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Deficiency Records for Ashbrook Care and Rehabilitation Center
A list of the most recent deficiencies for Ashbrook Care and Rehabilitation 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 Ashbrook Care and Rehabilitation 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? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2023-12-15 | 2024-02-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-12-15 | 2024-02-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-15 | 2024-01-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-15 | 2024-01-22 | 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 | 2023-12-15 | 2024-01-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-15 | 2024-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-15 | 2024-01-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-15 | 2024-01-20 | 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 | 2023-12-15 | 2024-01-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-15 | 2024-01-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-15 | 2024-01-19 | N |
| 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 | 2023-12-15 | 2024-01-18 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-12-15 | 2024-01-15 | N |
| 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 | 2023-12-15 | 2024-01-15 | 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 | 2023-12-15 | 2024-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2024-01-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-15 | 2024-01-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-15 | 2024-01-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-15 | 2023-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-15 | 2023-12-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-12-15 | 2023-12-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-15 | 2023-12-16 | N |
| Post nurse staffing information every day. | Health | 2023-12-15 | 2023-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-06 | 2023-03-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-06 | 2023-03-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-06 | 2023-03-03 | 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 | 2023-02-06 | 2023-02-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-06 | 2023-02-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-02-06 | 2023-02-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-06 | 2023-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-06 | 2023-02-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-06 | 2023-02-07 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-06 | 2023-02-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-06 | 2023-02-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-06 | 2023-02-07 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-02-06 | 2023-02-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-06 | 2023-02-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-11-06 | 2020-11-24 | 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 | 2020-11-06 | 2020-11-24 | 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 | 2020-11-06 | 2020-11-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-11-06 | 2020-11-24 | N |
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