Ashland Nursing and Rehabilitation
906 Thompson Street, Ashland, VA 23005
Ashland Nursing and Rehabilitation is a nursing home in Ashland, Virginia. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 1 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (804) 798-3291
- Last standard health inspection
- February 9, 2024 (2 years ago)
- Certified beds
- 190
- Residents per day, on average
- 132.8
- Ownership type
- For profit - Corporation
- Legal business name
- 906 Thompson Street Opco LLC
- Chain
- Avardis Health
- Takes part in
- Medicare and Medicaid
More health citations than the Virginia average (161 vs 39).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of October 8, 2026
Fine
CMS changed the fine from March 18, 2026 from $8,140 to $36,491.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
3 citations
Health inspection on July 2, 2026
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0580 6 times since 2020.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 10, 2026.
CMS has cited this home for F0600 5 times since 2020.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for F0658 4 times since 2020.
Payment stopped
June 18, 2026 (4 months ago)
CMS stopped payment for new admissions from June 18, 2026, for 28 days.
CMS update of May 27, 2026
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
1 citation
Fire safety inspection on March 19, 2026
CMS lists this as a complaint inspection.
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on April 16, 2026.
CMS has cited this home for K0211 2 times since 2022.
13 citations
Health inspection on March 18, 2026
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
26 of 289 Virginia homes (9%) got a citation at the immediate jeopardy level in 2026.
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 29, 2026.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 2, 2026.
CMS has cited this home for F0689 4 times since 2020.
Citation F0838. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
CMS lists it as corrected on July 2, 2026.
CMS has cited this home for F0838 2 times since 2025.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on April 29, 2026.
CMS has cited this home for F0584 5 times since 2020.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on April 29, 2026.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 16, 2026.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on April 29, 2026.
CMS has cited this home for F0607 3 times since 2024.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on July 16, 2026.
Citation F0941. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on July 2, 2026.
CMS has cited this home for F0941 3 times since 2024.
Citation F0942. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on July 2, 2026.
CMS has cited this home for F0942 3 times since 2024.
Citation F0944. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on July 2, 2026.
CMS has cited this home for F0944 3 times since 2024.
Citation F0949. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on July 2, 2026.
CMS has cited this home for F0949 3 times since 2024.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on July 2, 2026.
Fine
March 18, 2026 (7 months ago)
CMS fine of $36,491 on March 18, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from not rated by CMS to 3 of 5.
CMS update of November 20, 2025
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS removed its abuse icon from this home.
Name
CMS lists a new legal business name for this home.
37 citations
Health inspection on August 21, 2025
CMS lists this as a complaint inspection.
Citation F0565. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on November 17, 2025.
Citation F0680. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure the activities program is directed by a qualified professional.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0680 2 times since 2024.
Citation F0838. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
CMS lists it as corrected on November 17, 2025.
Citation F0840. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0840 2 times since 2022.
Citation F0868. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on November 17, 2025.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0880 2 times since 2023.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on November 17, 2025.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on November 17, 2025.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0610 2 times since 2024.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0656 4 times since 2020.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0657 4 times since 2022.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0677 3 times since 2020.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0679 2 times since 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 17, 2025.
Citation F0802. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
CMS lists it as corrected on November 17, 2025.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0804 3 times since 2022.
Citation F0809. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0809 2 times since 2024.
Citation F0553. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS lists it as corrected on November 17, 2025.
Citation F0557. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on November 17, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on November 17, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on November 17, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0609 2 times since 2024.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on November 17, 2025.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0687 2 times since 2024.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0725 2 times since 2024.
Citation F0730. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0730 3 times since 2024.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0745 3 times since 2022.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0842 2 times since 2020.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
CMS lists it as corrected on November 17, 2025.
Citation F0941. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on November 17, 2025.
Citation F0942. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on November 17, 2025.
Citation F0943. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0943 2 times since 2024.
Citation F0944. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on November 17, 2025.
Citation F0945. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
CMS lists it as corrected on November 17, 2025.
Citation F0946. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0946 2 times since 2024.
Citation F0947. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on November 17, 2025.
CMS has cited this home for F0947 2 times since 2024.
Citation F0949. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on November 17, 2025.
CMS update of June 25, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to not rated by CMS.
CMS update of May 28, 2025
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of August 29, 2024
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
8 citations
Health inspection on April 11, 2024
CMS lists this as a complaint inspection.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 7, 2024.
CMS has cited this home for F0684 4 times since 2020.
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on May 7, 2024.
CMS has cited this home for F0690 3 times since 2020.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 7, 2024.
CMS has cited this home for F0812 4 times since 2020.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on May 7, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 7, 2024.
CMS has cited this home for F0695 2 times since 2024.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
CMS lists it as corrected on May 7, 2024.
CMS has cited this home for F0700 2 times since 2024.
Citation F0730. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on May 7, 2024.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on May 7, 2024.
1 citation
Fire safety inspection on April 11, 2024
CMS lists this as a complaint inspection.
Citation E0037. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on May 7, 2024.
CMS has cited this home for E0037 2 times since 2024.
65 citations
Health inspection on February 9, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0680. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure the activities program is directed by a qualified professional.
CMS lists it as corrected on April 11, 2024.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 11, 2024.
Citation F0580. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 11, 2024.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 11, 2024.
Citation F0622. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
CMS lists it as corrected on April 11, 2024.
CMS has cited this home for F0622 2 times since 2020.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS lists it as corrected on April 11, 2024.
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on April 11, 2024.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 11, 2024.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on May 7, 2024.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 11, 2024.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 11, 2024.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on April 11, 2024.
Citation F0686. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 11, 2024.
CMS has cited this home for F0686 2 times since 2022.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 11, 2024.
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 7, 2024.
