Inspection Report Summary
The most recent inspection on May 16, 2025, identified deficiencies related to failure to protect residents from abuse, misappropriation of controlled medication, and inadequate investigation of alleged abuse. Earlier inspections showed a pattern of issues including resident dignity and care concerns, medication management problems, infection control lapses, and supervision failures, with one prior immediate jeopardy finding related to resident elopement and harm. Inspectors cited main themes of resident abuse and medication security, along with ongoing challenges in investigation and response to complaints. Complaint investigations were mostly unsubstantiated except for the substantiated abuse and elopement cases, with no enforcement actions or fines listed in the available reports. The inspection history indicates persistent challenges with resident protection and medication handling, with no clear trend of sustained improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 16, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, misappropriation of resident property, and failure to properly investigate alleged violations at Ashton Medical Lodge.
Complaint Details
The complaint investigation involved allegations of abuse and neglect including rough handling of Resident #1 by CNA A, misappropriation of controlled medication for Resident #3, and failure to properly investigate Resident #4's report of being hit by an employee. Resident #1 was cognitively impaired and unable to communicate effectively. Witnesses observed aggressive handling by CNA A. Resident #3's medication was missing due to improper narcotic storage and counting. Resident #4's allegation was not thoroughly investigated, and no employee was suspended. The facility's investigation was deemed insufficient.
Findings
The facility failed to protect residents from abuse, including rough handling of Resident #1 by a CNA, misappropriation of controlled medication for Resident #3, and inadequate investigation of alleged abuse reported by Resident #4. The facility also failed to ensure proper narcotic storage and counting procedures.
Deficiencies (3)
Failed to protect Resident #1 from abuse when handled roughly by CNA A on 4.24.25.
Failed to prevent misappropriation of Resident #3's Lorazepam Oral Concentrate on 08/03/2024 from medication cart.
Failed to respond appropriately to alleged violations; no thorough investigation of Resident #4's report of being hit by an employee.
Report Facts
Residents reviewed for abuse: 15
Residents reviewed for drug diversion: 16
Residents reviewed for alleged verbal abuse investigation: 8
BIMS score Resident #1: 5
BIMS score Resident #3: 1
BIMS score Resident #4: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in abuse finding for rough handling of Resident #1. | |
| LVN C | Licensed Vocational Nurse | Named in misappropriation and medication storage deficiency; signed for medications and involved in narcotic count issues. |
| HK B | Housekeeper | Witnessed rough handling of Resident #1 by CNA A. |
| DON | Director of Nursing | Interviewed regarding abuse and investigation procedures. |
| Administrator | Interviewed regarding investigation and suspension of CNA A and overall facility response. | |
| ADON | Assistant Director of Nursing | Interviewed regarding medication room access and narcotic control. |
| WCN D | Wound Care Nurse | Conducted skin assessment related to Resident #4's allegation. |
Inspection Report
Routine
Deficiencies: 10
Date: Feb 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, inadequate accommodation of resident needs, failure to provide necessary personal care, improper catheter and nephrostomy bag care, unsafe feeding tube management, inadequate respiratory care, pharmaceutical service deficiencies, medication storage issues, food safety and temperature control problems, kitchen sanitation lapses, and infection prevention and control program failures.
Deficiencies (10)
Failure to ensure resident's nephrostomy bag was placed in a privacy bag, compromising dignity.
Failure to keep resident call lights within reach, risking unmet needs.
Failure to provide nail trimming for a resident needing assistance, risking injury and infection.
Failure to place resident's urinary catheter nephrostomy bag below the bladder, risking urinary tract infections.
Failure to maintain head of bed elevation during feeding tube infusion, risking aspiration pneumonia.
Failure to document administration of controlled medication accurately, risking underdose, overdose, and diversion.
Failure to label insulin pen with open date, risking ineffective medication use.
Failure to maintain food at safe and appetizing temperatures, risking foodborne illness and diminished quality of life.
Failure to maintain kitchen sanitation including unsealed spice bottles and dirty condiment bottles, risking foodborne illness.
