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Deficiency Records for Ashley Manor Health and Rehabilitation

A list of the most recent deficiencies for Ashley Manor Health and Rehabilitation. 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 Manor Health 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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-11-09 2023-12-15 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-11-09 2023-12-15 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 2023-11-09 2023-12-15 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-11-09 2023-12-15 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2023-11-09 2023-12-15 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-11-09 2023-12-15 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-11-09 2023-12-15 N
Provide activities to meet all resident's needs. Health 2023-11-09 2023-12-15 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-11-09 2023-12-15 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 2023-11-09 2023-12-15 N
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 2023-11-09 2023-12-15 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 2023-11-09 2023-12-15 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 2023-11-09 2023-12-15 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2023-11-09 2023-12-15 N
Provide and implement an infection prevention and control program. Health 2023-11-09 2023-12-15 N
Implement a program that monitors antibiotic use. Health 2023-11-09 2023-12-15 N
Establish staff and initial training requirements. Fire Safety 2023-11-09 2023-12-15 N
Conduct testing and exercise requirements. Fire Safety 2023-11-09 2023-12-15 N
Use approved construction type or materials. Fire Safety 2023-11-09 2023-12-15 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 2023-11-09 2023-12-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-11-09 2023-12-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-11-09 2023-12-15 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-11-09 2023-12-15 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-11-09 2023-12-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-11-09 2023-12-15 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-11-09 2023-12-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-11-09 2023-12-15 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-11-02 2022-12-02 Y
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-06-24 2022-07-22 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 2022-06-24 2022-07-22 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-06-24 2022-07-22 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-06-24 2022-07-22 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-06-24 2022-07-22 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-06-24 2022-07-22 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2022-06-24 2022-07-22 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-06-24 2022-07-22 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-06-24 2022-07-22 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-06-24 2022-07-22 N
Assure the security of all personal funds of residents deposited with the facility. Health 2020-02-07 2020-03-16 N
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Health 2020-02-07 2020-03-16 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 2020-02-07 2020-03-16 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-02-07 2020-03-16 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2020-02-07 2020-03-16 N
Have proper medical gas storage and administration areas. Fire Safety 2020-02-07 2020-03-16 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2020-02-07 2020-03-16 N

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