Ashland Nursing And Rehabilitation

Observation made on 8/18/25 at 2:30 p.m.

The five tables had residents at each table eating their meal.

There were the domes that come on the food trays, in the center of the tables with trash in them.

A second observation was made on 8/19/25 at 12:15 p.m.

The five tables had residents at each table eating their meal.

There were domes, again observed, in the center of the four tables with trash in them.

An interview was conducted with RN (registered nurse) #1 on 8/19/25 at 12:25 p.m. RN #1 stated that the domes with the trash in them in the center of the table is not a dignified manner to eat.

The facility policy, “Social Dining Program” documented in part, “Policy: The social dining program is designed to create a quiet, relaxed social atmosphere in which residents can eat in a leisurely fashion, interact with others, achieve and maintain the highest possible level of independence and consume a sufficient amount of food…All non-edible items, i.e., bread wrappers, sugar packets, cellophane, etc. shall be removed from the table.” ASM (administrative staff member) 1, the ED (executive director), and ASM #2, the DCS (director of clinical services), were made aware of the above on 8/19/25 at 5:10 p.m.

No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

A review of the 11/6/24 Resident Council meeting minutes revealed the following “new business” items of concern: CNAs (certified nursing aides) not making beds or changing bed linens, pain medications not being given in a timely fashion, and a shortage of paper towels and toilet paper in rooms.

A review of the 11/12/24 Resident Council meeting minutes revealed no evidence that the new concerns raised in the 11/6/24 meeting had been resolved.

Additionally, these minutes revealed the following “new” concerns: beds not being made or linens changed, smoking times needing to be reviewed, resident/staff respect, residents not being introduced to caregivers each shift, and missing clothing items.

A review of the 11/18/24 Resident Council meeting minutes revealed no evidence that the new concerns raised in the 11/12/24 meeting had been resolved.

Additionally, these minutes revealed the following “new” concerns: CNAs and nurses treating residents with respect, lack of housekeeping services on the weekends, snacks on each unit, residents going to the kitchen to request coffee, and more trips needed to area stores.

A review of the 11/25/24 Resident Council meeting minutes revealed no evidence that the new concerns raised in the 11/18/24 meeting had been resolved.

Additionally, these minutes revealed the following “new” concerns: beds not being made, staff treating residents disrespectfully, adding a smoke break after dinner, CNAs and nurses on their cell phones, call bells not working, medications being given late, and missing personal items.

A review of the 12/2/24 Resident Council minutes revealed no evidence that the new concerns raised in the 11/25/24 meeting had been resolved.

Additionally, these minutes revealed the following “new” concern: beds not being made.

A review of the 12/26/24 Resident Council minutes revealed no evidence that the new concerns raised in the 11/25/24 meeting had been resolved.

On 8/20/25 at 4:45 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of clinical services, were informed of these concerns.

On 8/20/25 at 5:13 p.m., ASM #1 was interviewed. He stated that he started working at the facility within the last month. He could not provide evidence of resolutions for grievances expressed in November and December 2024 Resident Council meetings. It is his process to review all concerns identified as grievances during a Resident Council meeting, and to make sure these are appropriately documented so they can be tracked. He reviews each and every new concern from the past 24 hours during each day’s morning meeting with staff. He assigns responsible staff to each concern and emphasized that the resident/responsible party must be involved in the resolution process. He added that resolutions need to occur in a timely manner, must be documented, and the loop must be closed.

A review of the facility policy, “Complaint/Grievance,” revealed, in part: “The Center will support each resident’s right to voice a complaint/grievance without fear of discrimination or reprisal.

The center will make prompt efforts to resolve the complaint/grievance and inform the resident of the progress toward resolution.” No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify a resident's responsible party of a change in condition for one of 27 residents in the survey sample, Resident #12The findings include:For Resident #12 (R12), the facility staff failed to notify the resident's responsible party when the resident presented with behaviors and was transferred to the hospital on 4/24/24. A review of R12's clinical record revealed a nurse's note dated 4/24/24 that documented, Pt (Patient) transferred out to ER for further eval (evaluation) related to med refusal, aggressive behaviors, combativeness with staff during ADL (activities of daily living) care, impulsiveness and inappropriate responses to eval questions. Pt eval by psych MD (Medical Doctor) and nurse advised to send to ER for psychosis.

Further review of R12's clinical record failed to reveal R12's responsible party was notified regarding the resident's behaviors and hospital transfer. On 8/20/25 at 11:20 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that once the nurses identify something is wrong with a resident, they are supposed to call the representative, let him or her know what is going on, and make them aware the resident is being transferred to the hospital. On 8/20/25 at 5:00 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern.

The facility policy titled, Family Notification documented, 1.

The family will be notified of any resident changes . No further information was presented prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Observation at the end of the hallway between the day room and exit door revealed a strong stale urine odor.

Observation on the end of the main hallway of the memory care unit revealed a strong stale urine odor present at the end of the hall near the exit door.

Additional observations on 8/18/2025 at 2:14 p.m. and 4:00 p.m. and 8/19/2025 at 8:52 a.m., revealed the findings above on the [NAME] unit.

On 8/19/2025 at 12:16 p.m., an interview was conducted with OSM (other staff member) #1, the director of housekeeping who stated that resident rooms were cleaned daily.

She stated that to control odors on the [NAME] unit the staff scrubbed the bathrooms, used a degreaser on the floors and had a scrubbing machine that circled the floor to bring up any set in stains like urine.

She stated that the goal was to do this once a week and they tried to do it twice a week. OSM #1 stated that two rooms from that unit were deep cleaned every day, and they stripped and waxed the floors depending on how they looked.

