Deficiency Records for Ashton Creek Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Ashton Creek Health and Rehabilitation 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-17 | 2023-12-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-17 | 2023-12-07 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-19 | 2023-10-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-23 | 2023-09-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-19 | 2023-08-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-07-19 | 2023-08-19 | N |
| Develop a communication plan. | Fire Safety | 2023-07-19 | 2023-08-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-19 | 2023-08-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-07-19 | 2023-08-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-19 | 2023-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-19 | 2023-08-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-11 | 2023-08-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-11 | 2023-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-11 | 2023-08-11 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-07-11 | 2023-08-11 | 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 | 2023-07-11 | 2023-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-12 | 2023-04-28 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-04-12 | 2023-04-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-26 | 2023-02-08 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-20 | 2022-12-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-20 | 2022-12-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-20 | 2022-11-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-20 | 2022-11-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-20 | 2022-11-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-20 | 2022-11-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-13 | 2022-10-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-09-13 | 2022-10-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-13 | 2022-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-13 | 2022-10-07 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-09-13 | 2022-10-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-13 | 2022-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-13 | 2022-10-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-30 | 2022-07-15 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-14 | 2022-04-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-30 | 2021-12-13 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-20 | 2021-09-20 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2021-07-20 | 2021-08-21 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-07-20 | 2021-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-20 | 2021-08-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-20 | 2021-08-21 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-07-20 | 2021-08-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-07-20 | 2021-08-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-20 | 2021-08-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-20 | 2021-08-21 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-21 | 2021-06-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-21 | 2021-06-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-21 | 2021-06-27 | N |