Citation F0697. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 11, 2024.
CMS has cited this home for F0697 2 times since 2020.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on April 11, 2024.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on April 11, 2024.
Citation F0727. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS lists it as corrected on April 11, 2024.
Citation F0730. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on May 7, 2024.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on April 11, 2024.
CMS has cited this home for F0758 2 times since 2020.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on April 11, 2024.
Citation F0809. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
CMS lists it as corrected on April 11, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 7, 2024.
Citation F0843. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
CMS lists it as corrected on April 11, 2024.
Citation F0940. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS lists it as corrected on April 11, 2024.
Citation F0943. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on April 11, 2024.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on April 11, 2024.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on April 11, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on April 11, 2024.
CMS has cited this home for F0558 2 times since 2022.
Citation F0559. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS lists it as corrected on April 11, 2024.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on April 11, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on April 11, 2024.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 11, 2024.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on April 11, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 11, 2024.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on April 11, 2024.
CMS has cited this home for F0623 2 times since 2020.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on April 11, 2024.
CMS has cited this home for F0645 2 times since 2022.
Citation F0675. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor each resident's preferences, choices, values and beliefs.
CMS lists it as corrected on April 11, 2024.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on April 11, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 7, 2024.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on April 11, 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS lists it as corrected on April 11, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on May 7, 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on April 11, 2024.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on April 11, 2024.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
CMS lists it as corrected on May 7, 2024.
Citation F0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS lists it as corrected on April 11, 2024.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on April 11, 2024.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on April 11, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 11, 2024.
CMS has cited this home for F0760 2 times since 2020.
Citation F0776. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
CMS lists it as corrected on April 11, 2024.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on April 11, 2024.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS lists it as corrected on April 11, 2024.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on April 11, 2024.
Citation F0810. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
CMS lists it as corrected on April 11, 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 11, 2024.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
CMS lists it as corrected on April 11, 2024.
Citation F0909. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
CMS lists it as corrected on April 11, 2024.
Citation F0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on April 11, 2024.
Citation F0941. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on April 11, 2024.
Citation F0942. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on April 11, 2024.
Citation F0944. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on April 11, 2024.
Citation F0946. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on April 11, 2024.
Citation F0949. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on April 11, 2024.
2 citations
Fire safety inspection on February 9, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation E0037. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on May 7, 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 2, 2024.
CMS has cited this home for K0353 2 times since 2020.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of December 21, 2023
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
3 citations
Health inspection on November 20, 2023
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on December 19, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on December 19, 2023.
CMS has cited this home for F0757 2 times since 2020.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 19, 2023.
13 citations
Health inspection on June 7, 2022
CMS lists this as a standard inspection.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on July 12, 2022.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on July 12, 2022.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 12, 2022.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on July 12, 2022.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on July 12, 2022.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 12, 2022.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 12, 2022.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 12, 2022.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 12, 2022.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on July 12, 2022.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on July 12, 2022.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on July 12, 2022.
Citation F0840. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
CMS lists it as corrected on July 12, 2022.
6 citations
Fire safety inspection on June 7, 2022
CMS lists this as a standard inspection.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on July 19, 2022.
Citation K0400. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet fire sprinkler requirement for tall buildings.
CMS lists it as corrected on July 19, 2022.
Citation K0916. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on July 19, 2022.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on July 19, 2022.
Citation K0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 19, 2022.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 19, 2022.
19 citations
Health inspection on February 6, 2020
CMS lists this as a standard inspection.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on March 10, 2020.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 10, 2020.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on March 10, 2020.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 10, 2020.
Citation F0757. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on March 10, 2020.
Citation F0760. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on March 10, 2020.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 10, 2020.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on March 10, 2020.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on March 10, 2020.
Citation F0622. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
CMS lists it as corrected on March 10, 2020.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on March 10, 2020.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on March 10, 2020.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 10, 2020.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on March 10, 2020.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on March 10, 2020.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on March 10, 2020.
Citation F0836. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
CMS lists it as corrected on April 18, 2019.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on March 10, 2020.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on March 10, 2020.
4 citations
Fire safety inspection on February 6, 2020
CMS lists this as a standard inspection.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on March 4, 2020.
Citation K0300. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet other general requirements that are deficient.
CMS lists it as corrected on March 4, 2020.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 4, 2020.
Citation K0914. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on March 4, 2020.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- ASHLAND PARENTCO LLC5% or greater direct ownership interest · 100% · since 05/01/2025
- NTS HOLDCO LLC5% or greater indirect ownership interest · 100% · since 05/01/2025
- SNF MGR LLCOperational/managerial control · not applicable · since 05/01/2025
- GHANNAM, WASEEMOperational/managerial control · not applicable · since 04/01/2026
- HOBACK, TIFFANYOperational/managerial control · not applicable · since 05/01/2025
- JONES, TEQUILLAOperational/managerial control · not applicable · since 05/01/2025
- MCCAIN, SHALANDREAOperational/managerial control · not applicable · since 05/01/2025
- MORGAN, DANIELOperational/managerial control · not applicable · since 05/01/2025
- PALMER, DEVONOperational/managerial control · not applicable · since 03/04/2026
Questions
When was Ashland Nursing and Rehabilitation last inspected?
CMS lists February 9, 2024 as the date of its most recent standard health inspection.
How many citations (violations) does Ashland Nursing and Rehabilitation have?
CMS lists 161 health citations since February 6, 2020. CMS also calls these deficiencies.
Has Ashland Nursing and Rehabilitation been fined?
CMS lists 1 fine in the past three years, $36,491 in total.
What is the CMS star rating of Ashland Nursing and Rehabilitation?
Its CMS overall star rating is 1 of 5.
Is Ashland Nursing and Rehabilitation a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.