She stated that the lingering urine odors on the unit seemed to come from the bathrooms, and they assigned one housekeeper dedicated to that unit and rotated them around to find who was the best fit for that unit. OSM #1 stated that lingering urine odors were not homelike.

She observed the hallways of the [NAME] unit at that time and stated that all she could smell at that time were the cleaning products from the floor tech cleaning the floor today.

On 8/20/2025 at 1:09 p.m., an interview was conducted with OSM (other staff member) #2, activities assistant, who stated that odors were minimized on the [NAME] unit by keeping the residents as clean and dry as they could and have housekeeping do their part to keep the unit clean.

On 8/20/2025 at 4:30 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the findings.

No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

clinical services) were made aware of the above concern. No further information was presented prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility’s documents revealed one “Witness Statement” for R2 by an LPN (licensed practical nurse) dated 05/30/2025.

The witness statement documented, “Resident was observed sitting at doorway of room.

When approaching resident, I observed his nose was bleeding. I also observed one eye was swollen and his lip was bleeding.

Resident could not recall what happened.” Review of the facility’s documents failed to evidence interviews were conducted or attempted with other facility residents, (R2), (R3), additional facility staff and evidence of review of medical record documents.

On 08/20/2025 at approximately 5:33 p.m. an interview was conducted with ASM (administrative staff member) #1, executive director, regarding the procedure for an investigation related to a resident-to-resident altercation with injury.

When asked what documentation constitutes a complete investigation he stated he would obtain statements from residents involved, other witnesses, staff members, summary of the investigation and other supportive documentation . ASM #1 was asked to review the investigative file for the resident-to-resident altercation dated 05/30/2025.

When asked if the documentation evidenced a complete investigation he stated no.

On 08/20/2025 at approximately 4:30 p.m., ASM #1 and ASM #2, director of clinical services, were made aware of the above findings.

No further information was provided prior to exit.

Complaint deficiency

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview, facility document review and clinical record review, the facility staff failed to report an allegation of abuse in a timely manner for one of 27 residents in the survey sample, Resident #7.

The findings include: For Resident #7 (R7) the facility staff failed to report an allegation to the state agency in a timely manner.

The incident occurred on 12/27/25 and was not reported to the state agency until 12/30/25.

The facility synopsis of event dated, 12/30/24 with the incident dated 12/27/24, documented in part, The Interim DON was notified that the nurse witnessed (R7) hit (R26) in the face.

She was not able to get to them in time.

The residents were separated.

Skin assessments were done.

Note discoloration to the side of (R26)'s face. MD and RP updated. (R7) will be placed on Q 15 (minute) safety checks.

The final report to the state agency documented in part, On 12/30/24 the Interim DON was notified that the Nurse witnessed (R7) hit (R26) in the face.

She was not able to get to them in time.

The residents were separated.

Skin assessments were done.

Note discoloration to the side of (R26)'s face. MD and RP updated. (R7) will place Q 15 safety checks.

The final report to the state agency was obtained through their corporate office, it was not in the file.

Review of the file folder for the investigation of the facility synopsis of event, failed to evidence any documentation of an investigation.

The only documentation that was in the folder was the clinical record documents for each resident.

There were no witness statements, staff or resident interviews or assessments of residents involved and any other residents, in the file folder. An interview was conducted with ASM (administrative staff member) #1, the executive director, on 8/20/25 at 8:30 p.m. ASM #1 stated if there is an allegation of abuse, it must be reported to the state agency within two hours.

The facility policy, Abuse, Neglect, Exploitation & Misappropriation documented in part, Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is designated as an abuse coordinator.

Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred.

Facility staff should be aware of and comply with their individual requirements and responsibilities for reporting by law. ASM #1 and ASM #2, the director of clinical services, were made aware of the above concern on 8/20/25 at 4:40 p.m. No further information was obtained prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility’s documents revealed one “Witness Statement” for R2 by an LPN (licensed practical nurse) dated 05/30/2025.

The witness statement documented, “Resident was observed sitting at doorway of room.

When approaching resident, I observed his nose was bleeding. I also observed one eye was swollen and his lip was bleeding.

Resident could not recall what happened.” Review of the facility’s documents failed to evidence interviews with other facility residents, (R2), (R3), additional facility staff and supporting documentation.

On 08/20/2025 at approximately 5:33 p.m. an interview was conducted with ASM (administrative staff member) #1, executive director, regarding the procedure for an investigation related to a resident-to-resident altercation with injury.

When asked what documentation constitutes a complete investigation he stated he would obtain statements from residents involved, other witnesses, staff members, summary of the investigation and other supportive documentation . ASM #1 was asked to review the investigative file for the resident-to-resident altercation dated 05/30/2025.

When asked if the documentation evidenced a complete investigation he stated no.

On 08/20/2025 at approximately 4:30 p.m., ASM #1 and ASM #2, director of clinical services, were made aware of the above findings.

No further information was provided prior to exit.

Complaint deficiency

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

An interview was conducted on 8/19/25 at 4:37 p.m. with OSM (other staff member) #5, the social worker.

OSM #5 stated she has copies of the letter and bed hold notice but could not evidence that it was actually sent out.

ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were made aware of the above findings on 8/20/25 at 4:40 p.m.

No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility’s nursing progress notes failed to evidence documentation that R1 may have refused care for personal hygiene on 02/14/2025.

An interview was conducted with LPN (licensed practical nurse) #4, the unit manager, on 8/20/25 at 11:39 a.m. LPN #4 stated the purpose of the care plan is specialized for each resident and is to be updated with behaviors, refusals of care, medication changes and psychotropic medications.

On 08/20/2025 at approximately 4:30 p.m., ASM #1 and ASM #2, director of clinical services, were made aware of the above findings.

No further information was provided prior to exit.

