Ashley Healthcare Center
Ashley Healthcare Center in Ashley, MI — inspection on February 25, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R29's Vital
were noted to be within normal limits.
There were no other records that revealed vital signs or assessments in R29's Electronic Medical Record (EMR).
Review of R29's hospital Chief Complaint-Reason for Admission dated [DATE] revealed .has been actively dying over the past 2 days with agonal respiration (gasping irregular breaths) and tachycardia (fast heartbeat over 100 beats per minute) on hospice and was brought to the emergency department for altered mental status.
ED (Emergency Department) physician contacted the patient's son who resides in (out of state) and the son indicated that he wishes full resuscitation and intubation mechanical ventilation support and the patient was intubated. (R29) was found in respiratory failure and intubated and was found to have right lower lobe pneumonia with thick secretions suctioned and also tested positive for Covid-19 infection. (R29) was found to have severe acidosis (too much acid in body fluids) with hyperkalemia (high potassium levels in the blood) and admitted to intensive care unit with septic shock started on Intravenous fluid and broad-spectrum antibiotic. In an interview and record review on [DATE] at 1:47 PM, the Director of Nursing (DON) stated that R29's condition went back and forth.
The DON reviewed progress notes from [DATE] and stated she was unsure why staff would not have sent R29 to the hospital on [DATE] after hospice directed the transfer if R29's condition required it.
Upon review of R29's EMR, the DON was unable to locate any documentation of an acute assessment for R29 or acute monitoring for a change of R29's condition. R29 was unresponsive on [DATE] with continued decline until transfer to the hospital on [DATE]. R29's vital signs were taken 5 times within that 14-day period.
The DON stated the facility needed to start an SBAR (situation-background-assessment-recommendation) program (used to ensure concise, accurate, and rapid information exchange during critical situations, handoffs, or shifts) and put acute residents with condition changes on a watch list and if the resident needs to be sent to the hospital for treatment the facility should do so.
When asked if there should have been acute documentation and a transfer sooner than [DATE] for R29, the DON stated yes.
Review of facility policy/procedure Change in a Resident's Condition or Status, revised [DATE] revealed .the nurse supervisor/charge nurse will notify the resident's family or representative when.it is necessary to transfer the resident to a hospital.will promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical condition.