Ashley Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Ashley Rehabilitation and Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 1, 2024

  Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure a resident was free from abuse for 1 (Resident #5) of 3 sampled residents reviewed for abuse. Specifically, the facility failed to ensure Resident #5 was free emotional abuse. The Immediate Jeopardy began on 09/02/2024, when CNA #4 made inappropriate statements to Resident #5 when she walked into the shower room while Resident #5 was taking a shower with help of CNA #4. CNA #4 and showed an inappropriate picture to Resident #5. The facility failed to investigate this incident until 09/09/2024. The facility had failed to train staff in abuse and neglect. […]

• Immediate jeopardy, isolatedF678Nov 1, 2024

  Based on record review, interview, and facility policy review the facility to administer Cardiopulmonary Resuscitation (CPR) upon discovering 1 (Resident #62) sampled resident pulseless and breathless despite the resident being a full code. The Facility notified of the Immediate Jeopardy on [DATE] at 1:40 PM. The Facility Plan of Removal (POR) noted the facility will continue CPR upon discovering a resident pulseless and breathless when the resident is a full code signed [DATE]. The findings include: According to the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] Resident #62 had a Brief Interview of Mental Status of 15 indicating cognitively intact. Resident #62 had diagnoses of heart failure and morbid obesity. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2026

  Based on observation, interview and facility document review, the facility failed to ensure that the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and potential development of foodborne pathogens in one of one kitchen observed. The findings include: During an observation of the lunch meal preparation on 05/13/2026 at 10:45 AM, [NAME] #6 was observed pureeing rice. [NAME] #6 took the lid off the chicken base put it upside down on the preparation table, obtained the needed amount of chicken base in the container with a plastic spoon and mixed it in a container of water. […]

• No harm, potential for more than minimal, widespreadF725Nov 1, 2024

  Based on interview and record review, the facility failed to ensure there was sufficient nursing staff to meet the residents' needs for 7 shifts reviewed from 09/01/2024 through 09/30/2024. On 10/28/2024 at 3:42 PM, Resident #29 was interviewed and stated the resident believed the daytime [shift] was understaffed because residents do not receive showers as they should. Resident #29 stated the resident's scheduled bath/shower days were Tuesday, Thursday, and Saturday. Resident #29 stated the resident did not receive a shower on Saturday, 10/26/24, due to the facility on ly had one Certified Nursing Assistant (CNA) working the hall the resident resided. The resident alleged the facility has two CNAs working in the building some nights. […]

• No harm, potential for more than minimal, widespreadF732Nov 1, 2024

  Based on observation, interview, and record review, the facility failed to post the daily nurse staffing information, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents. The total census was 60. A Shift Staffing Schedule, dated 10/28/2024 for the 7:00 AM to 3:00 PM shift, was reviewed and did not have the facility's name, the number and actual hours worked by staff, the resident census or the licensed staff scheduled to work. The shift staffing schedule, dated 10/28/2024 for the 11:00 PM to 7:00 AM shift, was reviewed and only one Certified Nursing Assistant's (CNA's) name was listed on the sheet. […]