Ashley Medical Center Nursing Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF578Dec 15, 2021

  Based on record review, review of facility policy, and staff interview, the facility failed to ensure the medical record for 5 of 12 sampled residents (Resident #9, #10, #11, #13 and #18) accurately reflected the resident's code level directive. Failure to ensure the resident or the resident's legal representative signed the code level directive has the potential to inaccurately reflect the resident's wishes for life-sustaining services. Findings include: Review of the facility policy titled Provider Statement/Code Level Directive occurred on 12/14/21. This policy, revised 07/14/16, stated, . The provider statement identifies if the resident is capable, or incapable of making decisions independently. […]

• No harm, potential for more than minimal, patternF804Dec 15, 2021

  Based on observation, review of facility policy, resident interviews, review of resident council meeting minutes, and meal test tray, the facility failed to serve foods at palatable temperatures for 1 of 1 meal observed (noon meal 12/14/21). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Holding Temperatures occurred on 12/14/21. This form, dated 1998-1999, stated, . Serve/Hold: Hot Foods - above 140 degrees Fahrenheit (F) . check temperature of item every 30 minutes . Cold Foods - at 41 degrees F or below . Review of the 09/02/21 Resident Council meeting minutes occurred on 12/13/21. […]

• No harm, potential for more than minimal, patternF886Dec 15, 2021

  Based on review of facility policy and staff interview, the facility failed to include all elements required for 1 of 1 facility policy reviewed for resident and staff refusal of [CONDITION(S)]-CoV-2 (COVID-19) testing. Failure to have a process in place for testing refusal may lead to a lack of further required interventions. Findings include: Review of the facility policy titled Testing Residents and Healthcare Personnel for [CONDITION(S)]-Cov-2 occurred on 12/15/21. This undated policy lacked a procedure for staff and residents who refused COVID-19 testing. During an interview on 12/15/21 at 9:10 a.m., an administrative staff member (#1) confirmed the facility failed to have a procedure established for staff and/or residents who refused COVID-19 testing.

• No harm, potential for more than minimal, isolatedF557Jul 2, 2025

  Based on observation and staff interview, the facility failed to provide access to a personal phone for 1 of 1 sampled resident (Resident #13). Failure to place a resident's personal phone within reach limits the residents' ability to communicate with friends and family and may result in loneliness.Findings include: Review of the facility admission packet occurred on 07/02/25. This packet contained A Guide to Your Rights as a Resident of a Nursing Facility in North Dakota. Page 16 of this document stated, You have the right to safe, clean and comfortable surroundings, allowing you to keep your personal belongings to the extent space permits. […]

• No harm, potential for more than minimal, isolatedF641Jul 2, 2025

  Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #11 and #13). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan, and the care provided to the residents. Findings include:SECTION E: BehaviorThe Long-Term Care Facility RAI User's Manual, revised October 2024, pages E-1 to E-2 stated, . E0100: Potential Indicators of Psychosis . Hallucinations . Delusions . Review the resident's medical record for the 7-day look-back period. […]