Ashley Manor Health & Rehabilitation

Inspectors wroteReviewed AT Based on interview and record review, the facility failed to have adequate nursing staff available to meet the needs of the residents as determined by their facility assessment and extended call light wait times. The facility census was 45. 1. Review of the facility policy titled, Answering the Call Light, undated, showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs. Staff are directed: -If the resident needs assistance, indicate the approximate time it will take for you to respond; -If the resident's task is something you can fulfill, complete the task within five minutes if possible; -If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. 2. [...]

Inspectors wroteReviewed AT Based on interview and record review, facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was completed for four employees (Staffing coordinator, Dietary Assistant L, Minimum Data Set (MDS) Coordinator, and Licensed practical nurse (LPN) K,) out of ten sampled employees. The facility census was 45. 1. Review of the facility's policy titled Tuberculosis (TB) Employee Screening, not dated, showed all employees are screened for Latent Tuberculosis Infection (LTBI) and active TB disease using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment. Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment. [...]

Inspectors wroteReviewed AT Based on observation, interview, and record review, facility staff failed to ensure four residents (Residents #1, #30, #15 and #17) of 18 sampled residents, wheelchairs were maintained in good repair. The facility census was 45. 1. Review of the facility policy titled, Maintenance Request Policy, undated, showed: -Mainenance forms are located at the nursing desk, staff are to fill out and place on clipboard; -The request is reviewed and repairs are done; -Maintenance staff performs the work and notes repairs in the TELS Electronic Maintenance Request program. Review of the facility policy titled, TELS Wheelchair Cleaning, undated, showed; -Night shift staff will do the inspections of each residents wheelchair and clean as necessary; -Staff will inform maintenance of any issues via the TELS program or logbook at the nursing station. 3. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 49. 1. Review of the dietary manager's (DM) personnel records, showed a hire date of 10/15/23. Review showed the records did not contain documentation of prior dietary manager experience in a long-term care facility and certification or other education required for the director of nutritional services position. During an interview on 11/07/23 at 9:52 A.M., the DM said he/she had prior experience as a DM in a long-term care facility from 2016 to 2019 and he/she became the DM for this facility on in October 2023. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of the residents by failing to keep the call lights within reach for three residents (Resident #5, #14, and #41) and failed to accommodate a resident with bariatric needs for one resident (Resident #6) The facility census was 49. 1. Review of facility's Call Light policy, revised March 2021, showed, when a resident is in bed or confined to a chair that the call light is within easy reach of the resident. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/10/23, showed staff assessed resident as: -Moderately cognitively impaired; [...]

