Inspection Reports for The Meadows at Ashland
1700 Furnas Street, NE, 68003
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than Nebraska average
Nebraska average: 4.2 deficiencies/year
Deficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
7 residents
Based on a May 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
May 14, 2025
Visit Reason
This Notice of Disciplinary Action was issued due to the facility's failure to implement interventions to prevent falls, based on violations found in a revisit survey dated May 14, 2025.
Findings
The disciplinary action is based on violations of Nebraska statutes related to health care facility licensure and practices detrimental to resident health or safety, specifically the failure to implement fall prevention interventions.
Report Facts
Disciplinary action extension: 180
Notice finalization period: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action. |
| Dan Taylor | Administrator | Listed as contact in Health Facilities Licensure Unit. |
Notice
Deficiencies: 0
Mar 5, 2025
Visit Reason
This Notice of Disciplinary Action was issued due to violations found during a survey dated March 5, 2025, specifically the facility's failure to implement interventions to prevent falls, resulting in probation for 90 days starting March 28, 2025.
Findings
The facility was found to have violated licensure regulations related to accidents and failure to implement fall prevention interventions, as documented in the CMS-2567 Report incorporated by reference.
Report Facts
Probation period days: 90
Date of survey: Mar 5, 2025
Date probation begins: Mar 28, 2025
Date probation reports due: Apr 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Health Facilities Licensure Unit contact named in the notice |
| Linda Stenvers | Administrative Specialist | Certified mailing of the Notice of Disciplinary Action |
Inspection Report
Renewal
Capacity: 97
Deficiencies: 0
Feb 19, 2025
Visit Reason
The document is related to the renewal of the nursing home license for The Meadows at Ashland, including renewal applications and certifications for the facility's continued operation.
Findings
The documents certify that The Meadows at Ashland meets statutory requirements for licensure renewal as a skilled nursing facility with special care units, including Alzheimer's care. The renewal application includes detailed facility information, ownership, and care program disclosures.
Report Facts
Total licensed beds: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey L. Baker | Administrator | Named in renewal application as facility administrator |
| Amanda Novak | Director of Nursing | Named in renewal application as director of nursing |
| Devora Kirschner | Authorized Representative | Signed renewal application and Alzheimer's special care unit disclosure |
| Ari Silberstein | Authorized Representative | Signed renewal application |
Inspection Report
Renewal
Capacity: 97
Deficiencies: 0
Mar 20, 2023
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification materials for Azria Health Ashland, indicating the renewal of the facility's license.
Findings
The documents verify that Azria Health Ashland meets statutory requirements for licensure renewal as a skilled nursing facility with special care units including Alzheimer's and physical therapy services. The renewal application includes detailed disclosures about care philosophy, staffing, environment, and programming.
Report Facts
Total licensed beds: 97
Alzheimer's unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey L. Baker | Administrator | Named as administrator on the renewal application and contact for ownership verification. |
| Misty Masters | Director of Nursing | Named as Director of Nursing on the renewal application. |
| Aaron N Kaminer | Authorized representative signing the renewal application. | |
| Steve Hornung | Named in ownership verification letter. |
Inspection Report
Renewal
Capacity: 97
Deficiencies: 0
Mar 5, 2020
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification documents for Azria Health Ashland, indicating the facility's license renewal process and compliance with statutory requirements.
Findings
The documents confirm that Azria Health Ashland meets statutory requirements for licensure renewal as a Skilled Nursing Facility with specialized services including Alzheimer's/Special Care Unit. The facility has a maximum capacity of 97 beds and provides detailed disclosures about care philosophy, staffing, environment, and family support programs.
Report Facts
Number of beds to be relicensed: 97
Maximum Capacity for Alzheimer’s Beds: 18
Semi Private Rate: 263
Private Rate: 378
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Gieselman | Administrator | Named as Administrator and authorized representative signing the renewal application and Alzheimer's Special Care Unit Disclosure |
| Courtney Flanagan | Director of Nursing | Named as Director of Nursing on renewal application |
| Steve Hornung | Owner | Named as owner of BCP Ashland, LLC, the legal owning entity |
| Noah Kaminer | Owner | Named as owner of AHO, LLC dba Azria Health Olathe |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 22, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ashland Care Center regarding allegations of failure to protect residents from abuse, ensure prompt response to call lights, administer medications as ordered, and provide required bathing.
Findings
The investigation found the facility in compliance with all relevant regulations; no concerns were identified related to abuse, call light response, medication administration, or bathing services.
Complaint Details
The complaint allegations included failure to protect residents from abuse, failure to ensure prompt response to call lights, failure to administer medications as ordered, and failure to provide bathing as required. All allegations were found to be unsubstantiated with the facility in compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health |
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 1
May 20, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to protect residents from abuse.
Findings
The investigation included interviews, record reviews, and observations. The facility was found to be in compliance with regulations regarding the abuse allegation, but a related deficiency was cited for failure to report and investigate alleged abuse incidents involving two residents.
Complaint Details
The complaint alleged the facility failed to protect residents from abuse. The allegation was not substantiated, but the facility failed to report and investigate incidents involving Residents 1, 4, and 5 as required.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse to the State Agency and to complete an investigation and submit the results for two residents. | SS=D |
Report Facts
Facility Census: 7
Deficiency Completion Date: 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the complaint investigation letter |
| Joseph Shafer | Administrator | Facility administrator addressed in the letter |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 97
Deficiencies: 17
Apr 10, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Ashland Care Center from April 10 to April 16, 2019, by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found deficient in multiple areas including failure to provide care according to physician orders, failure to give appropriate discharge notice, failure to maintain resident dignity during dining, failure to offer Medicare fiscal intermediary review, failure to maintain a safe and clean environment, failure to provide 30 day discharge notice, failure to send bed hold notices, failure to complete discharge summaries, failure to follow wound care orders, failure to ensure pressure ulcer treatment, failure to check enteral tube placement, failure to secure medications properly, and infection control deficiencies including improper hand hygiene and PPE use. Additionally, life safety code deficiencies were noted including hazardous area enclosures, fire drill practices, electrical receptacle covers, ventilation system maintenance, and oxygen concentrator safety.
