A list of the most recent deficiencies for Ashby Ponds Inc. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-06 | 2022-06-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-06 | 2022-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-28 | 2022-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-28 | 2022-05-31 | 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 | 2021-04-06 | 2021-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-06 | 2021-05-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-26 | 2021-05-10 | 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 | 2021-03-26 | 2021-05-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-26 | 2021-05-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-26 | 2021-05-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-26 | 2021-05-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-03-26 | 2021-05-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-26 | 2021-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-26 | 2021-05-10 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-08-05 | 2019-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-05 | 2019-10-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-05 | 2019-10-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-05 | 2019-10-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-05 | 2019-10-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-05 | 2019-10-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-05 | 2019-10-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-11 | 2019-08-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-11 | 2019-08-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-11 | 2019-08-23 | 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 | 2019-07-11 | 2019-08-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-11 | 2019-08-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-11 | 2019-08-23 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-07-11 | 2019-08-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-07-11 | 2019-08-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-11 | 2019-08-23 | 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 | 2019-07-11 | 2019-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-11 | 2019-08-23 | N |
| Dispose of garbage and refuse properly. | Health | 2019-07-11 | 2019-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-08-23 | N |
