Ashton Health and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 30, 2025

  Based on record review, and Nurse Practitioner (NP), Medical Director, and staff interviews, the facility failed to provide care in a safe manner when Resident #1 rolled out of her bed that was raised to just below the hip onto the floor during incontinence care. Resident #1 was sent to the emergency room (ER) for pain in her right shoulder and right hip with some deformity and external rotation. Resident #1 was diagnosed with an unusual right hip impaction fracture (occurs when a bone is broken and the broken ends are forced into each other) of the femoral head (the rounded end of thigh bone that fits into the socket of the hip joint). Resident #1 was admitted to the hospital and underwent hip replacement. This was for 1 of 3 residents (Resident #1) reviewed for accidents. […]

• Actual harm, isolatedF689Nov 19, 2021

  Based on observation, record review, staff and resident interviews, the facility failed to implement effective interventions to prevent further [CONDITION(S)] for a resident that experienced [CONDITION(S)] while smoking in 1 of 3 residents (Resident #35) reviewed for smoking. The findings included: Resident #35 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus, right below the knee amputation and muscle weakness. An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #35 was cognitively intact for decision making and was documented as not a current tobacco user. A nurse progress note, dated 3/19/2021, written by Nurse #6 read during a dressing change to abdomen, this writer noticed area presented like a full thickness burn. […]

• Actual harm, isolatedF689Sep 16, 2021

  Based on record review, observation and staff interviews, the facility failed to protect a resident from a fall during bed mobility causing the resident to be lowered to the ground which resulted in a nondisplaced radial neck fracture (elbow). This was evident in 1 of 2 residents (Resident #2) reviewed for accidents. Findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included [CONDITION(S)] and [CONDITION(S)] affecting left non-dominant side and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired and required total assistance with 2 people for bed mobility and personal hygiene. […]

• No harm, potential for more than minimal, patternF641Nov 19, 2021

  Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the following areas: falls (Resident #78); gradual dose reduction (GDR) for an antipsychotic medication (Resident #78), administration of an anticoagulant medication (Resident #40) and hallucinations (Resident #35) for 3 of 39 sampled residents reviewed for MDS accuracy. The findings included: 1-a. Resident #78 was admitted to the facility on [DATE] with a cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation in Resident #78 ' s electronic medical record (EMR) revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #78 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. […]

• No harm, potential for more than minimal, patternF880Nov 19, 2021

  Based on observations, staff interviews, and record review, the facility staff failed to label, store, and clean/disinfect blood glucose meters (glucometers) dedicated for individual-resident use in a manner that would protect against the inadvertent use for additional residents and/or cross-contamination from contact with other meters or equipment. This occurred for 3 out of 4 sample residents (Resident #12, Resident #64, and Resident #30) who required a blood glucose check. The findings included: A review of the facility policy entitled Blood Sampling - Capillary (Finger Sticks) (Revised December 2018) read, in part: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. […]