Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ashland Health Services during CMS and state inspections, most recent first.
The facility did not test staff with symptoms of COVID-19 and failed to follow proper infection control procedures during catheter care for a resident with neurogenic bladder. Multiple staff members returned to work after experiencing symptoms such as fever, vomiting, and diarrhea without being tested, and a CNA used a soiled washcloth and a contaminated alcohol wipe during catheter care, contrary to facility policy.
A resident with severe cognitive impairment and multiple risk factors for constipation did not have bowel movements documented for several days, despite a care plan requiring monitoring and interventions. The CNA failed to follow the care plan and did not ensure alternative documentation when the electronic system was unavailable, leading to incomplete implementation of the resident's bowel management plan.
The facility failed to submit accurate PBJ data for multiple quarters due to agency staff not punching their hours on the facility time clock, leading to discrepancies in recorded hours. Despite having 24-hour licensed nursing coverage, the facility's data submission was inaccurate, affecting the reported staffing levels.
The facility failed to maintain an effective infection control program, lacking comprehensive surveillance logs for staff infections and proper PPE use. Staff entered rooms of residents on contact precautions without gloves, and there was inadequate communication about residents with MDROs during transfers. These deficiencies highlight lapses in protocol adherence and documentation.
The facility did not maintain documentation of COVID-19 vaccination screening, education, offering, and status for staff, as required by its infection control policy. This deficiency was confirmed by the DON and has the potential to affect all 40 residents.
The facility failed to document the offering or administration of pneumococcal vaccinations for several residents, despite CDC guidelines and facility policy. Five residents had no records of being offered or declining the recommended vaccines, such as PCV15, PCV20, or PPSV23. The Director of Nursing acknowledged the oversight, noting the absence of documentation and the failure to adhere to the facility's vaccination policy.
A resident with dysphagia did not receive a recommended video fluoroscopy swallow study (VFSS) to assess swallowing difficulties and determine safe diet recommendations. Despite multiple recommendations from the speech therapist, the facility failed to schedule the VFSS or provide evidence that the resident's family was informed. This oversight led to ongoing health issues, including hospitalizations for conditions related to swallowing difficulties.
A resident with a stage III pressure injury and a history of MRSA did not receive proper hand hygiene care during a dressing change. An LPN failed to wash or sanitize hands between glove changes while treating the wound, contrary to facility policy and CDC guidelines. The Interim DON confirmed the expected hand hygiene practices, and the LPN acknowledged the oversight.
A resident with a history of dehydration and swallowing difficulties did not receive adequate fluid intake due to the facility's lack of a tracking system and inaccurate dehydration assessments. The resident's care plan did not address hydration needs, and staff interviews revealed insufficient documentation and monitoring of fluid intake, leading to ongoing dehydration issues.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident's care plan lacked specific triggers and prevention strategies, and staff were unaware of the PTSD diagnosis. Another resident's PTSD, stemming from past gang involvement, was not addressed with individualized interventions. The facility did not ensure staff were informed or trained on managing potential retraumatization.
A resident with a history of substance use disorder was left with medications at their bedside without proper assessment or physician order for self-administration. Despite a care plan intervention requiring nurse supervision during medication administration, the medications were left unattended. The resident did not consume their breakfast and expressed discomfort, leading to the eventual removal of the medications. The facility's DON confirmed the lack of necessary assessments and physician orders.
The facility failed to ensure its activities program was directed by a qualified professional. The Life Enrichment Specialist (LES) I, acting as the Activity Director, lacked the necessary qualifications and had not enrolled in any courses to meet federal guidelines, despite being in the role for eight months. LES I managed all activity programming without oversight from a qualified professional, contrary to the facility's policy and federal requirements.
Failure to Implement Effective Infection Control and Catheter Care Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of COVID-19 testing for staff members exhibiting symptoms consistent with communicable diseases. Despite the facility's policy requiring surveillance and control of infections for all individuals, documentation showed that multiple staff members returned to work after experiencing symptoms such as nausea, vomiting, diarrhea, fever, sore throat, cough, and cold symptoms without being tested for COVID-19. Interviews with the Director of Nursing (DON) and Infection Preventionist (IP) revealed uncertainty regarding the criteria for testing symptomatic staff, and both confirmed that symptomatic staff had not been tested as required by CDC guidance and facility policy. Additionally, the facility failed to follow proper infection control procedures during catheter care for a resident with a diagnosis of neurogenic bladder. During an observed care episode, a Certified Nursing Assistant (CNA) used a soiled washcloth to clean the catheter insertion site and then used a contaminated alcohol wipe, which had been dropped on the floor, to disinfect the distal end of the catheter before connecting it to a leg bag. The CNA acknowledged that these actions were not acceptable, and the interim DON agreed with this assessment when informed of the observations. The deficiencies identified had the potential to affect all residents in the facility, as the lack of proper infection surveillance and control measures could contribute to the development and transmission of communicable diseases, including COVID-19. The improper catheter care practices also posed a risk of infection for the resident involved, who was cognitively intact and required catheter care every shift as ordered by a physician.
