Deficiency Records for Ashley Rehabilitation and Health Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Ashley Rehabilitation and Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-29 | 2023-10-29 | N |
| 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. | Health | 2023-09-29 | 2023-10-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-29 | 2023-10-29 | N |
| 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. | Health | 2023-09-29 | 2023-10-29 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-09-29 | 2023-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-29 | 2023-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-29 | 2023-10-29 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-09-29 | 2023-10-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-27 | 2023-10-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-27 | 2023-10-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-09-27 | 2023-10-29 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-09-27 | 2023-10-29 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-09-29 | 2023-09-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-11 | 2023-09-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-11 | 2023-09-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-24 | 2022-07-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-24 | 2022-07-24 | N |
| 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. | Health | 2022-06-24 | 2022-07-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-24 | 2022-07-24 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-06-24 | 2022-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-24 | 2022-07-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-10 | 2021-10-10 | N |
| Report COVID19 data to residents and families. | Health | 2021-09-10 | 2021-10-10 | N |
| 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. | Health | 2021-09-10 | 2021-10-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-10 | 2021-10-10 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-04-09 | 2021-05-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-09 | 2021-05-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-09 | 2021-05-09 | N |
| 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. | Health | 2021-04-09 | 2021-05-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-09 | 2021-05-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-04-09 | 2021-05-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-09 | 2021-05-09 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-04-08 | 2021-05-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-08 | 2021-05-08 | N |
