Ashton Creek Health and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jul 22, 2024

  Based on observation, interview, and record review the facility failed to ensure hand hygiene was performed when necessary, in the meal preparation and service process. 110 of 110 residents residing in the facility consumed food prepared in the facility kitchen. Findings include: During an observation on 7/16/24 at 9:15 AM the Dietary Manager (DM) picked up a garbage can lid from the floor and placed it back on top of the garbage can. No hand hygiene was performed, and she continued the kitchen tour opening the ice machine door and the walk-in cooler door. During an observation on 7/16/24 at 10:31 AM [NAME] 25 was using a blender to prepare pureed chicken for the lunch meal. During the process, the lid became loose, splattering a small amount of pureed chicken onto [NAME] 25's hands. […]

• No harm, potential for more than minimal, patternF583Jul 11, 2023

  Based on observation, interview, and record review the facility failed to ensure privacy for 4 of 32 residents reviewed. (Resident 13, Resident 38, Resident 48, and Resident 97) Findings include: 1.During an interview with Resident 97 and her husband on 7/6/23 at 10:24 AM, Registered Nurse (RN) 20 opened the door to Resident 97's room without knocking and offered her medicine. During the medication administration, Case Manager 21 opened the door without knocking and indicated she needed to speak to Nurse 20 when she finished her task. Resident 97's husband indicated it was not unusual for employees to come in the room without knocking. On 7/6/23 at 10:37 AM RN 20 opened the door and reentered Resident 97's room without knocking. Resident 97's record was reviewed on 7/10/23 at 3:09 PM. […]

• No harm, potential for more than minimal, patternF812Sep 13, 2022

  Based on observation, interview, and record review, the facility failed to ensure sanitary conditions in food service areas related to debris on dishes, the storage of wet cookware and glassware, and handwashing during food service. This deficient practice had the potential to affect 94 of 98 residents residing in the facility. 1. During an observation of the facility kitchen on 9/7/22 at 10:11 A.M., there were baking sheets and metal food storage pans were stacked. The sheets and pans were separated for inspection and were observed to be wet in all stacks of stored for food use. Clear, wet, fluid was observed between all of the stacked ready for use drinking glasses. […]

• No harm, potential for more than minimal, patternF888Apr 14, 2022

  Based on observation, interview and record review, the facility failed to ensure all staff were fully vaccinated for COVID-19 and failed to ensure those staff who were not fully vaccinated, adhered to additional precautions that would mitigate the spread of COVID-19. Findings include: On 4/13/22 at 2:05 P.M., record review of COVID-19 staff vaccination status for Providers was provided by the Director of Nursing (DON). Total number of staff were 184. Total of partially vaccinated staff was 4. Total number of completely vaccinated staff was 85. Total number of pending exemption was 1. Total number of granted exemption was 75. Total number of temporary delay/new hire was 0. Total number of not vaccinated without exemption/delay was 0. […]

• No harm, potential for more than minimal, patternF880Nov 30, 2021

  Based on observations, interviews and record reviews, the facility failed to properly prevent and/or contain COVID-19 related to donning and doffing Personal Protective Equipment (PPE) during 8 of 8 observations of 8 randomly observed residents (Resident J, Resident M, Resident N, Resident O, Resident P, Resident Q, Resident R, and Resident S). Findings include During observation on 11/29/21 at 9:30 A.M., Qualified Medication Aide (QMA) 1 was screening visitors at the front table just inside the door. QMA 1 had her mask down under her nose. During interview at the same time, QMA 1 indicated the mask slipped and did not fit well. During observation on 11/29/21 at 10:05 A.M., Licensed Practical Nurse (LPN) 1 was talking with someone at the nurses' station. […]