Ashley Healthcare Center: Barrier Precaution Failures - MI
It was not.
The resident, identified in inspection records only as R203, lives at Ashley Healthcare Center and carries diagnoses of autism, anxiety, and a gastrostomy, meaning she receives nutrition through a tube inserted directly into her stomach. Because of that feeding tube, her physician placed her on Enhanced Barrier Precautions in early April 2025. A care plan followed two days later. The signage went up on her door. The order was active and visible.
None of it stopped what inspectors observed on August 12, 2025, at 2:35 in the afternoon.
Two certified nursing assistants, identified in the report as CNA E and CNA I, entered R203's room and performed incontinence care. Neither wore a gown. The precaution sign was on the door as they walked in.
When an inspector spoke with CNA E at 3:00 that afternoon, the aide offered two explanations. First, she said she did not normally work that hallway and was unaware R203 required Enhanced Barrier Precautions. Then she added a second claim: that the precautions only applied to care directly involving the tube feeding, not to incontinence care.
That second explanation was not a misunderstanding born of unfamiliarity with the hall. It was a statement of belief about how the precautions worked. And it was wrong.
The facility's own policy, revised as recently as February 2025, lists the care activities that require gown and gloves under Enhanced Barrier Precautions. The list includes dressing, bathing, transferring, providing hygiene, and changing linens. Incontinence care falls squarely within that category. The signage posted on R203's door repeated the same information.
What made the inspection finding harder to explain away was what happened the following morning.
On August 13, a registered nurse identified as RN K told the inspector that R203 was on Enhanced Barrier Precautions because of her tube feeding, and that nursing assistants were not required to use the precautions because they did not do anything with the tube feeding. The nurse was not a floater unfamiliar with the hall. She offered this as a considered explanation of how the precautions applied.
The inspector then reviewed the facility's own door signage with RN K. The signage stated that gown and gloves were necessary when performing close-contact care such as incontinence care and transfers for residents on Enhanced Barrier Precautions.
The report does not describe what RN K said after that.
Enhanced Barrier Precautions exist to reduce the spread of multidrug-resistant organisms, pathogens that are difficult to treat precisely because standard antibiotics have limited effect on them. Residents with feeding tubes, wounds, or indwelling devices are at elevated risk of colonization. The precautions are not designed only to protect the resident during procedures directly involving the device. They apply to the full range of hands-on care, because contact with one part of a resident's body does not stay contained to that part.
The facility's own policy said so. The door sign said so. Neither reached the staff who were responsible for following them.
The inspection was conducted in response to a complaint. Inspectors reviewed seven residents on Enhanced Barrier Precautions and found the breakdown in R203's case. The violation was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale, though the agency's own framework acknowledges that potential harm counts.
R203 did not choose to have a feeding tube. She did not choose to need incontinence care. She did not choose to live in a facility where the nurse responsible for her hall believed the precautions posted on her door did not apply to the people walking through it.
The sign was there. It said what it said.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ashley Healthcare Center from 2025-08-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Ashley Healthcare Center in Ashley, MI was cited for violations during a health inspection on August 13, 2025.
Because of that feeding tube, her physician placed her on Enhanced Barrier Precautions in early April 2025.
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.