Ashton Memorial Living Center

In the surveyor’s words

From the most serious findings on record at Ashton Memorial Living Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 8, 2024

  Based on observation, food code review, and staff interview, it was determined the facility failed to ensure the food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA (Food Drug Administration) 2022 Food Code, Section 3-501.17 documented on-premises preparation Prepare and hold cold 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. […]

• No harm, potential for more than minimal, patternF730Nov 8, 2024

  Based on staff interview and review of employee personal files, it was determined the facility failed to provide a minimum of 12 hours of in-service education per year for 3 of 18 CNAs (#4, #5, and #7) whose personnel records were reviewed. Additionally, the facility failed to ensure each CNA's annual performance reviews were completed at least once every 12 months for 3 of 3 CNAs (#2, #4, and #5) whose personnel records were reviewed for sufficient and competent CNA staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility. Findings include: The following personnel records were reviewed on 11/6/24 for 12 hours of in-service education: 1. […]

• No harm, potential for more than minimal, patternF880Nov 8, 2024

  Based on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals served in their rooms, and follow appropriate cleaning of medical equipment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The following hand hygiene issues were observed during meal travel delivery: 1. On 11/4/24 at 8:32 AM, CNA #2 did not encourage Resident #26 to perform hand hygiene before eating. On 11/4/24 at 8:37 AM, CNA #2 stated, I did not offer Resident #26 hand hygiene and I should have. 2. […]

• No harm, potential for more than minimal, isolatedF628Dec 10, 2025

  Based on record review and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives at the time of the resident's transfer to the hospital. This was true for 1 of 2 residents (Resident #6) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed or room at the facility within a specified time. Findings include: Resident #6 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic heart failure and chronic kidney disease. Resident #6's medical record documented she was transferred to a hospital on 8/12/25, and returned on 8/15/25. […]

• No harm, potential for more than minimal, isolatedF695Dec 10, 2025

  Based on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 4 residents (Resident #1) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include:Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including sepsis and urinary tract infection.Resident #1's physician order for oxygen documented Oxygen PRN 2-3LPM to keep oxygen saturation >88%, start date 11/4/25.On 12/9/25 at 12:50 PM, Resident #1's medical record documented SpO2 information gathered on the following dates. […]