Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Ashley Healthcare Center during CMS and state inspections, most recent first.
A resident on hospice with intact cognition and full-code status experienced a progressive decline over several days, with documentation of lethargy, difficulty arousing, poor oral intake, inability to swallow, shallow respirations, and eventual unresponsiveness. Nursing notes showed that hospice and the resident’s son were contacted about the declining condition and code status, and hospice confirmed awareness of the full-code status and the need to send the resident out if required. Despite these changes, there was no evidence of acute assessments or systematic monitoring in the EMR, and vital signs were recorded only a few times over a two-week period. The resident continued to decline until being transferred to the hospital, where she was found in respiratory failure with pneumonia, COVID-19, severe acidosis, hyperkalemia, and septic shock. The DON later acknowledged that there was no acute assessment or monitoring documented and that the resident should have been transferred sooner.
Incorrect Code Status Documentation: A resident with paranoid schizophrenia and supplemental oxygen dependence had conflicting code status documentation, with the care conference report and guardian-signed code status form indicating full code while the active physician order listed DNR. RN, DON, and MDS RN interviews confirmed the order was entered incorrectly, and the resident stated he wanted resuscitation if his heart stopped.
A resident with type II DM, major depressive disorder, and hoarding disorder was cognitively intact and independent with ADLs, yet wanted to move closer to family or to a senior apartment. The DON stated the resident could self-administer meds and manage her diabetic device, but the SWT reported no discharge planning had been completed and no documentation could be found showing she could not relocate. Care conference notes reflected the resident intended to transfer closer to home, while the NHA stated the facility needed to contact the guardian about other options.
A resident with chronic pain, obesity, osteomyelitis, and pressure ulcers reported that staff did not position him correctly in bed, did not follow his transfer preferences, and did not help him stay comfortable. He was observed yelling in pain during transfers and unable to tolerate lying flat or on his left side. Staff were unaware he wanted to be up for breakfast, and the care plan did not include his transfer needs, positioning preferences, meal preferences, pain control, or pressure relief instructions.
A resident with cognitive and psychiatric diagnoses complained of right ear pain and buzzing, but staff did not document following the physician order to irrigate the ear for discomfort. The record showed the resident had ear wax issues after prior ER/hospital treatment, and when the ears were finally checked during survey, both ears were found to be full of old wax.
Incomplete skin assessment and wound management led to worsening pressure ulcers. A resident with osteomyelitis, DM, morbid obesity, chronic pain, and pressure ulcers of the back and coccyx had no documented admission measurements for the back wound, a weekly skin check marked no concerns, and no care plan instructions for transfers or positioning preferences. The resident repeatedly reported severe pain with movement and inability to lie flat or on his left side, while staff lacked a clear transfer plan and did not document wound measurements, refusals, or education before surveyors found the coccyx and shoulder/back wounds had worsened.
Failure to assess and document CPAP care for a resident. A resident reported that staff never cleaned his CPAP machine or provided cleaning supplies. The chart lacked a physician order for CPAP use or cleaning, no respiratory care plan or ongoing respiratory assessments were found, and the TAR did not show scheduled CPAP care or maintenance. The DON confirmed the resident should have had CPAP orders in place.
A resident with osteomyelitis, pressure ulcers, diabetes, morbid obesity, and chronic pain experienced severe pain during transfers and bed positioning, but his care plan did not include specific transfer or positioning instructions. He reported that improper placement in bed worsened tailbone pain and that movement caused extreme pain, while the MAR showed multiple missed PRN doses of hydrocodone-acetaminophen and the DON confirmed the facility had not met with him about his pain concerns.
A resident admitted with bipolar disorder was being evaluated for a recent increase in behaviors when a physician ordered a urinalysis and CMP blood draw. The orders were not found in the EMR physician orders, and there was no documentation that the specimens were obtained, results were monitored, or the cause of the behavior change was investigated. Staff reported the lab requisition was faxed, but the urine and blood specimens were not collected and no reliable process was in place to ensure ordered lab work was completed.
The facility failed to maintain accurate EMR documentation for two residents. One resident with bipolar disorder had a documented behavior change and physician orders for a UA and CMP, but the orders were not found in the EMR and there was no documentation that the labs were completed or that the resident was monitored. Another resident with paranoid schizophrenia and a guardian requested transfer closer to family, but the EMR lacked progress notes and care conference documentation showing the transfer discussions or referrals.
Failure to clean a resident’s CPAP machine was identified when the resident reported that no one had cleaned it since admission, and the machine was observed sitting on the windowsill with the tubing still connected and no cleaning supplies in the room. The DON confirmed there was no documentation in the TAR or medical record showing CPAP cleaning had been completed, despite the facility’s CPAP/BiPAP cleaning policy requiring routine cleaning of the equipment.
Failure to provide timely influenza and pneumococcal vaccines for two newly admitted residents. Both residents had signed consents and physician orders for the vaccines, but the EMR immunization records showed only Mantoux testing and no documentation that flu or pneumonia vaccines were administered or contraindicated. During interview, the DON/IP stated residents must be reviewed in MCIR to determine eligibility and reported not yet having access to MCIR in her new role.
