ASHTON HEALTH AND REHABILITATION

Nursing Home Inspector

5533 BURLINGTON ROAD
MC LEANSVILLE, NC 27301
Guilford County
Phone: 336-698-0045
Provider Number: 345548
Last Inspection: 07/13/2017

About the Nursing Home

Number of Beds: 134
Number of Residents: 115
Beds Available: 19
Percent Occupancy: 86%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

28

Facility
17

County
14

NC
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

28

2017
15

2016
3

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

7/13/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 8/7/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 8/7/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 8/7/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 8/7/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 8/7/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 8/7/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 8/7/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 8/7/2017
 

5/12/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 6/6/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 6/6/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 6/6/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/6/2016
 

6/18/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 8/6/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/14/2016
 

8/6/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 8/14/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 8/14/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NC State Avg
Number of Residents 115 86.86 84.96
Registered Nurses 0.85 0.66 0.72
Licensed Practical / Vocational Nurses 0.95 0.94 0.87
Certified Nursing Assistants 2.59 2.44 2.33
Total Staff Hours 4.38 4.04 3.91

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NC State Avg%
of high risk long-stay residents with pressure ulcers 8 8 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 91 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 93 93
of long-stay residents experiencing one or more falls with major injury 4 3 3
of long-stay residents who have depressive symptoms 0 1 2
of long-stay residents who lose too much weight 7 9 8
of long-stay residents who received an antianxiety or hypnotic medication 14 30 29
of long-stay residents who received an antipsychotic medication 10 13 13
of long-stay residents who self-report moderate to severe pain 3 5 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 32 25 23
of long-stay residents whose need for help with daily activities has increased 16 19 18
of long-stay residents with a catheter inserted and left in their bladder 1 2 1
of long-stay residents with a urinary tract infection 3 4 4
of low risk long-stay residents who lose control of their bowels or bladder 74 59 55
of short-stay residents assessed and appropriately given the pneumococcal vaccine 97 78 83
of short-stay residents who had an outpatient emergency department visit 12 10 13
of short-stay residents who made improvements in function 63 65 64
of short-stay residents who newly received an antipsychotic medication 0 1 1
of short-stay residents who self-report moderate to severe pain 16 14 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 94 75 81
of short-stay residents who were rehospitalized after a nursing home admission 18 18 20
of short-stay residents who were successfully discharged to the community 63 59 55
of short-stay residents with pressure ulcers that are new or worsened 0 0 0