Complaint Details
The complaint investigation included allegations that the facility failed to provide care according to practitioner's orders, ensure sufficient staffing, resolve grievances, give appropriate discharge notice, protect residents from abuse, and submit investigations timely. The investigation substantiated failure to provide care according to orders and failure to give appropriate discharge notice.
Severity Breakdown
SS=E: 3
SS=D: 11
SS=F: 2
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to provide care and services according to practitioner's orders including medication and wound treatments. | SS=D |
| Failed to give appropriate discharge notice and failed to notify resident/legal representative in writing of discharge reasons. | SS=D |
| Failed to maintain resident dignity during dining by placing clothing protectors without permission. | SS=E |
| Failed to offer Medicare fiscal intermediary review choice to resident. | SS=D |
| Failed to maintain a safe, clean, comfortable, and homelike environment including unclean ventilation covers, toilet bases, and fall alarm mats. | SS=D |
| Failed to send bed hold notices to resident and legal representative for hospitalizations. | SS=D |
| Failed to complete discharge summary for discharged resident. | SS=D |
| Failed to follow provider's wound care orders resulting in omitted treatments. | SS=D |
| Failed to ensure pressure ulcer treatment was followed per physician orders. | SS=D |
| Failed to check placement of enteral feeding tube prior to feeding administration. | SS=D |
| Failed to secure medications received from pharmacy properly, leaving them unattended in unsecured areas. | SS=E |
| Failed to follow infection control practices including hand hygiene, PPE use, and prevention of cross contamination for residents with C-Diff and wounds. | SS=E |
| Failed to maintain working ventilation system in two shared resident bathrooms. | SS=D |
| Failed to separate hazardous areas by smoke resistive partitions and self-closing doors, and had holes in walls and storage room used improperly. | SS=D |
| Failed to conduct fire drills under varied conditions and times on all shifts. | SS=F |
| Failed to provide approved cover plates for electrical receptacles and junction boxes. | SS=F |
| Failed to take precautions to prevent oxygen-enriched atmosphere by leaving oxygen concentrator on unattended. | SS=D |
Report Facts
Deficiencies cited: 16
Facility census: 69
Total licensed capacity: 97
Fire drills conducted: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Shafer | Administrator | Named in the introductory letter of the inspection report. |
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter. |
| LPN-E | Licensed Practical Nurse | Named in wound care and enteral feeding deficiencies. |
| NA-B | Nurse Aide | Named in infection control and hand hygiene deficiencies. |
| NA-V | Nurse Aide | Named in infection control and hand hygiene deficiencies. |
| DON | Director of Nursing | Named in multiple findings related to wound care, infection control, and policy confirmations. |
| ADON | Assistant Director of Nursing | Named in enteral feeding and infection control deficiencies. |
| RN-G | Registered Nurse | Named in infection control deficiencies. |
| LPN-Z | Licensed Practical Nurse | Named in medication security and infection control deficiencies. |
| Maintenance Director | Named in ventilation and hazardous area deficiencies. | |
| Maintenance Staff | Named in hazardous area, ventilation, and oxygen concentrator deficiencies. | |
| RN-G | Registered Nurse | Named in infection control deficiencies. |
| APRN | Advanced Practice Registered Nurse | Named in infection control deficiencies. |
| NM-W | Nurse Manager | Named in infection control deficiencies. |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Mar 19, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to follow regulatory guidelines for isolation procedures.
Findings
The facility failed to implement isolation precautions to prevent the spread of infection, specifically for a resident diagnosed with Clostridium Difficile (C-DIFF). Observations, interviews, and record reviews revealed cross contamination risks due to shared bathrooms and improper isolation practices affecting multiple residents.
Complaint Details
The complaint alleged that the facility failed to follow regulatory guidelines for isolation procedures. The investigation substantiated this allegation, finding failures in isolation precautions that could lead to cross contamination among residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow regulatory guidelines for isolation procedures to prevent cross contamination, specifically related to infection prevention and control. | SS=D |
Report Facts
Facility census: 73
Residents sampled: 5
Residents potentially affected: 3
Residents potentially affected by cohorting failure: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 14, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ashland Care Center on March 14-15, 2018, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The investigation found no violations related to the allegations of resident abuse, medication administration errors, or incomplete and inaccurate charting. Observations, record reviews, and interviews revealed no concerns in these areas.
Complaint Details
The complaint alleged that the facility failed to ensure residents were free from abuse, failed to provide medications according to the five rights, and failed to ensure charting was complete and accurate. All allegations were found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report as Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health |
Inspection Report
Annual Inspection
Census: 68
Capacity: 97
Deficiencies: 9
Dec 20, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Ashland Care Center from December 20, 2017 to December 27, 2017 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with most complaint allegations related to resident care and services. However, several deficiencies were cited related to life safety code violations including improper exit signage, hazardous area door issues, sprinkler head clearance obstructions, corridor door smoke resistance, improper use of extension cords, lack of oxygen in use signage, improper catheter bag positioning, and improper storage temperature of insulin medications.
Complaint Details
The visit was complaint-related and included investigation of multiple allegations including failure to protect residents from behaviors, failure to provide adequate meals, choices, housekeeping, hydration, staff training, fall evaluations, plan of care adherence, grooming, grievance resolution, and discharge procedures. All allegations were found to be in compliance with no violations.
