Deficiency Records for Ashley Healthcare Center
Updated as of May 01, 2024
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Deficiency Records for Ashley Healthcare Center
A list of the most recent deficiencies for Ashley Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Ashley Healthcare 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-13 | 2024-04-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-13 | 2024-03-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-13 | 2024-03-15 | 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 | 2024-02-13 | 2024-03-15 | 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 | 2024-02-13 | 2024-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-13 | 2024-03-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-02-13 | 2024-03-15 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-15 | 2024-03-11 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-02-15 | 2024-03-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-15 | 2024-03-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-15 | 2024-03-11 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-15 | 2024-03-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-15 | 2024-03-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-15 | 2024-03-11 | 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 | 2024-02-15 | 2024-03-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-15 | 2024-03-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-15 | 2024-03-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-15 | 2024-03-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-15 | 2024-03-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-15 | 2024-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-15 | 2024-03-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-15 | 2024-03-11 | 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 | 2023-09-21 | 2023-10-15 | 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 | 2023-09-21 | 2023-10-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-21 | 2023-10-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-21 | 2023-10-15 | 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 | 2023-09-21 | 2023-10-15 | 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 | 2023-09-19 | 2023-10-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-19 | 2023-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-08-30 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-05 | 2023-08-30 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-08 | 2023-05-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-08 | 2023-04-13 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-03-17 | 2023-04-05 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2023-03-17 | 2023-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-17 | 2023-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-17 | 2023-04-05 | Y |
| 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 | 2023-03-17 | 2023-04-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-17 | 2023-04-05 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-03-17 | 2023-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-17 | 2023-04-05 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-03-17 | 2023-04-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-17 | 2023-04-05 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-16 | 2023-04-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-16 | 2023-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-04-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-16 | 2023-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-05 | 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 | 2023-03-16 | 2023-04-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-16 | 2023-04-05 | 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 | 2023-03-16 | 2023-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-04-05 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-03-16 | 2023-04-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-16 | 2023-04-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-16 | 2023-04-05 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-08 | 2023-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-04 | 2022-10-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-04 | 2022-10-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-04 | 2022-10-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-04 | 2022-10-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-04 | 2022-10-17 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-02-03 | 2022-04-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-03 | 2022-03-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-03 | 2022-03-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-03 | 2022-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-03 | 2022-03-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-02 | 2021-10-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-02 | 2021-10-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-02 | 2021-10-22 | 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 | 2021-09-02 | 2021-10-22 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-09-02 | 2021-10-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-10-22 | Y |
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