Failure to properly don gloves and disinfect bodily fluids in dining area, risking transmission of communicable diseases.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication discrepancy: 1
Food temperature: 122.2
Food temperature: 143.9
Food temperature: 90
Food temperature: 95
Food temperature: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN H | Licensed Vocational Nurse | Stated expectation for nephrostomy bags to be inside privacy bags and placed below bladder |
| CNA I | Certified Nursing Assistant | Stated nephrostomy bags must be inside privacy bags and call lights must be within reach |
| DON | Director of Nursing | Provided multiple interviews on nephrostomy bag placement, call light rounds, nail care, and infection control |
| Administrator | Provided multiple interviews on nephrostomy bag placement, call light importance, insulin pen labeling, and infection control | |
| LVN K | Licensed Vocational Nurse | Described nail care responsibilities and resident preferences |
| ADON L | Assistant Director of Nursing | Described nail care procedures and infection control protocols |
| Activity Director | Described nail care and activities for residents | |
| Activity Assistant | Described nail care and resident preferences | |
| CNA C | Certified Nursing Assistant | Observed lowering head of bed flat during feeding tube infusion |
| CNA E | Certified Nursing Assistant | Observed lowering head of bed flat during feeding tube infusion |
| Medication Aide F | Reported protocol for oxygen tank changes and risks of empty tanks | |
| LVN G | Licensed Vocational Nurse | Described oxygen tank rounds and resident independence |
| Dietary Director | Discussed food temperature issues and kitchen sanitation | |
| Director of Rehabilitation | Observed cleaning bodily fluids without gloves or disinfectant | |
| Housekeeper | Described proper cleaning of bodily fluids and disinfecting procedures |
Inspection Report
Routine
Deficiencies: 1
Date: May 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with resident rights and dignity, specifically regarding staff behavior during feeding of residents.
Findings
The facility failed to ensure staff assisted residents in a dignified manner by sitting while feeding them, as staff were observed standing while feeding three residents. This failure could place residents at risk for decreased meal satisfaction and dignity.
Deficiencies (1)
Facility failed to ensure staff assisting Residents #1, #2, and #3 did not stand while feeding them.
Report Facts
Residents observed for resident rights: 6
Residents affected by deficiency: 3
Mental status exam score: 0
Date of observation: May 29, 2024
Date of observation: May 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Observed standing while feeding Resident #1 and attended Resident Rights in-service on 4/19/24 | |
| CNA B | Observed standing while feeding Resident #2 and brought a spare chair during observation | |
| CNA C | Observed standing while feeding Resident #3 | |
| Lead CNA | Monitored aides, brought chairs during feeding observations, and provided interview statements about staff behavior | |
| DON | Director of Nursing | Provided interview about expectations for staff to be seated while feeding residents |
| Administrator | Provided interview regarding staff standing during feeding and facility policy |
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 1
Date: Jan 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision of residents to prevent elopements, specifically focusing on an incident where Resident #1 eloped from the facility and was found outside in cold weather with hypothermia.
Complaint Details
The complaint investigation was substantiated with an Immediate Jeopardy identified on 2024-01-04 at 3:02 PM due to inadequate supervision leading to Resident #1's elopement and subsequent hospitalization for hypothermia. The Immediate Jeopardy was removed on 2024-01-05 at 6:28 PM after the facility implemented corrective actions.
Findings
The facility failed to provide adequate supervision to Resident #1, who eloped from the facility at night and was found approximately two hours later in cold weather after falling into a wet drainage ditch. Resident #1 was hospitalized with hypothermia and other diagnoses. The facility was cited for immediate jeopardy which was later removed, but the facility remained out of compliance at a severity level of actual harm. The investigation revealed lapses in supervision, delayed discovery of the resident's absence, and inadequate elopement risk assessments and interventions.
Deficiencies (1)
Failure to ensure residents received adequate supervision to prevent elopements, resulting in Resident #1 eloping and suffering hypothermia.
Report Facts
Facility census: 128
Resident elopement duration: 2
Temperature: 44
Medication administration time: 20.6
Steps from resident room to front door: 205
Staff in-service attendance: 93
Total staff: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Charge nurse on duty during Resident #1's elopement; provided key interview and described events and supervision lapses |
| CNA C | Certified Nursing Assistant | Found Resident #1 outside in a fetal position in a ditch; provided detailed statement about the incident |
| MA D | Medication Aide | Administered Resident #1's medications on the evening of elopement; provided written statement |
| CNA E | Certified Nursing Assistant | Participated in search and found Resident #1; provided written statement |
| Administrator | Facility Administrator | Provided multiple interviews regarding the incident, facility policies, and corrective actions |
| DON | Director of Nursing | Provided interviews, in-service training, and oversight of corrective actions |
| Regional Consultant | Regional Consultant Nurse | Provided interview regarding investigation and timeline of elopement |
| Resident #1's Nurse Practitioner | Nurse Practitioner | Provided medical perspective on Resident #1's condition and elopement consequences |
| Corporate Consultant RN | Corporate Consultant Registered Nurse | Provided interview on resident assessments and corrective actions |
| CNA F | Certified Nursing Assistant | Received in-service training post-incident; described new procedures |
Inspection Report
Routine
Deficiencies: 4
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services, medication storage and administration, food service safety, infection prevention and control, and overall regulatory requirements.
