A list of the most recent deficiencies for Ashley Healthcare 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? |
|---|---|---|---|---|
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-21 | 2023-10-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-21 | 2023-10-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-21 | 2023-10-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-21 | 2023-10-15 | 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 | 2023-09-21 | 2023-10-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-08-30 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-05 | 2023-08-30 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-08 | 2023-05-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-08 | 2023-04-13 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-03-17 | 2023-04-05 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2023-03-17 | 2023-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-17 | 2023-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-17 | 2023-04-05 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-17 | 2023-04-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-17 | 2023-04-05 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-03-17 | 2023-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-17 | 2023-04-05 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-03-17 | 2023-04-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-17 | 2023-04-05 | Y |
| 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. | Health | 2023-03-16 | 2023-04-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-16 | 2023-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-05 | 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 | 2023-03-16 | 2023-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-16 | 2023-04-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-16 | 2023-04-05 | 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 | 2023-03-16 | 2023-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-04-05 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-03-16 | 2023-04-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-16 | 2023-04-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-16 | 2023-04-05 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-04 | 2022-10-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-04 | 2022-10-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-04 | 2022-10-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-04 | 2022-10-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-04 | 2022-10-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-03 | 2022-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-03 | 2022-04-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-03 | 2022-04-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-02-03 | 2022-04-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-02-03 | 2022-04-15 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-02-03 | 2022-04-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-26 | 2022-03-18 | N |
| 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. | Health | 2022-02-03 | 2022-03-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-03 | 2022-03-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-03 | 2022-03-15 | 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 | 2022-02-03 | 2022-03-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-03 | 2022-03-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-03 | 2022-03-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-03 | 2022-03-15 | N |
| Respond appropriately to all alleged violations. | Health | 2022-02-03 | 2022-03-15 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-02-03 | 2022-03-15 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-03 | 2022-03-15 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-02-03 | 2022-03-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-03 | 2022-03-15 | 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 | 2022-02-03 | 2022-03-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-03 | 2022-03-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-03 | 2022-03-15 | 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 | 2022-02-03 | 2022-03-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-02-03 | 2022-03-15 | 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 | 2022-02-03 | 2022-03-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-03 | 2022-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-03 | 2022-03-15 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-02-03 | 2022-03-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-02-03 | 2022-03-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-03 | 2022-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-03 | 2022-03-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-03 | 2022-03-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-03 | 2022-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-03 | 2022-03-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-02 | 2021-10-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-02 | 2021-10-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-02 | 2021-10-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-02 | 2021-10-22 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-09-02 | 2021-10-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-10-22 | Y |