The facility failed to carry out its COVID-19 immunization process for two newly admitted residents who had signed consents and had physician orders for vaccination, but whose EMRs did not show the vaccine series had been started and did not document any contraindication. The DON/IP said resident eligibility should be checked in MCIR but she did not yet have access. The facility also did not maintain records of staff COVID-19 education, vaccine offering, or vaccination status, and the HR Coordinator and NHA reported no tracking system was in place despite the infection control policy requiring it.
A resident with a history of severe neurocognitive and psychiatric disorders exhibited escalating aggression, including physical and verbal abuse toward staff and other residents. Despite repeated incidents, the care plan was not updated in a timely manner, enhanced supervision was not implemented, and the interdisciplinary team was not notified. Another resident was physically assaulted, and the facility failed to investigate or report the incident as required by policy.
A resident with a history of psychiatric and behavioral issues was alleged to have hit her roommate, but the incident was not reported or investigated according to facility policy. The nurse involved believed the interaction was playful and did not notify the abuse coordinator or administrator, resulting in a failure to follow required abuse reporting procedures.
A resident with a history of rolling out of bed was left unattended with the bed raised, contrary to care plan interventions requiring the bed to be in the lowest position and the call light within reach. The resident fell from the bed and sustained a femur fracture when a CNA left the bedside to retrieve a lift, and observations confirmed that fall prevention measures were not consistently followed.
A resident with a gastrostomy and on Enhanced Barrier Precautions (EBP) did not receive proper infection control measures during incontinence care, as staff failed to wear required gowns. Staff interviews revealed confusion about when EBP should be applied, despite facility policy and signage indicating that gown and gloves are necessary for high-contact care activities.
A resident with severe cognitive impairment suffered a fall resulting in a fractured hip, but staff failed to promptly assess and manage pain, did not initiate appropriate mobility interventions, and delayed emergency medical treatment. The resident received only acetaminophen for severe pain, and the care plan was not updated to address new risks or interventions. An x-ray was not completed before hospital transfer, and documentation inconsistencies were noted.
The facility failed to monitor and store insulin properly, resulting in the presence of outdated and discontinued Novolin N insulin in the medication room refrigerator. The insulin, opened on 9/1/24, was not discarded as required, despite being discontinued. This oversight contradicts the facility's medication storage policy and the manufacturer's guidelines, risking the administration of outdated medication to residents.
The facility failed to maintain proper infection control procedures for residents in COVID-19 isolation, with room doors left open and staff not adhering to PPE protocols. Observations revealed staff wearing inappropriate masks and lacking required eye protection, contrary to the facility's policy. The DON acknowledged the need for proper PPE use, yet lapses were evident.
A resident with heart and kidney failure under hospice care was found with signs of dehydration, including dry lips and skin tenting, due to inaccessible water and call light. Despite informing the DON, the resident's water cup remained out of reach, and she expressed discomfort and pain, indicating a deficiency in providing necessary hydration and assistance.
A resident with heart and kidney failure, receiving hospice services, fell and sustained a forehead laceration. Care plan changes were made, and the responsible party and physician were notified, but the hospice service was not informed, violating the facility's hospice agreement.
The facility failed to post necessary signage and ensure proper use of PPE for two residents on Enhanced Barrier and Transmission Based Precautions. One resident with a urinary catheter had no EBP signage, and an LPN did not use a gown during care, contaminating supplies. Another resident tested positive for COVID-19, but there was no TBP signage, leaving staff unaware of required precautions.
A resident with severe cognitive impairment experienced a persistent urine odor in their bathroom due to maintenance issues. Despite routine cleaning, the odor persisted, with staff noting worn caulking and a potentially faulty wax ring around the toilet. The Nursing Home Administrator acknowledged the problem, identifying the bathroom as the source of the odor.
A facility failed to maintain accurate medical records for a resident with legal blindness and uropathy. Despite a physician's recommendation for a urinalysis due to catheter pain and red drainage, there was no documentation of a urine sample being collected. The RN could not recall details of the incident, and the DON did not document a decision made with the Medical Director regarding testing criteria.
The facility failed to ensure a qualified Infection Preventionist (IP) was present during a COVID-19 outbreak. The DON, who was certified as an IP, was on leave, and the NHA and an uncertified RN assumed IP duties. Three residents tested positive for COVID-19, and documentation was incomplete and inconsistent. The certified regional IP did not attend QA meetings during the DON's absence.