Severity Breakdown
SS=E: 7
SS=F: 1
SS=D: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure correct code and signage for magnetically locked delayed egress doors in SCU II unit. | SS=E |
| Failed to provide exit sign for second required exit in Sunset smoke compartment. | SS=E |
| Failed to ensure hazardous area doors close and latch properly in multiple smoke compartments. | SS=F |
| Failed to maintain required clearance to sprinkler heads in closets. | SS=E |
| Failed to ensure corridor room doors resist passage of smoke due to obstruction by resident's coat. | SS=E |
| Allowed use of extension cords in resident rooms instead of permanent wiring. | SS=E |
| Failed to post 'oxygen in use' signage on doors of rooms where oxygen was used. | SS=E |
| Failed to ensure urinary catheter drainage bag was positioned below the bladder during resident transfer. | SS=D |
| Failed to store insulin medications within manufacturer recommended temperature range. | SS=E |
Report Facts
Deficiencies cited: 9
Facility census: 68
Total licensed capacity: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed letter regarding complaint investigation findings. |
| Joseph Michael Shafer | Administrator | Facility administrator named in report. |
| Maintenance Staff A | Interviewed regarding life safety deficiencies including exit door codes, signage, door closures, sprinkler head clearance, oxygen signage. | |
| RN-C | Registered Nurse | Interviewed regarding catheter bag positioning and medication refrigerator temperature. |
| RN-A | Registered Nurse | Interviewed regarding medication refrigerator temperature and insulin storage. |
| NA-B | Nursing Assistant | Observed holding catheter drainage bag improperly during resident transfer. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 18, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ashland Care Center regarding alleged failures to evaluate causal factors for falls and to change fall interventions after residents were identified at risk for falls.
Findings
The investigation found no violations; the facility did evaluate causal factors for falls and did change fall interventions after residents were identified at risk. Records, observations, and interviews showed appropriate policies and individualized safety interventions were in place.
Complaint Details
The complaint alleged failure to evaluate causal factors for falls and failure to change fall interventions after residents were identified at risk. Both allegations were found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Renewal
Capacity: 97
Deficiencies: 0
Mar 3, 2017
Visit Reason
This document is a nursing home licensure renewal application and related licensing and certification documents for Ashland Care Center, verifying the renewal of the facility's license and certification.
Findings
The documents confirm that Ashland Care Center meets statutory requirements for licensure as a skilled nursing facility and nursing facility dual certification, with a licensed capacity of 97 beds. The renewal application includes ownership, staffing, and service details, as well as an Alzheimer's Special Care Unit Disclosure.
Report Facts
Licensed capacity: 97
Renewal fee: 1750
Staffing numbers: 2
Staffing numbers: 1
Private room rates: 217
Private room rates: 343
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peggy Ratzlaff | Administrator | Named as facility administrator and contact person on renewal application and Alzheimer's unit disclosure |
| Cara Nicholson | Director of Nursing | Named as Director of Nursing on renewal application |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 97
Deficiencies: 12
Oct 17, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding nutritional needs, food preparation, equipment cleanliness, staffing sufficiency, discharge notice, and abuse protection at Ashland Care Center.
Findings
The facility was found compliant with nutritional needs, food preparation, equipment cleanliness, staffing sufficiency, and abuse protection. However, the facility failed to provide appropriate discharge notice to one resident, violating state and federal regulations.
Complaint Details
The complaint investigation was triggered by allegations regarding nutritional needs, food preparation, equipment cleanliness, staffing sufficiency, discharge notice, and abuse protection. The facility was found non-compliant only for failure to provide appropriate discharge notice to one resident.
Severity Breakdown
SS=D: 4
SS=E: 4
SS=F: 4
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to provide appropriate discharge notice to one resident, violating state regulation 175 NAC 12-006.05(5) and federal regulation F 203. | SS=D |
| Failed to ensure two dependent residents were shaved in a manner to maintain grooming. | SS=D |
| Failed to ensure medication administration with less than a 5% medication error rate (11.54% error rate observed). | SS=D |
| Failed to act upon pharmacy consultant's recommendations and physician's order to reduce hypnotic medication use for one resident. | SS=D |
| Failed to ensure doors to hazardous areas were not obstructed, allowing potential smoke and gas spread. | SS=F |
| Failed to prohibit use of more than one locking device on doors within means of egress and maintain magnetic locks and signage for delayed egress. | SS=E |
| Failed to provide emergency lighting of at least 5 foot-candles in Special Care Unit II Dining Room. | SS=E |
| Failed to conduct fire drills at random times under varied conditions during 1st and 2nd shifts for five of five quarters. | SS=F |
| Failed to provide all required documentation of the annual fire alarm system test and semi-annual inspections. | SS=F |
| Failed to conduct annual inspections of the fire sprinkler system and quarterly testing of fire sprinkler alarm devices. | SS=F |
| Failed to maintain Hilton Dining Room exit door free of obstructions. | SS=E |
| Failed to ensure kitchen staff was trained on the use of the kitchen hood fire suppression system. | SS=F |
Report Facts
Facility census: 67
Total licensed capacity: 97
Medication error rate: 11.54
Number of medication opportunities observed: 26
Number of medication errors: 3
Number of residents affected by medication errors: 2
Number of residents sampled for discharge notice: 24
Number of residents with discharge notice deficiency: 1
Number of residents observed unshaven: 2
Facility census at time of inspection: 66
Number of smoke compartments affected by hazardous door obstruction: 1
Number of residents affected by hazardous door obstruction: 67
Number of smoke compartments with locking device deficiencies: 4
Number of residents affected by locking device deficiencies: 48
Number of residents affected by emergency lighting deficiency: 24
Number of smoke compartments affected by emergency lighting deficiency: 1
Number of residents affected by fire drill deficiency: 67
Number of smoke compartments affected by fire drill deficiency: 5
Number of residents affected by fire alarm testing deficiency: 67
Number of smoke compartments affected by fire alarm testing deficiency: 5
Number of residents affected by fire sprinkler inspection deficiency: 67
Number of smoke compartments affected by fire sprinkler inspection deficiency: 5
Number of residents affected by exit door obstruction: 17
Number of smoke compartments affected by exit door obstruction: 1
Facility census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peggy Ratzlaff | Administrator | Named as facility administrator in multiple documents |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Nursing Assistant C | Interviewed about shaving frequency for residents | |
| Licensed Practical Nurse A | Interviewed about shaving frequency and medication administration | |
| Licensed Practical Nurse B | Observed administering medication incorrectly | |
| Licensed Practical Nurse D | Interviewed about pharmacy consultant recommendations | |
| Social Service Director | Interviewed about discharge notice process | |
| Maintenance Staff A | Confirmed fire safety and door obstruction findings | |
| Kitchen Staff A | Failed to identify manual activation device for kitchen hood fire suppression system |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 6, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ashland Care Center regarding the facility's failure to identify a change in condition.
