Ashley Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF600Feb 3, 2022

  Based on observation, interview and record review, the facility failed to prevent abuse, and protect residents from continued abuse, due to widespread system failures beginning with the failure to complete a facility assessment to determine resident acuity and appropriate number of staff and the lack of properly trained, certified, and orientated staff in sufficient numbers to provide care. This deficient practice resulted in an Immediate Jeopardy (IJ) beginning on 9/4/21 when the facility failed to prevent resident to resident abuse between R4 and R23 and for Residents R2, R5, R27, R93, and R43, as a result of the facility's failure to prevent, thoroughly identify, protect residents, investigate, and report abuse to the State Agency. […]

• Immediate jeopardy, widespreadF675Feb 3, 2022

  Based on observation, interview and record review, the facility failed to provide an environment which supported and enhanced each resident's Quality of Life, resulting in an Immediate Jeopardy that began on 1/23/2022 due to the cumulative, dehumanizing, and widespread effect of noncompliance identified at but not limited to abuse, staffing, qualified staff, ADL care, social services, unnecessary [CONDITION(S)] meds, accidents and hazards and governing body. This noncompliance was found to be pervasive throughout the facility and created an environment that reflected a complete disregard of one or more residents' individuality and Quality of Life, which has caused or is likely to cause serious harm related to one or more residents' physical and psychosocial health, self-worth, self-esteem,… […]

• Immediate jeopardy, widespreadF677Feb 3, 2022

  Based on observation, interview, and record review, the facility failed to provide timely and consistent ADL (activities of daily living) care to 9 residents (Resident #42, Resident #148, Resident #145, Resident #20, Resident #143, Resident #146, Resident #151, Resident #17, and Resident #93, R#28), resulting in an immediate jeopardy, when beginning on 01/23/22, the facility failed to provide staffing to meet the ADL needs of the residents and allowed residents to (a) lay in their urine and feces for extended periods of time, (b) not receive meals timely or eating assistance if required, (c) go un-bathed, unkempt, and to be malodorous, (d) remain in bed for over 24 hours, and (e) unnecessarily utilize a bed pan for toileting. […]

• Immediate jeopardy, widespreadF689Feb 3, 2022

  Based on observation, interview and record review, the facility failed to prevent accidents and hazardous situations for 17 residents (Resident #148, Resident #144, Resident #42, Resident # 8, Resident #153, all 11 residents on the locked memory care unit, Resident #6, and Resident #3) resulting in an Immediate Jeopardy, when beginning on 01/23/22, the facility failed to (a) follow a strict ordered diet of NPO (nothing by mouth) and provide a functioning call light system for Resident #148, (b) implement standard safety protocols to prevent a fall and correctly assess for neurological changes after an unwitnessed fall for Resident #144, (c) safely transport Resident #8 and Resident #42 in a wheelchair, and assess Resident #42's level of staff assistance needed to safely complete activities… […]

• Immediate jeopardy, widespreadF725Feb 3, 2022

  Based on observation, interview, and record review, the facility failed to ensure systems were in place to provide sufficient staffing to meet resident needs (incontinence care, pressure ulcer prevention, oxygen therapy, ADL care, supervision, [CONDITION(S)] medication monitoring) for 6 residents (R143, R146, R151, R28, R93, and R17) reviewed for staffing, resulting in an Immediate Jeopardy when, beginning on 1/23/22, facility staff did not meet the basic needs of residents. This deficient practice placed all residents residing in the facility at risk for serious harm, injury, and/or death. Findings: Resident #143 (R143) Review of an Admission Record revealed R143 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]