A list of the most recent deficiencies for The Meadows at Ashland. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-12 | 2023-10-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-23 | 2023-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-23 | 2023-07-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-22 | 2023-07-21 | 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 | 2023-06-22 | 2023-07-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-22 | 2023-07-21 | 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 | 2023-06-22 | 2023-07-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-22 | 2023-07-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-05-24 | 2022-07-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-24 | 2022-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-24 | 2022-07-01 | 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 | 2022-05-24 | 2022-07-01 | 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 | 2022-05-24 | 2022-07-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-24 | 2022-07-01 | 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 | 2022-05-24 | 2022-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-24 | 2022-07-01 | 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 | 2022-05-24 | 2022-07-01 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-19 | 2022-07-01 | N |
| Meet other general requirements. | Fire Safety | 2022-05-19 | 2022-07-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-19 | 2022-07-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-19 | 2022-07-01 | 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 | 2022-05-19 | 2022-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-19 | 2022-07-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-19 | 2022-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-19 | 2022-07-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-19 | 2022-07-01 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-05-19 | 2022-07-01 | 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 | 2021-01-05 | 2021-02-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-01-05 | 2021-02-19 | 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 | 2021-01-11 | 2021-01-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-01-11 | 2021-01-21 | N |
| 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 | 2021-01-11 | 2021-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-01-11 | 2021-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-01-11 | 2021-01-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-01-11 | 2021-01-21 | 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 | 2021-01-11 | 2021-01-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-01-11 | 2021-01-21 | 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 | 2021-01-11 | 2021-01-21 | 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 | 2021-01-11 | 2021-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-01-11 | 2021-01-21 | N |