Inspectors wroteBased on interview and record review, facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff prior to hire to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) as direted by the facility policy for five employees (maintenance director, admissions coordinator, licensed practical nurse (LPN) C, housekeeper D and dietary aide E) out of a sample of six. The facility census was 49. 1. Review of the facility's Abuse Prevention Program policy, revised December 2016, showed the facility will conduct background checks and will not knowingly employ or otherwise engage any individual who has: -Been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for four sampled residents (Residents #13, #20, #29, and #104). The facility census was 49. 1. Review of the facility's Electronic Transmission of the MDS policy, revised November 2019, showed all MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records are completed and electronically encoded into out facility's MDS information system and transmitted to Centers for Medicare & Medicaid Services (CMS) QIES Assessment Submission and Processing (ASAP) system in accordance with currant Omnibus Budget Reconciliation Act (OBRA) regulations governing the transmission of MDS data. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain professional standards of care when they failed to have physician orders and documentation for self-care of a tracheostomy (a procedure where an opening is created in the neck so a tube can be inserted into the trachea(windpipe) from the outside of the neck to help air and oxygen reach the lungs) for one resident (Resident # 2), and failed to complete assessments after unwitnessed falls for six residents (Resident #9, #11, #15, #22, and #27). The facility census was 49. 1. Review of the facility's Tracheotomy Care policy, revised August 2013, showed tracheotomy tubes should be changed as ordered and as needed (at least monthly). 2. Review of Resident #2's Minimum Date Set (MDS), a federally mandated assessment tool, dated 10/07/23, showed staff assessed the resident as follows: -Cognitive intact; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to properly propel two residents (Resident #21 and #41) in their wheelchairs in a manner to prevent accidents and failed to ensure the residents' environment remained free of accident hazards when to staff failed to properly store razors. The facility census was 49. 1. Review of the facility's policies showed the facility did not provide a policy for wheelchair safety. 2. Review of Resident #21's Quarterly Minimum Date Set (MDS), a federally mandated assessment tool dated 08/21/23, showed staff assessed resident as: -Cognitively intact; -Uses a wheelchair; -Required total dependence of staff when wheeled 150 feet; -Diagnosis of multiple sclerosis (a long-lasting disease of the central nervous system). [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to accurately complete entrapment assessments for bed rails for four residents (Resident #5, #6, #41 and #103). The facility census was 49. 1. Review of the facility's Restraints: Bed Rail Safety Check, undated, directed staff as follows: -When using bed rails, close attention must be given to the design of the rails and the relationship between rails and other parts of the bed; -Seven areas in the bed system that are a potential for entrapment, entrapment may occur in flat or raised bed positions , with the rails partially or fully raised; -Regularly inspect each of the seven areas on each bed with restraints - use the bed rail safety check to determine if a resident's bed meets the safety measurement requirements suggested by the United States Food and Drug Administration (FDA). [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a registered nurse (RN), for at least eight (8) consecutive hours per day, seven days a week. The facility census was 49. 1. Review of the facility's Staffing, Scheduling and Postings Policy, revised October 24, 2022, showed the facility must use the services of a registered nurse for eight consecutive hours a day, seven days per week, unless a wavier applies. The facility will employ sufficient nursing staff as determined by resident assessments and individual plans of care. Review of the facility's Facility Assessment Tool, Dated 5/22/23, showed staff it directed facility staff to staff the following way: -Director of Nursing (DON): 1 DON RN full-time days; -Assistant Director of Nursing (ADON): full-time days; -Registered Nurse (RN) or Licensed Practical Nurse (LPN): one for each shift. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to wash or sanitize their hands in between glove changes during perineal care for two residents (Resident #6 and #7), failed to wash or sanitize their hands in between gloves changes, did not wash or sanitize their hands before preparing wound dressing supplies, and did not provide a barrier for wound care suppplies for one resident (Resident #4). Facility staff failed to wash or sanitize their hands or wear gloves during wound care for one resident (Resident #21), failed to maintain transmission based precautions to prevent the transmission of ESCHERICHIA COLI- Extended Spectrum Beta-Lactamase ([E.Coli-ESBL] (E. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain residents' dignity and privacy when staff failed to close the privacy curtains and left the door open during care for two resident's (Resident #4 and #7) and failed to recognize one resident (Resident #43) who was exposed to the hallway while in their room with their door open. The facility census was 49. 1. Review of the facility's Resident Rights Policy, revised December 2016, showed: -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -Be treated with respect, kindness, and dignity; -Privacy and confidentiality. 2. Review of Resident #4's admission Minimum Date Set (MDS), a federally mandated assessment tool, , dated 10/02/23, showed staff assessed the resident as follows: -Moderate cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a clean, comfortable, homelike environment for three resident (Resident #6, #47 and #102) rooms when facility staff did not ensure resident's rooms were in good repair. The facility census was 49. 1. Review of the facility's Homelike Environment policy, revised February 2021, showed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. 2. Observation on 11/06/23 at 9:46 A.M., showed the bathroom ceiling in room [ROOM NUMBER] had patch work started but was unfinished. The tiled floors were broken and had rust colored stains. 3. Observation on 11/06/23 at 10:23 A.M., showed a large unpainted patched area above Resident #6's bed. 4. [...]

Inspectors wroteBased on interview and record review, facility staff failed to accurately update a new diagnosis within the Pre-admission Screening and Resident Review (PASARR) documentation to incorporate the recommendations into resident assessment and care plan for two residents (Resident #5 and #14) out of four sampled residents. The facility census was 49. 1. Review of the facility's policy titled, admission Criteria, revised March 2019, showed staff are directed to do the following: -All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the PASARR process: -The facility conducts a level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends. The facility census was 49. 1. Review of the facility's records showed the facility did not have a policy for activities. 2. Review of the facility's Activity Calendar, dated October 2023, showed the following: -Saturday, 10/04/23: Bingo; -Sunday, 10/05/23: Resident #6's Bible Study; -Saturday, 10/11/23: Bingo; -Sunday, 10/12/23: Resident #6's Bible Study; -Saturday, 10/18/23: Bingo; -Sunday, 10/19/23: Resident #6's Bible Study; -Saturday, 10/25/23: Bingo; -Sunday, 10/26/23: Resident #6's Bible Study. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to keep records of the monthly Medication Regimen Review (MRR) conducted by the pharmacy and the recommendations of the resident's psychotropic gradual dose reduction (GDR's) signed by the physician with rational for four residents (Resident #6, #14, #15 and #41). The facility census was 49. 1. Review of the facility's policy titled, Medication Regimen Review, revised February 2020, showed staff were directed to do the following: -Recommendations and apparent irregularities will be reported timely to ensure the safe and appropriate medication utilization to meet the individual needs of the residents; -A hard copy of the recommendation will be addressed to the attending physician as part of the consultant's regular monthly report with a timely response; [...]

