Below 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 Adept Nursing & Rehab Of Ashland during CMS and state inspections, most recent first.
Two residents received omeprazole after eating breakfast instead of 60 minutes prior as ordered, and one resident did not have their mouth rinsed after using Trelegy Ellipta, resulting in a medication error rate of 12% during observed medication passes. The errors were confirmed by the MA and DON, and were not in accordance with facility policy or medication instructions.
A resident receiving multiple psychotropic medications for anxiety and depression did not have documented education or informed consent for their use, despite facility policy requiring this prior to medication initiation or increase. The DON confirmed the absence of a psychotropic consent form in the resident's record.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
Two residents requiring noninvasive ventilator support did not have care plans reflecting the use of a Trilogy machine, and staff had not received training or competency testing for its use. Despite physician orders and the presence of the machines at bedside, only some nurses were able to assist residents appropriately, as confirmed by both resident interviews and the DON.
A resident with PTSD and a history of trauma, substance use, and homelessness was admitted without a trauma-based assessment or trauma-informed care plan. The care plan did not address the resident's known triggers or mental health needs, despite facility policy requiring culturally competent and trauma-informed care.
Two residents with cognitive impairment were involved in an altercation, but their Comprehensive Care Plans were not updated to reflect new behavioral interventions or documentation of the incident. The DON confirmed that required documentation and notifications were not completed, despite facility policies mandating timely care plan revisions and individualized behavioral health interventions.
Three residents with known fall risks experienced falls and injuries due to the facility's failure to implement and maintain care plan interventions, including leaving a resident unattended in a dining room, allowing another to attempt a self-transfer without proper equipment, and not ensuring that call lights and personal items were within reach for a resident with repeated falls.
During a COVID outbreak, staff failed to consistently wear masks or wore them incorrectly, and soiled linens were carried against uniforms instead of being bagged. Additionally, reusable dishes from a COVID-positive resident's room were placed in a common dining area, contrary to infection control policy. Staff interviews confirmed these lapses in protocol.
The facility failed to ensure two nurse aides completed the required 12 hours of continuing education to maintain their certification. A review showed that one aide completed 5.5 hours and another 2.5 hours in the past year. This was confirmed by the facility educator, despite the policy requiring 12 hours annually.
The facility failed to maintain safe water temperatures in the Memory Care Unit, with temperatures ranging from 122 to 136 degrees Fahrenheit, exceeding the safe limit of 120 degrees. This issue arose after a new water heater was installed, and the DOM confirmed that water temperatures had not been checked in the MCU since then. The DOM also admitted to not knowing how to calibrate the thermometer used for temperature checks.
The facility failed to ensure proper mechanical ventilation in the Memory Care Unit bathrooms, affecting all 9 resident rooms. Observations noted a strong urine odor, and vents were unable to pull up toilet paper, indicating malfunction. Staff interviews confirmed the vents were not checked or cleaned regularly, and maintenance procedures were inadequate, with no regular checks or Guardian Angel rounds addressing the issue.
The facility failed to provide weekly baths to three residents, despite their cognitive awareness and medical needs. One resident with muscle wasting experienced a nine-day gap between baths, while another with cerebral palsy had inconsistent bathing intervals. A third resident with hemiplegia reported infrequent baths, confirmed by a 15-day gap in records. Interviews with the Administrator and DON acknowledged the failure to meet the facility's bathing expectations.
The facility failed to accurately code the MDS for two residents, resulting in incorrect assessments of severe cognitive impairment with hallucinations and delusions. Despite the MDS entries, there was no supporting documentation in the residents' Behavior and Progress Notes. The Regional Nurse Consultant and DON confirmed the inaccuracies.
The facility failed to ensure routine bowel movements for two residents with severe cognitive impairment and occasional bowel incontinence. One resident had no documented bowel movements for two periods totaling seven days, and another for two periods totaling eleven days. No bowel medications were given, and no assessments were documented. Interviews with the DON and an LPN confirmed the absence of bowel medication orders, lack of bowel movement records, and no system to track residents' bowel movements.
