Data from CMS, updated September 1, 2026. How we rate · Report a correction
CMS file
CCN 555466
Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.
Adjusted total nurse hours: 5.23. Adjusted RN hours: 0.86. Case-mix total: 3.13. Case-mix index: 1.144.
Total nursing staff turnover: 21.7%. RN turnover: —. Administrators who left: —.
Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
CMS reports 1 fine totaling $66,134, and 1 payment denial.
| Date | Type | Amount or days |
|---|---|---|
| April 10, 2024 | Fine | $66,134 |
| April 10, 2024 | Payment Denial | 8 days |
Cycle 1 standard survey: May 22, 2025. Health deficiencies counted in cycle 1: 13. Cycle 1 total health score: 96.
Cycle 2 standard survey: October 20, 2023. Cycle 2/3 health deficiencies: 21. Total weighted health survey score: 138.
Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
The Health Deficiencies file lists 39 citations for this home, including 0 at immediate jeopardy and 2 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 20, 2026 |
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Complaint survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · March 19, 2026 |
| F679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · March 19, 2026 |
10 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
| F912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Environmental Deficiencies · Standard survey · Cycle 1 | B: pattern, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · June 16, 2025 |
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 8, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 8, 2025 |
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · May 9, 2024 |
18 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F803 | 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. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F908 | Keep all essential equipment working safely. Environmental Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F758 | 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. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
| F912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Environmental Deficiencies · Standard survey · Cycle 2 | B: pattern, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · November 20, 2023 |
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · October 31, 2023 |
4 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 28, 2021 |
| F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 28, 2021 |
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · June 28, 2021 |
| F912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Environmental Deficiencies · Standard survey · Cycle 3 | B: pattern, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · June 28, 2021 |
Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Ashby Care Center has an overall rating of 4 out of 5. The health inspection rating is 2, staffing is 5, and the quality measure rating is 5.
The Health Deficiencies file lists 39 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 2 are coded actual harm that is not immediate jeopardy (G, H, or I).
CMS reports 4.27 total nurse hours per resident per day, including 0.70 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.