Findings
The facility did identify changes in condition and acted upon them as required; therefore, no violation was found related to the allegation.
Complaint Details
The complaint alleged the facility failed to identify a change in condition. The investigation found the allegation unsubstantiated as the facility identified and responded to changes appropriately.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Dec 16, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint at Ashland Care Center on December 15-16, 2015, by representatives of the Department of Health and Human Services Division of Public Health. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Findings
The facility was found to have no violation related to misappropriation of residents' property. However, the facility failed to ensure sufficient staffing to provide resident cares, specifically bathing, resulting in residents receiving fewer baths than scheduled. The facility also failed to provide bathing in accordance with bath schedules for four residents requiring assistance. The facility maintained essential equipment appropriately.
Complaint Details
Complaint allegations included failure to protect residents from misappropriation, failure to ensure sufficient staff to provide resident cares, failure to ensure sufficient staffing, and failure to maintain essential equipment. The facility was found compliant regarding misappropriation and equipment maintenance but deficient in staffing and bathing care.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide bathing in accordance with bath schedules for four residents requiring assistance with bathing tasks (Residents 8, 9, 10, and 11). | SS=E |
| Facility failed to ensure sufficient nursing staff to provide nursing and related services to meet residents' needs, resulting in inadequate bathing provision. | SS=E |
Report Facts
Facility census: 70
Residents affected: 4
Bath aide availability: 9
Bath aide absence days: 3
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 2
Oct 20, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding failure to provide wound treatments, failure to follow physician orders, failure to complete written investigations within five working days, and failure to protect residents from abuse.
Findings
The facility was found to provide wound treatments and follow physician orders appropriately. However, the facility failed to report allegations of verbal abuse to state agencies as required for multiple residents and failed to complete written investigations within five working days. The facility did protect residents from abuse overall. Additionally, infection control deficiencies were found related to improper linen handling, uncleanable sit-to-stand lifts, and inadequate hand hygiene by staff.
Complaint Details
The complaint alleged failure to provide wound treatments to prevent infection and/or complications, failure to follow physician orders, failure to complete written investigations within five working days, and failure to protect residents from abuse. The investigation found wound care and physician orders were properly followed, but the facility failed to report verbal abuse allegations timely and failed to complete investigations within required timeframes. The facility did protect residents from abuse overall.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report allegations of verbal abuse to state agencies for 11 unidentified resident council attendees and two identified residents. | SS=E |
| Failure to ensure dirty linens were not placed on the floor, failure to maintain multi-use sit-to-stand lifts in a cleanable manner, and failure to ensure staff performed hand hygiene properly to prevent cross contamination. | SS=E |
Report Facts
Facility census: 74
Number of residents with unreported verbal abuse allegations: 13
Duration of hand hygiene observed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gay Harberts | Administrator | Named as aware of verbal abuse incident |
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Author of complaint investigation letter |
| LPN C | Licensed Practical Nurse | Observed performing inadequate hand hygiene during wound care and blood glucose testing |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 4
Jul 29, 2015
Visit Reason
An unannounced visit was conducted to investigate multiple complaints at Ashland Care Center from July 29, 2015 to August 4, 2015, including allegations of failure to protect residents from injuries, elopements, skin breakdown, abuse, insufficient staffing, medication errors, hygiene, housekeeping, food handling, pressure sore prevention, fall prevention, positioning, and resident-to-resident behaviors.
Findings
The facility was found to have implemented appropriate interventions and care in all investigated areas, with no deficiencies identified related to the complaints. The facility census was 71 residents during the investigation.
Complaint Details
The complaint investigation included allegations of failure to protect residents from injuries, elopements, skin breakdown, abuse, insufficient staffing, medication errors, hygiene, housekeeping, food handling, pressure sore prevention, fall prevention, positioning, resident-to-resident behaviors, and safety concerns. The investigation included resident record reviews, staff and resident interviews, observations, and policy reviews. No deficiencies were found related to care and treatment, but deficiencies were cited related to management of personal funds, infection control during water pass, emergency lighting, and exit signage.
Severity Breakdown
SS=D: 1
SS=F: 1
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure resident personal funds were available on nights and weekends for 2 residents. | SS=D |
| Facility failed to perform water pass procedure to prevent cross contamination of dirty to clean pitchers. | SS=F |
| Facility failed to provide emergency lighting of at least 1½ hour duration in accordance with NFPA 101, 7.9. | SS=E |
| Facility failed to ensure all means of egress are marked with exit signs in accordance with NFPA 101, 7.10. | SS=E |
Report Facts
Facility census: 71
Deficiency count: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gay Harberts | Administrator | Named in relation to complaint investigation and verification of emergency lighting deficiencies. |
| Dan Taylor | RN, Training Coordinator - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter. |
| Lori Wehrs | Registered Nurse | Investigator in complaint investigation. |
| Victoria Smith | Registered Nurse | Investigator in complaint investigation. |
| Dain Weiss | Registered Nurse | Investigator in complaint investigation. |
| Administrator A | Verified emergency lighting and exit signage deficiencies during inspection. | |
| Business Office Manager | Interviewed regarding resident trust fund availability. | |
| NA A | Nursing Assistant | Observed and interviewed regarding improper water pass procedure. |
| Director of Nursing | DON | Interviewed regarding water pass procedure and staff education. |
| Maintenance Director | Responsible for emergency lighting and exit sign inspections and corrective actions. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 14
May 15, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Ashland Care Center on May 12, 2014-May 15, 2014, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility failed to ensure residents were supervised in the dining room, failed to provide sufficient staff to meet residents' needs, failed to assist residents with activities of daily living, failed to ensure meals were attractive and palatable, and failed to implement or follow the plan of care. Other allegations including abuse, injury reporting, protection from adverse behaviors, activity opportunities, staff training, call light response, pest control, medication administration, and notification of condition changes were found to be compliant.
