Ashby Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing resident-centered activity program to support residents individualized activities needs for three of (Resident 1, 2 and 3 ) of three sampled residents when;Facility did not provide consistent resident-centered activities. Facility did not provide residents activities in the evening and on weekend. Facility did not address Resident 2's impaired cognition with individual activity care plan. Activities refers to any endeavor, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were provided the opportunity to participate in regular Resident Council meetings, as the facility did not hold scheduled or routine Resident Council meetings for a census of 27 residents. This failure had the potential to result in the inability of residents to voice their concerns or contribute to improving facility operations impacting their dignity and overall quality of life. During an interview on 3/4/26 at 2:13 p.m. with Administrator (ADM), ADM stated she was unaware of the location of resident council meeting minutes, provided a two-page list of resident names from the past two months and stated it was the attendance list for the past resident council meetings. During an interview on 3/5/26 at 10:51 a.m. [...]

Inspectors wroteBased on observation, interview and record review, for four of four sampled residents (Residents 1, 2, 3 and 4), the facility failed to ensure that activities were designed to meet the interests and the physical, mental, and psychosocial well-being of residents. This failure had the potential to result in residents not receiving individualized, meaningful activities that support their quality of life. During a review of Resident 1's admission Record (AR) dated 10/29/24, the AR indicated Resident 1 was admitted to the facility in October 2024 with diagnoses that included major depressive disorder (serious common mood disorder characterized by persistent sadness, loss of interest that significantly impacts daily functioning). [...]

Inspectors wroteBased on observation, interview, and record review, the hospital failed to ensure the accuracy of controlled drug records as evidenced by: 1. The facility failed to ensure the scheduled (narcotic) medication records (Controlled Drug Record, MAR) were accurate. For three (Residents 160, 165, 167) out of three residents sampled, the Controlled Drug Record (inventory of scheduled drug) and the Medication Administration Record (MAR, record of drug administration) were not accurate. This failure resulted in the potential for residents to be exposed to avoidable medication errors. In addition, this failure resulted in the potential for scheduled drug diversion. 2. The facility failed to ensure the Consultant Pharmacist reviewed the scheduled (narcotic) medication records (Controlled Drug Record, MAR) for accuracy. [...]

Inspectors wroteBased on interview and record review, for six of six sampled residents (Residents 119, 118, 116, 112, 113 and 111), the facility failed to offer or ensure an advance directive (a written instruction for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) was on file, when the facility did not offer or help the residents/representatives to locate or complete the advance directive. This failure had the potential for Residents 119, 118, 116 112, 113 and 111's wishes regarding provision of health care to not be honored.

Inspectors wroteBased on interview and record review, for five (Residents 118, 112, 164, 3, and 117) of five sampled residents, the facility failed to complete the quarterly Minimum Data Set assessments (MDS - Resident Assessment and care guide tool) according to the regulation. This failure had the potential to result in the delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of all its nurse aide staff at least once every 12 months, not following its policy and procedures and standards of practice. This failure had the potential to have incompetent nurse aides caring for residents, poor quality of care and quality of life for residents, risk for injury, accidents, infection, hospitalization, and possibly death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a full time (working 35 or more hours a week) Certified Dietary Manager for food and nutrition services for 24 Residents residing in the facility, not following standards of practice. This failure had the potential of not meeting the resident's nutritional needs, and placing residents at risk of not receiving meals/diet in a safe and sanitary manner, with the potential for infection, pressure injury, and possibly hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label food in the storage area (for the retention of food [before and after preparation] and associated dry goods), used for 13 out of 13 sampled residents' nourishment, not following their facility policy and procedure and professional standards of practice for food service safety. This failure has the potential for Residents not getting palatable food and nourishment, the potential for foodborne illnesses/outbreak, infection and potential for hospitalization. During a brief kitchen observation on 5/19/25, at 09:21 a.m., with the Dietary [NAME] (DC), Corn Flakes Cereal not in the original box, package labeled 6/9/2022. Bran Raisin package had been opened with no opened date labeled, and Oatmeal was still in its original manufacturer package and had no opened label on it. [...]

Inspectors wrote6. During a concurrent medication administration observation and interview, on 5/20/25 at 7:45 a.m., Licensed Vocational Nurse (LVN 1) identified residents to receive medication. LVN 1 administered medications to residents in the order of Resident 161, 117, 118, and 160. For each resident, LVN 1 used a portable blood pressure (BP, vital sign) machine. The resident's BP measurement included placing an inflatable cuff around the arm. In between each resident, LVN 1 returned to the medication cart (cart to store medications) to prepare medications. After using the machine on Residents 161 and 117, LVN 1 placed the BP cuff directly on the top of the medication cart. During medication administration to the four residents, LVN 1 did not clean the BP cuff or the top of the medication cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 13 sampled residents was free from physical restraints when the facility staff placed Resident 167 in a Geri chair with a hard table cover over the Geri chair (a large, padded chair that is designed to help seniors with limited mobility), preventing Resident 167's freedom of movement (change in place or position for the body or any part of the body that the person is physically able to control) and from getting in and out of the Geri chair at his own will. This failure placed Resident 167 at risk of self-injury, of not attaining and maintaining their highest practicable well-being or good quality of life.