Failure to Recognize and Respond to Acute Change in Condition for a Full-Code Hospice Resident
Penalty
Summary
Failure to recognize, assess, and respond to an acute change in condition occurred for one cognitively intact resident who was a full code and on hospice services. The resident had diagnoses including dementia, psychotic disturbance, anxiety, and insomnia, and an MDS BIMS score of 13 indicating intact cognition. Documentation showed that the resident’s code status remained full code per the admission record, hospice plan of care, and care conferences. A progress note documented that hospice was called when the resident was nonresponsive, with vital signs recorded at that time, and hospice indicated that if the resident needed to be sent to the hospital due to coding, the facility could do so. Over the following days, multiple progress notes described the resident as very lethargic, difficult to arouse, and later not responsive, with poor or no oral intake and very little fluid intake due to inability to swallow. Staff documented shallow respirations, mouth breathing, and that the resident appeared to be actively dying, with an inability to obtain a blood pressure and a respiratory rate of 40. Notes also showed attempts to contact the resident’s son regarding code status and declining condition, with hospice being notified and acknowledging the full code status and the need to send the resident out if required. Despite these documented changes, there was no evidence in the EMR of acute assessments or systematic acute monitoring in response to the resident’s declining condition. Vital sign records showed that vital signs were obtained only five times over a 14‑day period, and no additional vital signs or acute assessments were documented during the period of decline. The resident remained unresponsive with continued decline until transfer to the hospital, where she was found in respiratory failure, intubated, and diagnosed with right lower lobe pneumonia, COVID‑19 infection, severe acidosis, hyperkalemia, and septic shock. In interview, the DON acknowledged being unable to locate documentation of an acute assessment or acute monitoring for the change in condition and stated that the resident was unresponsive with continued decline until transfer, and that there should have been acute documentation and a transfer sooner. Facility policy required prompt notification of the resident, physician, and representative of changes in condition and transfer to the hospital when necessary, but the documentation did not show that this was carried out in a timely, acute response to the resident’s change in condition.
Incorrect Code Status Documentation
Penalty
Summary
The facility failed to accurately document the code status for one resident who had a court-appointed guardian and diagnoses including paranoid schizophrenia and dependence on supplemental oxygen. The resident’s care conference report stated he planned to continue as full code status, and his Resident Code Status form, signed by his guardian, also indicated full code. However, the resident’s active Physician’s Orders listed him as DNR. During interviews, RN K initially stated the resident was full code, then reviewed the MAR alert and Physician’s Orders and reported he was DNR. The resident stated he wished his heart to be started if it stopped. The DON reviewed the Physician’s Order and Resident Code Status form and said the DNR order was probably placed incorrectly because the resident should be full code. MDS RN D reviewed the Resident Code Status and stated, "I must have placed this incorrectly." The facility policy on Communication of Code Status stated the facility would implement procedures to communicate a resident’s code status to those individuals who need to know this information.
Failure to Complete Discharge Planning for a Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure that the discharge needs of one resident, R23, were met. R23 was admitted with diagnoses including type II diabetes mellitus, major depressive disorder, and hoarding disorder. An MDS assessment showed a BIMS score of 15, indicating that R23 was cognitively intact. In interview, R23 stated she did not belong at the facility, wanted to move closer to her family, and had requested multiple times to relocate to a senior apartment or another setting nearer her home. She also stated she had not seen her newly appointed guardian face to face since the guardian was appointed and said her rights were being violated. Record review showed R23 was independent with bed mobility, transfers, ambulation, dressing, eating, toileting, bathing, and movement on and off the unit, and the DON stated she self-administered medications and managed her diabetic device without difficulty. Care conference documentation noted that R23 intended to transfer to a facility closer to home, but the Social Work Tech stated nothing had been completed toward discharge planning and that she had been told not to start the discharge process. The SWT could not locate documentation showing that R23 was not capable of being discharged closer to home or to a senior apartment, and the NHA stated the facility needed to reach out to the guardian and ask about other options. The facility policy stated discharge planning begins on admission and includes discussing and documenting options when a resident wants discharge to a setting that may not meet needs or appear unsafe.
Care Plan Failed to Address Pain, Positioning, and Pressure Ulcer Needs
Penalty
Summary
The facility failed to implement a patient-centered care plan for pain and pressure ulcers for one resident with diagnoses including osteomyelitis, pressure ulcer of the right upper back, urinary tract infection, diabetes mellitus, morbid obesity, chronic pain, and an unstageable pressure ulcer of the back. During an interview, the resident reported staff did not position him correctly in bed, said he was 6 feet tall and was not placed high enough in bed, and stated that improper positioning increased pain to his tailbone. He also reported that staff did not listen to or assist him in becoming more comfortable, that he would return to bed more often if staff followed his preferences, and that he had pressure ulcers on his back and coccyx. The resident was observed during transfers and in bed with significant pain and limited tolerance for positioning. He yelled in pain during movement, could not tolerate lying flat or on his left side, and reported he was only comfortable sitting or lying on his right side. He stated transfers were extremely painful and that staff had not followed the transfer approach taught by the COTA. He also reported that after being placed in bed around 2:00 AM, he was not gotten up for breakfast or changed, and his room smelled like urine with wet sheets around his brief. Staff confirmed they were unaware he wanted to be up for breakfast, and the care plan did not include his preferences for being out of bed, transfer instructions, tolerance for positioning, meal preferences in a chair, pain control, or pressure relief/positioning needs. The DON also confirmed the resident had not been met with to discuss pain medication scheduling needs or medication related to mobility needs.