A resident with congestive heart failure, under hospice care, passed away in the facility. Despite the facility's Comprehensive Care Plan requiring notification of hospice and family, the facility did not notify the hospice nurse; the resident's representative made the call instead. Interviews confirmed the facility's failure to follow its post-mortem care policy.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to practitioner’s orders and manufacturer’s recommendations, resulting in a medication error rate of 12% based on 25 observed medication administration opportunities. Specifically, two residents received omeprazole after consuming breakfast, despite clear instructions on the medication card to administer the drug 60 minutes prior to meals. Both the medication aide and the Director of Nursing confirmed that the medication was not given at the correct time, as required. Additionally, one resident did not have their mouth rinsed after receiving Trelegy Ellipta, an inhaled medication, contrary to the instructions to rinse the mouth after use. The medication aide acknowledged this omission during the interview, and the Director of Nursing confirmed that the mouth should have been rinsed. The facility’s own Medication Administration policy also requires mouth rinsing after inhaler use and administration of medications within the specified time frame.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide required education and obtain informed consent for the use of psychotropic medications for one resident. Review of the facility's policy indicated that residents, families, or resident representatives must be informed of the benefits, risks, and alternatives to psychotropic medications, including any black box warnings, prior to starting or increasing such medications. For the resident in question, medical records showed active orders and administration of multiple psychotropic medications, including alprazolam, buspirone, sertraline, and trazodone, for conditions such as anxiety and depression. Despite the resident being cognitively intact, as evidenced by a BIMS score of 14, there was no documentation of informed consent for the use of these medications in the resident's medical record. The care plan and medication administration records confirmed ongoing use of these medications, and the DON verified that no psychotropic consent form was present for the resident as required by facility policy and regulation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Lack of Staff Training and Competency for Trilogy Ventilator Use
Penalty
Summary
The facility failed to provide staff training and competency testing for the use of a Trilogy machine, a noninvasive ventilator, for two residents who required this specialized respiratory support. Record reviews showed that the facility's assessment did not identify the capability or capacity to provide specialized respiratory care or services, despite having a policy in place for noninvasive ventilation. The policy outlined the use of devices such as CPAP, BiPAP, AVAPS, and Trilogy, but there was no evidence that staff were trained or tested for competency in using these machines. For one resident, the medical record indicated a history of chronic hypercapnic respiratory failure, COPD, obstructive sleep apnea, aspergillosis, histoplasmosis, and other lung conditions, with physician orders for specific Trilogy machine settings. The resident's care plan did not mention the use of the Trilogy machine, although the medication administration record showed that noninvasive ventilation was provided as ordered. Observations confirmed the presence of the Trilogy machine in the resident's room, and the DON acknowledged that staff had not received training on its use. Another resident with COPD, idiopathic sleep-related nonobstructive alveolar hypoventilation, and sleep apnea also had physician orders for Trilogy machine use. The care plan referenced CPAP/BiPAP but did not include interventions for the Trilogy machine. The resident reported needing assistance with the Trilogy mask and noted that only some nurses were knowledgeable about its use, while others were not. The DON confirmed the lack of staff training on the Trilogy machine for this resident as well.
Failure to Provide Trauma-Informed Care and Assessment
Penalty
Summary
The facility failed to evaluate and implement interventions to manage trauma triggers for a resident with a self-reported diagnosis of Post Traumatic Stress Disorder (PTSD). Record review showed that the resident had a history of PTSD related to previous domestic abuse, as well as other diagnoses including stroke, hypertension, diabetes mellitus, anxiety disorder, and bipolar disorder. The resident reported specific triggers, such as not liking water poured over the face due to past abuse, and had a history of substance use, homelessness, and legal issues. Despite this, the resident's care plan did not include any focus area related to anxiety, depression, mood, or past traumatic event triggers. Interviews and record reviews confirmed that the facility had not completed a trauma-based assessment or initiated a trauma-informed care plan upon the resident's admission, as required by facility policy. The facility's policy mandates culturally competent and trauma-informed care, including minimizing triggers and re-traumatization for trauma survivors. However, the lack of assessment and care planning for the resident's trauma history and triggers constituted a failure to provide care and services in accordance with these standards.
Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to update the Comprehensive Care Plans (CCPs) for two residents following an altercation between them. An incident report documented that one resident, with severe cognitive impairment and a diagnosis of Non-Alzheimer's Dementia, stuck their tongue out at another resident, who then physically grabbed the first resident. Staff immediately separated the residents. However, a review of both residents' progress notes and CCPs revealed no documentation of behaviors or new interventions related to the incident. The CCPs for both residents had not been updated around the time of the altercation, despite one resident having a history of verbal aggression and both having cognitive impairments. During an interview, the DON confirmed that there was no behavior documentation, care plan update, physician notification, or family notification regarding the incident, although these actions should have occurred. Facility policies require that care plans be reviewed and revised as necessary, with updates for new or modified interventions, and that behavioral health services be individualized and person-centered. The lack of documentation and care plan revision following the incident constituted a failure to meet these standards.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain effective interventions to prevent falls and accidents for three residents, despite their known risks and care plan directives. One resident with significant cognitive impairment, muscle weakness, and a history of falls was left unattended in a dining room, contrary to care plan instructions. The resident fell from a wheelchair with unlocked brakes, resulting in a hip fracture. Staff interviews confirmed that the resident was left alone, and the only intervention known to the nurse on duty was to offer restroom breaks and snacks, with no active supervision provided at the time of the fall. Another resident, also with a history of falls and impaired mobility, was dependent on staff for transfers and toileting. Despite this, the resident attempted a self-transfer to the toilet when staff were busy, resulting in a fall and subsequent ankle fracture. The care plan required the use of a sit-to-stand lift or Hoyer lift for transfers, but during the incident, a nursing assistant allowed the resident to attempt a pivot transfer without the appropriate equipment or intervention to prevent the fall. The resident and staff confirmed that the transfer was not performed according to the care plan, and the necessary assistive devices were not used. A third resident with muscle weakness, a history of falls, and cognitive awareness experienced multiple falls over several months. Observations revealed that care plan interventions, such as keeping the call light and personal items within reach, were not consistently implemented. The call light was found on the floor and out of reach, the urinal and TV remote were not accessible, and the overbed table was positioned so that the resident could not reach necessary items. These lapses in following the care plan contributed to repeated falls and injuries for the resident.
