Ashby Ponds INC

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 111 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 26.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 46 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 44 beds and averages 42.0 residents a day — about 95% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.44 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.31 hrs/resident/day on weekends vs 5.02 on weekdays — 14% thinner on weekends. RN hours go from 1.71 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

• Potential for harm · Ecited before2024-02-22 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 16 residents in the survey sample, Resident #93. The findings include: For Resident #93 (R93) the facility staff failed to implement the comprehensive care plan for completing dialysis communication forms on 01/26/2024, 01/29/2024, 02/07/2024, 02/09/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024 and on 02/21/2024. R93 was admitted to the facility with diagnoses that included but was not limited to end stage renal disease. R93's most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/08/2024, coded (R93) as scoring a 15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions. The physician's order for R93 dated 01/25/2024 documented in part, Dialysis M/W/F ([NAME]/Wednesday/Friday) . The…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-02-22 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement a complete pain management program for two of 16 residents in the survey sample, Residents #1 and #8. The findings include: 1. For Resident #1 (R1), the facility staff failed to conduct a complete pain assessment and failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medication of morphine (1). R1 was admitted with diagnoses that included but not limited to pain. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/11/2024, R1 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section J Pain Management coded R1 as having frequent pain at a pain level of five out of ten, with ten being the worse pain. The physician order for R1 documented in part, Morphine concentrate 100mg (milligrams)/5 ml (five milliliter) oral…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-02-22 · tag F0698 — failed to provide proper dialysis care — pattern
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and service for a complete dialysis (1) program for one of one dialysis residents in the survey sample, Resident #93. The findings include: For Resident #93 (R93) the facility staff failed to ensure dialysis communication forms were on 01/26/2024, 01/29/2024, 02/07/2024, 02/09/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024 and on 02/21/2024. R93 was admitted to the facility with diagnosis that included but was not limited to end stage renal disease. R93's most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/08/2024, coded (R93) as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The physician's order for R93 dated 01/25/2024 documented in part, Dialysis M/W/F ([NAME]/Wednesday/Friday) . The comprehensive care…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-02-22 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication, for one of 16 residents in the survey sample, Resident #26. The findings include: For Resident #26 (R26), the facility staff failed to ensure the physician documented the clinical rationale and intended duration of use for prn (as needed) lorazepam (1) which was ordered for more than 14 days. A review of R26's clinical record revealed a physician's order dated 12/4/23 for lorazepam 0.5mg (milligrams) every four hours prn for anxiety, nausea/vomiting, or shortness of breath. A review of R26's December 2023 and January 2024 MARs (medication administration records) revealed the resident was administered prn lorazepam on 12/5/23, 12/8/23, 12/12/23, 12/13/23, 12/19/23, 12/20/23, 12/21/23, 12/22/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, 12/31/23, 1/2/24, 1/3/24, 1/4/24, and 1/8/24. Further review of R26's clinical record failed to reveal the physician documented the clinical rationale and intended duration of use…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-02-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and facility document review, it was determined facility staff failed to store and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 02/20/2024 at approximately 6:30 p.m. an inspection of the kitchen was conducted with OSM (other staff member) #1, the chef which revealed the following: 1. On 02/20/2024 at approximately 6:30 p.m., an observation of inside of the walk-in refrigerator during the initial tour of the facility kitchen revealed four ladder racks with several hotel pans and sheet pans containing several different food items. Observation of the first ladder rack revealed a Mid hotel pan, measuring 21 inches long by 13 inches wide and three inches deep, containing quartered ham slices. Further observations revealed it was approximately half full and partially covered with plastic wrap, exposing the ham to the environment. Observation of a second ladder racked revealed two sheet pans filled with hash browns uncovered, exposing the hash browns to the environment; three other sheet pans, two 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-02-22 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to promote dignity for one of 16 residents in the survey sample, Resident #18. The findings include: For Resident #18 (R18), the facility staff failed to close the window blinds while completing treatment for the resident's sacral wound. On 2/22/24 at 9:57 a.m., an observation of RN (registered nurse) #3 and LPN (licensed practical nurse) #2 performing wound care on R18's sacrum was conducted. During wound care, R18 was lying in bed with his sacrum and buttocks exposed. The window blinds in the room remained open and the room was visible from an outside sidewalk and parking lot. One person was observed walking outside. On 2/22/24 at 2:43 p.m., an interview was conducted with LPN #1. LPN #1 stated staff should make sure window blinds and shades are closed before performing wound care on a resident's sacrum. On 2/22/24 at 3:13 p.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern. The…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-02-22 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control practices for one of 16 residents in the survey sample, Resident #35. The findings include: For Resident #35 (R35), the facility staff failed to perform hand hygiene when changing gloves during wound care. On 02/22/2024 at approximately 9:37 a.m., an observation was conducted of LPN (licensed practical nurse) #1 providing wound care to R35. After donning a pair of clean gloves, LPN #1 removed the soiled dressing from R35's left heel, removed her gloves with the dressing, disposed of the gloves and dressing in a trash can, donned a clean pair of gloves, cleaned R35's wound and applied a clean dressing. Observation revealed that LPN #1 failed to wash or sanitize her hands before putting on a clean pair of gloves after removing the old dressing. On 02/22/2024 at approximately 9:50 a.m., an interview was conducted with LPN #1. When informed of the observation she stated that she should have washed or sanitized her hands when she changed her…