Failure to Follow Ear Irrigation Order
Penalty
Summary
The facility failed to follow a physician order to treat and monitor a resident’s right ear discomfort. The resident was a male with diagnoses including mild cognitive impairment, atypical facial pain, PTSD, and mild neurocognitive disorder. He complained to staff that his right ear hurt and was buzzing, and he reported that nothing was being done about it. A physician note dated 1/14/26 documented the resident’s complaint of right ear and right neck pain after completing antibiotics and ear wax debridement in the ER/hospital, with a recommendation that ear wax was present and it was okay to irrigate the ear. The resident’s physician order dated 1/20/26 stated that the right ear may be irrigated for signs and symptoms of discomfort as needed, but the medical record contained no documentation that staff followed this order. When the Unit Manager reviewed the order, she could not find any documentation that the ear had been irrigated. During the survey, a Registered Nurse checked the resident’s ears and found both ears full of old wax after first needing to locate a functional otoscope on the unit.
Incomplete skin assessment and wound management led to worsening pressure ulcers
Penalty
Summary
The facility failed to thoroughly assess skin on admission, complete ongoing skin assessments, implement an effective treatment plan, and prevent worsening of pressure ulcers for one resident with diagnoses including osteomyelitis, diabetes mellitus, morbid obesity, chronic pain, and pressure ulcers of the back and coccyx. On admission, the resident’s face sheet identified a pressure ulcer on the right upper back and an unstageable pressure ulcer of the back, but the record reviewed by surveyors did not contain admission measurements for the back wound, and the weekly skin assessment dated 1/28/26 indicated no identified concerns. The observation detail list dated 1/27/26 documented a stage 1 coccyx pressure injury measuring 3 cm, but no back pressure ulcer was listed at that time. Surveyors observed the resident repeatedly reporting severe pain with movement and difficulty tolerating positioning in bed. The resident stated staff were not placing him correctly in bed, that his buttocks were not positioned high enough, and that he could not tolerate lying flat or on his left side. A COTA stated she had just started educating staff on how to transfer the resident and denied notifying the physician that he could not tolerate lying on his back or left side and had unbearable pain with transfers. The COTA had not implemented a care plan for the resident’s transfer needs, and the care plan contained no specific instructions for transfers, positioning preferences, or eating meals in his chair. The resident’s coccyx wound and right shoulder/back wound were later documented as larger than earlier measurements. Progress notes showed the coccyx area opened to 3.4 x 0.8 x 0.1 cm, then later measured 2.0 x 0.7 x 0.1 cm with peeling peri-wound skin, and the right shoulder wound measured 5.0 x 5.0 x 0.1 cm before later being measured at 3.5 x 3.0 cm. The resident was also observed lying in wet linens with urine odor after being placed in bed around 2:00 AM and not getting up for breakfast or having his brief changed. The DON and NHA could not locate admission or weekly wound measurements for the right shoulder wound, and the NHA could not locate education or refusal documentation related to wound care before the survey.
Failure to Assess and Order CPAP Care
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident who used CPAP. The resident was a [AGE]-year-old male admitted with diagnoses including osteomyelitis, pressure ulcers of the back, UTI, diabetes mellitus, morbid obesity, chronic pain, and an unstageable pressure ulcer, and he was his own responsible party. During interview, he stated the facility never cleaned his CPAP machine or provided cleaning equipment or supplies. Review of the medical record did not reveal a physician order for CPAP use or for its care and cleaning, did not reveal a respiratory care plan for the use and care of the CPAP machine or ongoing respiratory assessments, and did not reveal scheduled care or maintenance of the resident’s CPAP in the TAR. The DON confirmed the resident should have had physician orders for the CPAP machine and acknowledged the facility failed to ensure those orders were in place.
Inadequate Pain Management and Positioning for a Resident with Chronic Pain
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with osteomyelitis, pressure ulcers of the back and coccyx, diabetes mellitus, morbid obesity, and chronic pain. The resident reported that staff did not position him correctly in bed, that improper placement increased pain to his tailbone, and that he wanted the physician to address his pain medication. He was observed yelling in pain during transfers, unable to tolerate lying flat or on his left side, and stating that movement caused severe pain and a sensation like "10,000 volts of electricity" from his back to his legs. He reported he could only be comfortable sitting or on his right side in bed and needed the head of the bed elevated about 30 degrees because lying flat caused intolerable pain. The resident's care plan did not include specific instructions for transfers or positioning preferences and did not reflect consideration of his pain with transfers, bed positioning, or mobility. His physician ordered hydrocodone-acetaminophen every 6 hours as needed for chronic pain, but the MAR showed multiple days when he did not receive any doses and he never received the full 4 doses allowed in a day. The DON stated the resident had times of confusion and might not know when he could receive the next dose, and confirmed the facility had not met with him to discuss his pain concerns. A COTA also stated she had started staff training on how to transfer the resident but had not informed the physician of the pain he experienced with poor bed positioning and transfers.