Failure to Adhere to Infection Control Protocols During COVID Outbreak
Penalty
Summary
Surveyors identified multiple failures in the facility's infection prevention and control practices during a COVID outbreak. Staff were observed not wearing masks, wearing masks incorrectly, or removing masks while providing care or serving food. Specifically, a nursing assistant was seen serving breakfast without a mask, a medication aide removed their mask while speaking during resident care, and another staff member wore a mask under their chin. Interviews with staff, including the LPN, DON, and Infection Preventionist, confirmed that masks were required to be worn properly during the outbreak, but these protocols were not followed. Additional deficiencies were observed in the handling of soiled linens and reusable items. A medication aide was seen carrying dirty linens against their uniform through the hallway instead of placing them in a plastic bag as required by facility policy. Furthermore, reusable breakfast dishes from a COVID-positive resident's room were placed on a table in the dining room, potentially exposing others to contamination. Staff interviews confirmed that these actions were not in compliance with established infection control policies.
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that two nurse aides, who had been employed for more than one year, completed the required 12 hours of continuing education necessary to maintain their certification. A review of the education records for five staff members revealed that Nurse Aide O, hired on February 2, 2020, had only completed 5.5 hours of continuing education, while Nurse Aide P, hired on April 23, 1995, had completed just 2.5 hours within the past year. This deficiency was confirmed during an interview with the facility educator, who also serves as the Assistant Director of Nursing. The facility's policy, titled 'Nurse Aide Training Program' and dated August 1, 2023, mandates that each nurse aide receive at least 12 hours of in-service training annually, based on their employment date. The responsibility for coordinating and providing this education falls under the Staff Development Coordinator, with oversight from the Director of Nursing. Despite these guidelines, the facility did not meet the continuing education requirements for the two nurse aides, leading to a deficiency in compliance with the licensure reference number 175 NAC 12-006.04B(ii)(1).
Unsafe Water Temperatures in Memory Care Unit
Penalty
Summary
The facility failed to ensure safe water temperatures in the Memory Care Unit (MCU), which had the potential to affect all nine sampled resident rooms. During observations, water temperatures in the resident rooms were found to be significantly above the safe limit of 120 degrees Fahrenheit, with readings ranging from 122 to 136 degrees Fahrenheit. The issue was identified following the installation of a new 100-gallon water heater, which was set at 130 degrees Fahrenheit. The Director of Maintenance (DOM) confirmed that the water temperatures had not been checked in the MCU since the installation of the new water heater. Interviews revealed that the DOM was unaware of how to calibrate the thermometer used for measuring water temperatures and that maintenance staff only checked random bathroom water temperatures monthly. The DOM acknowledged that temperatures over 120 degrees Fahrenheit were too high and should be lower. Additionally, it was confirmed that no specific actions were taken to address water temperature checks in the MCU after the new water heater was installed. The Administrator confirmed that all water from bathroom faucets should be under 120 degrees Fahrenheit and noted that no residents had suffered burns from the water.
Inadequate Ventilation in Memory Care Unit Bathrooms
Penalty
Summary
The facility failed to ensure that the mechanical ventilation in the bathrooms of the Memory Care Unit (MCU) was functioning properly, affecting all 9 resident rooms on the unit. During an observation, a strong and stale urine odor was noted upon entering the MCU, and further inspection revealed that the bathroom vents were unable to pull up a single ply of toilet paper, indicating inadequate ventilation. Interviews with staff, including the Licensed Practical Nurse (LPN), Director of Maintenance (DOM), and Director of Housekeeping (DOH), confirmed that the vents were not functioning and were not regularly checked or cleaned. The facility's maintenance procedures were found to be lacking, as there were no regular maintenance rounds performed, and the Guardian Angel rounds conducted by facility managers did not include checks of the bathroom vents. The DOM confirmed that the ventilation system had not been checked, despite facility instructions to inspect exhaust fans monthly. Additionally, it was revealed that no Guardian Angel Rounds were performed on the MCU in May, and the rounds conducted in April and June did not identify any maintenance concerns. The Administrator confirmed the oversight in checking the ventilation system.
