Ashby Ponds Inc

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF656Feb 22, 2024

  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. […]

• No harm, potential for more than minimal, patternF697Feb 22, 2024

  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. […]

• No harm, potential for more than minimal, patternF698Feb 22, 2024

  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. […]

• No harm, potential for more than minimal, patternF758Feb 22, 2024

  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. […]

• No harm, potential for more than minimal, patternF812Feb 22, 2024

  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. […]