Inspectors wroteBased on record review and interview, facility staff failed to maintain a Quality Assessment and Assurance (QAA), (identification, assessment, correction and monitoring of important aspects of resident care to enhance quality) committee consisted of the minimum required members. The facility census was 49. 1. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program Policy, revised March 2020, showed: -The following individuals serve on the committee; Administrator or designee, Director of nursing, Medical Director, Infection Perfectionist; -The following departments, as required by the administrator; Pharmacy, Social Services, activity services, environmental services, human resources and medical records; -The committee meets at least quarterly (or more often as necessary). [...]

Inspectors wroteReviewed Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. The facility census was 49. 1. Review of the facility's policy titled, Antibiotic Stewardship Program, revised December 2016, showed: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewwardship program, if antibiotics are indicated the antibiotic stewardship will include; -Drug name; -Dose; -Frequency of administration; -Duration of treatment (start and stop date) or (number of days of therapy); -Route of administration; -Indication of use. Review of the facility's antibiotic stewardship book showed facility staff did not track antibiotic usage from January 2023 to July 2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent cross-contamination and out dated use. Facility staff failed to maintain kitchen floors and equipment in a clean and sanitary manner to prevent the growth of bacteria. Facility staff failed to wash their hands as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to cover waste containers used in food-preparation and utensil-washing areas when not in actual use. The facility census was 43. 1. Review of facility's Food Storage (Dry, Refrigerated, and Frozen) policy dated 2020, showed All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care to meet basic hygiene needs for five residents (Resident #19, #24, #25, #31, and #43) out of twelve sampled residents. Additionally, staff failed to answer call lights in a timely manner for two residents (Resident #12 and #43) out of eight sampled residents. The facility census was 43. 1. Review of the facility's Bath, Shower Policy, dated February 2018, showed staff are directed: -The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; -Document the date and time the shower/bath was performed; -The name and title of the individual(s) who assisted the resident; -All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin); -Notify the supervisor if the resident refuses the shower/tub bath; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food items in accordance with the nutritionally calculated menus to four of four residents who received pureed diets (Residents #5, #31, #37 and #297). The facility census was 43. 1. Review of the facility's Menu Planning and Requirements policy, dated 2020, showed Menus are planned in advance and are varied for the same day of consecutive weeks. Regular and therapeutic menus are planned by a nutrition professional in accordance to the community's approved diet manual. The planned menus are reviewed and approved by a registered dietician (RD). Deviations from the planned menu allow for individualized nutrition based on nutritional or medical needs and/or resident requests. These deviations are indicated on a meal card or other communication tool for the serving staff. [...]

Inspectors wroteBased on interview and record review, facility staff failed to offer the pneumococcal (infection caused by bacteria) immunization to four residents (#16, #26, #35, and #39) out of five sampled residents per their facility policy, and in accordance with national standards of practice. The facility census was 43. Review of the U.S. Department of Health and Human Services Centers for Disease Control and Prevention, pneumococcal and influenza vaccine timing for adults, dated 2022, showed the following: -Four types of pneumonia vaccines are acceptable for adults 65 years or older. PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13), PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvanc), PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20), and PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax); [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney), or have a system in place for ongoing communication with the dialysis clinic for one resident (Resident #25) who received dialysis. The facility census was 43. 1. Review of the facility's Hemodialysis (performed outside the body via machine) Access Care policy, revised September 2010, showed staff are directed as follows: -Documentation: The general medical nurse should document in the resident's medical record every shift as follows: -If dialysis was done during shift, -Any part of report from dialysis nurse post(after)-dialysis; -Observations post-dialysis 2. [...]