Ashton Commons Senior Living.

“Medication administrations were not documented on the resident's medication administration record (MAR) for August 2025, despite controlled drug records showing the medications were administered at 11:56am, 1:00pm, 2:00pm, and 3:00pm. This is a repeat violation of the requirement to record medication administration information at the time the medication is administered.”

“A resident's morphine prescription was increased to 10mg by mouth every hour as needed at 6:44pm, but at 7:25pm the resident was administered morphine 5mg instead of the new dose, and did not begin receiving the correct dose until 8:38pm. This is a repeat violation of the requirement to follow the prescriber's orders.”

“The current licensing inspection summary dated 12/19/24 was not posted in the home in a conspicuous and public place.”

“The resident contract did not include the actual amount the resident would be charged per month for the home's available services.”

“Resident #2, who required 24-hour supervision for safety due to dementia diagnosis, fell out of bed on 4/4/25 between 8:40-9:00 p.m. and was not discovered until 6:11 a.m. on 4/5/25, remaining on the floor overnight. This constitutes neglect.”

“Staff Person A, hired at an unspecified date, did not receive required first-day orientation in general fire safety and emergency preparedness, including evacuation procedures, staff duties, designated meeting place, smoking safety, fire extinguishers, smoke detectors/fire alarms, and emergency services notification.”

“Staff Person A completed their 40th scheduled work hour but had not received required orientation on resident rights, emergency medical plan, mandatory reporting of abuse and neglect under the Older Adult Protective Services Act, and reporting of reportable incidents and conditions.”

“The enabler bar on resident #3's bed was not well-secured and could be moved approximately 2 feet away from the bed, posing an entrapment and fall hazard.”

“Medication administration records did not document blood sugar readings at the time insulin was administered. On 11/25/24 and 11/26/24, staff documented that insulin was held due to blood sugars below 150, but no actual blood sugar readings were recorded. On 11/26/24, insulin was documented as administered without a corresponding blood sugar test.”

“Facility failed to follow prescriber's orders for insulin administration. Insulin was documented as held without blood sugar verification, and administered without blood sugar testing, contrary to the prescriber's directive to hold if blood sugars are less than 150.”

“Alleged neglect of a resident was not immediately reported to the Department of Aging in accordance with the Older Adults Protective Services Act. The incident was discovered at approximately 5:45 p.m. on 9/15/24 but was not verbally reported to the Department of Aging until 9/16/24 at approximately 12:45 p.m.”

“A resident requiring assistance with toileting, bladder, and bowel management was neglected. On 9/15/24 at approximately 5:45 p.m., the resident was found lying in heavily soiled linens and clothing, soaked with urine, with no toileting or bladder/bowel management care provided since early morning despite the support plan requiring routine checks and physical assistance.”

“The resident's support plan did not identify the frequency of routine checks for bowel and bladder management and still indicated not applicable for both, despite the resident's assessment indicating need for assistance with bladder and bowel management.”

“A hospice binder containing confidential resident information including date of birth, diagnoses, medications, POLST form, ADL/IADL interventions, and nursing notes was left unlocked, unattended, and accessible in a desk drawer at the first floor care base. A prescription for the resident's eye medication was also accessible.”

“The written resident-home contract for resident #2, admitted in 2023, was not dated.”

“The resident-home contract for resident #9, dated 2022, was not signed by the resident. This is a repeat violation from 7/20/2023.”

“Five resident-home contracts (residents #3, #4, #2, #5, #6) do not contain notice informing the resident or designated person of the right to rescind the contract for up to 72 hours after initial signature and pay only for services received.”

“On the 3rd floor personal laundry cupboard, there was an unlabeled spray bottle with green liquid, which violates the requirement that poisonous materials be stored in their original, labeled containers.”

“An allegation of physical abuse by staff was not reported to the local Area Agency on Aging within the required timeframe. The facility failed to immediately report suspected abuse in accordance with the Older Adult Protective Services Act.”

“Following an allegation of physical abuse involving a staff person, the facility failed to immediately suspend or develop a plan of supervision for the staff member. The staff person continued to work unsupervised until after completing their shift.”

“A hospice binder containing confidential resident information including date of birth, diagnoses, medications, POLST form, ADL/IADL interventions, and nursing notes was left unlocked, unattended, and accessible in a desk drawer at the first floor care base. A prescription for the resident's eye medication was also accessible.”

“The written resident-home contract for resident #2, admitted in 2023, was not dated.”

“The resident-home contract for resident #9, dated 2022, was not signed by the resident. This is a repeat violation from 7/20/2023.”

“Five resident-home contracts (residents #3, #4, #2, #5, #6) do not contain notice informing the resident or designated person of the right to rescind the contract for up to 72 hours after initial signature and pay only for services received.”

“On the 3rd floor personal laundry cupboard, there was an unlabeled spray bottle with green liquid, which violates the requirement that poisonous materials be stored in their original, labeled containers.”

“Four resident deaths were not reported to the Department's personal care home regional office or complaint hotline within the required 24 hours. Deaths occurred on separate dates but reporting was delayed beyond the regulatory timeframe for all four residents.”