Inspection Reports for
Ashton Creek Health and Rehabilitation Center

This citation relates to Complaint IN00442678.

The facility failed to provide effective pain management for Resident O, who had fractures and inflammatory arthritis causing severe pain. Despite physician orders for scheduled opioid medication, the resident did not consistently receive pain medication on schedule, resulting in inadequate pain relief and interference with rehabilitation.

Complaint IN00442678 was substantiated with federal/state deficiencies cited related to pain management. Complaint IN00441977 had no deficiencies related to the allegation.

The facility failed to provide effective pain management for 1 of 3 residents reviewed for pain. Resident O experienced severe pain that was not adequately managed, with pain medications not administered timely or routinely as prescribed.

This citation is related to complaint IN00438109.

The facility failed to ensure proper monitoring of meal intakes and weights for two residents, resulting in significant unaddressed weight loss. Documentation of meal intake was incomplete, and supplements were not consistently offered or ordered as indicated in care plans. Staff inconsistencies in weight monitoring and failure to follow Nutrition at Risk (NAR) policy were noted.

Complaint IN00438109 resulted in federal/state deficiencies cited. Complaints IN00437388 and IN00435894 had no deficiencies related to the allegations.

The facility was found deficient in multiple areas including failure to provide adequate assistance with denture care and grooming for one resident, failure to monitor meal intakes and weights for two residents, and failure to ensure proper hand hygiene during meal preparation and service affecting all residents.

This citation is related to complaint IN00438109.

The facility failed to provide adequate assistance with denture care and facial hair grooming for Resident 40, failed to monitor meal intakes and weights for Residents B and 305, and failed to ensure hand hygiene was performed by dietary staff during meal preparation and service.

This citation relates to Complaint IN00421741 for the failure to timely report suspicious injury and Complaint IN00421612 for failure to assess and treat pressure ulcers as ordered.

The facility failed to timely report suspected abuse related to suspicious injuries on Resident N and failed to assess timely and follow physician orders for treatment of a pressure ulcer for Resident O. Both deficiencies were found to have minimal harm or potential for actual harm and affected a few residents.

Complaint IN00421612 had federal/state deficiencies cited related to pressure ulcer care. Complaint IN00421620 had no deficiencies cited. Complaint IN00421741 had federal/state deficiencies cited related to reporting alleged violations.

The facility was found deficient in timely reporting of a suspicious injury of unknown source for one resident, and failed to timely assess and follow physician orders for treatment of a pressure ulcer for another resident. One complaint was substantiated with deficiencies cited, one complaint had no deficiencies, and another complaint had deficiencies related to reporting alleged violations and pressure ulcer care.

At this PSR survey, the facility was found in compliance with Emergency Preparedness Requirements. However, the facility was found not in compliance with Life Safety Code requirements due to failure to enforce the non-smoking policy on campus, specifically staff smoking near the employee entrance. A plan of correction was implemented to address this deficiency.

This Federal citation is related to Complaint IN00415361. Resident D would refuse care at times but no refusal documentation was available. Resident D had severe cognitive impairment and required one-person assistance with personal hygiene. Personal hygiene, including oral care, was not completed on multiple dates between 7/24/23 and 8/22/23 as documented in the point of care history report.

The facility failed to ensure oral hygiene care was completed for 1 of 3 dependent residents (Resident D). Interviews and record reviews revealed Resident D did not receive assistance with oral hygiene on multiple occasions despite needing help and family requests for twice daily care.

Complaint IN00415361 was substantiated with federal/state deficiencies cited at F677 related to failure to provide oral hygiene care to Resident D.

The facility failed to ensure oral hygiene was completed for 1 of 3 dependent residents (Resident D). Interviews and record reviews confirmed Resident D did not receive assistance with oral hygiene on multiple occasions, including the day of the survey.

The facility was found not in compliance with Emergency Preparedness Requirements, including failure to review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, and Training and Testing program annually. Additionally, Life Safety Code deficiencies were identified including a laundry door propped open without a compliant release device, kitchen corridor doors blocked open, sprinkler heads loaded with dirt in the carport, and failure to enforce the non-smoking policy on campus.

The facility was found deficient in multiple areas including failure to ensure resident privacy, inconsistent bathing care, inadequate care planning and staff education for a resident with a shunt, inconsistent management and documentation of tube feeding for a resident, and unsafe medication storage practices for some residents.

The facility was found deficient in multiple areas including failure to ensure resident privacy, inconsistent bathing care, inadequate care for a resident with a shunt, inconsistent tube feeding management, and unsafe medication storage practices.

The complaint alleged that Resident D's ileostomy bag was leaking liquid stool into her abdominal surgical wound, causing continuous contamination, dermatitis, and recurrent cellulitis. The resident was reportedly left lying in stool-covered towels until staff could change the bag and felt neglected due to the time-consuming nature of her care.

The facility failed to follow physician orders for follow-up wound care and ileostomy management for Resident D, resulting in ongoing wound infection, leakage of the ileostomy bag, skin irritation, and inadequate referral to the wound clinic. The resident experienced continuous contamination of the abdominal wound due to a poorly sealed ostomy bag and was admitted to the hospital as a result.

Complaint IN00404416 was substantiated with federal/state deficiencies cited at F684 and F691 related to wound care and ileostomy management. Complaint IN00404800 had no deficiencies cited.

The facility failed to follow physician orders for follow-up wound care and failed to provide necessary care and services for management of an ileostomy for one resident (Resident D). The resident experienced ongoing issues with leaking ileostomy bags contaminating a surgical abdominal wound, causing pain, skin irritation, and infection risk. The facility did not complete ordered referrals to the wound clinic and lacked proper documentation and interventions to manage the ileostomy and wound care.

Complaint IN00399776 was substantiated with federal/state deficiencies cited at F623 related to failure to provide proper notice before transfer/discharge. Complaint IN00400088 was substantiated with no deficiencies cited.

The facility failed to ensure that residents were properly notified of discharge for 1 of 8 residents reviewed (Resident B). Specifically, Resident B was discharged without proper notice and documentation, including failure to provide a timely Notice of Medicare Non-Coverage (NOMNC) and transfer/discharge forms signed by the resident or representative.

The facility was found not in compliance with Life Safety Code requirements, including obstructions in a corridor exit path affecting 30 residents and a kitchen corridor door blocked from closing affecting 50 residents. The facility failed to implement systemic plans to prevent recurrence of these deficiencies.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements, with multiple deficiencies related to means of egress, cooking facilities, sprinkler system installation, smoking regulations, electrical systems maintenance, and use of power cords.

The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, inaccurate Minimum Data Set (MDS) assessments, inadequate cleansing during bathing, failure to ensure residents were free from accident hazards related to smoking, improper handling of tube feeding supplies, failure to monitor narcotic medication side effects, and unsanitary food service conditions.