Deficiency Records for Ashley Manor Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Ashley Manor Health and Rehabilitation. 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 | 2023-11-09 | 2023-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-09 | 2023-12-15 | 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 | 2023-11-09 | 2023-12-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-09 | 2023-12-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-09 | 2023-12-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-09 | 2023-12-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-09 | 2023-12-15 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-09 | 2023-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-09 | 2023-12-15 | 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 | 2023-11-09 | 2023-12-15 | 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 | 2023-11-09 | 2023-12-15 | 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 | 2023-11-09 | 2023-12-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-11-09 | 2023-12-15 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-11-09 | 2023-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-09 | 2023-12-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-09 | 2023-12-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| Use approved construction type or materials. | Fire Safety | 2023-11-09 | 2023-12-15 | 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 | 2023-11-09 | 2023-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-09 | 2023-12-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-02 | 2022-12-02 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-24 | 2022-07-22 | 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 | 2022-07-22 | 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 | 2022-07-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-24 | 2022-07-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-24 | 2022-07-22 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-24 | 2022-07-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-24 | 2022-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-24 | 2022-07-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-24 | 2022-07-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-24 | 2022-07-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-27 | 2021-08-20 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2021-07-27 | 2021-08-20 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2020-02-07 | 2020-03-16 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2020-02-07 | 2020-03-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-07 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-07 | 2020-03-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-07 | 2020-03-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-07 | 2020-03-16 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-07 | 2020-03-16 | N |
