Ashley Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to accurately document the code status for 1 resident (R18) of 1 resident reviewed for advance directives.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge needs were met for 1 resident (R23) of two residents reviewed for discharge concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a patient centered care plan for pain and pressure ulcers for 1 Resident (R1) of 13 residents reviewed for care plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders to treat and monitor health conditions for 1 Resident (R2) of 1 Resident reviewed for medical complaints.

Inspectors wroteBased on interview and record review, the facility failed to recognize, assess and respond to an acute change of condition for 1 (R29) resident of 2 residents reviewed for change of condition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to thoroughly assess skin on admission, do ongoing assessments, implement an effective treatment plan, and prevent the worsening of pressure ulcers for 1 resident (R1) of 2 residents reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer.

Inspectors wroteBased on observations, interviews and record review the facility failed to assess, monitor and implement a respiratory care plan for 1 Resident (R1) on Continuous Positive Airway Pressure (CPAP).

Inspectors wroteBased on observations, interviews and record review, the facility failed to adequately treat 1 Resident (R1) for pain of 1 Resident reviewed for pain.

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services to meet the needs of one resident (R9) of one resident reviewed for laboratory services.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate, clear, and concise Electronic Medical Record (EMR) for 2 residents (R18, and R9) of 14 residents reviewed.

Inspectors wroteBased on observations, interview and record review, the facility failed to clean 1 resident's (R1) Continuous Positive Airway Pressure (CPAP) machine of 1 Resident on CPAP.

Inspectors wroteBased on interview and record review, the facility failed to operationalize the facility infection control policy to provide influenza and pneumococcal vaccines timely for two newly admitted Residents (R1 and R21) of six residents reviewed for immunizations.

Inspectors wroteBased on interview and record review the facility failed to operationalize the facility infection control policy to provide Covid-19 vaccine timely for two newly admitted Residents (R1 and R21) of six residents reviewed for immunizations and failed to implement a process to track and monitor staff Covid-19 education and immunization status.

Inspectors wroteThis citation pertains to intake 2621833Based on interview and record review, the facility failed to protect the resident's (Resident #301) right to be free from physical abuse by a resident (Resident #300).

Inspectors wroteThis citation pertains to intake 2621833Based on interview and record review, the facility failed to implement their abuse policy resulting in an allegation of physical abuse to go unreported with no investigation.

Inspectors wroteThis citation pertains to intake #2579353. Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for 1 resident (R203) of three residents reviewed for falls resulting in R203 falling from her raised bed to the floor and sustaining a fracture of her femur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 resident (R203) of 7 residents reviewed.

Inspectors wroteThis citation pertains to intake # MI00153789 and #MI00152893 Based on interview and record review, the facility failed to provide quality care to one of three residents reviewed (Resident #100) resulting in the delay of on-going assessments including pain assessments and providing adequate pain relief, the initiation of potential hip fracture mobility interventions, and emergency medical treatment, following a fall that resulted in a fractured hip.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor for outdated medications and maintain proper storage of insulin in the facility medication room refrigerator, resulting in the storage of discontinued and outdated insulin and the potential for outdated medication to be administered to facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control procedures in one room (room [ROOM NUMBER]) and for 3 of 6 residents ( R37, R48, and R52) in isolation for COVID-19, potentially affecting 14 of 51 residents, resulting in the potential for cross contamination and the spread of COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (R206) was provided adequate, accessible hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the hospice service of a change in the plan of care for one resident (R206) after a fall and Care Plan changes had been implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) ensure proper posting of Enhanced Barrier Precaution (EBP) and Transmission Based Precaution (TBP) signage, 2) ensure proper use of Personal Protective Equipment (PPE), and 3) ensure prevention of contamination of treatment supplies and the treatment cart for 2 residents (Resident #33 and #394) of 3 residents reviewed for Transmission Based Precautions, resulting in the increased potential for cross-contamination, bacterial harborage and spread of infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean environment for 1 Resident #29 (R29) of 14 residents reviewed for clean environment, resulting in a consistent offensive odor coming from R29's bathroom.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate health record for 1 resident (Resident #33) of 14 residents reviewed for accuracy of medical records, resulting in unclear documentation and the potential for miscommunication and an unclear picture of the resident's health care status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights and fluids were within reach for 2 residents (Resident #49 and Resident #12) out of 3 resident reviewed for accommodation of needs.

Inspectors wroteThis citation pertains to Intake Number(s): MI00139878, MI00139961, MI00141377, MI00142340. Based on interview and record review, the facility failed to report an allegation of abuse timely to the state agency and law enforcement for 6 of 6 residents, Resident #25, #35, #43, #52, #106, and #109 (R25, R35, R43, R52, R106 and R109) reviewed for timely reporting. This deficient practice resulted in allegations of abuse with injury and serious injury to go unreported to local law enforcement and uninvestigated.

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified Infection Preventionist was present to properly assess, implement, and manage the Infection Prevention and Control Plan during a COVID 19 outbreak.

Inspectors wroteThis citation pertains to Intake Number(s): MI00139878 Based on interview, and record review the facility failed to follow the facility to thoroughly investigation abuse for 1 of 6 residents, Resident #106, (R106) reviewed for abuse.