Failure to Implement and Document Bowel Management Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement and follow a complete care plan to address a resident's medical need for bowel management. The resident, who had a history of stroke with left-sided paralysis, chronic pain, dementia, traumatic brain injury, epilepsy, anemia, and constipation, was dependent on staff for all activities of daily living and had severe cognitive impairment. The care plan identified the resident as being at risk for constipation due to lack of exercise and medications, with interventions including medication administration, monitoring effectiveness, and documentation of bowel movements (BMs). However, the Certified Nursing Assistant (CNA) did not document the resident's BMs for two days, and the BM flow sheet showed no recorded BMs for five days. During this period, the resident's family member noticed changes in the resident's condition, including unusual abdominal movements and altered appearance, and reported these to the nurse. The resident was on multiple medications known to increase the risk of constipation, including opioids, iron supplements, and antipsychotics, with several prescribed interventions for constipation. The lack of documentation was attributed to a computer system outage, during which the CNA failed to ensure alternative documentation or communication per facility protocol. This resulted in the care plan not being fully implemented or followed as required.
Inaccurate PBJ Data Submission Due to Agency Staff Time Clock Issues
Penalty
Summary
The facility failed to submit accurate data to the Centers for Medicare and Medicaid Services (CMS) for the mandatory Payroll Based Journal (PBJ) for the third quarter of 2023, fourth quarter of 2023, and the first quarter of 2024. This issue arose because agency staff did not punch their hours on the facility's time clock, leading to inaccurate hours being recorded in the facility's computer system. The Nursing Home Administrator (NHA) acknowledged the problem during an interview, attributing the low weekend staffing data in the PBJ report to this discrepancy. However, upon review, the surveyor did not identify any concerns related to low weekend staffing coverage, as the data reviewed met the facility's staffing assessment. Further investigation revealed that the facility failed to have licensed nursing coverage 24 hours a day on specific dates in the fourth quarter of 2023 due to two agency Registered Nurses (RNs) not punching the facility time clock. This resulted in the facility lacking accurate data for the PBJ report, despite having licensed nursing coverage 24 hours a day. The surveyor was unable to verify the effectiveness of the corrective processes the facility implemented to address the PBJ errors, as the quarter 2 2024 PBJ report was unavailable for review at the time of the survey.
Inadequate Infection Control Program and Protocol Adherence
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility lacked a comprehensive surveillance log for staff infections, with only minimal documentation available through emails from the Infection Preventionist. This documentation was insufficient, as it did not include critical information such as return-to-work dates for staff who tested positive for infections like influenza A and COVID-19. Additionally, the facility experienced multiple outbreaks, yet there was no formal documentation or tracking system in place to monitor these incidents effectively. The survey also revealed that staff did not adhere to proper infection control practices, particularly in the use of personal protective equipment (PPE). Observations showed that staff entered rooms of residents on contact precautions without wearing gloves, despite clear signage indicating the requirement. This lapse in protocol was compounded by the absence of gloves in supply bins outside the rooms, forcing staff to retrieve them from inside the rooms, which could potentially increase the risk of contamination. Furthermore, the facility's communication and documentation regarding residents with Methicillin-Resistant Organisms (MDROs) were inadequate. Two residents with MRSA were not properly identified in their care plans or diagnosis sheets, leading to a lack of communication about their MDRO status during transfers to other facilities. This oversight was acknowledged by the staff, who admitted that the process for reporting MDROs needed improvement. The facility's Director of Nursing was unaware of the specific procedures for reporting MDROs during resident transfers, indicating a gap in staff training and protocol adherence.