References: (1) The loss of muscle function in part of your body.

This information was obtained from the website: https://medlineplus.gov/paralysis.html.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

A review of R25's clinical record revealed the following nurses' notes:

1/24/25- At about 345pm staff member observed resident on top of another resident (in bed number) hitting him in the face.

Cna (Certified nursing assistant) that observed incident immediately separated residents.

Writer assessed resident. No new skin concerns noted.

When asked why were you hitting him, he stated, he was in my room. NP (Nurse Practitioner) called and made aware.

Sister called and made aware of incident.

3/21/25- Writer informed by cna that resident slapped another resident in the face.

Writer asked resident what happened, and resident stated, 'She was trying to take my juice.' (Name of responsible party) called and made aware of incident. (Name of nurse practitioner) called and informed. No new orders given at the moment.

Further review of R25's clinical record failed to reveal the resident's care plan (dated 8/14/23) was reviewed and revised after the 1/24/25 and 3/21/25 incidents.

On 8/20/25 at 11:20 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of the care plan is to specialize in the needs of the resident. LPN #4 stated a resident's care plan should be updated when a resident hits another resident and should include the interventions there were put in place.

On 8/20/25 at 5:00 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern.

No further information was presented prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Review of the facility’s nursing progress notes failed to evidence documentation that R1 may have refused care for personal hygiene on 02/14/2025.

On 08/21/2025 at approximately 9:05 a.m. an interview was conducted with ASM (administrative staff member) #2, director of clinical services.

When asked how often a resident receives personal hygiene she stated that it should be done daily and documented if the resident refuses.

After reviewing the personal hygiene point of care dated 02/14/2025 for R1, ASM #2 stated that it could not be determined that R1 received personal care on 02/14/2025.

On 08/20/2025 at approximately 4:30 p.m., ASM #1 and ASM #2, director of clinical services, were made aware of the above findings.

No further information was provided prior to exit.

Complaint deficiency References: (1) The loss of muscle function in part of your body.

This information was obtained from the website: https://medlineplus.gov/paralysis.html.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

to residents daily to ensure that they are engaged and to give them something to do and a sense of purpose in their day-to-day living.

On 08/20/2025 at approximately 4:30 p.m., ASM #1 and ASM #2, director of clinical services, were made aware of the above findings.

No further information was provided prior to exit.

• For Resident #8 (R8), the facility staff failed to evidence the resident had participated in activities from

February 2025 through June 2025.

On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/10/25, the resident was coded as having both short- and long-term memory difficulties.

On the admission MDS assessment, with an assessment reference date of 10/7/24, the resident was coded it being very important to have books, magazines, and newspapers; being around animals, keeping up with the news, going outside, participating in religious activities and doing things with a group of people.

The comprehensive care plan dated, 11/17/24, documented in part, “Focus: (R8) is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (if dependent) Disease process dementia, confusion, PTSD.

Interventions: All staff to converse with resident while providing care.

Encourage ongoing family involvement.

Invite the residents’ family to attend special events, activities, meals.

Introduce the resident to residents with similar background, interests and encourage/facilitate interaction.

Invite the resident to scheduled activities.” On 8/19/2025 at 3:35 p.m., a request was made to ASM (administrative staff member) #2, the director of clinical services, for evidence of participation in activities from 2/1/2025-6/30/2025 for R8.

On 8/19/2025 at 2:14 p.m., an interview was conducted with OSM (other staff member) #2, the activities assistant, who stated that they had been handling activities on the memory care unit since 6/28/25.

She stated that she worked as a CNA (certified nursing assistant) on the unit prior to that date and there was someone who would come over off and on to do some activities, but it was not every day.

She stated that she did some activities with residents on the memory care unit in addition to her CNA duties when there was no activities director in place to keep residents occupied. OSM #2 stated R8 likes conversation, telling stories, likes to color, participate in reminiscing, doing word games and balloon toss.

ASM #1, the executive director and ASM #2 made aware of the above concern on 8/20/25 at 4:40 p.m.

No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

activity sheet that documented the activities for the day, and the attendance logs of residents.

She stated that her current activities staff consisted of herself and two activities assistants with one dedicated to the memory care unit. OSM #9 stated that they offered activities such as one-on-one, spa treatments, devotionals, religious activities, arts and crafts and games.

She stated that activities should be offered to residents daily to ensure that they are engaged and to give them something to do and a sense of purpose in their day-to-day living.On 8/20/2025 at 10:57 a.m., an interview was conducted with LPN (licensed practical nurse) #4, who stated that there was a time in early 2025 when there was no activities director.

She stated that one of her CNA staff would play some games and take residents outside on the memory care unit to give them something to do. LPN #4 stated that the facility tried to have someone come in from the outside, but the CNA had done most everything for memory care until the new activities director and activities aide started in June 2025.The facility policy Group Activities dated 11/01/2021, documented in part, Group activities are scheduled to enhance the resident's well-being and self-esteem.

The activities are planned and organized to meet a specific purpose.The facility policy Community Life Director dated 11/01/2021, documented in part, The Community Life department provides and coordinates services and support to meet the interests and social needs of each resident.

Programming focuses on enhancing the physical, mental, and psychosocial well-being of each resident incorporating the domains of wellness. A Community Life Director, in addition to the above requirements, has completed additional training and/or credentialing by an accredited body in therapeutic recreation services or a training course approved by the state and is licensed or registered by the state in which practicing if applicable.The facility job description for Manager of Resident Activities documented in part, .The primary purpose of your job position is to assist in planning, organizing, developing the operation of the Activity Department in accordance with current federal, state and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Executive Director, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.On 8/19/25 at 2:43 p.m., ASM #1, the executive director and ASM #2, the director of clinical services were made aware of the concern.No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide foot care for one of 27 residents in the survey sample, Resident #14.The findings include:For Resident #14 (R14), the facility staff failed to provide foot care to maintain trimmed toenails.On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/26/2025, the resident was assessed as being severely impaired for making daily decisions.