  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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-04-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The facility staff failed to date and dispose of expired or opened food during the facility task kitchen observation on 4/26/22 at 4:17 PM in one of three kitchen areas. The findings include: On 4/26/22 at 4:17 PM, an observation was conducted in the main kitchen. In the dry storage room a 12 ounce box of penne pasta was loosely wrapped with saran wrap and had a green label which revealed, date opened 10/21/21 and date expired 1/21/22. The penne pasta box was approximately one half full. In addition, there was a plastic bag with shell pasta that was tied together with both ends of the bag. The shell pasta bag contained approximately one pound of shells. There was no label on bag of date opened or date expired. An interview was conducted on 4/26/22 at 4:25 PM with OSM (other staff member) #2, the dietary aide. When asked to review the penne pasta box and the shell pasta bag, OSM #2 stated, They should not be like that. We…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2022-04-28 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and staff interview the facility staff failed to follow infection control practices for one of seven residents in the medication administration observation, Resident # 34 (R34). The facility staff placed their ungloved finger on the inside of the medication cup while administering medications to (R34). The findings include: (R34) was admitted with diagnoses that included but were not limited to: vitamin deficiency and pressure ulcer. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/024/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired of cognition for making daily decisions. On 04/27/2022 at approximately 8:19 a.m., the medication administration observation was conducted with LPN (licensed practical nurse) # 1. LPN # 1 unlocked and opened the medication cabinet and removed several medication bubble packs and a small 30 ml (milliliter) plastic medication cup. LPN # 1 then verified (R34's) medication bubble packs 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2021-03-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner. In the walk in refrigerator, a bottle of zesty orange sauce without an open or use by date and a ten pound container of sweet-and-sour duck sauce, was observed available for use past the labeled use by date of 2/21/21 on the container. Then findings include: On 03/23/2021 at approximately 8:36 a.m., an observation of the facility's kitchen was conducted with OSM [other staff member] # 1, general manager for continued care dining. Observation of the walk-in refrigerator in the facility's kitchen revealed the following: - One 5.4 pound bottle of zesty orange sauce approximately three-quarters full found on a top shelf available for use. Further observation failed to evidence an open date or a use-by-date. OSM # 1 was then asked to observe the bottle of orange sauce for a manufacturer's use-by-date. OSM # 1 agreed that a use-by date was not on the bottle. - One 10 pound container of sweet-and-sour duck sauce approximately three-quarters full…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$9,438 in federal fines across 4 penalties.

• $2,447 — penalty dated 2023-10-10
• $2,098 — penalty dated 2023-10-02
• $1,748 — penalty dated 2023-09-25
• $3,145 — penalty dated 2023-09-05

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ERICKSON SENIOR LIVING — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 48 rows in the source record cover these 31 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $10.3M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

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