Ashby Care Center

In the surveyor’s words

From the most serious findings on record at Ashby Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 10, 2024

  Based 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. Findings: Review of the Admission Record showed the facility admitted Resident 3 on 3/11/2023. The diagnoses included dementia (memory difficulty). Resident 3 received hospice services (end-of-life comfort care) while at the facility. […]

• Actual harm, isolatedF656Oct 13, 2023

  Based 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 . Findings: A review of Resident 1's admission record indicated resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, cancer of the spine, difficulty in walking, abnormalities of gait (manner of walking), and mobility. […]

• No harm, potential for more than minimal, widespreadF755May 22, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF565Oct 20, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF679Oct 20, 2023

  Based 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. Findings: 1. Review of Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 4/21/23, indicated: Resident 3's Basic Interview of Mental status (BIMS- score was 14 meaning cognitively intact). Resident 3's activity preferences included listening to music, doing things with groups of people and participate in religious services or practices that were very important. […]