Rejection of care was documented occurring 1 to 3 days during the assessment period but not daily. R14 was assessed as requiring substantial to maximal assistance with personal hygiene and bathing. R14 was not documented as being diabetic.On 8/18/2025 at 11:37 a.m., an observation was made of R14 in the hallway of the memory care unit that they resided on. R14 was observed walking in the hallway outside of their room in bare feet. R14's feet were observed with long untrimmed toenails that were uneven and approximately 1/8 inch from the nailbed.

The comprehensive care plan for R14 documented in part, Focus: [Name of R14] has an ADL (activities of daily living) self-care performance deficit r/t (related to) factors that include dementia, lack of coordination, and hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side.

Date Initiated: 09/11/2023 . It further documented, Focus: [Name of R14] does not cooperate with care refused medication, refuse Shower, refuse foot care Podiatry, refuses skin assessment.

Resident resist care.

Sometimes requires two persons assist.

Removes gripper socks. refuse medications r/t Personal choice.

Refuses lab at times.

Date Initiated: 12/04/2023.

Review of the nursing progress notes from 5/1/2025 to the present failed to evidence documentation of refusal of personal hygiene or attempts made to trim the toenails.A podiatry note for R14 dated 4/18/2025 documented the toenails trimmed by the podiatrist on that day.

The clinical record failed to evidence R14's toenails trimmed after 4/18/2025.On 8/20/2025 at 10:57 a.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that R14 was cooperative at times but also refused care frequently and it was all in how she was approached.

She stated that the nurses were allowed to trim toenails if the resident was not diabetic.

She stated that they tried to have the podiatrist trim the nails of the residents that resided in the memory care unit when he came in monthly, but there were times when they refused. LPN #4 stated that when the resident refused, the nurse should notify the physician and the responsible party and document it in the medical record. On 8/20/2025 at 11:57 a.m., an observation was made with LPN #4 of R14 in her room however she refused to allow LPN #4 to see her feet at that time. On 8/20/25 at 1:09 p.m., an interview was conducted with OSM (other staff member) #2, activities assistant/CNA. OSM #2 stated that she worked as a CNA on the memory care unit until recently when she started working as the activities assistant and was familiar with the residents there.

She stated that the podiatrist trimmed the residents toenails, but she was not sure of how often he came in or who he saw when he came in because he saw the residents that the nurse put on the list.The facility policy Grooming Activities revised 3/19/19 documented in part, Grooming activities are provided to assist the residents in meeting their physical needs as well as self-esteem needs.

Procedure: 1.

Grooming activities shall be offered daily. 2.

Grooming activities shall include, but are not limited to: .Nail Care.

The facility policy Activities of Daily Living effective 2/1/22 documented in part, .CNA will report any changes in ability or refusals to the nurse. CNA will document care provided in the medical record .On 8/20/2025 at 4:30 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of clinical services were made aware of the findings.No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Residents were separated immediately after incident involving resident A slapping Resident B with an open hand to the right face.

Resident A relocated back to his room with the 1:1 CNA (Certified Nursing Assistant). DON (Director of Nursing), Administrator, NP/MD (Nurse Practitioner/Medical Doctor), Non-emergent police station and RPs are [sic] both parties called and notified.An initial facility synopsis submitted to the SA (state agency) on 4/27/25 documented, It was reported that (R25) touched a female resident, (another resident-R23) on the breast open hand on top of her clothes.

Staff immediately separated them.

While staff was separating the residents, (R25) struck (R22) in the face with an open hand.

The residents were assessed, no injuries noted. On 8/20/25 at 11:20 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated one on one monitoring consists of a nurse, CNA, or residential aide monitoring the resident at arm's length and keeping the resident in sight at all times. LPN #4 stated the psychiatric nurse practitioner, doctor, and administrative staff are responsible for discussing and deciding when a resident is removed from one on one monitoring. LPN #4 stated R25 independently ambulated and his behaviors depended on how he was approached. LPN #4 stated R25 liked to go to the dining room but noise and chaos agitated him. LPN #4 stated maybe R25 should not have been taken off one on one monitoring. On 8/20/25 at 1:09 p.m., an interview was conducted with OSM (other staff member) #2 (activities assistant/CNA). OSM #2 stated one on one monitoring consists of making sure the resident is within arm's reach of staff at all times and is evidenced by singing off check sheets. OSM #2 stated R25 was really nice but could be combative and did not want anyone in his space. On 8/20/25 at 5:00 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern.

The facility did not provide a policy regarding supervision. No further information was presented prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

4/27/25 (9:05 p.m.) documented, Residents were separated immediately after incident involving resident A slapping Resident B with an open hand to the right face.

Resident A relocated back to his room with the 1:1 CNA. DON (Director of Nursing), Administrator, NP/MD (Nurse Practitioner/Medical Doctor), Non-emergent police station and RPs are [sic] both parties called and notified.An initial facility synopsis submitted to the SA (state agency) on 4/27/25 documented, It was reported that (R25) touched a female resident, (another resident-R23) on the breast open hand on top of her clothes.

Staff immediately separated them.

While staff was separating the residents, (R25) struck (R22) in the face with an open hand.

The residents were assessed, no injuries noted.

