Ashley Healthcare Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

of a new Director of Nursing around the beginning of August 2025. NHA reported that resident Progress Notes were reviewed daily and confirmed the IDT was aware of Resident R300's increased behaviors. NHA reported that due to Resident R300's increased behaviors it was decided to move Resident R300 from the MCU to the East Unit (on 08/28/2025). NHA reported IDT/behavior management meeting notes are documented in the resident Progress Notes. NHA was notified that there were no notes pertaining to the meetings in the EMR and she reported she would provide the IDT notes if available. No IDT/behavior management notes were received as of 09/24/2025 at 5:30 PM indicating the meetings did not take place for Resident R300.NHA confirmed that Resident R300's Care Plan was not updated with behavioral interventions until after she was transferred to the hospital on [DATE REDACTED]. NHA reported she implemented new interventions (on 09/10/2025) in preparation for her return to the facility from her hospitalization if she is able to return. Review of the facility policy Abuse, Neglect and Exploitation implemented 11/1/22 (no review/revision date) revealed: Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment.B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. 1. An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission. 2. The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment.D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashley Healthcare Center

103 West Wallace Street Ashley, MI 48806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

spending time together and playing. When asked why she did not put this information in the chart (RN J) stated she thought that would be too much information.Review of the facility policy Abuse, Neglect and Exploitation implemented 11/1/22 (no review/revision date) revealed: Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a.

Prohibit and prevent abuse.b. Establish policies and procedures to investigate any such allegations; and c.

Include training for new and existing staff on activities that constitute abuse.and resident abuse prevention.3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator.

Event ID:

Facility ID:

If continuation sheet