Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Ashley Medical Center Nursing Home during CMS and state inspections, most recent first.
A resident was repeatedly observed without access to her personal phone, which was placed out of reach on a windowsill despite posted instructions for staff to keep it on the table. The resident stated she wanted the phone within reach, and administrative staff acknowledged her right to access it.
Surveyors found that two residents had inaccurate MDS coding: one was incorrectly documented as having delusions, and another was recorded as receiving an injection that was not supported by the medical record. An administrative staff member confirmed the errors in MDS coding.
A resident receiving daily anticoagulation therapy with Coumadin did not have their care plan updated to include problems, goals, or interventions related to this therapy, despite facility policy requiring care plan review and revision. This was confirmed by an administrative nurse during staff interview.
The facility failed to properly use assistive devices during transfers for two residents, leading to potential safety risks. One resident was transferred with a loosely placed gait belt that provided no support, while another was left unattended on a sit-to-stand lift with unlocked wheels, causing the lift to move. Staff did not ensure proper use of the devices, despite the residents' difficulties in standing and comprehending safe transfer procedures.
A facility failed to ensure accurate medication labeling for a resident during insulin administration. A nurse used a Novolog insulin pen with incorrect label instructions, which did not match the resident's current physician orders. The nurse confirmed the label was incorrect and acknowledged that a new label should have been ordered from the pharmacy.
Two CNAs failed to follow enhanced barrier precautions for a resident by not changing soiled gloves before continuing care and not disinfecting a lift after use. An administrative nurse confirmed that staff are expected to sanitize lifts between residents.
Resident Denied Access to Personal Phone
Penalty
Summary
Facility staff failed to ensure a resident had access to her personal phone, as required by resident rights policies. Multiple observations over two days showed the resident in her recliner, wheelchair, or bed, with her personal phone placed on a windowsill behind her recliner, out of reach. A sign in the room instructed staff to place the phone on the table daily and return it to the charger at bedtime, but this was not followed. During an interview, the resident expressed a desire to have the phone within reach, and administrative staff confirmed the resident's right to access her phone.
Inaccurate MDS Coding for Behavior and Medication Administration
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, as identified through record review, reference to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and staff interviews. For one resident, the quarterly MDS was coded to indicate the presence of delusions during the seven-day look-back period; however, a review of the medical record for that period did not show any evidence that the resident experienced delusions. This discrepancy indicates that the MDS did not accurately reflect the resident's behavioral status as required by the RAI manual. For another resident, the significant change MDS was coded to show that the resident received an injection once during the seven-day look-back period. However, the medical record did not support that any injection was administered during that time. An administrative staff member confirmed that the MDSs for both residents were coded incorrectly. These inaccuracies in MDS coding could result in assessments that do not accurately represent the residents' current status and needs.
Failure to Update Care Plan for Anticoagulation Therapy
Penalty
Summary
The facility failed to review and revise the care plan for a resident receiving anticoagulation therapy, as required by facility policy and regulatory standards. Record review showed that the resident had a physician's order for daily Coumadin and the admission Minimum Data Set (MDS) identified anticoagulant use. Despite this, the resident's current care plan did not include any problems, goals, or interventions related to anticoagulation therapy. This omission was confirmed by an administrative nurse during staff interview, who acknowledged that the care plan had not been updated to reflect the resident's current status.
Improper Use of Assistive Devices During Resident Transfers
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for two residents during transfers. For one resident, a certified nurse aide (CNA) placed a gait belt loosely around the resident's chest instead of the waist, which resulted in the belt sliding up under the resident's arms and providing no support during the transfer. This occurred on two separate occasions, with different CNAs failing to tighten the gait belt prior to or during the transfer, despite the resident having difficulty standing and turning. An administrative nurse confirmed that staff are expected to place the gait belt around the resident's waist, make it snug, and readjust as needed. In another incident, a CNA assisted a resident with a sit-to-stand lift but failed to lock the wheels of the lift and left the resident unattended while obtaining supplies. The resident, who sometimes does not comprehend how to safely participate in transfers, let go of the lift handles and began to fidget, causing the lift to move. The CNA had to remind the resident multiple times to hold onto the lift handles, but the resident did not comply until the CNA completed all cares. The CNA then moved the lift over to the wheelchair and lowered the resident without ensuring the resident held onto the lift handles.
Medication Labeling Deficiency During Insulin Administration
Penalty
Summary
The facility failed to ensure accurate labeling of medications for a resident during insulin administration. An observation revealed that a nurse removed a Novolog insulin pen from the medication cart, which had a label with incorrect administration instructions. The label indicated to administer 8 units in the morning, 14 units at lunch, and 16 units in the evening. However, the resident's current physician orders required 15 units at 8:00 a.m., 15 units at 11:30 a.m., and 16 units at 5:30 p.m. The nurse confirmed that the label on the insulin pen was incorrect and acknowledged that a new label should have been ordered from the pharmacy, as per the facility's policy on medication administration and safe handling.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff followed enhanced barrier precautions for a resident during care. Two certified nurse aides (CNAs) entered the room of a resident who was under enhanced barrier precautions, as indicated by signage. The CNAs donned gloves and gowns and assisted the resident to bed using a full body lift. They removed the resident's soiled brief and provided incontinence care. However, the CNAs did not change their soiled gloves before applying a clean brief and adjusting the resident's clothing, bedding, catheter, and lift. After completing these tasks, the CNAs removed their gloves and exited the room with the lift, failing to disinfect it and perform hand hygiene as required by the facility's policy. An administrative nurse later stated that the expectation is for staff to sanitize all mechanical lifts between residents. This failure to adhere to the facility's infection control practices may result in the spread of infections within the facility.
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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 Ashley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wishek Living Center | 17.4 mi | ★★★★★ | 0 | 0 |
| Avera Eureka Health Care Center | 22.1 mi | ★★★★★ | 0 | 0 |
| Wentz Living Center | 36.9 mi | ★★★★★ | 1 | 0 |
| Strasburg Nursing Home | 38.4 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.