The facility staff could not provide nursing schedules that documented how many nurses and CNAs were staffed on each unit for each shift from January 2025 through April 2025. On 8/20/25 at 10:17 a.m., an interview was conducted with OSM (other staff member) #10 (the interim staffing coordinator). OSM #10 stated wing three (which included the dementia unit where R25 resided and a separate hall) contained 58 beds and should staff two nurses and four CNAs during the day shift, two nurses and four CNAs during the evening shift, and two nurses and three CNAs during the night shift. OSM #10 stated it is important to appropriately staff the building, so residents get good care. On 8/20/25 at 11:20 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated R25 independently ambulated and his behaviors depended on how he was approached. LPN #4 stated R25 liked to go to the dining room but noise and chaos agitated him. LPN #4 stated staffing on the dementia unit probably was not sufficient from January 2025 through April 2025 because of the residents' behaviors, and R25 could have been supervised more closely if there had been more staff. On 8/20/25 at 1:09 p.m., an interview was conducted with OSM #2 (activities assistant/CNA). OSM #2 stated R25 was really nice but could be combative and did not want anyone in his space. OSM #2 stated residents on the dementia unit require more staffing due to their needs. OSM #2 stated residents with dementia require more attention and monitoring because they wander into other residents' rooms. On 8/20/25 at 5:00 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern.

The facility did not provide a specific policy regarding staffing.

The facility policy titled, Abuse, Neglect, Exploitation & Misappropriation documented, 3.

Prevention: The center is committed to the prevention of abuse, neglect, misappropriation of resident property, and exploitation.

The following systems have been implemented: Sufficient numbers of staff to meet the needs of the residents . No further information was presented prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to complete an annual performance evaluation for one of five CNA (certified nursing assistant) records reviewed, CNA #5.The findings include:For CNA #5, the facility staff failed to provide evidence of the required annual performance evaluation in the past 12 months.On 8/20/25 at 5:13 p.m., CNA #5's most recent performance evaluation was requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff performance evaluations from this point forward.

She stated she could not speak to why the evaluation had not been done in a timely manner in the past, but in the future, she will be taking care of these.On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of 27 residents in the survey sample, Resident #20.

The findings include:For Resident #20 (R20), the facility staff failed to assess the resident's psychosocial status and implement psychosocial interventions to address physical abuse on 1/24/25. A review of R20's clinical record revealed a nurse's note dated 1/24/25 that documented, At about 345pm staff member observed another resident on top of resident in bed (number) hitting him in the face.

Writer assessed resident small skin tear noted to resident's nose.

Facial swelling and bruising noted to left side of resident's face.

Vitals checked, 128/77 (blood pressure), 97.9 (temperature), 72 (pulse), 18 (respirations). NP (Nurse Practitioner) called and made aware of incident.

Xray order given. (Name of power of attorney) called and made aware of incident. No concerns voiced.

She stated she would be in tomorrow to see resident.

Further review of R20's clinical record failed to reveal the resident's psychosocial status related to the physical abuse was assessed or psychosocial interventions were implemented. On 8/19/25 at 4:42 p.m., an interview was conducted with OSM (other staff member) #5 (the social services coordinator). OSM #5 stated that after a resident is hit by another resident, the social services staff interviews the resident who was hit and completes a psychosocial assessment of the resident. OSM #5 stated the staff also monitors the resident to make sure he or she is okay, and to see how he or she is coping every week for at least four weeks. OSM #5 stated this should be documented in the clinical record. On 8/20/25 at 5:00 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern.

The facility policy titled, Assessments-Social History and Psychosocial Assessment documented, It is the policy of The Company to: Assess resident's psychosocial needs .4.

Social Services will complete the Social Services Progress Review quarterly, with significant changes and as needed. No further information was presented prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation and staff interview, it was determined that the facility staff failed to provide sufficient staff in one of one facility kitchens.

The findings include:On 08/18/2025 at approximately 3:50 p.m., an observation of the last food cart for the resident's lunch revealed it arrived on Unit One at 3:50 p.m.

Further observations revealed the last lunch tray was served to a resident on Unit one at 4:10 p.m. On 08/19/2025 at approximately 11:15 a.m. an interview was conducted with OSM (other staff member) #7 and OSM #6, account manager for dietary. OSM #6 stated the first breakfast food carts are sent to the floor between 7:35 a.m. and 7:40 a.m., the first lunch food carts are sent to the floor at 11:45 a.m., and the first dinner food carts are sent to the floor at 4:30 p.m.

When informed of the observation of the resident's first lunch cart arriving on Unit Three at 2:00 p.m. and the last lunch cart arriving on Unit One at 3:50 p.m. she stated that it was not acceptable for the residents and the residents should not have to wait for the meals.

When asked to describe the procedure to make sure the resident's meals are served in a timely manner OSM #6 stated that she makes sure all the assigned dietary staff are in the building, if short staffed she will call staff in to work, use facility staff to help out and jump in to help get the meals to the residents on time. OSM#7 stated the kitchen did not have enough staff to get the meal out on time on 08/18/2025.

The facility's policy Frequency of Meals documented in part, Policy Statement. At least three daily meals will be provided, at regular times comparable to normal mealtimes in the community.Procedures. 1.

The Dining Service Director coordinates with the residents, administrator and/or Director of Nursing Services to establish the meal and snack times that are comparable with the normal times in the community. On 08/19/2025 at approximately 5:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Complaint deficiency

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of three facility units, Unit One.

The findings include:On 08/18/2025 at approximately 3:50 p.m., a test tray consisting of chicken stir-fry, chopped spinach, enhanced potatoes was placed on a food cart in the facility's kitchen, sent to Unit One of the facility.

The cart was followed by the surveyor, OSM (other staff member) #7, district manager for dietary. At approximately 4:10 p.m., the last lunch tray was served to a resident on Unit One and OSM # 7 was asked to remove cover from the test plate then proceeded to take the temperatures of the food.