Failure to Complete Ordered Lab Testing
Penalty
Summary
The facility failed to provide laboratory services to meet the needs of one resident who was admitted with diagnoses including bipolar disorder and was being evaluated for a recent increase in behaviors. A physician documented an order to perform a urinalysis and collect a CMP serum blood draw, and the note stated the orders were entered and urine would be collected. However, review of the EMR physician orders did not show the lab orders had been entered as documented in the progress note. Further review of the EMR did not show documentation that the lab specimens were obtained, that lab results were monitored, or that any attempts were made to determine the root cause of the resident’s increased behaviors. During interview, the RN who entered the progress note stated she had placed the physician’s orders into the EMR and faxed a lab requisition form, but she could not locate documentation that the lab work had been completed. The UM reported neither the CMP serum draw nor the urine specimen was obtained, and the facility had no mechanism in place other than shift-to-shift report to ensure ordered lab work was completed.
Incomplete EMR Documentation for Behavior Change and Transfer Request
Penalty
Summary
The facility failed to maintain an accurate, clear, and concise EMR for two residents. For one resident with bipolar disorder, the EMR progress note documented that a physician evaluated the resident for a recent increase in behaviors and gave orders for a urinalysis and CMP serum blood draw, with the note stating the orders were entered and urine would be collected. However, the physician orders were not found in the EMR, and there was no further documentation showing that the lab specimens were obtained, that results were received, that the resident was monitored, or that staff attempted to determine the cause of the behavior change. The RN who entered the note stated she had placed the physician's orders into the EMR, but she could not locate them or any documentation showing the labs were completed or the behavior change was communicated for continuity of care. The UM also reported that neither the CMP nor the urinalysis specimen was obtained. For another resident with paranoid schizophrenia and dependence on supplemental oxygen, who also had a court-appointed guardian, the record showed the court instructed the guardian to find placement closer to the resident's home and family. The resident told staff he wanted to transfer to a facility closer to family and said he had discussed this with the social worker, but he reported nothing had been done. The social worker and NHA acknowledged discussions and referrals related to the transfer request, and the NHA reviewed a concern form showing the resident requested transfer and several referrals had been sent. However, the NHA and social worker found no progress notes or care conference documentation in the EMR regarding the transfer discussions or the facility's efforts to facilitate the request.
Failure to Clean Resident CPAP Equipment
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to clean one resident’s CPAP machine. The resident was an adult male admitted with diagnoses including osteomyelitis, pressure ulcer of the right upper back, urinary tract infection, diabetes mellitus, morbid obesity, chronic pain, and an unstageable pressure ulcer of unspecified part of the back. He was his own responsible party and reported that he cleaned and cared for his CPAP machine at home, but no one had cleaned it since admission to the facility. During observation, no cleaning equipment or supplies were visible in the resident’s room, and the CPAP machine was sitting on the windowsill with the tube still connected to the machine. The DON confirmed that the resident should have orders for CPAP cleaning and that such cleaning would be documented in the TAR if it had been completed, but no documentation could be located showing that the CPAP had been cleaned since admission. Review of the resident’s record found no documentation related to cleaning of the CPAP machine. The facility’s CPAP/BiPAP Cleaning policy stated that CPAP/BiPAP equipment is to be cleaned in accordance with CDC guidelines and manufacturer recommendations, including weekly cleaning of headgear/straps and tubing.
Failure to Provide Timely Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to operationalize its infection control policy for influenza and pneumococcal immunizations for two newly admitted residents. One resident was admitted on 1/27/2026 and was able to make their own medical decisions; the EMR contained a signed Vaccine Consent form dated 1/28/2026 indicating acceptance of the influenza and pneumonia vaccines. A physician order dated 2/2/2026 stated the resident may have pneumococcal and annual influenza vaccines and that vaccines should be administered to patients who had not already received them unless contraindicated. However, the immunization record showed only a Mantoux Skin Test and no documentation that influenza or pneumonia vaccines were given. The progress notes did not show that either vaccine was contraindicated. A second resident was admitted on 1/23/2026 and was their own responsible party. The EMR contained a signed Vaccine Consent form dated 1/28/2026 showing acceptance of influenza and pneumonia vaccines, and a physician order dated 1/23/2026 directing vaccines to be administered per CDC guidelines unless contraindicated. The immunization record again showed only a Mantoux Skin Test and no documentation of influenza or pneumococcal vaccination, and the progress notes did not document any contraindication. During interview on 2/24/2026, the DON/IP stated residents must be reviewed in MCIR to determine vaccine eligibility and reported she had not yet had access to MCIR in her new role.
