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 |