Two surveyors observed OSM #7 obtaining the food temperatures of the test tray.

The chopped spinach was 118 degrees F (Fahrenheit), the stir-fry was 111 degrees F, and the potatoes were 115 degrees F.

The test tray was sampled by two surveyors, OSM #7 for appropriate holding temperatures and palatable taste.

When asked to describe the taste of the food OSM #7 stated the food was lukewarm.

After tasting all the food on the test tray OSM #7 was asked if the food was palatable OSM #7 did not provide an answer. On 08/19/2025 at approximately 11:15 a.m. an interview was conducted with OSM #7 and OSM #6, account manager for dietary.

When informed of the food temperatures obtained on the test tray for lunch on 08/18/2025 as stated above, OSM #6 stated the food temperatures should have been 140 degrees F or greater.

When asked about the food being palatable at the temperatures obtained on the test tray she stated it would not taste good because it was cold and the temperature dropped too much.

The facility's policy Food: Quality and Palatability documented in part, Policy Statement.

Food will be prepared by methods that conserve nutritive value, flavor and appearance.

Food will be palatable, attractive and served at a safe and appetizing temperature.

Definitions.

Food palatability refers to the taste and/or flavor of the food.

Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns.

Procedures. 2.

The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code. On 08/19/2025 at approximately 5:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Complaint deficiency

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation and staff interview, it was determined that the facility staff failed to serve lunch in a timely manner on one of three facility units, Unit One.

The findings include:On 08/18/2025 at approximately 3:50 p.m., an observation of the last food cart for the resident's lunch revealed it arrived on Unit One at 3:50 p.m.

Further observations revealed the last lunch tray was served to a resident on Unit one at 4:10 p.m. On 08/19/2025 at approximately 11:15 a.m. an interview was conducted with OSM (other staff member) #7 and OSM #6, account manager for dietary. OSM #6 stated the first breakfast food carts are sent to the floor between 7:35 a.m. and 7:40 a.m., the first lunch food carts are sent to the floor at 11:45 a.m., and the first dinner food carts are sent to the floor at 4:30 p.m.

When informed of the observation of the resident's first lunch cart arriving on Unit Three at 2:00 p.m. and the last lunch cart arriving on Unit One at 3:50 p.m. she stated that it was not acceptable for the residents and the residents should not have to wait for the meals.

When asked to describe the procedure to make sure the resident's meals are served in a timely manner OSM #6 stated that she makes sure all the assigned dietary staff are in the building, if short staffed she will call staff in to work, use facility staff to help out and jump in to help get the meals to the residents on time.

OSM#7 stated the kitchen did not have enough staff to get the meal out on time on 08/18/2025.

The facility's policy Frequency of Meals documented in part, Policy Statement. At least three daily meals will be provided, at regular times comparable to normal mealtimes in the community.Procedures. 1.

The Dining Service Director coordinates with the residents, administrator and/or Director of Nursing Services to establish the meal and snack times that are comparable with the normal times in the community. On 08/19/2025 at approximately 5:00 p.m., ASM (administrative staff member) #1, executive director, and ASM #2, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Complaint deficiency

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, it was determined that the facility staff failed to review and revise the facility assessment after a change of ownership effective 6/1/2025.The findings include:

Review of the provided facility assessment documented a date of 7/18/2024.

The facility assessment documented the former executive director and director of clinical services at the facility. It further documented information under the staff training/education and competencies that reflected the previous owner.On 8/20/2025 at 5:08 p.m., an interview was conducted with ASM (administrative staff member) #1, the executive director, who stated that the facility assessment provided was from 2024 prior to the change of ownership. He stated that they had planned to update the assessment in a QAPI (Quality Assurance Performance Improvement) meeting that they had scheduled for 8/20/2025. ASM #1 stated that the change of ownership sale was completed effective 6/1/2025 when the former owner ceased to exist and the new owner took over. He stated that they had to renew all their contracts and change the names on everything.

When asked if the facility assessment should have been updated, ASM #1 stated that he did not think that the patient aspect much would change but there would be some things that would need to be reviewed and revised, same as the contracts. On 8/21/2025 at 9:03 a.m., ASM #1, the executive director was made aware of the concern.No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to provide evidence of updated contracts with outside providers for three of three contracts reviewed, potentially affecting all residents.The findings include:The facility staff failed to provide updated contracts for mobile imaging services, mobile imaging equipment, and an agreement for contract dialysis services.On 8/20/25 at 5:13 p.m., copies of current facility contracts were requested as part of the extended survey process. ASM (administrative staff member) #1, the executive director, stated he may not be able to provide the survey team with contracts that meet the regulation. He stated that due to the facility sale in June of 2024, the former company ceased to exist, and a new company took over as owner. He added: We had to go back in and negotiate contracts with all of our venders.On 8/21/25 at 8:36 a.m., ASM #1 provided a book of contracts for outside service providers to the facility. A review of three of these contracts revealed there was no contractual agreement between the providers of mobile imaging, the mobile imaging equipment company, and the facility's dialysis providers.

All of these contracts were between the outside provider and the name of the previous owner of the facility, a company no longer in existence.On 8/21/25 at 11:06 a.m., ASM #1 was interviewed. He stated the former owner of the facility filed for bankruptcy protection and was sold on 6/1/25. He explained that on that day, the bankrupt company ceased to exist. He stated he and the corporate staff had attempted to contact the facility's attorneys. He said that they had not yet been able to secure the legal documents needed to satisfy the regulation. ASM #1 did not provide the survey team with a policy related to updated contracts with outside providers.No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

On 8/21/25 at 7:16 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of clinical services). ASM #2 stated the above incident should have been documented in R23's clinical record.

On 8/21/25 at 8:56 a.m., ASM #1 (the executive director) was made aware of the above concern.