Failure to Document and Track COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to operationalize its infection control policy for COVID-19 vaccination for two newly admitted residents who had both completed vaccine consent forms and had physician orders in the electronic medical record. One resident was admitted on 1/27/2026 and made their own medical decisions; the record showed a signed consent on 1/28/2026 for the COVID-19 series/vaccine and the recommended annual booster, and a physician order on 2/2/2026 to administer vaccines requested to patients who had not already received them unless contraindicated. A second resident was admitted on 1/23/2026 as their own responsible party; the record showed a completed consent on 1/28/2026 for the COVID-19 series/vaccine and the recommended annual booster, and a physician order on 1/23/2026 to administer vaccines requested to patients who had not already received them unless contraindicated. Review of both residents’ immunization records did not show that the COVID-19 vaccine series had been initiated. The progress notes for either resident did not document that the vaccine was contraindicated. During interview, the DON who was also the Infection Preventionist stated residents must be reviewed in MCIR to determine vaccine eligibility, but she had not yet obtained access to MCIR and had not been in the role very long. The facility policy stated residents are to be screened, educated, offered the vaccine, and documented as having received it, refused it, or having a contraindication. The facility also failed to maintain a process to track and monitor staff COVID-19 education and immunization status. The DON/IP reported she did not maintain documentation of staff COVID-19 screening, education, or vaccination status. The NHA stated she was not aware whether staff immunization status was maintained, and the HR Coordinator reported she did not keep a record of staff COVID-19 offering or immunization status. The HR Coordinator stated new staff are offered COVID-19 education and vaccination, but the education is only read if they accept vaccination, and she had never been told to maintain a record of staff vaccination status. The infection prevention and control policy required documentation of staff education, vaccine offering or access information, and staff COVID-19 vaccine status in accordance with CDC NHSN.
Failure to Protect Residents from Abuse Due to Inadequate Behavioral Interventions and Supervision
Penalty
Summary
A resident with a history of major depressive disorder, major neurocognitive disorder due to Alzheimer's disease, and psychotic mood disorder was admitted to the facility and exhibited escalating aggressive and disruptive behaviors. Documentation shows that the resident became physically and verbally abusive towards staff and other residents, including making threats of physical harm, entering other residents' rooms, and taking their belongings. Despite repeated incidents of aggression, including physical assaults on staff and threats to other residents, the care plan was not updated in a timely manner to address these behaviors, and enhanced supervision or monitoring was not implemented. The facility failed to notify the interdisciplinary team (IDT) or provider of the resident's escalating behaviors and did not conduct behavior management evaluations or update interventions in response to the resident's aggression. There was also a lack of documentation regarding IDT meetings or behavioral management discussions, and the care plan was not revised to reflect new or worsening behaviors until after the resident was transferred to the hospital. Additionally, the facility did not report or investigate an allegation of resident-to-resident physical abuse, nor did it document provider notification or assessment following incidents of aggression and ineffective medication administration. Another resident was physically assaulted by the aggressive resident, resulting in tenderness to the jaw and the need for non-pharmacologic pain relief. The facility's own investigation confirmed physical contact occurred. The facility's policies required ongoing assessment, care planning, and monitoring for residents with behaviors that might lead to conflict or abuse, but these were not followed. The failure to implement timely interventions, update care plans, and notify appropriate staff and providers contributed to the deficiency in protecting residents from abuse.
Failure to Report and Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy when an allegation of resident-to-resident physical abuse was not reported or investigated. A female resident with major depressive disorder and major neurocognitive disorder due to Alzheimer's disease, who had a history of physical aggression toward staff, was alleged to have hit her roommate on the left hand. The incident was documented in a progress note by a registered nurse, but there was no evidence that the allegation was reported to the abuse coordinator as required by facility policy. The nurse assessed the resident and found no injury, and believed the interaction was playful based on the residents' relationship, but did not document all details in the chart or initiate the required reporting process. Interviews revealed that the nursing home administrator was not made aware of the allegation, and staff did not follow the policy for immediate reporting of abuse allegations. The facility's written policy requires all alleged violations to be reported to the administrator and investigated, but this process was not followed in this case. The failure to report and investigate the allegation resulted in noncompliance with the facility's abuse prevention and response procedures.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions for a resident with a history of rolling out of bed. The resident, who had diagnoses including autism, anxiety, and developmental disorder, was care planned to have a fall mat on the left side of the bed, the bed kept in the lowest position when not providing care, and frequently used items including the call light within reach. Despite these interventions, a CNA left the resident unattended with the bed raised to hip level while retrieving a lift, during which time the resident rolled off the bed and sustained a femur fracture. The resident's care plan and facility policy required supervision and specific interventions to minimize fall risk, but these were not followed at the time of the incident. Observations and interviews confirmed that the call light was not within the resident's reach, contrary to care plan directives. The CNA involved acknowledged leaving the bedside with the bed elevated, and the Nursing Home Administrator confirmed the resident's history of rolling out of bed. Facility documentation and staff interviews further substantiated that the required fall prevention measures were not consistently implemented, directly leading to the resident's fall and injury.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who was admitted with diagnoses including autism, anxiety, and a gastrostomy requiring tube feedings. The resident's care plan and physician's orders indicated the need for EBP, and facility policy required gown and gloves to be available and used during high-contact care activities, such as incontinence care, for residents on EBP. During an observation, two certified nursing assistants provided incontinence care to the resident without wearing gowns, despite signage on the door indicating EBP was required. Interviews with the staff involved revealed a lack of awareness and understanding regarding the application of EBP. One CNA was not aware that the resident required EBP and believed that EBP was only necessary for care related to the tube feeding, not incontinence care. A registered nurse also stated that EBP was not required for CNAs since they did not handle the tube feeding. However, facility signage and policy defined high-contact care activities, such as incontinence care and transfers, as requiring gown and gloves for residents on EBP.
