A list of the most recent deficiencies for Ashby Care 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-23 | 2023-12-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-23 | 2023-12-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-23 | 2023-12-04 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-10-23 | 2023-12-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-23 | 2023-12-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-23 | 2023-12-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-10-23 | 2023-12-04 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-20 | 2023-11-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-20 | 2023-11-20 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-10-20 | 2023-11-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-20 | 2023-11-20 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-20 | 2023-11-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-20 | 2023-11-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-20 | 2023-11-20 | 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 | 2023-10-20 | 2023-11-20 | 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 | 2023-10-20 | 2023-11-20 | 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 | 2023-10-20 | 2023-11-20 | 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 | 2023-10-20 | 2023-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-20 | 2023-11-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-20 | 2023-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-20 | 2023-11-20 | N |
| Keep all essential equipment working safely. | Health | 2023-10-20 | 2023-11-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-20 | 2023-11-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-20 | 2023-11-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-20 | 2023-11-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-13 | 2023-10-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-27 | 2023-08-01 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-07-28 | 2021-08-20 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-07-28 | 2021-08-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-06-23 | 2021-07-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-16 | 2021-06-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-16 | 2021-06-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-16 | 2021-06-28 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-06-16 | 2021-06-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-21 | 2019-11-20 | 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 | 2019-10-21 | 2019-11-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-09-12 | 2019-11-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-12 | 2019-11-06 | 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 | 2019-09-12 | 2019-11-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-11-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-12 | 2019-11-06 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-05-06 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-06 | Not Fixed | 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 | 2022-05-06 | Not Fixed | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-06 | Not Fixed | N |