Failure to Document COVID-19 Vaccination Program for Staff
Penalty
Summary
The facility failed to maintain proper documentation regarding the COVID-19 vaccination program for its staff, which is a critical component of its infection control program. The surveyor's review of the facility's policies revealed that the facility had a policy in place to educate and offer the COVID-19 vaccine to residents and staff, and to document these actions. However, upon examination, there was no evidence of documentation for staff screening, education, offering of the vaccine, or the current vaccination status of staff members. During an interview with the Director of Nursing (DON), it was confirmed that there was no documentation available to verify compliance with the facility's COVID-19 vaccination policy. This lack of documentation has the potential to affect all 40 residents in the facility, as it indicates a failure to adhere to the established infection control protocols designed to minimize the risk of COVID-19 transmission.
Lack of Documentation for Pneumococcal Vaccinations
Penalty
Summary
The facility failed to maintain a comprehensive system for ensuring that residents received or were offered pneumococcal vaccinations, as evidenced by the lack of documentation for five residents reviewed. These residents, identified as R5, R8, R9, R24, and R31, had no records indicating they were offered or declined the recommended pneumococcal vaccines, such as PCV15, PCV20, or PPSV23, despite CDC guidelines and the facility's own policy requiring such offers and documentation. For instance, R5, who had previously received PPSV23, had no documentation of being offered PCV15 or PCV20, which should have been administered at least one year after the last PPSV23 dose. The deficiency was further highlighted during an interview with the Director of Nursing (DON) from a sister facility, who was unable to provide additional information on the residents' vaccination status. The DON acknowledged the lack of documentation and stated there was no excuse for the oversight. The facility's policy mandates that each resident be assessed for pneumococcal immunization upon admission, and any refusals should be documented along with the education provided. However, the surveyor found that these procedures were not followed, leading to the deficiency.
Failure to Schedule Recommended Swallow Study
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was admitted with multiple health issues including dysphagia, had a physician's order for a video fluoroscopy swallow study (VFSS) to assess swallowing difficulties and determine safe diet recommendations. Despite the recommendation being made on 12/16/23, the VFSS was not scheduled, and the resident continued to experience health issues related to swallowing difficulties, including hospitalizations for conditions such as hypernatremia, pneumonia, and urinary tract infections. The speech therapist repeatedly recommended the VFSS to determine the safety of the resident's diet, but the facility did not provide evidence that the appointment was scheduled or that the resident's family was informed about the recommendation. The social worker responsible for scheduling appointments prior to 02/19/24 reported that the resident's family was supposed to schedule the VFSS, but there was no documentation to confirm this arrangement. Consequently, the resident's care plan and dietary needs were not adequately addressed, leading to ongoing health concerns.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during a dressing change for a resident with a stage III pressure injury (PI). The resident, identified as R21, has a medical history that includes cerebral palsy, peripheral vascular disease, and a long-standing stage III PI on the outer left ankle. The pressure injury, which was initially unstageable, had been present since August 2023 and had tested positive for MRSA on two occasions. Despite the presence of an infection control plan, the facility did not adhere to the necessary hand hygiene protocols during wound care. During an observation on June 3, 2024, a Licensed Practical Nurse (LPN) was seen performing a dressing change on the resident's ankle wound. The LPN sanitized his hands upon entering the room and donned gloves before removing the old dressing. However, after removing the gloves, the LPN failed to wash or sanitize his hands before proceeding to cleanse the wound. The LPN continued to handle various items and change gloves without proper hand hygiene, which is contrary to both the facility's policy and CDC guidelines. The Interim Director of Nursing (IDON) confirmed the expected practice of hand hygiene, which includes washing hands before starting, after removing dirty gloves, and before placing clean ones. The LPN acknowledged the lapse in hand hygiene when interviewed, admitting that he should have washed his hands between glove changes. This deficiency in hand hygiene practices during wound care could potentially lead to cross-contamination and infection, particularly in a resident with a history of MRSA.