Failure to Provide Timely Assessment and Pain Management After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Alzheimer's disease experienced a fall resulting in a fractured hip. Following the fall, the resident exhibited clear signs of severe pain, inability to bear weight, and abnormal alignment of the right leg. Despite these symptoms, the facility did not promptly initiate emergency medical treatment or appropriate mobility interventions for a potential hip fracture. The resident was placed in a recliner rather than being immobilized, and the care plan was not updated to reflect the new risk factors or interventions needed for pain and immobility. Pain assessments and management were inadequate. Only one pain assessment was documented from the time of the fall until 6 PM, with a pain rating of 10/10, and only one additional assessment was recorded overnight, with a pain rating of 8/10. The only pain medication administered was acetaminophen, which was documented as non-effective for the resident's severe pain. No other pain relief measures were provided, and the resident continued to experience excruciating pain until transfer to the hospital the following morning. The facility also failed to ensure timely diagnostic evaluation, as the x-ray ordered after the fall was not completed before the resident's transfer to the hospital. Upon arrival at the emergency department, the resident was found to have a comminuted, displaced, and angulated hip fracture, and surgery was scheduled. The emergency room physician noted the lack of immediate transfer to the hospital despite the resident's severe pain and significant injury. Documentation inconsistencies were also noted regarding whether the fall was witnessed and the care provided post-fall.
Improper Storage and Monitoring of Insulin
Penalty
Summary
The facility failed to properly monitor and store medications, specifically insulin, in the medication room refrigerator. During an observation, a vial of Novolin N insulin was found, which had been opened and placed in service on 9/1/24, despite being discontinued and should have been discarded. The Doctor's Orders indicated that Humulin N was ordered for the resident on 8/31/24 and discontinued on 9/2/24. The manufacturer's package insert for Novolin N specifies that opened vials should be kept at room temperature and discarded after 6 weeks of use. The facility's policy on medication storage, last reviewed on 9/27/23, mandates that all medications be stored according to the manufacturer's recommendations. The presence of outdated and discontinued insulin in the medication room refrigerator indicates a failure to adhere to these guidelines, posing a risk of administering outdated medication to residents.
Infection Control Deficiencies in COVID-19 Isolation Rooms
Penalty
Summary
The facility failed to maintain proper infection control procedures for residents in isolation for COVID-19, potentially affecting 14 of 51 residents. Observations revealed that room doors for residents under Airborne Contact Precautions were left open, contrary to the signage indicating that doors should remain closed to maintain negative pressure. This was observed in the rooms of three residents, all of whom tested positive for COVID-19. The Director of Nursing (DON) stated that leaving doors open was permissible to reduce the trauma of isolation, despite the potential risk of virus transmission. Staff were observed not adhering to the required personal protective equipment (PPE) protocols. In one instance, a certified nursing assistant (CNA) was seen exiting a resident's room wearing a surgical mask under an N95 respirator, which is against the guidelines as it prevents the N95 from properly sealing. Another CNA was observed exiting a room without wearing the required eye protection, acknowledging the oversight only after leaving the room. Additionally, a laundry staff member entered a COVID-19 isolation room wearing only a surgical mask, without the necessary PPE such as an N95 mask, gown, gloves, and eye protection. The facility's COVID-19 Prevention, Response, and Reporting policy requires healthcare personnel to adhere to standard precautions and use appropriate PPE, including an N95 respirator, gown, gloves, and eye protection when entering the room of a resident with COVID-19. However, multiple staff members failed to comply with these protocols, as evidenced by the observations and interviews conducted during the survey. The DON acknowledged the requirement for all staff to wear the necessary PPE when in any COVID-19 room, yet lapses in adherence were evident.
Inadequate Hydration and Assistance for Resident
Penalty
Summary
The facility failed to ensure adequate and accessible hydration for a resident, identified as R206, who was admitted with heart and kidney failure and was under hospice care. Observations revealed that R206 was frequently found in bed with dry and peeling lips, a dry tongue, and signs of dehydration such as skin tenting. Despite these observations, the resident's water cup was consistently placed out of reach, and the call light button was also inaccessible, preventing the resident from requesting assistance. The resident expressed discomfort, stating she felt cold, terrible, and had a dry mouth, which hindered her ability to speak. The Director of Nursing (DON) was informed of the resident's condition and the inaccessibility of water, yet subsequent observations showed no change in the situation. The resident continued to be found with her water cup out of reach, and no moisture swabs were available in the room. The resident was observed asking for help and pain relief, indicating ongoing distress and unmet needs. These findings highlight a deficiency in the facility's provision of necessary hydration and assistance to the resident, contributing to her discomfort and potential health risks.
