Facility Watch Inspection records for every certified US nursing home

Ashland Nursing and Rehabilitation

906 Thompson Street
Ashland, VA 23005
(804) 798-3291

Special Focus Facility — SFF CandidateAbuse icon
CCN
495362
Certified beds
190
Ownership
For profit - Corporation
Chain
Avardis Health

Nurse staffing

3.99
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.46 hours per resident per day

Nursing staff turnover: 62% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected March 18, 2026

11 citations · from a complaint investigation · Health
C
F0732 No actual harm with potential for minimal harm · Widespread

Post nurse staffing information every day.

Deficient, Provider has no plan of correction
D
F0554 No actual harm with potential for more than minimal harm · Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Deficient, Provider has date of correction · corrected April 29, 2026
D
F0607 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected April 29, 2026
D
F0941 No actual harm with potential for more than minimal harm · Isolated

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Deficient, Provider has no plan of correction
D
F0942 No actual harm with potential for more than minimal harm · Isolated

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Deficient, Provider has no plan of correction
D
F0944 No actual harm with potential for more than minimal harm · Isolated

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has no plan of correction
D
F0949 No actual harm with potential for more than minimal harm · Isolated

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has no plan of correction
E
F0584 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected April 29, 2026
F
F0838 No actual harm with potential for more than minimal harm · Widespread

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Deficient, Provider has no plan of correction
J
F0600 Immediate jeopardy to resident health or safety · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected April 29, 2026
J
F0689 Immediate jeopardy to resident health or safety · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has plan of correction

Inspected August 21, 2025

37 citations · from a complaint investigation · Health
D
F0553 No actual harm with potential for more than minimal harm · Isolated

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0557 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0584 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0628 No actual harm with potential for more than minimal harm · Isolated

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0725 No actual harm with potential for more than minimal harm · Isolated

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0730 No actual harm with potential for more than minimal harm · Isolated

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0745 No actual harm with potential for more than minimal harm · Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0849 No actual harm with potential for more than minimal harm · Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0941 No actual harm with potential for more than minimal harm · Isolated

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0942 No actual harm with potential for more than minimal harm · Isolated

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0943 No actual harm with potential for more than minimal harm · Isolated

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0944 No actual harm with potential for more than minimal harm · Isolated

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0945 No actual harm with potential for more than minimal harm · Isolated

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0946 No actual harm with potential for more than minimal harm · Isolated

Provide training in compliance and ethics.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0947 No actual harm with potential for more than minimal harm · Isolated

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Deficient, Provider has date of correction · corrected November 17, 2025
D
F0949 No actual harm with potential for more than minimal harm · Isolated

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0600 No actual harm with potential for more than minimal harm · Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0607 No actual harm with potential for more than minimal harm · Pattern

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0610 No actual harm with potential for more than minimal harm · Pattern

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0657 No actual harm with potential for more than minimal harm · Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0677 No actual harm with potential for more than minimal harm · Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0679 No actual harm with potential for more than minimal harm · Pattern

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0802 No actual harm with potential for more than minimal harm · Pattern

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0804 No actual harm with potential for more than minimal harm · Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected November 17, 2025
E
F0809 No actual harm with potential for more than minimal harm · Pattern

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Deficient, Provider has date of correction · corrected November 17, 2025
F
F0565 No actual harm with potential for more than minimal harm · Widespread

Honor the resident's right to organize and participate in resident/family groups in the facility.

Deficient, Provider has date of correction · corrected November 17, 2025
F
F0680 No actual harm with potential for more than minimal harm · Widespread

Ensure the activities program is directed by a qualified professional.

Deficient, Provider has date of correction · corrected November 17, 2025
F
F0838 No actual harm with potential for more than minimal harm · Widespread

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Deficient, Provider has date of correction · corrected November 17, 2025
F
F0840 No actual harm with potential for more than minimal harm · Widespread

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Deficient, Provider has date of correction · corrected November 17, 2025
F
F0868 No actual harm with potential for more than minimal harm · Widespread

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Deficient, Provider has date of correction · corrected November 17, 2025
F
F0880 No actual harm with potential for more than minimal harm · Widespread

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected November 17, 2025

Inspected April 11, 2024

8 citations · from a complaint investigation · Health
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected May 7, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected May 7, 2024
D
F0700 No actual harm with potential for more than minimal harm · Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Deficient, Provider has date of correction · corrected May 7, 2024
D
F0730 No actual harm with potential for more than minimal harm · Isolated

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected May 7, 2024
D
F0770 No actual harm with potential for more than minimal harm · Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Deficient, Provider has date of correction · corrected May 7, 2024
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected May 7, 2024
E
F0690 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected May 7, 2024
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected May 7, 2024

Inspected February 9, 2024

65 citations · from a complaint investigation · Health
D
F0552 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0559 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0583 No actual harm with potential for more than minimal harm · Isolated

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0584 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0607 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0623 No actual harm with potential for more than minimal harm · Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0645 No actual harm with potential for more than minimal harm · Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0675 No actual harm with potential for more than minimal harm · Isolated

Honor each resident's preferences, choices, values and beliefs.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0676 No actual harm with potential for more than minimal harm · Isolated

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected May 7, 2024
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0688 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected May 7, 2024
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0699 No actual harm with potential for more than minimal harm · Isolated

Provide care or services that was trauma informed and/or culturally competent.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0700 No actual harm with potential for more than minimal harm · Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Deficient, Provider has date of correction · corrected May 7, 2024
D
F0712 No actual harm with potential for more than minimal harm · Isolated

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0740 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0745 No actual harm with potential for more than minimal harm · Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0776 No actual harm with potential for more than minimal harm · Isolated

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0791 No actual harm with potential for more than minimal harm · Isolated

Provide or obtain dental services for each resident.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0803 No actual harm with potential for more than minimal harm · Isolated

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0805 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0810 No actual harm with potential for more than minimal harm · Isolated

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0887 No actual harm with potential for more than minimal harm · Isolated

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0909 No actual harm with potential for more than minimal harm · Isolated

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0925 No actual harm with potential for more than minimal harm · Isolated

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0941 No actual harm with potential for more than minimal harm · Isolated

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0942 No actual harm with potential for more than minimal harm · Isolated

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0944 No actual harm with potential for more than minimal harm · Isolated

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0946 No actual harm with potential for more than minimal harm · Isolated

Provide training in compliance and ethics.