Complaint Details
The complaint investigation included allegations that the facility failed to ensure residents were free from abuse, failed to report injury of unknown origin within 24 hours, failed to ensure residents were supervised in the dining room, failed to provide sufficient staff, failed to protect residents from residents with adverse behaviors, failed to assist residents with activities of daily living, failed to ensure meals were attractive and palatable, failed to ensure residents have opportunity for activities outside the facility, failed to ensure staff were trained, failed to answer call notification systems promptly, failed to implement or follow the plan of care, failed to ensure pest free environment, failed to administer medications according to orders, and failed to notify health care practitioner of change in condition. Findings showed compliance with abuse protection, injury reporting, adverse behavior protection, activity opportunities, staff training, call light response, pest control, medication administration, and notification of condition changes. Deficiencies were found in supervision in dining, staffing, ADL assistance, meal quality, and plan of care implementation.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 2
SS=G: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure residents are supervised in the dining room resulting in a fall with injury. | — |
| Failed to provide sufficient staff to meet residents' needs. | — |
| Failed to assist resident with activities of daily living, including incontinent care delays. | — |
| Failed to ensure meals were attractive and palatable; food often served cold. | — |
| Failed to implement or follow the plan of care; many care plan interventions not implemented. | — |
| Failed to have resident or representative sign Skilled Nursing Facility Determination on Continued Stay or Notice of Medicare Non-Coverage for multiple residents. | SS=D |
| Failed to maintain dignity and respect during dining service related to assessment of vital signs, injection administration, standing while assisting residents with meal consumption, and discussing medical care within hearing of others. | SS=E |
| Failed to revise plan of care for resident with suicidal ideation. | SS=D |
| Failed to assess and implement plan of care to address ongoing bruises for two residents. | SS=D |
| Failed to ensure one resident was provided care to prevent incontinent episodes in a timely manner. | SS=D |
| Failed to have sufficient nursing staff to provide care to prevent falls, maintain dignity during dining, complete infection control tasks related to mechanical lifts, and provide toileting assistance. | SS=G |
| Failed to ensure food was maintained at proper temperature to prevent microbial growth. | SS=D |
| Failed to prepare and serve food in a sanitary manner, including improper glove use and handwashing. | SS=F |
| Failed to provide a safe, sanitary environment by staff failing to wash hands, sanitize lifts, and properly handle linens. | SS=E |
Report Facts
Facility census: 71
Residents requiring 2 staff assist: 5
Residents in SCU: 18
Facility census: 68
Occupant load: 80
Residents in SCU II: 42
Residents in smoke compartments: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin Eddy | Administrator | Named in complaint investigation letter and plan of correction |
| Gay Harberts | Administrator | Named in subsequent complaint investigation and plan of correction |
| Eve Lewis | Program Manager | Signed complaint investigation letter and informal conference report |
| Kathleen Philippi | Registered Nurse | Surveyor and complaint investigator |
| Victoria Smith | Registered Nurse | Surveyor and complaint investigator |
| Rebecca Young | Registered Nurse | Surveyor and complaint investigator |
| Dain M. Weiss | RN | Reviewer of informal conference report |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 3
Sep 17, 2013
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to provide necessary care and services to prevent injuries from residents with adverse behaviors, to maintain a safe environment free of accident hazards, and to ensure sufficient nursing staff to supervise residents with adverse behaviors.
Findings
The facility failed to ensure procedures were available to prevent injuries from residents with adverse behaviors, failed to identify causal factors and revise interventions to prevent ongoing falls for residents, and failed to ensure sufficient staffing to supervise residents with adverse behaviors. Multiple incidents of resident-to-resident physical altercations and falls were documented, with inadequate staff response and alarm system failures noted.
Complaint Details
The complaint investigation was triggered by concerns about the facility's failure to prevent injuries from residents with adverse behaviors, inadequate supervision to prevent falls, and insufficient nursing staff to supervise residents with behavioral issues. The facility census was 82 at the time of the investigation.
Severity Breakdown
SS=E: 1
SS=G: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide care/services for highest well-being, resulting in injuries from resident physical altercations. | SS=E |
| Failure to maintain a resident environment free of accident hazards and provide adequate supervision to prevent falls. | SS=G |
| Insufficient 24-hour nursing staff per care plans to supervise residents with adverse behaviors. | SS=D |
Report Facts
Resident census: 82
Falls documented: 26
Missed hourly rounds: 46
Missed hourly rounds: 82
Fall incidents: 4
Fall incidents: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA G | Medication Aide | Witnessed resident altercation and reported emergency button issues |
| LPN A | Licensed Practical Nurse | Interviewed regarding falls and behavior logs |
| NA E | Nursing Assistant | Interviewed about staffing and break coverage |
| NA F | Nursing Assistant | Interviewed about emergency button availability and staffing |
| ADON | Assistant Director of Nursing | Interviewed about staffing and unit conditions |
Inspection Report
Routine
Deficiencies: 10
Apr 18, 2013
Visit Reason
The inspection was a routine survey to assess compliance with state and federal regulations governing skilled nursing facilities, including housekeeping, maintenance, care planning, pest control, and life safety code standards.
