Ashland Health And Rehabilitation

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident's call light was readily accessible for one (1) of 49 residents observed during the initial tour. Resident #22.Findings Include: Review of the facility policy titled Call Light Standard revised 3/19, revealed under, Policy Explanation and Compliance Guidelines: . 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. During the initial tour on 4/13/26 at 10:28 AM, Resident #22 was observed lying in bed, which was positioned against the wall on his right side. The call light was not visible or accessible to the resident. Further observation revealed the call light cord was wedged between the wall and the mattress, and the call light device was located on the floor under the bed, rendering it inaccessible to the resident. An interview with Certified Nurse Aide (CNA) #1 on 4/15/26 at 10:18 AM revealed that when staff made rounds to provide care, they were expected to ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to ensure medications were accurately labeled and corresponded with the physician's order for one (1) of three (3) residents observed during medication pass (Resident #47) Findings Include:Review of facility policy titled, Medication Order & Dispensing Variance Protocol dated 03/2026, revealed, .Procedures.1. a. Licensed nursing staff must verify that the medication label, physician's order, and Medication Administration Record (MAR) match prior to each medication administration.3. e. Ensure the physician's order and Medication Administration Record (MAR) are updated in Point Click Care (PCC) to accurately reflect the medication being dispensed and administered.An observation during medication administration on 4/15/2026 at 9:15 AM revealed an order on the electronic Medication Administration Record (EMAR) for Benztropine Mesylate Tablet 1 milligram (mg) with instructions to administer 0.5 mg tablet by mouth two times a day for mood disorder. Licensed Practical Nurse (LPN) #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident requiring oral care for one (1) of three (3) sampled residents. Resident #3 Findings Include: Review of the facility policy titled The Care Plan with a revision date of 4/2019 revealed, The Comprehensive Care Plan is completed within seven (7) days after the MDS (minimum data set) is completed . Record review of the Activities of Daily Living (ADL) Care Plan for Resident #3 revealed under, Focus: The resident has an ADL self care performance deficit r/t (related to) Hemiplegia from hx (history) of CVA (Cerebrovascular Accident) affecting left side. Further review revealed the care plan was not developed for oral care. An observation of Resident #3 on 5/07/25 at 8:40 AM revealed she was sitting in her wheelchair in the hallway and was alert but confused and did not answer questions appropriately. Her lower lip was observed as dry and cracked with peeling skin. An observation of Resident #3 on 5/07/25 at 10:05 AM revealed she was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide oral care for one (1) of three (3) residents requiring assistance with activities of daily living (ADLs). Resident #3 Findings Include: Review of the facility policy titled Oral Care, with a revision date of 6/2022, revealed under Standard: It is the standard of this facility that every resident will receive oral care at least twice daily, and as needed. Additionally revealed under Process: . 10. Inspect the resident's mouth, teeth and gums for open areas of irritation; notify the supervising nurse immediately of any problems noted or any complaints by the resident. 11. Apply lip balm to the resident's lips and use lemon and glycerin swabs to lubricate the resident's mouth . A telephone interview with a confidential source on 5/06/25 at 1:32 PM revealed Resident #3 was admitted to the facility after suffering a stroke and explained the resident had lost function of the left side of her body. The source revealed that the resident only received hydration through a feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident and staff interview, record review, and facility policy review, the facility failed to develop a resident specific comprehensive care plan that identified trigger specific interventions for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 19 care plans reviewed. Resident #45 Findings Include: Review of the facility policy titled RAI (Resident Assessment Instrument)/Care Planning Management with a revision date of 4/2019 revealed under, The Care Plan: The Comprehensive Care Plan is completed within seven (7) days after the MDS (Minimum Data Set) is completed and reviewed quarterly thereafter. Review of the facility policy titled Trauma Informed Care with a revision date of 10/2022 revealed under, Policy Explanation and Compliance Guidelines: . 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professional to develop and implement individualized care plan interventions. 6. The facility will identify triggers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident and staff interview, record review, and facility policy review, the facility failed to complete a trauma informed care assessment for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 53 residents residing in the facility. Resident #45 Findings Include: Review of the facility policy titled Trauma Informed Care with a revision date of 10/22 revealed, Standard: It is the standard of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Record review of the admission Record revealed the facility re-admitted Resident #45 on 10/02/24 with medical diagnoses that included Post Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder, and Major Depressive Disorder. Record review of the admission Social History dated 10/03/24 for Resident #45 revealed there was no documentation regarding Post…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and facility policy reviews the facility failed to clean and disinfect a multi-use glucometer with the approved disinfecting wipe for two (2) of two (2) medication carts reviewed. Findings Include: Record review of the policy titled, Diabetic Management, dated 04/2019, revealed, Cleaning and disinfecting your EvenCare G2 Meter: .4. To disinfect your meter, clean the meter surface with one of the following disinfecting wipes: Dispatch Hospital Cleaner Disinfectant Towel with Bleach (1 minute). Medline Micro-Kill Disinfecting, Deodorizing, cleaning wipes with Alcohol (30 seconds). Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (1 minute). Medline Micro-Kill Bleach Germicidal Bleach Wipes (2 minutes) . An observation and interview on 11/19/23 at 4:10 PM, with Licensed Practical Nurse (LPN) #4, the LPN used the glucometer to check finger stick blood sugar (FSBS) of a resident and upon return to the B hall medication cart LPN#4 retrieved a pack of 75% alcohol disinfecting wipes and wiped the glucometer with the alcohol wipe for about 15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review the facility failed to prevent a resident from being physically restrained by the sound of a chair alarm for one (1) of three (3) residents with chair alarms reviewed. Resident #23. Findings include: Review of the facility policy titled, Restraint Standards; Physical Restraints with a revision date of 4/2023 revealed under, Physical Restraints Standard .The goal of this facility is to ensure that each resident attains and maintains his/her highest practical level of function and well-being in an environment that limits restraint use to circumstances in which the medical symptoms of the resident warrant the use of the least restrictive restraint. On 11/19/23 at 3:40 PM, an observation and interview revealed a chair alarm on Resident #23's wheelchair that was pinned to the back of her shirt. This observation revealed the resident propels herself with her feet in the wheelchair. During an interview at the same time with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to identify and analyze information obtained from a Minimum Data Set assessment for a chair alarm restraint prior to developing the comprehensive care plan for one (1) of three (3) residents with a chair alarm, Resident #23. Findings include: Review of the typed statement on facility letterhead dated 11/21/23 revealed the facility did not have a policy regarding MDS assessment. The facility uses the current RAI (Resident Assessment Instrument) Manual and was signed by the Administrator. During an observation and interview on 11/19/23 at 3:40 PM, revealed a chair alarm on Resident #23's wheelchair that was pinned to the back of the resident's shirt. This observation revealed the resident propels herself with her feet in the wheelchair. An interview at the same time with Resident #23 revealed that the resident is alert to herself and pleasantly confused on time and place. The resident was asked if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to identify and properly care plan a restraint for a resident with a chair alarm for one (1) of three (3) residents with a chair alarm reviewed. Resident #23 Findings Include Review of the facility policy titled, Care Planning Management with a revision date of 04/2019 revealed under Process for Completing the .Care Plans .Standard; It is the practice of this facility to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Objective .#1. To identify resident's individual needs and care requirements, #2. To assure that an interdisciplinary team assesses the emotional, psychosocial, mental, and physical needs of each resident. Care Conference Protocol .After the team reviews the triggered areas of concern, a care plan decision will be made. Problems will be identified and written in an interdisciplinary, CAA (Care Area Assessment) integrated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.