Ashland Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ashland Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 18, 2026

  Based on observations, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to protect one of eight residents in the survey sample, Resident #1, from sexual abuse when the resident was unable to consent to sexual acts and failed to prevent neglect due to lack of adequate supervision for Resident #1 with a history of elopement. This resulted in Immediate Jeopardy and substandard quality of care. After the Immediate Jeopardy was removed the scope and severity level was lowered to a level two (2) pattern.The findings include:a. […]

• Immediate jeopardy, isolatedF689Mar 18, 2026

  Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide an accident and hazard free environment which lacked supervision involving two of eight residents in the survey sample, Residents #1, and #2. This resulted in Immediate Jeopardy and substandard of care. After the Immediate Jeopardy was removed the scope and severity was lowered to a level two (2) pattern. The findings include: a. For Resident #1, the facility staff failed to supervise the resident with a known wandering and exit seeking behavior and failed to secure exit doors, resulting in the Resident eloping.Resident #1 was most recently admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF838Mar 18, 2026

  Based on staff interview and facility document review, the facility staff failed to review and revise the Facility Assessment with changes in the administrative team members.The findings include:Review of the Facility assessment on 5/13/2026 documented the name of the administrator prior to November 2025. The next administrator employed was not listed, and the current interim administrator, who started in February 2026, was not listed. The Current Director of Nursing was not listed, and she came in November 2025. The Medical Director listed had ended his contract with the facility on April 1, 2026. The date the assessment was updated or revised was August 27, 2025.[NAME] interview was conducted with the Executive Director on 5/13/2026 at 4:50 p.m. […]

• No harm, potential for more than minimal, widespreadF565Aug 21, 2025

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to facilitate resident council meetings for three of nine months, potentially affecting all residents, and failed to resolve grievances identified in the resident council meetings for two months reviewed.1. The facility staff failed to facilitate resident council meetings from 5/1/2025 through the present potentially affecting all residents in the facility. A review of the facility resident council meeting minutes from 10/1/2024 to the present failed to evidence any meeting minutes after 4/17/2025. […]

• No harm, potential for more than minimal, widespreadF680Aug 21, 2025

  Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure the activities program was directed by a qualified professional between 1/29/2025 and 6/27/2025 potentially affecting all residents in the facility.The findings include:The facility staff failed to ensure a director of activities was in place between 1/29/2025 and 6/27/2025.On 8/19/2025 at 2:09 p.m., an interview was conducted with Resident #17 (R17) who stated that they could remember a time this year when there were no activities. R17 stated that he liked to go to various activities, but there were none being done that he knew of. He stated he thought there should have been someone to do them for him and other residents. […]