No further information was presented prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview, facility documentation, and clinical record review, it was determined the facility staff failed to evidence communication between the hospice company and the facility for one of 27 residents in the survey sample, Resident #19 (R19).

The findings include: For Resident #19, the facility staff failed to evidence communication between the hospice company and the facility.

The physician order dated, 6/12/25, documented, Resident admitted to (Name of Hospice).A request was made for communication between the facility and the hospice company. On 8/20/25 at 1:27 p.m. ASM (administrative staff member) #2, the director of clinical services, presented information related to hospice communication.

The documents had been faxed to the facility on 8/20/25.

The documents contained notes from visits from the hospice company on 6/12/25, 6/13/25, 6/27/25 and 7/1/25.

When asked the process for having the information from the hospice company available to the staff caring for the residents, ASM #2 stated, when the facility receives information, it is given to the medical records department and uploaded in the miscellaneous file in PCC (initials of electronic medical records system).

When asked the expectation when the information is to be in the record, she stated she would have to check on that. ASM #2 stated she had checked on the unit to see if there was a hospice communication book, there was none.

She stated she spoke with the nurse down on the unit and stated she speaks with the hospice staff members, and they share information.

When asked if this information should be available to all staff including the physicians, ASM #2 stated yes.

The facility policy, Hospice Care, documented in part, Communication with hospice representatives, hospice medical director and the patient/resident's attending physician to ensure coordination of care.

Ensure the following information is obtained from hospice: Most recent hospice plan of care, hospice election form, physician certification and recertification of the terminal illness, Names and contact information for hospice personnel involved in the care of the patient/resident, how to access hospice's 24 hour on call system, medication information for the patient/resident, hospice physician and attending physician orders for the patient/resident and provide education to the hospice staff on center policies and procedures, including: resident rights, documentation and forms. ASM #1, the executive director and ASM #2 made aware of the above concern on 8/20/25 at 4:40 p.m. No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure attendance of the infection preventionist at one of five QAPI (quality assurance performance improvement) meetings reviewed, Q4 (quarter four) 2024 potentially affecting all residents in the facility.The findings include:

Review of the provided facility QAPI meeting sign-in attendance sheets failed to evidence the infection preventionist present at the Q4 2024 meeting.On 8/21/2025 at 9:28 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of clinical services, who stated that the infection preventionist had resigned in November of 2024 and the assistant director of nursing was covering the role at the time of the QAPI meeting and was not present at the meeting. On 8/21/2025 at 10:01 a.m., an interview was conducted with ASM #1, the executive director who stated that QAPI meetings were held quarterly at a minimum and attended by the interdisciplinary team which included the administrator, director of nursing, medical director, infection preventionist, social services, unit managers, maintenance and other staff.The facility policy Quality Assurance Performance Improvement Program (QAPI) revised 10/24/2022 documented in part, Policy: The center and organization has a comprehensive, data-drive Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. QAA (Quality Assessment and Assurance Committee) members include but are not limited to: a) Executive Director, b) Medical Director/designee, c) Director of Nursing/designee, d) Infection Preventionist.On 8/21/2025 at 10:03 a.m., ASM #1, the executive director was made aware of the concern.No further information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to implement a complete infection control program for two of two months reviewed, November and December 2024.

The findings include:For November and December 2024, the facility staff failed to provide evidence of a surveillance system to identify possible communicable diseases before they can spread to other persons in the facility.On 8/18/25 at 4:30 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of clinical services, were asked to provide evidence of the facility's infection surveillance system for November and December 2024.On 8/19/25 at 1:18 p.m., ASM #2 stated the infection surveillance logs for November and December 2024 could not be located.

She stated she and the current infection preventionist had only been working at the facility since January 2025.

She stated she had searched for the logs and could not find them.On 8/19/25 at 3:56 p.m., LPN (licensed practical nurse) #1, the infection preventionist, was interviewed.

She stated she had started work at the facility in this role in mid-December

• She recalled a GI (gastrointestinal) issue on Wing 2, but stated it was not Norovirus.

She stated a few people (two or three) had nausea and a little vomiting, but Norovirus was not identified and there were no overarching trends.

She said there were no concerns about PPE availability during that time or at any time since.

She stated she is now responsible for the infection surveillance system for the entire facility.

She pulls the 24 hour reports and new orders for each day, updating the line list and antibiotic usage sheet each weekday.

She is responsible for tracking all infections and antibiotic usage.

She stated it is important to track infections so facility staff can track and trend, determine where problems lie with staff practice, and make changes as necessary to prevent infections from spreading.On 8/20/25 at 4:45 p.m., ASM #1, and ASM #2, the director of clinical services, were informed of these concerns.A review of the facility policy, Surveillance for Infections, revealed, in part: The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions.The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated infections, to guide appropriate interventions, and to prevent future infections.The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to provide communications training for one of ten staff records reviewed, CNA (certified nursing assistant) #5.The findings include:For CNA #5, the facility staff failed to provide required communications training.On 8/20/25 at 5:13 p.m., CNA #5's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff training.

She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these.

She stated she will be keeping up with the required training content and tracking the training for each staff member.

She explained that staff training is one way to meet residents' needs.

She added that managers are responsible for making sure staff are trained in order to provide the highest level of care possible for residents. On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.A review of the policy, In-Service Training-General, revealed, in part: Employees will be provided training on required topics on an annual basis.

Additional training may be provided based on the center Facility Assessment, areas of deficiency identified and to improve the overall knowledge of the staff.Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the and the center Facility Assessment.

Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

For RN #2 and OSM #15, the facility staff failed to provide required resident rights training.On 8/20/25 at 5:13 p.m., RN #2's and OSM #15's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff training.