Findings
The facility was found deficient in housekeeping and maintenance services, comprehensive care planning, pest control, fire safety code compliance including improper storage of soiled linen and trash, incorrect exit door codes, fire alarm testing, sprinkler system maintenance, microwave safety, and electrical wiring compliance.
Severity Breakdown
SS=E: 7
SS=D: 2
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide maintenance and repair to cabinets and doors in resident rooms and bath houses. | SS=E |
| Failed to develop a comprehensive care plan for management of limitations in range of motion for one resident. | SS=D |
| Failed to review and revise care plan interventions to meet the needs of two residents with behavioral issues. | SS=E |
| Failed to maintain an effective pest control program; live bugs and ants observed in resident rooms. | SS=D |
| Failed to store soiled linen and trash within a separation of hazardous area; restroom door lacked self-closing device. | SS=E |
| Failed to post the correct exit code to a magnetically locked exit door, delaying egress during emergency. | SS=E |
| Failed to test transmission of fire alarm signal within 24 hours before or after a 3rd shift drill. | SS=F |
| Failed to maintain sprinkler system by missing sprinkler escutions in resident rooms. | SS=E |
| Failed to provide smoke detection connected to fire alarm system in resident rooms with microwaves. | SS=E |
| Allowed use of electrical adaptors not in accordance with electrical code, increasing fire risk. | SS=E |
Report Facts
Facility census: 75
Total licensed capacity: 49
Residents affected by fire safety code violation: 30
Residents affected by sprinkler system deficiency: 35
Residents affected by microwave smoke detection deficiency: 30
Residents affected by electrical adaptor violation: 23
Inspection Report
Routine
Census: 81
Deficiencies: 1
Oct 2, 2012
Visit Reason
The inspection was conducted to assess compliance with medication administration regulations, specifically to ensure the facility is free of medication error rates of five percent or greater.
Findings
The facility failed to ensure medication error rates were below 5%, with an observed medication error rate of 11.76% based on 6 errors out of 51 medications administered to 18 residents. Errors included incorrect timing of medication administration, improper medication handling, and leaving medication with residents unsupervised.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure medication error rates of 5% or greater did not occur, with 6 medication errors affecting four residents. | SS=E |
Report Facts
Medication observations: 51
Medication errors: 6
Resident sample size: 11
Facility census: 81
Medication error rate: 11.76
Audit frequency: 2
Audit duration: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Counseled by DON following medication error observations | |
| Staff B | Counseled by DON following medication error observations | |
| Staff E | Counseled by DON following medication error observations | |
| DON | Director of Nursing | Reviewed medication error findings and counseled staff |
| MA A | Medication Aide | Observed administering medications with errors |
| MA B | Medication Aide | Observed administering medications with errors |
| LPN E | Licensed Practical Nurse | Observed administering medications with errors |
| ADON | Assistant Director of Nursing | Interviewed regarding medication administration errors |
Inspection Report
Routine
Census: 81
Deficiencies: 14
Jan 23, 2012
Visit Reason
Routine inspection of Ashland Care Center to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility failed to provide proper perineal care techniques to prevent urinary tract infections for 2 of 5 residents observed. Additionally, multiple life safety code deficiencies were identified including door latching issues, hazardous area separations, emergency lighting failures, exit sign deficiencies, sprinkler system coverage and maintenance issues, smoking area safety, kitchen hood fire suppression training, prohibited heating devices, flammable decorations, oxygen safety signage, and electrical code violations.
Severity Breakdown
SS=D: 1
SS=E: 7
SS=F: 6
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to provide perineal care using techniques to prevent urinary tract infections with 2 of 5 residents observed. | SS=D |
| Doors protecting corridor openings failed to latch properly and were obstructed. | SS=E |
| Failed to provide separation of hazardous areas from other compartments; multiple doors failed to self-close or latch. | SS=F |
| Staff failed to carry key to locked egress gate, potentially delaying egress. | SS=E |
| Emergency lighting failed to operate in generator room. | SS=F |
| Exit signs were not connected to emergency generator or battery backup; illumination and size deficiencies noted. | SS=F |
| Fire drills were not conducted throughout the month and third shift drills were not tested by pulling alarm within 24 hours. | SS=F |
| Generator room lacked sprinkler protection. | SS=F |
| Sprinkler system not properly maintained: obstructions, foreign matter, ceiling tiles out of place, unsealed penetrations, missing sprinkler wrench. | SS=F |
| Smoking areas lacked safe design ashtrays and metal containers with self-closing covers. | SS=E |
| Kitchen staff not trained on kitchen hood fire suppression system and procedures. | SS=F |
| Prohibited heating pad found in resident room without physician order. | SS=E |
| Oxygen in use signs not posted in resident rooms where oxygen was used. | SS=E |
| Electrical violations including extension cords, non-hospital grade power strips, uncovered junction box. | SS=E |
Report Facts
Total sample size: 34
Facility census: 81
Facility census: 79
Residents affected: 60
Residents affected: 27
Residents affected: 20
Residents affected: 67
Residents affected: 14
Residents affected: 4
Inspection Report
Annual Inspection
Census: 76
Capacity: 80
Deficiencies: 11
Mar 29, 2011
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including resident rights, care planning, accident prevention, nutrition, medication administration, infection control, and life safety.
Findings
The facility was found deficient in multiple areas including failure to notify residents of roommate changes, incomplete care plan revisions for nutrition, inadequate fall prevention and unsafe water temperatures, significant medication errors related to insulin administration timing, improper dishwashing machine operation, inadequate infection control in laundry practices, and several life safety code violations including emergency lighting, exit signage, sprinkler system inspection, and electrical wiring.