Failure to Provide Weekly Baths to Residents
Penalty
Summary
The facility failed to ensure that residents received baths at least once weekly, as evidenced by the cases of three residents. Resident 87, who was admitted with muscle wasting and atrophy, was documented to have received a bath on 5/29/24 and 6/7/24, resulting in a nine-day gap without a bath. Despite being cognitively intact with a BIMS score of 14, Resident 87 reported not receiving a bath since shortly after admission. Similarly, Resident 7, diagnosed with cerebral palsy and also cognitively intact with a BIMS score of 15, experienced inconsistent bathing, with records showing a bath on 5/9/24 and then not again until 5/26/24, followed by another gap until 6/6/24. Resident 36, who has hemiplegia and hemiparesis following a cerebral infarction, also with a BIMS score of 15, reported that baths were hardly once a week. Documentation confirmed a 15-day gap between baths from 5/22/24 to 6/6/24. Interviews with the facility Administrator and the DON confirmed that the facility's expectation was for residents to receive a bath at least once weekly, which was not met for these residents.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded correctly for two residents, leading to inaccuracies in their assessments. For Resident 53, the Quarterly MDS indicated severe cognitive impairment with hallucinations and delusions, despite the absence of documentation supporting these symptoms in the Behavior and Progress Notes from May 1, 2024, through June 13, 2024. The Regional Nurse Consultant confirmed the lack of documentation for hallucinations or delusions during an interview, acknowledging the incorrect marking on the MDS. Similarly, Resident 75's Quarterly MDS also indicated severe cognitive impairment with hallucinations and delusions, yet there was no documentation of these symptoms in the Care Plan or Behavior and Progress Notes from April 1, 2024, through May 1, 2024. The Regional Nurse Consultant confirmed the absence of documentation for hallucinations or delusions during the specified period, indicating an error in the MDS coding. The Director of Nursing confirmed that the facility used the Resident Assessment Instrument manual for guidance to ensure MDS accuracy.
Failure to Ensure Routine Bowel Movements for Residents
Penalty
Summary
The facility failed to ensure routine bowel movements for two residents, both of whom had severe cognitive impairment and were occasionally incontinent of bowels. Resident 53, with a primary diagnosis of Alzheimer's Disease, had no documented bowel movements for two separate periods totaling seven days. Despite a previous hospital admission for a small bowel obstruction, no bowel medications were given, and no bowel assessments were documented during this time. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the absence of bowel medication orders, lack of bowel movement records, and the absence of bowel assessments. Similarly, Resident 75, also diagnosed with Alzheimer's, had no documented bowel movements for two separate periods totaling eleven days. No PRN bowel medications were administered, and there were no bowel assessments documented. Interviews with the DON and LPN confirmed the lack of bowel movement records and the absence of a system to track residents' bowel movements. The DON acknowledged that without a bowel list, there was no way to know which residents had not had a bowel movement in two or more days, and no bowel movement audits were being conducted in the facility.
Failure to Notify Hospice Provider of Resident's Death
Penalty
Summary
The facility failed to notify a hospice provider regarding the death of a resident who was under hospice care. The resident, who had congestive heart failure, was admitted to hospice on 2/22/24 and passed away in the facility on 3/4/24. The facility's Comprehensive Care Plan for the resident included instructions to notify hospice and family of any changes. However, when the resident passed away at 9:50 PM, the facility did not notify the hospice nurse; instead, the resident's representative made the call to the hospice company. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed that the hospice nurse had been informed earlier in the day that the resident was declining. Despite this, the facility did not follow its own policy for post-mortem care, which required documentation of the date and time of death and notification to the physician, family, funeral home, and hospice. The failure to notify the hospice nurse was acknowledged by both the Administrator and the DON during their interviews.
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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 Ashland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adept Nursing & Rehab Of Gretna | 9.1 mi | ★★★★★ | 17 | 0 |
| Nye Summit | 11.4 mi | ★★★★★ | 0 | 0 |
| Adept Nursing & Rehab Of Waverly | 12.1 mi | ★★★★★ | 0 | 0 |
| Newport House | 16 mi | ★★★★★ | 8 | 0 |
| Brookestone Meadows Rehabilitation And Care Center | 16.2 mi | ★★★★★ | 0 | 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.