethargy and drowsiness due to trazodone, a medication used for insomnia. Despite signs of adverse effects, the facility did not adjust the care plan to include additional safety measures, leading to the resident's fall in the shower while being assisted by a nursing assistant. In another incident, the facility failed to ensure the use of a gait belt during the transfer of Resident D, who required more than limited assistance with transfers. Resident D, who had a history of stroke and muscle weakness, was dropped during a transfer from a recliner to a wheelchair because the staff member did not use a gait belt. Although the resident was not injured, the lack of adherence to the facility's policy on gait belt use during transfers contributed to the fall risk for Resident D.
Failure to Provide Required Medical and Contact Information During Resident Discharge
Penalty
Summary
The facility failed to ensure the required medical and contact information was sent to the hospital for a resident. Resident 54, who had diagnoses including stage 4 chronic kidney disease and a stage 4 pressure ulcer of the sacral region, was discharged to the hospital. The nurse's note indicated that the resident was sent to the emergency department for evaluation due to no output in the catheter and other medical concerns. However, the clinical record lacked documentation to verify that essential information, such as the contact information of the practitioner responsible for the resident's care, the resident's representative information, advance directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary information, was sent to the hospital to ensure a safe and effective transition of care. An interview with the Director of Nursing (DON) revealed that while the facility typically sent a bed hold policy, continuity of care documentation, and code status with the resident in a packet given to the EMTs, this was not always documented in the progress notes. Upon reviewing Resident 54's clinical record, the DON confirmed that there was no documentation to verify that the necessary information was sent to the hospital for Resident 54.
Failure to Revise Care Plans for Depression and Shower Refusal
Penalty
Summary
The facility failed to timely revise a resident's care plans for refusal of showers and depression with individualized interventions. Resident 20, who had diagnoses including depression and anxiety, had a care plan that was not updated to reflect her request to discontinue Lexapro due to adverse effects. Despite the resident's tearfulness and multiple health concerns, the care plan did not include interventions to address these issues or encourage her participation in activities like bingo and dining room meals. Additionally, Resident 20's care plan for refusal of showers was not updated to reflect her preference for evening showers and specific caregivers. Interviews with staff revealed that the resident preferred certain CNAs for her showers and would refuse if they were not available. The care plan did not include this information, leading to inconsistencies in her care. The facility's Comprehensive Care Plan Guidelines Policy requires that new areas of concern be addressed in the care plan. However, the care plans for Resident 20 were not revised to include her preferences and changing needs, resulting in a deficiency in her care.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for two residents, Resident E and Resident 16. Resident E, who was admitted to the facility from the hospital, did not receive her prescribed medications, Glucofunction and Nutrient capsules, on multiple occasions due to the medications being unavailable. The Director of Nursing (DON) confirmed that the medications were not delivered from the pharmacy and speculated that staff retrieved them from another part of the facility after the missed administrations. The facility's admission checklist indicated that there was no second check of the orders to ensure medication delivery. Resident 16 did not receive the prescribed Nevanac eye drops due to insurance coverage issues. Despite the pharmacy notifying the facility multiple times about the medication not being covered and the high out-of-pocket cost, the facility failed to resolve the issue promptly. The nursing notes indicated attempts to contact the eye doctor and the pharmacy, but the medication was never delivered. The DON acknowledged that the resident's nurse should have addressed the issue immediately upon receiving the pharmacy's communication. The facility's policy on medication orders requires that telephone or verbal orders be recorded and addressed promptly. However, the facility did not adhere to this policy, resulting in Resident 16 not receiving the necessary eye medication for several days. The pharmacy confirmed that they had communicated the issue multiple times, but the facility did not respond in a timely manner, leading to the deficiency in medication administration for both residents.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as the timely destruction of medications for an expired resident. During a medication storage observation, it was found that an opened bottle of Timolol eye drops for a resident was not labeled with the date it was opened. Additionally, an opened bottle of Tylenol labeled for a resident who had expired several months prior was still present in the medication room. Furthermore, the controlled medication lock box inside the medication refrigerator was not permanently affixed, as required, due to a broken metal wire that had not been reported or addressed by the staff. The Director of Nursing (DON) was unaware of the issue with the controlled medication lock box and could not determine how long it had been in that condition. The facility's policy requires that multi-use vials be dated when first accessed and that expired medications not be administered to residents. The failure to adhere to these policies was observed during the survey, indicating lapses in medication management and storage protocols within the facility.