Severity Breakdown
SS=D: 4
SS=E: 3
SS=F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to notify residents and/or legal representatives of roommate changes for 3 residents. | SS=D |
| Failure to review and revise care plan interventions to maintain resident weight and prevent weight loss for 2 residents. | SS=D |
| Failure to implement fall prevention measures for 1 resident and maintain safe water temperatures in bathhouses and resident rooms. | SS=E |
| Significant medication errors related to insulin administration timing for 2 residents. | SS=D |
| Dishwashing machine not maintaining required wash and rinse temperatures and chemical sanitizer levels. | SS=E |
| Failure to wash resident co-mingled sweaters in hot water or use disinfectant in household washing machine. | SS=E |
| Failure to provide two-bulb lighting outside of one exit. | SS=E |
| Failure to test and maintain battery backup emergency lights throughout the facility. | SS=F |
| Failure to test and maintain battery backup exit signs throughout the facility. | SS=F |
| Failure to inspect the automatic sprinkler system annually. | SS=F |
| Use of extension cord as permanent wiring for kitchen ice machine. | SS=D |
Report Facts
Facility census: 76
Total licensed capacity: 80
Residents recently moved: 12
Residents affected by roommate notification deficiency: 3
Resident sample size: 32
Resident 37 Fall Risk Score: 27
Water temperature: 131
Resident 103 weight loss: 34.6
Resident 98 weight loss: 23
Resident 74 blood glucose: 268
Resident 58 blood glucose: 121
Dishwasher wash temperature: 108
Dishwasher rinse temperature: 110
Dishwasher sanitizer concentration: 10
Household washer temperature: 77
Facility census: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Acknowledged lighting and emergency light deficiencies |
| DON | Director of Nursing | Interviewed regarding fall prevention and medication administration |
| Social Worker | Responsible for notifying residents of roommate changes | |
| Dietary Manager | Re-educated on care plan updates and dishwashing procedures | |
| Registered Dietician | Interviewed regarding resident nutrition and care plans | |
| Maintenance Director | Responsible for lighting, water temperature, sprinkler system, and electrical issues | |
| LPN J | Licensed Practical Nurse | Observed administering insulin to residents |
| Laundry and Housekeeping Supervisor | Interviewed regarding laundry infection control practices | |
| Dietary Aide F | Observed dishwashing machine operation | |
| Dietary Aide G | Interviewed regarding dishwasher temperature requirements | |
| Dishmachine Repairman | Interviewed regarding dishwasher repairs |
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 1
Jan 12, 2011
Visit Reason
The document is a Plan of Correction submitted by Ashland Care Center in response to a deficiency cited during a survey related to free of accident hazards, supervision, and devices to prevent accidents.
Findings
The facility failed to follow procedures to prevent a fall for one resident due to inadequate monitoring of bath safety straps on bath chairs. The resident fell and sustained injuries including a contusion to the head. Safety straps on bath chairs were found worn and cracked, and corrective actions including re-education of staff and safety audits were planned.
Deficiencies (1)
| Description |
|---|
| Failure to ensure the resident environment remains free of accident hazards, specifically failure to monitor bath safety straps on bath chairs leading to a resident fall. |
Report Facts
Facility census: 80
Resident Fall Risk Review Tool score: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Interviewed regarding the resident fall incident |
| Bath Aide | BA | Interviewed about bath chair safety strap inspections and usage |
| Maintenance Director | Interviewed about maintenance and replacement of bath chair safety straps | |
| Central Supply Supervisor | CS D | Provided education to bath aides and responsible for safety audits of bath chairs |
Document
Capacity: 97
Deficiencies: 0
APP2016
Visit Reason
The document contains a Nursing Home Licensure Renewal Application and related materials for Ashland Care Center, including certification, occupancy permit, and various care program guidelines and policies.
Findings
No inspection findings or deficiencies are reported. The document primarily consists of administrative and programmatic information, including ownership, occupancy, care philosophies, training, and program guidelines.
Report Facts
Total licensed beds: 97
Renewal application bed count: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gay Harberts | Administrator | Named in the Nursing Home Licensure Renewal Application (page 2). |
| Cara Nicholson | Director of Nursing, R.N. | Named in the Nursing Home Licensure Renewal Application (page 2). |
| Richard A. Doyle | Treasurer & Chief Financial Officer | Listed as an officer in the Ownership Control - Officers & Directors table (page 4). |
| Bruce J. Mackey Jr. | President & Chief Executive Officer | Listed as an officer in the Ownership Control - Officers & Directors table (page 4). |
Notice
Capacity: 97
Deficiencies: 0
APP2018
Visit Reason
The document serves as a licensure renewal application and certification for Ashland Care Center, verifying the facility's license and endorsement for Alzheimer's Special Care Unit and Memory Care.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal and Alzheimer's Special Care Unit endorsement, including ownership information, staffing patterns, care philosophy, and facility features.
Report Facts
Total licensed beds: 97
Maximum endorsed capacity: 12
Renewal fees: 1950
Staffing pattern: 2
Staffing pattern: 2
Staffing pattern: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Michael Shafer | Administrator | Named as administrator on licensure renewal and Alzheimer's Special Care Unit Disclosure |
| Cara Nicholson | Director of Nursing, R.N. | Named on licensure renewal application |
| Bruce J. Mackey Jr. | President & CEO | Named as authorized representative and applicant signature on renewal and endorsement applications |
| Lisa Newcomb | Licensing Manager | Named as contact person on Alzheimer's Special Care Unit Disclosure |
Notice
Capacity: 97
Deficiencies: 0
CHOW2023
Visit Reason
The document set includes a skilled nursing facility license issuance based on a request for a new license due to a change of ownership, renewal card, licensure application, occupancy permit, and an assignment and assumption agreement for ownership transfer.
Findings
No inspection findings or deficiencies are reported. The documents primarily certify licensure, ownership, capacity, and regulatory compliance for operation.