Failure to Notify Hospice of Care Plan Changes After Resident Fall
Penalty
Summary
The facility failed to notify the hospice service of a change in the plan of care for a resident, identified as R206, after the resident experienced a fall. R206 was admitted to the facility with diagnoses including heart and kidney failure and began hospice services shortly after admission. On January 8, 2025, R206 was observed with a large dressing on her forehead, having sustained a laceration from a fall earlier that day. The medical record indicated that care plan changes were made following the fall, and the responsible party and physician were notified. However, the documentation did not reflect that the hospice service was informed of the fall and the subsequent changes to the care plan, as required by the facility's hospice agreement. An interview with RN G confirmed that while the physician and responsible party were contacted, the hospice service was not notified of the care plan changes.
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to ensure proper posting of Enhanced Barrier Precaution (EBP) and Transmission Based Precaution (TBP) signage, proper use of Personal Protective Equipment (PPE), and prevention of contamination of treatment supplies and the treatment cart for two residents. Resident #33, who was admitted with diagnoses including legal blindness and obstructive and reflux uropathy, had an active order for EBPs due to a urinary catheter. However, there was no EBP or PPE instruction signage on Resident #33's door, and staff were unaware of the need for these precautions. During a procedure, an LPN did not use a gown as required and contaminated treatment supplies by carrying them without proper precautions. Resident #394, admitted with post-procedural complications and neoplasm of the pancreas, tested positive for COVID-19 and was placed on TBPs. Despite this, there was no signage on Resident #394's door indicating the need for TBPs or PPE, leading to staff being unaware of the precautions required. The Director of Nursing acknowledged the oversight in placing the necessary signage. The facility's policies on EBPs and TBPs were not followed, resulting in increased potential for cross-contamination and spread of infection.
Persistent Urine Odor in Resident's Bathroom Due to Maintenance Issues
Penalty
Summary
The facility failed to maintain a clean and odor-free environment for a resident diagnosed with dementia, who has severe cognitive impairment and requires assistance with all activities of daily living. During an initial tour, a strong urine odor was detected in the resident's room, particularly in the bathroom. Certified Nurse Assistants confirmed the persistent odor, noting that the resident often misses the toilet, and despite routine cleaning efforts, the smell remains. Further investigation revealed that the bathroom floor was wet, potentially with urine, and the caulking around the toilet was worn, allowing urine to penetrate gaps. The Maintenance Director suggested that the wax ring might be faulty, contributing to the odor issue. The Nursing Home Administrator acknowledged the problem and identified the bathroom as the source of the odor.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain an accurate health record for a resident, resulting in unclear documentation and potential miscommunication regarding the resident's health care status. The resident, who was admitted with diagnoses including legal blindness and obstructive and reflux uropathy, had a physician communication form indicating concerns about pain related to a Foley catheter and red drainage. The physician recommended a urinalysis, but the electronic medical record lacked documentation of a urine sample being collected or any follow-up on the physician's order. During interviews, the RN involved could not recall how she learned of the resident's complaints and was unsure if the urine sample was collected and sent to the lab. The DON reported discussing the situation with the Medical Director and deciding that the resident did not meet the criteria for urine testing, but this conversation was not documented in the medical record. The facility's policy requires that each resident's medical record accurately represent their experiences and include complete, accurate, and timely documentation, which was not adhered to in this case.
Failure to Ensure Qualified Infection Preventionist During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was present to properly assess, implement, and manage the Infection Prevention and Control Plan during a COVID-19 outbreak. The Director of Nursing (DON) had attained an IP certificate, but was on leave from 10/7/23 through 12/13/23. During this period, the Nursing Home Administrator (NHA) and a Registered Nurse (RN) without IP certification assumed the IP duties. The NHA acknowledged not meeting the regulatory requirements of an IP, and the RN was not certified as an IP. Despite the availability of a certified regional IP for guidance, there was no record of their attendance at Quality Assurance (QA) meetings during the DON's absence. The DON was unaware of who provided the Infection Control report during her leave. During the DON's leave, three residents tested positive for COVID-19 between 11/13/23 and 11/22/23. The facility's COVID-19 Notification postings and Exposure Checklists were reviewed, revealing inconsistencies in the duration of guidance followed and incomplete documentation. The checklists for the COVID-19 positive residents were unsigned and undated, although the NHA had initialed the individual tasks. This lack of proper documentation and oversight during the COVID-19 outbreak highlights the deficiency in the facility's infection prevention and control program during the DON's absence.
What surveyors are citing around you — mapped
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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 86 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 Ashley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Fulton | 11.3 mi | ★★★★★ | 19 | 1 |
| Ovid Healthcare Center | 13.5 mi | ★★★★★ | 11 | 0 |
| Hazel I Findlay Country Manor | 13.6 mi | ★★★★★ | 12 | 0 |
| Schnepp Senior Care And Rehabilitation Center | 16.8 mi | ★★★★★ | 4 | 0 |
| Michigan Masonic Home | 17.2 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.