Ashley Rehabilitation and Health Care Center

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (May 28, 2026)

EPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0605 · Deficient, Provider has date of correction (Jan 10, 2026)

DKeep residents' personal and medical records private and confidential.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0583 · Complaint inspection · Deficient, Provider has date of correction (Jul 3, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Jul 3, 2025)

FProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0725 · Complaint inspection · Deficient, Provider has date of correction (Dec 31, 2024)

FPost nurse staffing information every day.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0732 · Deficient, Provider has date of correction (Jan 1, 2025)

FProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Dec 31, 2024)

FEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Potential for more than minimal harm · Administration Deficiencies · Tag F0837 · Deficient, Provider has date of correction (Dec 31, 2024)

FConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Potential for more than minimal harm · Administration Deficiencies · Tag F0838 · Deficient, Provider has date of correction (Dec 31, 2024)

FInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Potential for more than minimal harm · Administration Deficiencies · Tag F0847 · Deficient, Provider has date of correction (Jan 1, 2025)

FProvide a neutral and fair arbitration process and agree to arbitrator and venue.

Potential for more than minimal harm · Administration Deficiencies · Tag F0848 · Deficient, Provider has date of correction (Dec 31, 2024)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Dec 31, 2024)

FImplement a program that monitors antibiotic use.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0881 · Deficient, Provider has date of correction (Dec 31, 2024)

FDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Potential for more than minimal harm · Administration Deficiencies · Tag F0941 · Deficient, Provider has date of correction (Dec 31, 2024)

FProvide training in compliance and ethics.

Potential for more than minimal harm · Administration Deficiencies · Tag F0946 · Deficient, Provider has date of correction (Dec 31, 2024)

FEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0947 · Complaint inspection · Deficient, Provider has date of correction (Dec 31, 2024)

FProvide behavior health training consistent with the requirements and as determined by a facility assessment.

Potential for more than minimal harm · Administration Deficiencies · Tag F0949 · Deficient, Provider has date of correction (Dec 31, 2024)

EEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Dec 31, 2024)

DDevelop and implement policies and procedures to prevent abuse, neglect, and theft.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Deficient, Provider has date of correction (Dec 31, 2024)

DEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0661 · Deficient, Provider has date of correction (Dec 31, 2024)

DProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Dec 31, 2024)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Dec 31, 2024)

DTry 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.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0700 · Deficient, Provider has date of correction (Dec 31, 2024)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Dec 31, 2024)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Deficient, Provider has date of correction (Dec 31, 2024)

DEnsure 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.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Complaint inspection · Deficient, Provider has date of correction (Dec 31, 2024)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Complaint inspection · Deficient, Provider has date of correction (Feb 1, 2024)