Findings
The facility was found deficient in pharmaceutical services including medication cart management with loose and expired medications, failure to lock medication carts when unattended, food service safety violations including unlabeled and unclean food storage and poor hand hygiene by kitchen staff, and failure to maintain proper infection control practices such as hand hygiene by nursing staff during medication administration.
Deficiencies (4)
Failure to provide pharmaceutical services including accurate acquiring, receiving, dispensing, and administering of drugs; presence of loose pills and expired medications in medication carts.
Failure to ensure medication cart #1 was locked when unattended.
Failure to store, prepare, distribute, and serve food in accordance with professional standards including unlabeled and undated food items, unclean kitchen surfaces, and improper hand hygiene by kitchen staff.
Failure to maintain an infection prevention and control program; specifically, failure of RN to wash or sanitize hands prior to putting on gloves and administering medication.
Report Facts
Medication carts reviewed: 8
Medication carts with deficiencies: 3
Loose pills found: 6
Expired medications found: 2
Expired medication pills: 13
Glove changes without hand washing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Failed to wash or sanitize hands prior to putting on gloves and administering medication to Resident #72 |
| LVN B | Licensed Vocational Nurse | Left medication cart #1 unattended and unlocked; assigned to check all medication carts |
| LVN C | Licensed Vocational Nurse, Charge Nurse | Responsible for checking medication carts daily; stated DON checked occasionally |
| Administrator | Facility Administrator | Stated expectations for medication cart security and hand hygiene |
| Corporate Consultant Nurse | Consultant Nurse | Reported no policy for unlocked carts; responsible for training; commented on infection control expectations |
| Dietary Director | Dietary Director | Reported on kitchen cleanliness, food labeling, and hand hygiene practices |
| Staff Educator | Staff Educator | Responsible for training on hand hygiene and infection control; acknowledged need for additional training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of abuse involving a nurse and Resident #1 at Ashton Medical Lodge.
Complaint Details
The complaint involved an allegation by Resident #1 that LVN D molested her, including exposure and inappropriate touching. The allegation was reported late to HHSC by the facility. The Administrator conducted an internal investigation and police investigation, which found the allegation unsubstantiated. Family members expressed doubts about the credibility of the allegation. The Administrator did not report the allegation to HHSC as he believed Hospice had reported it and due to family requests.
Findings
The facility failed to report an allegation of abuse to the Texas Health and Human Services Commission (HHSC) in a timely manner after the allegation was made by Resident #1 against LVN D. The allegation was investigated internally and by police, found to be unsubstantiated, but the facility did not report it to HHSC as required by policy and state law.
Deficiencies (1)
Failure to timely report suspected abuse to proper authorities as required by state law and facility policy.
Report Facts
Residents reviewed for abuse: 10
BIMS score: 10
Date of admission: Jan 6, 2023
Date of progress note: Jan 14, 2023
Date of facility investigation: Jan 15, 2023
Date of personnel background check: Apr 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Named in abuse allegation and investigation |
| LVN E | Licensed Vocational Nurse | Wrote progress note documenting the abuse allegation |
| Administrator | Facility Administrator and Abuse Coordinator | Responsible for facility investigation and reporting of abuse allegations |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 28, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, staffing, infection control, and assessment data transmission at Ashton Medical Lodge.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity due to staff cell phone use during care, untimely transmission of resident assessment data, inadequate supervision and improper use of mechanical lifts during transfers, insufficient staffing levels impacting resident care, and lapses in infection prevention practices such as improper glove use and handwashing technique.
Deficiencies (5)
Failure to treat residents with respect, dignity, and care; staff used cell phones in presence of residents during care.
Failure to complete and transmit resident assessment data within required timeframe for Resident #3.
Failure to ensure adequate supervision and proper mechanical lift use for Resident #87, resulting in unsafe transfers.
Failure to provide sufficient nursing staff to meet resident needs, resulting in delayed call light response, inadequate assistance with transfers, and unmet care needs.
Failure to maintain infection prevention and control program; staff failed to change contaminated gloves and improperly turned off faucet after handwashing.
Report Facts
Residents affected: 9
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 2
Staff shortage: 17
Staff to resident ratio: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PCA B | Failed to change gloves after contamination during incontinent care | |
| CNA D | Failed to turn off faucet with paper towel after handwashing before assisting Resident #87 | |
| MDS coordinator A | Forgot to timely transmit Resident #3's quarterly MDS | |
| DON | Director of Nursing | Provided interviews on cell phone policy, staffing, mechanical lift expectations, and infection control |
| AD | Administrator | Provided interviews on staffing and customer service |
| Administrator | Commented on mechanical lift use and staff cell phone use | |
| Nurse educator | Conducted competency checks and training on infection control and glove use | |
| CNA C | Involved in improper mechanical lift transfer of Resident #87 |
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