Ashland Health and Rehabilitation

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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) . [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]