Inspectors wroteBased on interview, the facility failed to ensure the Infection Preventionists (infection control nurse or designee) had completed specialized training in infection prevention and control. This failure had the potential to contribute to the residents' development of contracting healthcare acquired infections (infections from receiving treatment at a facility).

Inspectors wroteBased on observation, interview and record review, the facility had six resident rooms (Rooms 1, 3, 5, 7, 8, and 9) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.

Inspectors wroteThe facility failed to ensure proper medication storage when: 1. Medication refrigerator was not padlocked 2. Medication room dry storage temperature log did not have entries for December 2 and 3, 2024 3. Medication room refrigerator had nutritional supplements along with food items that were not labeled with names and dates 4. The medication room had a staff's clothing item hanging on the door. This failure can potentially result in unsafe medication storage practices and impact the safety and well-being of all 29 residents.

Inspectors wroteThe facility failed to ensure infection control measures were followed when: 1. Outside resident room [ROOM NUMBER] was an open lid bin which contained a used yellow gown. Next to this open bin was a container of unused personal protective equipment (PPE) supplies 2. Inside the medication room, a bag of adult brief pads was found on the floor 3. Inside the medication room, under the sink was a half-full container of water and located next to two containers of chemical agents, one of which was perineal wash. 4. Biohazard door was unlocked. This failure can potentially result to cross contamination of clean product items and impact the physical health, safety and well-being of all 29 residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide the necessary pain medication for one of three sampled residents (Resident 3) Resident 3 required wound dressing changes, three times per week, which were painful and required premedication. The licensed nursing staff did not administer the required pain medication before wound care. This caused unnecessary pain and distress for Resident 3.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to facilitate the resident's right to organize resident group (council) meetings. The group council meetings stopped during the COVID-19 (a respiratory virus that is easily spread causing mild, moderate, or serious illness) lockdown and were never resumed. There was no designated staff person approved by the residents to be responsible for assisting and responding to the resident's concerns or requests that result from group meetings. This failure had the potential to cause residents emotional distress and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities. The facility did not have an active activity program or staff responsible for providing assistance with the activities program. This failure had the potential to cause residents emotional distress and decline in their quality of life.

Inspectors wroteBased on observation, interview, and medical review, the facility failed to provide pharmaceutical services to meet the needs of four of 14 sampled residents (Residents 63, 162, 163, and 170) when the facility failed to perform daily glucometer (small machine that measures blood glucose or sugar level) quality control checks to ensure accurate readings. This failure had the potential risk of adverse consequences associated with the glucometer used for Residents 163 and 170 whose insulin dosage (medication that lowers the blood glucose) were dependent on the accuracy of the glucometer readings. For Residents 63 and 162, this had the risk of incorrect blood glucose readings and inappropriate medical interventions for Residents 63 and 162.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have Registered Dietitian (RD) oversight of the kitchen and clinical nutrition care (ensuring residents are consuming an adequate amount of nutrients for good health) since 7/28/23. There was no full-time Dietary Manager (DM) to manage kitchen operations when the menu was not being followed (cross-reference 803), unsanitary conditions in the kitchen (cross-reference 812), no pest control program (cross-reference 925), and the nutrition status of one (Resident 159) was not being maintained (cross-reference 692). These failures placed 26 of 26 residents who received food from the kitchen at risk for compromised nutritional status and had the potential for transmission of food borne illness.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed when the Cold [NAME] Bean Salad was substituted for Creamy Cucumber Celery Salad on Monday 10/16/23. The lunch menu for 10/16/23 had already included a hot green bean side dish. This failure had the potential to result in not meeting the nutritional needs of the residents and compromising the nutritional status of the residents.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. A refrigerator in the kitchen was dirty, food was not labeled and dated, the door was dirty with smudges. The top freezer of the refrigerator had crusted food and food crumbs, and food was not labeled and dated. A reach-in freezer had food crumbs and the door had dark, brown build-up. This had the potential to contaminate the food or the hands of food workers, that could lead to food borne illness. 2. Dry food storage bins had yellow and brown stains and were not safe for storing food. This had the potential to contaminate the food stored inside. 3. Island shelves storing clean dishware and trays were sticky with grime and food crumbs in the corners. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop an effective Quality Assurance and Performance Improvement plan (QAPI) that identified and addressed the following: - Lack of activity program for residents, - No designated staff person responsible for providing assistance with resident group meetings and activities program, - No resident group meetings since 2020, - Late completion and transmission of Minimum Data Set (MDS- Resident Assessment tool used to guide care). These failures had the potential to cause the residents emotional distress, and decline in residents quality of life and quality of care.

