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Deficiency Records for Ashland Nursing and Rehabilitation
A list of the most recent deficiencies for Ashland Nursing 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 Ashland Nursing 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? |
|---|---|---|---|---|
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-09 | 2024-05-07 | 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 | 2024-02-09 | 2024-05-07 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-02-09 | 2024-05-07 | 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 | 2024-02-09 | 2024-05-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-09 | 2024-05-07 | Y |
| 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 | 2024-02-09 | 2024-05-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-09 | 2024-05-07 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2024-02-09 | 2024-05-07 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-02-09 | 2024-04-11 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-09 | 2024-04-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-09 | 2024-04-11 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-02-09 | 2024-04-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-09 | 2024-04-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-09 | 2024-04-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-09 | 2024-04-11 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-09 | 2024-04-11 | 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 | 2024-02-09 | 2024-04-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-09 | 2024-04-11 | 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 | 2024-02-09 | 2024-04-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-09 | 2024-04-11 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2024-02-09 | 2024-04-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-09 | 2024-04-11 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-02-09 | 2024-04-11 | 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 | 2024-02-09 | 2024-04-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-09 | 2024-04-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-09 | 2024-04-11 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-02-09 | 2024-04-11 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-02-09 | 2024-04-11 | 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 | 2024-02-09 | 2024-04-11 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2024-02-09 | 2024-04-11 | N |
| Provide or obtain dental services for each resident. | Health | 2024-02-09 | 2024-04-11 | 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 | 2024-02-09 | 2024-04-11 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-02-09 | 2024-04-11 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-02-09 | 2024-04-11 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2024-02-09 | 2024-04-11 | 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 | 2024-02-09 | 2024-04-11 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-02-09 | 2024-04-11 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-02-09 | 2024-04-11 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-02-09 | 2024-04-11 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-02-09 | 2024-04-11 | N |
| Provide training in compliance and ethics. | Health | 2024-02-09 | 2024-04-11 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-09 | 2024-04-11 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-02-09 | 2024-04-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-09 | 2024-04-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-09 | 2024-04-11 | Y |
| 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 | 2024-02-09 | 2024-04-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-09 | 2024-04-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-09 | 2024-04-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-09 | 2024-04-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-09 | 2024-04-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-09 | 2024-04-11 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-02-09 | 2024-04-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-09 | 2024-04-11 | Y |
| Provide appropriate foot care. | Health | 2024-02-09 | 2024-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-09 | 2024-04-11 | 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 | 2024-02-09 | 2024-04-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-09 | 2024-04-11 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-02-09 | 2024-04-11 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-02-09 | 2024-04-11 | Y |
| 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 | 2024-02-09 | 2024-04-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-09 | 2024-04-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-09 | 2024-04-11 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-02-09 | 2024-04-11 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-09 | 2024-04-11 | Y |
| 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 | 2024-02-09 | 2024-04-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-09 | 2024-04-11 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-02-09 | 2024-04-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-16 | 2024-04-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-20 | 2023-12-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-20 | 2023-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-20 | 2023-12-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-07 | 2023-10-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-10-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-10-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-07 | 2023-10-17 | 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 | 2023-09-07 | 2023-10-17 | Y |
| 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 | 2023-09-07 | 2023-10-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-07 | 2023-10-17 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-09-07 | 2023-10-17 | Y |
| 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 | 2023-09-07 | 2023-10-17 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-07 | 2023-10-17 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-09-07 | 2023-10-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-07 | 2023-10-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-07 | 2023-10-17 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-26 | 2022-12-07 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-26 | 2022-12-07 | 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 | 2022-10-26 | 2022-12-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-26 | 2022-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-26 | 2022-12-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-26 | 2022-12-07 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-26 | 2022-12-07 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-23 | 2022-07-19 | 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 | 2022-06-23 | 2022-07-19 | N |
| Meet fire sprinkler requirement for tall buildings. | Fire Safety | 2022-06-23 | 2022-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-23 | 2022-07-19 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-06-23 | 2022-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-23 | 2022-07-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-07 | 2022-07-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-07 | 2022-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-07 | 2022-07-12 | 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 | 2022-06-07 | 2022-07-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-06-07 | 2022-07-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-07 | 2022-07-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-07 | 2022-07-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-07 | 2022-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-07 | 2022-07-12 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-06-07 | 2022-07-12 | 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 | 2022-06-07 | 2022-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-07 | 2022-07-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-07 | 2022-07-12 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-06-07 | 2022-07-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-06 | 2020-03-10 | 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 | 2020-02-06 | 2020-03-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-06 | 2020-03-10 | 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 | 2020-02-06 | 2020-03-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-06 | 2020-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-06 | 2020-03-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-06 | 2020-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-06 | 2020-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-06 | 2020-03-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-06 | 2020-03-10 | 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 | 2020-02-06 | 2020-03-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-06 | 2020-03-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-06 | 2020-03-10 | 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 | 2020-02-06 | 2020-03-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-06 | 2020-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-06 | 2020-03-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-06 | 2020-03-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-02-06 | 2020-03-10 | 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 | 2020-02-19 | 2020-03-04 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-02-19 | 2020-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-19 | 2020-03-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-19 | 2020-03-04 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2020-02-06 | 2019-04-18 | N |
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