Ashby Care Center

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Pharmacy Service Deficiencies

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

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nutrition and Dietary Deficiencies

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.

Nutrition and Dietary Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Pharmacy Service Deficiencies

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Pharmacy Service Deficiencies

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

Nutrition and Dietary Deficiencies

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.

Nutrition and Dietary Deficiencies

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.

Nutrition and Dietary Deficiencies

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

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

Keep all essential equipment working safely.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Smoke Deficiencies

Properly provide smoke detection systems in areas open to corridors.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Pharmacy Service Deficiencies

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.

Pharmacy Service Deficiencies

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.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.