She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these.

She stated she will be keeping up with the required training content and tracking the training for each staff member.

She explained that staff training is one way to meet residents' needs.

She added that managers are responsible for making sure staff are trained in order to provide the highest level of care possible for residents.On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.A review of the policy, In-Service Training-General, revealed, in part: Employees will be provided training on required topics on an annual basis.

Additional training may be provided based on the center Facility Assessment, areas of deficiency identified and to improve the overall knowledge of the staff.Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the and the center Facility Assessment.

Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to provide training in prevention of resident abuse, neglect, and exploitation for one of ten staff records reviewed, RN (registered nurse) #2.The findings include:For RN #2, the facility staff failed to provide required training in the prevention or resident abuse, neglect, and exploitation.On 8/20/25 at 5:13 p.m., RN #2's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff training.

She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these.

She stated she will be keeping up with the required training content and tracking the training for each staff member.

She explained that staff training is one way to meet residents' needs.

She added that managers are responsible for making sure staff are trained in order to provide the highest level of care possible for residents.On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.A review of the policy, In-Service Training-General, revealed, in part: Employees will be provided training on required topics on an annual basis.

Additional training may be provided based on the center Facility Assessment, areas of deficiency identified and to improve the overall knowledge of the staff.Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the and the center Facility Assessment.

Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to provide QAPI (quality assurance and performance improvement) training for two of ten staff records reviewed, RN (registered nurse) #2 and OSM (other staff member) #15, a member of the dietary staff.The findings include:For RN #2 and OSM #15, the facility staff failed to provide required QAPI training.On 8/20/25 at 5:13 p.m., RN #2's and OSM #15's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff training.

She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these.

She stated she will be keeping up with the required training content and tracking the training for each staff member.

She explained that staff training is one way to meet residents' needs.

She added that managers are responsible for making sure staff are trained in order to provide the highest level of care possible for residents. On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.A review of the policy, In-Service Training-General, revealed, in part: Employees will be provided training on required topics on an annual basis.

Additional training may be provided based on the center Facility Assessment, areas of deficiency identified and to improve the overall knowledge of the staff.Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the and the center Facility Assessment.

Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to provide infection control training for one of ten staff records reviewed, RN (registered nurse) #2.The findings include:For RN #2, the facility staff failed to provide required infection control training.On 8/20/25 at 5:13 p.m., RN #2's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff training.

She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these.

She stated she will be keeping up with the required training content and tracking the training for each staff member.

She explained that staff training is one way to meet residents' needs.

She added that managers are responsible for making sure staff are trained in order to provide the highest level of care possible for residents.On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.A review of the policy, In-Service Training-General, revealed, in part: Employees will be provided training on required topics on an annual basis.

Additional training may be provided based on the center Facility Assessment, areas of deficiency identified and to improve the overall knowledge of the staff.Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the and the center Facility Assessment.

Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to provide compliance and ethics training for one of ten staff records reviewed, RN (registered nurse) #2.

The findings include:For RN #2, the facility staff failed to provide required compliance and ethics training.On 8/20/25 at 5:13 p.m., RN #2's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff training.

She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these.

She stated she will be keeping up with the required training content and tracking the training for each staff member.

She explained that staff training is one way to meet residents' needs.

She added that managers are responsible for making sure staff are trained in order to provide the highest level of care possible for residents.On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.A review of the policy, In-Service Training-General, revealed, in part: Employees will be provided training on required topics on an annual basis.

Additional training may be provided based on the center Facility Assessment, areas of deficiency identified and to improve the overall knowledge of the staff.Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the and the center Facility Assessment.

Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

For CNA #5 and CNA #8, the facility staff failed to provide at least 12 hours of education annually for the past 12 months.On 8/20/25 at 5:13 p.m., CNA #5's and CNA #8's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff training from this point forward.

She stated she could not speak to why the required hours were not done in the past, but in the future, she will be taking care of these. On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.No additional information was provided prior to exit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Ashland Nursing and Rehabilitation

906 Thompson Street Ashland, VA 23005

SUMMARY STATEMENT OF DEFICIENCIES

Based on staff interview and facility document review, the facility staff failed to provide behavioral health training for two of ten staff records reviewed, RN (registered nurse) #2 and OSM (other staff member) #15, a member of the dietary staff.

The findings include:For RN #2 and OSM #15, the facility staff failed to provide required behavioral health training.On 8/20/25 at 5:13 p.m., RN #2's and OSM #15's education records were requested. ASM (administrative staff members) #1, the executive director, and #2, the director of clinical services, were present at this meeting. ASM #1 stated the facility staff may not be able to provide the survey team with the requested information because of the recent sale of the facility and the current staff's lack of access to old personnel records.On 8/21/25 at 9:04 a.m., ASM #5, the assistant director of clinical services, was interviewed.

She stated she is very new to this role and will be taking over staff training.

She stated she could not speak to why the required trainings were not done in the past, but in the future, she will be taking care of these.

She stated she will be keeping up with the required training content and tracking the training for each staff member.

She explained that staff training is one way to meet residents' needs.

She added that managers are responsible for making sure staff are trained in order to provide the highest level of care possible for residents. On 8/21/25 at 11:10 a.m., ASM #1 and ASM #2 were informed of these concerns.A review of the policy, In-Service Training-General, revealed, in part: Employees will be provided training on required topics on an annual basis.

Additional training may be provided based on the center Facility Assessment, areas of deficiency identified and to improve the overall knowledge of the staff.Required education and in-services may include a combination of requirements based on Federal, State, and/or local regulations, company required in-service education topics and the and the center Facility Assessment.

Each center is responsible to ensure that required Federal, State, and/or Local regulations are followed accordingly.No additional information was provided prior to exit.

Facility ID: