Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Ashton Medical Lodge during CMS and state inspections, most recent first.
Surveyors found that one med cart was left unlocked and unattended with multiple medications, and two med carts contained an opened insulin pen for a resident with type 2 DM that was not dated when first used. An LVN walked past the unlocked cart without securing it, and an RN confirmed that nurses are responsible for dating insulin pens upon opening. Facility leadership, including the ADON, DON, and Administrator, stated that carts are expected to be locked when unattended and that insulin pens must be dated and used within 28–30 days, consistent with facility policy and manufacturer instructions.
A resident with dementia, arthritis, weakness, and impaired mobility, care planned as a two-person assist with possible use of a sit-to-stand lift, was transferred by two CNAs using an improper two-person gait-belt technique. Instead of holding only the gait belt as taught by therapy and expected by the DON, the CNAs hooked their arms under the resident’s shoulders and one grabbed the back of the resident’s pants during a stand-pivot transfer from wheelchair to bed, causing the resident to cry out in pain. The resident’s representative reported that the resident routinely complained of pain when aides pulled under her arms, and staff interviews confirmed that this incorrect method was being used despite existing training and documented orders indicating use of a sit-to-stand lift for transfers.
A resident with a PEG tube and physician orders requiring verification of tube placement before each feeding, medication, and fluid administration did not receive care consistent with those orders and facility policy. During a medication pass, an LVN flushed the PEG tube with water, administered Loperamide through the tube, and flushed again without auscultating or checking residual to confirm tube placement. In interviews, the LVN admitted she forgot to verify placement and acknowledged the medication could go to the wrong area if the tube was not correctly positioned, and the ADON confirmed that tube placement should have been checked before administering the medication.
A resident with heart failure, muscle weakness, and moderate cognitive impairment, ordered to receive continuous O2 via nasal cannula with shift O2 saturation checks, was repeatedly observed with the nasal cannula left on the bed and on the wheelchair when not in use, instead of being stored in the provided plastic bag. The resident reported that staff, not the resident, removed and placed the cannula. A CNA admitted placing the cannula on the wheelchair without bagging it and acknowledged this was improper. The ADON, DON, and Administrator all stated that cannulas were expected to be stored in bags when not in use and that failing to do so could lead to contamination and respiratory infections, while the existing cannula policy did not address storage when not in use.
A resident with severe cognitive impairment was handled roughly by a CNA during care, including aggressive removal of clothing and a forceful transfer to bed, despite the resident verbally expressing distress. A housekeeper witnessed the incident and reported it, and facility leadership acknowledged that care should have been stopped when the resident refused.
A resident with severe cognitive impairment and multiple medical conditions did not receive a prescribed controlled substance, Lorazepam, due to its misappropriation after it was improperly stored outside of a double-locked system. The medication was placed in a refrigerator accessible to multiple staff members, and required narcotic counts and secure storage procedures were not followed, resulting in the medication's disappearance.
A resident with moderate cognitive impairment reported being hit by an employee, but the facility did not conduct a thorough investigation into the allegation. Despite the resident expressing concerns about rough care and believing she was bruised, leadership did not review all relevant documentation or suspend any staff, and the investigation was closed without identifying a perpetrator.
The facility failed to ensure dignified feeding practices by not having staff seated while feeding residents, as required by policy. This was observed in three residents with severe cognitive impairments and other medical conditions. Despite reminders and the presence of a meal monitor, staff continued to stand while feeding, citing a dining room remodel as a reason for the lack of chairs. The facility's policy emphasized the importance of being at eye level with residents for dignified feeding, but this was not consistently practiced.
Unlocked Med Cart and Undated Insulin Pen on Multiple Medication Carts
Penalty
Summary
The deficiency involves failure to ensure that medications were stored securely in locked compartments and that insulin pens were properly dated when opened. During observation, a nurse medication cart on hall 5 assigned to LVN A was found unlocked and unattended in the hallway for at least 10 minutes, with no staff supervising it. LVN A walked past the cart without noticing it was unlocked and only attempted to unlock it upon returning, at which point she was informed it had been left unsecured. Inside the cart were several insulin pens and other medications. LVN A acknowledged that leaving the cart unlocked could allow unauthorized individuals, including residents, to access the medications. Additional observations revealed issues with medication labeling and dating on another nurse medication cart. On the hall 1 cart, an insulin pen belonging to Resident #100 was found opened but without any date indicating when it had been placed into use. Resident #100 was an older adult with type 2 diabetes, admitted with orders for Fiasp FlexTouch and Humalog KwikPen insulin pens to be administered subcutaneously according to sliding scale before meals and at bedtime. RN B, who was present during the cart check, stated that it was usually each nurse’s responsibility to date insulin pens when first opened so staff would know when they expired, and she did not know who had opened the undated pen. Interviews with facility leadership confirmed that the observed practices did not meet facility expectations or policies. The ADON stated that medication carts were expected to be locked when unattended and that nurse managers were responsible for checking carts to ensure opened medications were dated, noting that the undated insulin should have been removed from the cart. Another ADON reported that each nurse was responsible for checking for expired or undated insulin in the carts and that she conducted random checks. The DON and Administrator both affirmed that medication carts were to be locked when unattended and that nurses were expected to date insulin pens upon opening. Facility documents and manufacturer pamphlets indicated that insulin pens are only good for 28–30 days after opening and that items must be dated when opened, underscoring that the undated, opened insulin pen and the unlocked cart were not in compliance with established procedures.
Improper Two-Person Transfer Technique and Failure to Follow Transfer Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate supervision and appropriate assistance devices during transfers, resulting in an incorrect two-person transfer. The resident was an elderly female with dementia, arthritis, weakness, and gait and mobility abnormalities, with a BIMS score of 3/15 indicating severe cognitive impairment. Her care plan and orders specified that she was a two-person assist and may use a sit-to-stand lift for transfers, and the electronic ADL flow sheets indicated a sit-to-stand lift was to be used. Despite these directives, staff performed a manual two-person gait-belt transfer that did not follow trained technique. On the observed date, two CNAs transferred the resident from her wheelchair to bed using a gait belt but also hooking their arms under the resident’s arms/shoulders and, in one case, grabbing the back of the resident’s pants. The wheelchair was locked, the gait belt was applied, and on a count of three the CNAs assisted the resident to stand and pivot to the bed. During the transfer, the resident repeatedly yelled "ow, ow, ow" and complained of pain, which ceased after she was positioned in bed. The resident’s responsible party reported that the resident always complained of pain when aides hooked under her arms during transfers and that once the pulling on the arms stopped, the pain resolved. Interviews with staff and therapy confirmed that the transfer technique used was inconsistent with facility training and expectations. One CNA stated she had been trained to perform two-person gait-belt transfers by placing the gait belt and hooking arms under the resident, and acknowledged routinely hooking under residents’ arms and grabbing their pants. Another CNA reported that the resident preferred a two-person transfer over the sit-to-stand lift because the lift made her arms hurt, and admitted to sometimes leaving the wheelchair unlocked during transfers, though in this instance it was locked. The PTA described the correct two-person gait-belt transfer method as holding only the gait belt, with wheelchair brakes locked and arms preferably removed, and stated that under-arm lifting and grabbing pants were incorrect and had been addressed in in-services. The DON similarly stated that staff were expected to hold the gait belt only and that hooking under the arms or grabbing the seat of the pants was not acceptable, confirming that the observed transfer did not meet facility expectations for safe transfer technique.
Failure to Verify PEG Tube Placement Before Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate treatment and services for a resident with a PEG tube, as required by the resident’s care plan, physician orders, and facility policy. The resident was admitted with a diagnosis of gastrostomy status and had a care plan and physician orders directing that the head of bed be elevated 30–45 degrees at all times and that PEG tube placement be checked prior to each feeding, medication, and fluid administration by auscultation and checking residual every shift, with feedings to be held if residual was 100 cc. The facility’s tube medication administration policy required staff to check for correct tube placement by injecting air and listening with a stethoscope to the abdomen or aspirating stomach contents before administering medications via the tube. During an observation of a medication pass, an LVN administered Loperamide via the resident’s PEG tube by flushing the tube with water, pouring 30 ml of the medication into the tube, and then flushing again with water, without checking tube placement beforehand. The LVN did not auscultate or check residual prior to administering the medication, contrary to the physician’s orders, the resident’s care plan, and facility policy. In a subsequent interview, the LVN stated she became nervous and forgot to check PEG tube placement and acknowledged that if placement was not checked, the tube might not be in the correct position and the medication could go to the wrong area instead of the stomach. The ADON confirmed that the LVN should have checked PEG tube placement before administering the medication and stated that a possible negative outcome could be that the PEG tube was not where it was supposed to be and the medication would not go to the right area.
Improper Storage of Oxygen Nasal Cannula When Not in Use
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards of practice for one resident who required continuous oxygen therapy. The resident, an older adult with lack of coordination, muscle weakness, heart failure, and a care plan identifying risk for altered respiratory status following a recent surgical procedure, had physician orders for continuous oxygen at 2 L/min via nasal cannula with O2 saturation checks every shift. The care plan also directed respiratory assessments and documentation every shift. During multiple observations on the same day, surveyors noted that the resident’s oxygen nasal cannula was repeatedly left out and not stored in a bag when not in use, despite a storage bag being available on the oxygen concentrator and on the back of the wheelchair. The resident, who had a BIMS score indicating moderate cognitive impairment, consistently reported that she did not remove or place the nasal cannula on the bed or wheelchair and that staff were responsible for handling the device. A CNA confirmed that he assisted the resident to bed and placed the nasal cannula on the back of the wheelchair without storing it in the bag, acknowledging that it should have been bagged and that failure to do so could lead to contamination and infection. The ADON, DON, and Administrator each stated that the expectation was for oxygen nasal cannulas not in use to be stored in plastic bags and acknowledged that leaving them out could result in cross-contamination and respiratory infections. Review of the facility’s policy on administration of cannula showed it did not address how the cannula should be stored when not in use.
Failure to Protect Resident from Rough Handling and Abuse by CNA
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment was not protected from abuse by a certified nursing assistant (CNA). The resident, who had a history of lack of coordination, anxiety disorder, and type 2 diabetes, was handled roughly by the CNA during care. According to witness statements and record review, the CNA removed the resident's shirt aggressively, causing the resident to slam back into her wheelchair, and then transferred the resident to the bed in a rough manner that shook the bed. The resident was heard repeatedly saying "No" and "Stop" during the incident. A housekeeper witnessed the event from outside the room and reported that the CNA was aggressive in removing the resident's clothing and transferring her to the bed. The housekeeper also noted that the resident was not very verbal but was clearly expressing distress during the incident. The witness did not observe the resident striking out at the CNA, despite the CNA's claims that the resident was combative. The incident was reported to the charge nurse immediately after it occurred. Interviews with facility leadership revealed that both the Director of Nursing and the administrator acknowledged the CNA should have stopped providing care when the resident expressed refusal and distress. The facility's abuse and neglect policy states that residents have the right to be free from all forms of abuse, including physical and mental abuse, and that such incidents must be reported immediately. The failure to protect the resident from rough handling and to respect her expressed wishes constituted a violation of her right to be free from abuse.
Failure to Secure and Account for Controlled Substance Resulting in Misappropriation
Penalty
Summary
The facility failed to protect a resident's property by not ensuring the proper storage and accounting of a controlled substance, Lorazepam Oral Concentrate, prescribed as needed for anxiety. The medication was delivered and signed for by an LVN, but was placed in a refrigerator in the medication room instead of the required double-locked storage, as the lock box was reportedly broken and could not be opened. The medication was subsequently unaccounted for and its whereabouts remain unknown. Multiple staff members, including nurses and medication aides, had access to the medication room and refrigerator, and there was only one key to the lock box, which was not used. The medication was not administered to the resident during the period in question, as there was no documented need for it. The resident involved was an elderly female with severe cognitive impairment, a history of sacral fracture, pressure ulcer, dementia, and anxiety disorder. The facility's investigation confirmed the misappropriation of the controlled substance and identified failures in following policy for narcotic counts and secure storage. The incident was not detected until several days after the medication was delivered, and the required narcotic counts were not performed correctly, allowing the misappropriation to go unnoticed.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident with moderate cognitive impairment. The resident, who had diagnoses including Parkinson's disease, hypertension, dementia, and chronic pain, reported being hit by an employee at night. The incident report documented the allegation, but the resident was unable to identify or describe the alleged perpetrator. A subsequent skin assessment found no bruising or new open areas, but the resident voiced concerns about rough care during showers and believed staff had bruised her buttocks, though no bruising was observed at the time. Interviews with facility leadership revealed that the Director of Nursing (DON) and Administrator were unaware of all relevant documentation, including a progress note indicating the resident's concerns about rough care. The DON stated that the investigation was considered complete after the resident could not provide identifying information, and no staff member was suspended during the process. The Administrator also indicated that, due to the lack of identification, little action was taken, and he was not informed of all pertinent notes. The facility's abuse/neglect policy requires thorough investigation of all allegations, but the documentation and actions taken did not demonstrate a comprehensive investigation in this case.
Failure to Ensure Dignified Feeding Practices
Penalty
Summary
The facility failed to treat residents with respect and dignity by not ensuring that staff were seated while feeding residents, which is a requirement for promoting a dignified existence and enhancing the quality of life. This deficiency was observed in three residents who required assistance with eating due to severe cognitive impairments and other medical conditions such as strokes, dementia, and dysphagia. The staff members were observed standing while feeding these residents, which was against the facility's policy that required staff to be at eye level with residents to facilitate better communication and provide feeding in a dignified manner. The observations were made during meal times when CNAs were seen standing while feeding the residents. The lead CNA acknowledged that the aides forgot to get chairs and mentioned that it was a dignity issue for staff to be seated while feeding. Despite the presence of a meal monitor and a nurse responsible for ensuring proper feeding practices, the staff continued to stand while feeding residents, even after being reminded of the requirement to sit. The Director of Nursing (DON) also stated that staff were expected to be seated to engage with residents about their meals, but the ongoing dining room remodel was cited as a reason for the lack of available chairs. The facility's policy on feeding residents in the dining room emphasized the importance of staff being at eye level with residents for dignified feeding. However, the Administrator initially dismissed the issue, attributing it to the chaos of the dining room remodel and the unavailability of chairs. The report highlighted that the lead CNA was able to quickly provide chairs, indicating that the issue could have been addressed. The facility had previously conducted in-services on resident rights, emphasizing the importance of treating residents with dignity and respect, but these practices were not consistently followed during the observed incidents.
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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 Midland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mabee Health Care Center | 1.6 mi | ★★★★★ | 10 | 0 |
| Focused Care At Midland | 5 mi | ★★★★★ | 3 | 0 |
| Midland Medical Lodge | 5.1 mi | ★★★★★ | 12 | 0 |
| Focused Care At Hogan Park | 5.9 mi | ★★★★★ | 4 | 0 |
| Parks Health Center | 9.5 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.