Deficiency Records for Ashton Creek Health and Rehabilitation Center
Updated as of June 01, 2021
This is not the most recent data for Ashton Creek Health and Rehabilitation Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-15 | 2021-03-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-02-15 | 2021-03-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-16 | 2021-01-14 | N |
| Report COVID19 data to residents and families. | Health | 2020-12-16 | 2021-01-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-07-07 | 2020-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-15 | 2019-08-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Develop a communication plan. | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-05-22 | 2019-06-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-22 | 2019-06-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-22 | 2019-06-21 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-22 | 2019-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-22 | 2019-06-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-22 | 2019-06-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-05-22 | 2019-06-21 | N |
| 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. | Health | 2019-05-22 | 2019-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-22 | 2019-06-21 | N |
| Develop a communication plan. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2018-05-11 | 2018-06-20 | 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 | 2018-05-11 | 2018-06-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-11 | 2018-06-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-11 | 2018-06-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-04-24 | 2018-05-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-24 | 2018-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-24 | 2018-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-08-01 | 2017-08-25 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-23 | 2017-07-07 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-23 | 2017-07-07 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-23 | 2017-07-07 | N |