Report Facts
Total licensed beds: 97
Alzheimer's beds capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Baker | Administrator | Named as facility administrator on licensure application and correspondence. |
| Misty Masters | Director of Nursing | Named as Director of Nursing on licensure application. |
| Ari Silberstein | Authorized Signatory | Signed the Assignment and Assumption Agreement as authorized signatory for The Meadows at Ashland LLC. |
| Steve Hornung | Manager | Signed the Assignment and Assumption Agreement as manager of BCP Ashland, LLC. |
| Timothy Tesmer, MD | Chief Medical Officer | Signed the license issuance letter from the Department of Health and Human Services. |
Notice
Capacity: 97
Deficiencies: 0
APP2019
Visit Reason
This document serves as a licensure renewal application and certification for Ashland Care Center, verifying that the facility meets statutory requirements and is licensed through the renewal date.
Findings
The documents confirm the facility's licensure status, ownership information, occupancy permit, and endorsement for Alzheimer's Special Care Unit. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 97
Maximum endorsed capacity: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Michael Shafer | Administrator | Named as administrator on the renewal application and Alzheimer's Special Care Unit Disclosure. |
| Cara Nicholson | Director of Nursing, R.N. | Named as Director of Nursing on the renewal application. |
| Lisa Newcomb | Licensing Manager | Contact name for the legal owning entity Five Star Quality Care NE, Inc. |
| Katherine E. Potter | President and Chief Executive Officer | Listed as an officer of the ownership company Five Star Quality Care-NE, LLC. |
| Richard A. Doyle | Executive Vice President, Chief Financial Officer and Treasurer | Listed as an officer of the ownership company Five Star Quality Care-NE, LLC. |
Notice
Deficiencies: 0
DAN032911
Visit Reason
This Notice of Disciplinary Action was issued due to the facility's failure to implement interventions to prevent significant weight loss among residents, resulting in probation for 90 days starting April 23, 2011.
Findings
The Department of Health and Human Services determined that the facility violated licensure regulations related to unplanned weight loss and required submission of a Plan of Correction detailing assessment, intervention, and monitoring processes for residents with weight loss.
Report Facts
Probation period length: 90
Report submission due date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Administrator | Recipient of reports and signatory on termination letter of probation |
| Joann Schaefer | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II, Office of Long Term Care Facilities | Certified mailing of the Notice of Disciplinary Action |
Notice
Capacity: 97
Deficiencies: 0
APP2021
Visit Reason
This document serves as a renewal application for the nursing home license of Azria Health Ashland, including verification of licensure and occupancy permit.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal and occupancy with a capacity of 97 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 97
Maximum capacity for Alzheimer's beds: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie A Clifton | Administrator | Named as administrator and contact person on the renewal application and Alzheimer's Special Care Unit Disclosure. |
| Noah Kaminer | Owner | Named as owner and authorized representative on the renewal application. |
| Steve Hornug | Owner | Named as owner and authorized representative on the renewal application. |
Notice
Deficiencies: 0
DAN051514
Visit Reason
This document serves as a Notice of Disciplinary Action against Ashland Care Center for violations of the Health Care Facility Licensure Act, specifically related to insufficient staffing and failure to ensure food was prepared and served in a sanitary manner.
Findings
The facility was placed on probation for 90 days beginning June 13, 2014, due to failure to provide sufficient staffing to supervise and assist residents, and again placed on probation beginning July 24, 2014, for failure to ensure food safety and sanitation. The probation periods required submission of plans of correction and compliance with specified conditions.
Report Facts
Probation period length: 90
Probation period length: 90
Dates of disciplinary actions: May 29, 2014
Dates of disciplinary actions: Jul 8, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Contact for submission of plans of correction and responses |
| Joseph M. Acierno | MD, JD, Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice of Disciplinary Action |
Document
Capacity: 97
Deficiencies: 0
APP2022
Visit Reason
The documents serve to renew the nursing home license, verify occupancy permit, disclose Alzheimer's special care unit details, and provide ownership information for Azria Health Ashland.
Findings
No inspection findings are reported. The documents confirm licensure renewal, occupancy capacity, and Alzheimer's care program details including staffing and care philosophy.
Report Facts
Total licensed beds: 97
Maximum capacity for Alzheimer's beds: 18
Renewal application date: 2022
Occupancy permit issue date: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Douglas A. Williams | Administrator | Named as administrator on renewal application and Alzheimer's care disclosure. |
| Doug Williams | Administrator | Named on renewal application. |
| Terri Pope-Wood | Director of Nursing | Named on renewal application. |
| Steve Hornung | Owner | Named in ownership listing and renewal application. |
| Aaron N Kaminer | Owner | Named in ownership listing and renewal application. |
Notice
Deficiencies: 0
DAN091713
Visit Reason
The notice was issued to inform Ashland Care Center of disciplinary action due to violations related to failure to identify causal factors and revise interventions to prevent falls, resulting in probation for 90 days starting October 18, 2013.
Findings
The Department of Health and Human Services found that the facility failed to identify causal factors and revise interventions to prevent falls, violating licensure regulations. The facility was placed on probation and required to submit a Plan of Correction and regular reports on falls.
Report Facts
Probation period: 90
Report due date: 28
Notice mailing date: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Recipient of required reports and contact for response |
| Joseph M. Acierno | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II, Office of Long Term Care Facilities | Certified mailing of the Notice |
Notice
Capacity: 97
Deficiencies: 0
APP2024
Visit Reason
This document serves as a renewal application for the nursing home license of The Meadows at Ashland, confirming licensure and certification status and providing ownership and facility information.
Findings
The documents confirm that The Meadows at Ashland is licensed as a Skilled Nursing Facility with a total licensed capacity of 97 beds, including special care and treatment for Alzheimer's and other therapies. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 97
Alzheimer's unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey L. Baker | Administrator | Named as the facility administrator in the renewal application and ownership attachment (page 2 and page 4). |
| Amanda Novak | Director of Nursing | Named as Director of Nursing in the renewal application (page 2). |
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