Deficient, Provider has date of correction · corrected April 11, 2024
D
F0949 No actual harm with potential for more than minimal harm · Isolated

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0550 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0580 No actual harm with potential for more than minimal harm · Pattern

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0610 No actual harm with potential for more than minimal harm · Pattern

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0622 No actual harm with potential for more than minimal harm · Pattern

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0625 No actual harm with potential for more than minimal harm · Pattern

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0655 No actual harm with potential for more than minimal harm · Pattern

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0657 No actual harm with potential for more than minimal harm · Pattern

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected May 7, 2024
E
F0658 No actual harm with potential for more than minimal harm · Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0677 No actual harm with potential for more than minimal harm · Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0679 No actual harm with potential for more than minimal harm · Pattern

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0686 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0695 No actual harm with potential for more than minimal harm · Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected May 7, 2024
E
F0697 No actual harm with potential for more than minimal harm · Pattern

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0725 No actual harm with potential for more than minimal harm · Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0726 No actual harm with potential for more than minimal harm · Pattern

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0727 No actual harm with potential for more than minimal harm · Pattern

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0730 No actual harm with potential for more than minimal harm · Pattern

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected May 7, 2024
E
F0758 No actual harm with potential for more than minimal harm · Pattern

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0804 No actual harm with potential for more than minimal harm · Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0809 No actual harm with potential for more than minimal harm · Pattern

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected May 7, 2024
E
F0843 No actual harm with potential for more than minimal harm · Pattern

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0940 No actual harm with potential for more than minimal harm · Pattern

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0943 No actual harm with potential for more than minimal harm · Pattern

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Deficient, Provider has date of correction · corrected April 11, 2024
E
F0947 No actual harm with potential for more than minimal harm · Pattern

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Deficient, Provider has date of correction · corrected April 11, 2024
F
F0680 No actual harm with potential for more than minimal harm · Widespread

Ensure the activities program is directed by a qualified professional.

Deficient, Provider has date of correction · corrected April 11, 2024

Inspected November 20, 2023

3 citations · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected December 19, 2023
D
F0757 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected December 19, 2023
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected December 19, 2023

Inspected September 7, 2023

13 citations · from a complaint investigation · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected October 17, 2023
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected October 17, 2023
D
F0692 No actual harm with potential for more than minimal harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected October 17, 2023
D
F0803 No actual harm with potential for more than minimal harm · Isolated

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Deficient, Provider has date of correction · corrected October 17, 2023
D
F0806 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Deficient, Provider has date of correction · corrected October 17, 2023
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected October 17, 2023
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected October 17, 2023
E
F0725 No actual harm with potential for more than minimal harm · Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected October 17, 2023
E
F0727 No actual harm with potential for more than minimal harm · Pattern

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Deficient, Provider has date of correction · corrected October 17, 2023
E
F0760 No actual harm with potential for more than minimal harm · Pattern

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected October 17, 2023
E
F0800 No actual harm with potential for more than minimal harm · Pattern

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Deficient, Provider has date of correction · corrected October 17, 2023
E
F0804 No actual harm with potential for more than minimal harm · Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected October 17, 2023
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected October 17, 2023

Inspected June 7, 2022

13 citations · Health
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0645 No actual harm with potential for more than minimal harm · Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0745 No actual harm with potential for more than minimal harm · Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0806 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Deficient, Provider has date of correction · corrected July 12, 2022
D
F0840 No actual harm with potential for more than minimal harm · Isolated

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Deficient, Provider has date of correction · corrected July 12, 2022
E
F0584 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected July 12, 2022
E
F0804 No actual harm with potential for more than minimal harm · Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Deficient, Provider has date of correction · corrected July 12, 2022
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected July 12, 2022

Inspected February 6, 2020

19 citations · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0584 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0622 No actual harm with potential for more than minimal harm · Isolated

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0623 No actual harm with potential for more than minimal harm · Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0697 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0758 No actual harm with potential for more than minimal harm · Isolated

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0836 No actual harm with potential for more than minimal harm · Isolated

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Past Non-Compliance · corrected April 18, 2019
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected March 10, 2020
D
F0919 No actual harm with potential for more than minimal harm · Isolated

Make sure that a working call system is available in each resident's bathroom and bathing area.

Deficient, Provider has date of correction · corrected March 10, 2020
E
F0600 No actual harm with potential for more than minimal harm · Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected March 10, 2020
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected March 10, 2020
E
F0677 No actual harm with potential for more than minimal harm · Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected March 10, 2020
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected March 10, 2020
E
F0757 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected March 10, 2020
E
F0760 No actual harm with potential for more than minimal harm · Pattern

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected March 10, 2020
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected March 10, 2020

Penalties

DateTypeAmount
March 18, 2026Fine$8,140

Ownership transfers

EffectiveSellerBuyer
06/01/2025Ashland Facility Operations, LLC906 Thompson Street Opco LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.