Failure to Timely Obtain Urinalysis
Penalty
Summary
The facility failed to timely obtain a urinalysis (UA) as ordered by the physician for a resident with diagnoses including diabetes and kidney failure. The resident, who was cognitively intact, reported urinary frequency, dysuria, and urgency during a Nurse Practitioner visit. A STAT UA with culture and sensitivity was ordered on the same day. However, the Director of Nursing Services confirmed that the UA was not sent to the lab as required. The facility's current Ordering Lab Test Policy mandates that once the specimen is collected, the Lab Services Customer Care Team should arrange for the transport of STAT specimens to the contracted partner.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control policy during medication administration for two residents. In the first instance, a Registered Nurse (RN) did not perform hand hygiene before donning gloves and administering eye drops to a resident after touching various surfaces, including a medication cart and keys. This lapse in protocol was confirmed by a Regional Nurse Consultant during an interview. In the second instance, a Licensed Practical Nurse (LPN) picked up a dropped tablet from the top of a medication cart with bare hands and administered it to a resident without performing hand hygiene. The LPN explained that she did not have a replacement tablet and was unsure if the facility's emergency drug supply carried the medication. Both instances were observed during medication administration rounds and were in direct violation of the facility's infection prevention and control policy, which emphasizes the importance of hand hygiene and proper glove use to prevent the spread of infection. The facility's Infection Prevention and Control General Guidelines policy, as well as guidelines from the Centers for Disease Control and Prevention (CDC), were not followed in these instances. The policy clearly states that hand washing is the most important method of infection prevention and control, and that gloves should be worn when coming into contact with potentially contaminated surfaces or materials. The CDC guidelines also emphasize that gloves are not a substitute for hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them. These lapses in protocol were observed and documented, highlighting a failure in maintaining proper infection control practices within the facility.
Failure to Timely Address Grievance Regarding Resident's Hygiene
Penalty
Summary
The facility failed to timely address a grievance for Resident B, who was cognitively intact and frequently incontinent of bowel and bladder. The incident occurred when Resident B was transported to a doctor's appointment after attending an out-of-facility activity. Upon arrival at the appointment, Resident B's family member discovered that she had been incontinent of bowel and had not been cleaned up before leaving the facility. The family member had to clean Resident B and requested the bus driver to return to the facility to get clean clothes. The bus driver informed the Executive Director about the incident and brought back clean clothing for Resident B. However, the grievance filed by the family member on the same day was not resolved promptly. The Social Services Director found the grievance in the log without a resolved date and was unsure why it had not been addressed. The facility's policy required concerns to be reviewed in the morning meeting and followed up within 24-48 hours, but this was not adhered to in this case. The grievance was eventually resolved 13 days later, with the Social Services Director contacting the family member and informing them that staff had been educated on the importance of cleanliness and hygiene before appointments.
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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 Shelbyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willows Of Shelbyville | 3.8 mi | ★★★★★ | 16 | 0 |
| Especially Kidz Health & Rehab | 3.8 mi | ★★★★★ | 6 | 0 |
| Morristown Manor | 8.5 mi | ★★★★★ | 0 | 0 |
| Waldron Rehabilitation And Healthcare Center | 9 mi | ★★★★★ | 7 | 0 |
| Homeview Center Of Franklin | 15.4 mi | ★★★★★ | 3 | 0 |
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