A list of the most recent deficiencies for Ashland Nursing 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-20 | 2023-12-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-20 | 2023-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-20 | 2023-12-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-07 | 2023-10-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-10-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-10-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-07 | 2023-10-17 | 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 | 2023-09-07 | 2023-10-17 | Y |
| 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 | 2023-09-07 | 2023-10-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-07 | 2023-10-17 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-09-07 | 2023-10-17 | Y |
| 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 | 2023-09-07 | 2023-10-17 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-07 | 2023-10-17 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-09-07 | 2023-10-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-07 | 2023-10-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-07 | 2023-10-17 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-26 | 2022-12-07 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-26 | 2022-12-07 | 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 | 2022-10-26 | 2022-12-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-26 | 2022-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-26 | 2022-12-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-26 | 2022-12-07 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-26 | 2022-12-07 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-23 | 2022-07-19 | 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 | 2022-06-23 | 2022-07-19 | N |
| Meet fire sprinkler requirement for tall buildings. | Fire Safety | 2022-06-23 | 2022-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-23 | 2022-07-19 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-06-23 | 2022-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-23 | 2022-07-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-07 | 2022-07-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-07 | 2022-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-07 | 2022-07-12 | 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 | 2022-06-07 | 2022-07-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-06-07 | 2022-07-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-07 | 2022-07-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-07 | 2022-07-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-07 | 2022-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-07 | 2022-07-12 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-06-07 | 2022-07-12 | 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 | 2022-06-07 | 2022-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-07 | 2022-07-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-07 | 2022-07-12 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-06-07 | 2022-07-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-01 | 2021-09-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-06 | 2020-03-10 | 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 | 2020-02-06 | 2020-03-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-06 | 2020-03-10 | N |
| 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 | 2020-02-06 | 2020-03-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-06 | 2020-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-06 | 2020-03-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-06 | 2020-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-06 | 2020-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-06 | 2020-03-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-06 | 2020-03-10 | 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 | 2020-02-06 | 2020-03-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-06 | 2020-03-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-06 | 2020-03-10 | 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 | 2020-02-06 | 2020-03-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-06 | 2020-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-06 | 2020-03-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-06 | 2020-03-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-02-06 | 2020-03-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-02-19 | 2020-03-04 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-02-19 | 2020-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-19 | 2020-03-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-19 | 2020-03-04 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2020-02-06 | 2019-04-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-28 | 2019-01-17 | 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 | 2018-11-28 | 2019-01-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-11-28 | 2019-01-17 | 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 | 2018-11-28 | 2019-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-28 | 2019-01-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-28 | 2019-01-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-11-28 | 2019-01-17 | 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 | 2018-11-01 | 2018-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-01 | 2018-12-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-01 | 2018-12-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-11-01 | 2018-12-04 | 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 | 2018-11-01 | 2018-12-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-01 | 2018-12-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-01 | 2018-12-04 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-11-01 | 2018-12-04 | 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 | 2018-11-01 | 2018-12-04 | N |
| Provide or obtain dental services for each resident. | Health | 2018-11-01 | 2018-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-01 | 2018-12-04 | N |
| Dispose of garbage and refuse properly. | Health | 2018-11-01 | 2018-12-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-01 | 2018-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-01 | 2018-12-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-11-01 | 2018-12-04 | N |