Inspectors wroteBased on interview and record review the facility failed to develop a policy and procedure for an active water management program to address prevention of Legionnaires (LD) and other opportunistic pathogens (disease causing) in water. The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. This failure had the potential to cause spread of water borne pathogen growth in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following equipment was maintained in good repair as follows: 1. [NAME] refrigerator with top freezer: the bottom right side of the rubber gasket on the freezer door was torn and peeled away from the door. 2. Reach-in stainless steel freezer: the door frame was broken off the hinges, the rubber gasket was torn across the top of the lid and there was ice buildup on the inside walls. The Freezer had a crack with the insulation covered with masking tape. This failure had the potential for the refrigerator and freezers to not maintain appropriate temperatures and put the facility at risk for diminished quality of food stored in the freezer and/or affecting the safe storage of food leading to foodborne illness for 26 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functioning call light (communication system) for four of 26 sampled residents (Residents 8, 158, 159, and 160). The facility had no documented call light system tests since 6/9/22. This deficient practice resulted in Residents 8, 158, 159, and 160 not being able to summon staff for care and assistance in an emergency. For all residents, this had the potential for being unable to call for help if the call lights fail to work.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pest free environment when pest droppings and cobwebs were seen in the kitchen and inside the dry food storage. This failure had the potential to contaminate food and cause foodborne illness to 27 of 27 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to conduct comprehensive Minimum Data Set assessments (MDS, an assessment tool used to direct resident care) for six of thirteen sampled residents (Resident 5, 58, 60, 61, 62 and 63) as required by the regulation. These failures had the potential to result in not planning and meeting the residents' needs, strengths, and goals of care.

Inspectors wroteBased on interview and record review, for six (Resident 4, 5, 60, 61, 63 and 159) of thirteen sampled residents, the facility failed to complete the quarterly Minimum Data Set assessments (MDS - Resident Assessment and care guide tool) according to the regulation. This failure had the potential to result in the delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time.

Inspectors wroteBased on interview and record review, for four (Resident 3, 59, 61, and 164) of 13 sampled residents , the facility failed to electronically transmit accurate and complete Minimum Data Set (MDS - an assessment screening tool used to guide care), data to the CMS system within 14 days after the facility completes a resident's assessment. Definition: CMS - The Centers for Medicare & Medicaid Services provides health coverage through Medicare and Medicaid-a government national health insurance program that provided health insurance for adults and children with limited income and resources. These failures had the potential to result in the delay of assessment of residents' needs, goals of care and inability to monitor each residents progress over time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition status for one ( (Resident 159) of three residents when Resident 159 lost 24% of her body weight in the last nine months. Resident 159 was not seen by a Registered Dietitian (RD) for a dietary evaluation since June 2023. This failure had the potential to cause additional weight loss and increase Resident 159's risk of morbidity (the condition of suffering from a disease or medical condition) and mortality (death).

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (Resident 59 and 2 ) of five sampled residents were free from unnecessary drug when; 1. Resident 59 was administered Zyprexa (antipsychotic) drug without adequate clinical indication for its use. Antipsychotic medications are used to treat mental health conditions, capable of affecting the mind, emotions, and behavior. 2. Resident 2's PRN (as needed) order for Haldol (antipsychotic) drug had no informed consent and stop date. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic conditions related to dementia. [Reference: www.[NAME].comp]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medications. These failures had the potential to result in the administration of expired medications to the residents and possible adverse (unwanted, undesirable) side effects or receiving medications that have become less effective for treatment.

Inspectors wroteBased on observation and interview, the facility had six residents (Rt) rooms (room [ROOM NUMBER], 3, 5, 7, 8 and 9) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to correctly identify one (Resident 1) of three sampled residents as a high fall risk and revise the fall care plan accordingly and as needed to maintain Resident 1's physical well-being. This failure resulted in an uwitnessed fall and Resident 1 sustained a subdural hematoma (a collection of blood in the top of the brain), left humeral head fracture (broken upper arm bone) and fracture of the pubic ramus (broken bone in the pelvis) requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records and account of discontinued controlled medications (medications which fall under United States Drug Enforcement Agency (DEA) Scheduled II-V (2 through 5) which have a potential for abuse, ranging from low to high, and may also lead to physical or psychosocial dependency) medications for two (Resident 153, and Resident 159) of three sampled residents. This failure had the potential for the diversion of the antianxiety medication Ativan (lorazepam) and sedative temazepam (Restoril) for unauthorized use.

Inspectors wroteBased on interview and record review, for one of 13 sampled residents (Resident 157), the facility failed to complete the annual Minimum Data Set (MDS, an assessment tool used to guide care) as required. This deficient practice had the potential to result in Resident 157 not receiving the appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility staff did not notify the physician to re-evaluate the resident's mental capability or capacity to be their own responsible party (RP) for medical decisions for one, (Resident 110) of six sampled residents. After hospitalization, Resident 110 became more aggressive and confused and was not able to give consent in the absence of a conservator (a judge appoints a RP to care for another adult who does not have the capacity to make decisions about their health and finances). This resulted in Resident 110 signing consents for antipsychotic (Seroquel) and anti-anxiety medications (Ativan) without full awareness and understanding of the medications and their potential side effects or have a conservator act on the resident's behalf. Definition: Antipsychotic medication: [...]

Inspectors wroteBased on observation and record review, the facility had six resident rooms (Rooms 1, 3, 5, 7, 8, and 9) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.