Ashland Nursing And Rehabilitation
Ashland, Hanover County, Virginia · CCN 495362 · For-profit (Corporation) · part of Avardis Health (38 facilities, chain average 2 stars)
CMS rates Ashland Nursing And Rehabilitation 1 of 5 overall as of August 2026. 190 certified beds, 157 residents a day on average. 174 citations on record from the current inspection cycles, 2 at immediate jeopardy; 1 fine totalling $36,491 and 1 payment denial.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
- Special Focus Facility candidate. On CMS’s list of facilities that qualify for the program but are not yet in it.
- No health inspection in more than two years, by CMS’s own flag.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 2 / 2 of 5 |
Staffing
| Total nurse staffing | 3.02374 hours per resident per day |
|---|---|
| Registered nurses | 0.41259 hours per resident per day |
| Weekend total | 2.64734 hours per resident per day |
| Nursing staff turnover | 57.6% (registered nurses 69.2%) |
| Administrators who left | 3 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-07-02 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-16 |
| 2026-07-02 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2026-06-10 |
| 2026-07-02 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-16 |
| 2026-03-18 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-18 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2026-07-02 |
| 2026-03-18 complaint survey |
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. Administration Deficiencies · tag F0838 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2026-07-02 |
| 2026-03-18 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-18 complaint survey |
Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-18 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-16 |
| 2026-03-18 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-18 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-16 |
| 2026-03-18 complaint survey |
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · tag F0941 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-02 |
| 2026-03-18 complaint survey |
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · tag F0942 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-02 |
| 2026-03-18 complaint survey |
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-02 |
| 2026-03-18 complaint survey |
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-07-02 |
| 2026-03-18 complaint survey |
Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2026-07-02 |
| 2025-08-21 complaint survey |
Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · tag F0565 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · tag F0680 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
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. Administration Deficiencies · tag F0838 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
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. Administration Deficiencies · tag F0840 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · tag F0868 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · tag F0802 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
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. Nutrition and Dietary Deficiencies · tag F0809 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · tag F0553 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · tag F0557 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide appropriate foot care. Quality of Life and Care Deficiencies · tag F0687 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · tag F0745 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
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. Administration Deficiencies · tag F0849 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · tag F0941 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · tag F0942 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0943 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Infection Control Deficiencies · tag F0945 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide training in compliance and ethics. Administration Deficiencies · tag F0946 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · tag F0947 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2025-08-21 complaint survey |
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-11-17 |
| 2024-04-11 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-07 |
| 2024-04-11 complaint survey |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-07 |
| 2024-04-11 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-07 |
| 2024-04-11 complaint survey |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-07 |
| 2024-04-11 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-07 |
| 2024-04-11 complaint survey |
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. Quality of Life and Care Deficiencies · tag F0700 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-07 |
| 2024-04-11 complaint survey |
Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-07 |
| 2024-04-11 complaint survey |
Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · tag F0770 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-07 |
| 2024-02-09 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · tag F0680 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | 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. Resident Rights Deficiencies · tag F0622 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | 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. Resident Rights Deficiencies · tag F0625 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-07 |
| 2024-02-09 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-07 |
| 2024-02-09 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
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. Nursing and Physician Services Deficiencies · tag F0726 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | 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. Nursing and Physician Services Deficiencies · tag F0727 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-07 |
| 2024-02-09 complaint survey |
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. Pharmacy Service Deficiencies · tag F0758 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
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. Nutrition and Dietary Deficiencies · tag F0809 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-05-07 |
| 2024-02-09 | 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. Administration Deficiencies · tag F0843 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · tag F0940 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0943 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · tag F0947 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Resident Rights Deficiencies · tag F0559 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · tag F0623 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Honor each resident's preferences, choices, values and beliefs. Quality of Life and Care Deficiencies · tag F0675 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-07 |
| 2024-02-09 complaint survey |
Provide appropriate foot care. Quality of Life and Care Deficiencies · tag F0687 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-07 |
| 2024-02-09 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | 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. Quality of Life and Care Deficiencies · tag F0700 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-05-07 |
| 2024-02-09 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · tag F0712 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · tag F0740 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · tag F0745 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Administration Deficiencies · tag F0776 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | 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. Nutrition and Dietary Deficiencies · tag F0803 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · tag F0810 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
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. Infection Control Deficiencies · tag F0887 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | 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. Environmental Deficiencies · tag F0909 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 complaint survey |
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Administration Deficiencies · tag F0941 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Resident Rights Deficiencies · tag F0942 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Administration Deficiencies · tag F0944 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Provide training in compliance and ethics. Administration Deficiencies · tag F0946 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2024-02-09 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. Administration Deficiencies · tag F0949 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-04-11 |
| 2023-11-20 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-19 |
| 2023-11-20 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-19 |
| 2023-11-20 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-19 |
| 2023-09-07 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
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. Nursing and Physician Services Deficiencies · tag F0727 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Nutrition and Dietary Deficiencies · tag F0800 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
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. Nutrition and Dietary Deficiencies · tag F0803 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-17 |
| 2023-09-07 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-10-17 |
| 2022-06-07 | 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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · tag F0745 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2022-06-07 | 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. Administration Deficiencies · tag F0840 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-12 |
| 2020-02-06 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | 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. Resident Rights Deficiencies · tag F0622 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · tag F0623 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | 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. Administration Deficiencies · tag F0836 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2019-04-18 |
| 2020-02-06 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
| 2020-02-06 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2020-03-10 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-03-18 | Payment denial for 28 days from 2026-06-18 | — |
| 2026-03-18 | Fine | $36,491 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Ashland Parentco LLC Organization | 5% or greater direct ownership interest | 100% | 2025-05-01 |
| Nts Holdco LLC Organization | 5% or greater indirect ownership interest | — | 2025-05-01 |
| Vaop Holdco LLC Organization | 5% or greater indirect ownership interest | — | 2025-05-01 |
| Ohi Assets (Va) Ashland, LLC Organization | 5% or greater security interest | — | 2025-05-01 |
| Ohi Assets (Va) Ashland, LLC Organization | adp of the snf | — | 2025-05-01 |
| Snf Mgr LLC Organization | adp of the snf | — | 2025-04-16 |
| Snf Mgr LLC Organization | operational/managerial control | — | 2025-05-01 |
| Ghannam, Waseem Individual | adp of the snf | — | 2026-04-01 |
| Hoback, Tiffany Individual | adp of the snf | — | 2025-05-01 |
| Jones, Tequilla Individual | adp of the snf | — | 2025-05-01 |
| Mccain, Shalandrea Individual | adp of the snf | — | 2025-05-01 |
| Morgan, Daniel Individual | adp of the snf | — | 2025-05-01 |
| Palmer, Devon Individual | adp of the snf | — | 2026-03-04 |
| Hoback, Tiffany Individual | managing control - governing body | — | 2025-05-01 |
| Morgan, Daniel Individual | managing control - governing body | — | 2025-05-01 |
| Ghannam, Waseem Individual | operational/managerial control | — | 2026-04-01 |
| Hoback, Tiffany Individual | operational/managerial control | — | 2025-05-01 |
| Jones, Tequilla Individual | operational/managerial control | — | 2025-05-01 |
| Mccain, Shalandrea Individual | operational/managerial control | — | 2025-05-01 |
| Morgan, Daniel Individual | operational/managerial control | — | 2025-05-01 |
| Palmer, Devon Individual | operational/managerial control | — | 2026-03-04 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Ashland Nursing And Rehabilitation.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Hanover County.