Ashland Nursing: Hospice Communication Failures - VA
The failure came to light during an August inspection when investigators asked to see documentation of coordination between the facility and hospice providers. For Resident 19, who had been admitted to hospice services on June 12, administrators scrambled to produce any records of communication.
They couldn't find any.
Administrative staff member number 2, the director of clinical services, finally presented hospice documentation at 1:27 p.m. on August 20 — but only after the documents had been faxed to the facility that same day. The records contained notes from hospice visits on June 12, June 13, June 27, and July 1, spanning nearly three weeks of care.
When inspectors asked how hospice information was supposed to reach staff caring for residents, the clinical director explained that incoming documents get sent to medical records and uploaded to a miscellaneous file in the facility's electronic system. But when pressed about when this information should appear in resident records, she admitted she would have to check on that.
The clinical director went to the nursing unit to look for a hospice communication book. There wasn't one.
She spoke with a nurse on the unit, who said she talks with hospice staff members and they share information verbally. When inspectors asked whether this information should be available to all staff including physicians, the clinical director agreed it should.
The facility's own hospice care policy requires extensive coordination. Staff must communicate with hospice representatives, the hospice medical director, and the resident's attending physician to ensure coordinated care. The policy mandates obtaining the most recent hospice plan of care, hospice election forms, physician certifications of terminal illness, and contact information for hospice personnel.
The policy also requires getting information about the hospice's 24-hour on-call system, medication details, and physician orders. In return, facility staff must educate hospice workers about center policies including resident rights and documentation requirements.
None of this coordination was documented for Resident 19.
The breakdown reveals a system where dying residents' care depends on informal conversations between nurses rather than the systematic communication required by federal regulations. Without proper documentation, night shift staff, weekend workers, and physicians may lack critical information about a resident's hospice treatment plan, medication changes, or comfort care needs.
Federal regulations require nursing homes to either provide hospice services directly or assist residents in transferring to facilities that will arrange such services. The coordination requirement ensures that residents receiving end-of-life care get seamless treatment between their nursing home and hospice providers.
The clinical director and executive director were notified of the violation at 4:40 p.m. on August 20. Inspectors provided no additional information before completing their survey.
For families choosing hospice care for loved ones in nursing facilities, the violation highlights a critical question: How can they ensure their relatives receive coordinated end-of-life care when the facility has no reliable system for tracking hospice communications?
The inspection found the communication failure affected few residents and caused minimal harm. But for terminally ill people and their families, any breakdown in coordination during their final weeks can mean the difference between comfort and confusion, between dignity and neglect.
Resident 19's case represents what inspectors found in their sample review. The actual scope of communication failures with hospice providers at Ashland Nursing remains unclear, as does whether other dying residents experienced similar coordination breakdowns during their final days.
The facility must now implement systems to ensure hospice communications reach all relevant staff members and get properly documented in resident records. Until then, families of terminally ill residents face uncertainty about whether their loved ones' end-of-life care is truly coordinated between the nursing home and hospice providers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ashland Nursing and Rehabilitation from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Ashland Nursing and Rehabilitation
- Browse all VA nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
ASHLAND NURSING AND REHABILITATION in ASHLAND, VA was cited for violations during a health inspection on August 21, 2025.
The failure came to light during an August inspection when investigators asked to see documentation of coordination between the facility and hospice providers.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at ASHLAND NURSING AND REHABILITATION?
- The failure came to light during an August inspection when investigators asked to see documentation of coordination between the facility and hospice providers.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in ASHLAND, VA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from ASHLAND NURSING AND REHABILITATION or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 495362.
- Has this facility had violations before?
- To check ASHLAND NURSING AND REHABILITATION's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.