Failure to Ensure Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R23, was offered sufficient fluid intake to maintain proper hydration. R23, who was admitted to the facility after hospitalization for dehydration, confusion, and weakness, had a history of dehydration and required moderate assistance with eating due to dysphagia. Despite these needs, the facility did not have a system in place to track R23's daily fluid intake, resulting in the resident consistently receiving less than 50% of the recommended daily fluid intake over several months. R23's care plan did not include a specific plan for hydration, and the facility's assessments of R23's dehydration risk were inaccurate. The assessments failed to account for R23's history of dehydration, swallowing difficulties, and need for assistance with eating. Additionally, the facility did not update R23's care plan in response to changes in condition, such as episodes of diarrhea, vomiting, and signs of dehydration, which were documented in the resident's progress notes. Interviews with facility staff, including a speech therapist and a registered nurse, revealed that there was a lack of documentation and monitoring of R23's fluid intake. The Director of Nursing acknowledged that the dehydration assessments were not accurate and that there was no care plan in place to address R23's hydration needs. This lack of accurate assessment and monitoring contributed to R23's ongoing issues with dehydration and related health complications.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent trauma-informed care for two residents diagnosed with PTSD. For one resident, identified as R31, the facility did not determine the cause of PTSD or identify potential triggers that could lead to retraumatization. Despite being aware of the resident's PTSD diagnosis, the facility did not develop an individualized care plan with specific interventions to prevent retraumatization. The Social Services Director (SSD) acknowledged the lack of follow-up with the resident's therapist to obtain necessary information about the PTSD, which was only discovered after a significant delay. Staff members responsible for R31 were not informed about the PTSD diagnosis, potential triggers, or appropriate interventions. Another resident, identified as R1, also did not receive individualized trauma-informed care. The facility's care plan for R1 lacked specific triggers and prevention strategies related to the resident's PTSD, which stemmed from past gang involvement and violence. Although the resident's care plan included general interventions for anxiety and PTSD, it did not provide detailed guidance for staff on how to address potential retraumatization. Staff members responsible for R1 were unaware of the PTSD diagnosis, its cause, or effective interventions to manage potential retraumatization. The facility's failure to provide individualized trauma-informed care plans for both residents resulted in a lack of guidance for staff on how to manage potential retraumatization. This deficiency was compounded by the lack of communication and training for staff regarding the residents' PTSD diagnoses and specific needs. The facility's inaction in obtaining necessary information and developing comprehensive care plans contributed to the deficiency in providing trauma-informed care.
Medication Administration Deficiency Due to Lack of Supervision
Penalty
Summary
The facility failed to administer medications safely and effectively for a resident with a history of substance use disorder, including chronic opioid use and alcohol abuse in remission. The resident, who was observed to have intact cognition, was left with medications at their bedside without a proper assessment or physician order authorizing self-administration. The resident's care plan included an intervention requiring a nurse to remain in the room during medication administration due to a history of hiding and hoarding medications. However, this intervention was not followed, as the medications were left unattended in the resident's room. During the survey, it was noted that the resident did not consume their breakfast and expressed discomfort, stating they would not eat or take their medications until feeling better. The medications, which included several prescription drugs, were eventually removed from the room. The facility's Director of Nursing confirmed that there was no physician order or assessment completed for the resident to self-administer medications, and the resident's physician later refused to authorize self-administration due to the resident's history. The LPN involved admitted to leaving the medications at the bedside after the resident indicated they would take them later.
Unqualified Activity Director in LTC Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by federal guidelines. The Life Enrichment Specialist (LES) I, who assumed the role of Activity Director, did not meet the necessary qualifications. LES I had a background as a Certified Nursing Assistant but lacked the education or certification required to direct the activities program. Despite working 30-40 hours weekly and managing all activity programming schedules, LES I had not enrolled in any courses to meet the federal guidelines, even after eight months in the role. The facility's policy on activities, last reviewed in July 2022, mandates that the activities program should support residents' choices based on comprehensive assessments and care plans. The policy outlines that activities should enhance residents' well-being, promote physical and cognitive activity, and reflect their interests and cultural preferences. However, the surveyor noted that LES I, who was responsible for supervising and creating the life enrichment program, did not have the required qualifications or oversight from a qualified professional. During the survey, LES I stated that she was responsible for completing various assessments and coordinating the activity programming, including holding Resident Council Meetings and working with the Resident Care Management Director on the Minimum Data Set Assessment. Despite these responsibilities, LES I had not signed up for any courses to meet the federal guidelines, and there was no one on staff overseeing her work. The Nursing Home Administrator acknowledged that course information had been sent to LES I, but no enrollment had occurred, indicating a lack of compliance with the federal requirements for the role.
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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) |
|---|---|---|---|---|
| Court Manor Health Services | 0.8 mi | ★★★★★ | 0 | 0 |
| Northern Lights Hcc | 7.3 mi | ★★★★★ | 6 | 0 |
| Villa Maria Health And Rehab Ctr | 34.6 mi | ★★★★★ | 2 | 0 |
| Sky View Nursing Center | 34.7 mi | ★★★★★ | 5 | 0 |
| Westgate Nursing & Rehabilitation Community | 34.9 mi | ★★★★★ | 5 | 0 |
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