Inspection Reports for
Ashley Manor Care Center – Arlington

.151 Activity requirements: no activities were offered to residents due to staff time constraints; the administrator stated they were working on providing activities.

.161.04 Designated smoking areas: the facility did not have clearly marked designated smoking areas; residents were observed vaping outside without signage.

.260.06 Housekeeping and maintenance services: the facility was not maintained in a clean, safe, and orderly manner with flies observed, scuffs and scrapes on walls, worn dining tables, damaged flooring with urine odor, separated kitchen countertop seams, black window seals, cobwebs, and chipped vinyl siding.

.305.02.b Current medication orders and treatment orders: Resident #3 did not receive ordered Vitamin B-12 three times and topical pain medication six times; the nurse was unaware of these missed medications.

.310.04.e Psychotropic or behavior modifying medication: Residents #2 and #3 did not have required behavioral updates included in their six-month psychotropic medication reviews; the former administrator did not complete these reviews.

.319.03 Nursing assessment: comprehensive nursing assessments were not completed prior to admission for Residents #1, #2, and #3.

.320.03 Signature, date, and approval of agreement: Negotiated Service Agreements were not signed and dated by Residents #1, #3, and #5 nor their legal guardians; the former administrator did obtain the required signatures.

.330.05.b Admission records: the facility did not obtain history and physical results for Residents #4, #5, and two unsampled residents; the marketer was responsible but did not obtain these records before admission.

.330.13.e Personnel records: two of five employees did not have documented evidence of dementia and mental illness training in their personnel files despite caring for residents with these diagnoses.

.460.02.d Frequency of meals: snacks were not served or offered three times a day; staff lacked time and residents had to request snacks.

.600.04.a Sufficient personnel: insufficient staff were scheduled to meet resident needs; one care staff was unable to provide assistance with eating, activities, or snacks due to workload.

39-3321.5 Qualifications and requirements of administrator: the former administrator did not notify licensing when Resident #3 sustained a pelvic fracture after a fall and when Resident #5 fell multiple times requiring paramedics.

.403 Fire and life safety standards for existing buildings: the facility was unable to produce documentation for monthly and annual emergency lighting testing and monthly visual inspections of wet suppression system gauges and control valves (previously cited 11/07/2022).

.410 Requirements for emergency actions and fire drills: the facility failed to produce documentation of bi-monthly emergency egress and relocation drills, including at least two night drills when residents were sleeping (previously cited 12/09/2021 and 11/07/2022).

.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: the facility emergency plan lacks a designated point of assembly, fire extinguishers were not inspected monthly and one was covered in grease-laden dust without an inspection tag, emergency lighting testing was incomplete, staff emergency response training was not reviewed bi-monthly, and fire alarm smoke detection sensitivity testing was incomplete (previously cited 1/22/2018).

.405.03 Medical gases: no documented continuing education program for staff on oxygen risks and no documented policy for elimination of ignition sources or misuse of flammable substances.

.410 Requirements for emergency actions and fire drills: only four documented drills in the past twelve months with only one during the evening shift, no drills documented evacuating to a designated point of assembly, and the emergency plan did not list a point of assembly.

.330.15 Fire and life safety records: missing documentation including annual fire alarm report, annual sprinkler inspection report, and sensitivity testing within the past five years for zoned fire alarm smoke detection.

.215.08.g. Identify and Monitor Patterns: the administrator did not monitor patterns of incidents and accidents nor develop interventions to prevent recurrences; no monitoring and tracking system was in place (previously cited 4/13/2017).

.250.09. Plumbing: water temperatures were found between 125 and 132 degrees Fahrenheit, including 132 degrees in the resident shower room; the administrator stated the temperature will be corrected immediately.

.260.07. Toxic Chemicals: toxic chemicals were stored in an unlocked cabinet in the laundry room accessible to cognitively impaired residents (previously cited 4/13/2017).

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: no documented inservice for staff and residents on disaster plan roles and responsibilities, no documentation for testing of special locking arrangements at front door, and no documentation for monthly control valve and wet gauge inspections.

.405.01.a. Electrical installations and equipment: multiple plug adapters are prohibited; Christmas tree and television were plugged into multiple plug adapters and corrected on site.

.405.03. Medical gases: no documented inservice on oxygen risks, unsecured oxygen cylinders in room 4 and office, and no sign for resident use of oxygen in room 1; some issues corrected on site.

.410. Requirements for emergency actions and fire drills: only five fire drills documented, with the last drill ending in May 2021 and no drills available for 2020.

.215 Requirements for a facility administrator: the facility did not have a licensed administrator from 6/6/2021 to 6/27/2021, for a total of 20 days; the current administrator confirmed there was no record of a licensed administrator for that time frame.

.405.05 Structure, Maintenance, Equipment to Assure Safety: no documentation for a 90 minute annual test of the emergency lighting.

.405.01 Medical Gases: no record of emergency lighting testing documented at 30 seconds monthly and 90 minutes annually.

.405.03 Medical Gases: six unsecured oxygen cylinders in resident closet Room B.

.410.02 Fire Drills: facility failed to conduct one fire drill per shift per quarter; only three fire drills on record for one quarter of the previous four quarters.

.415.04 Fire Alarm Smoke Detection System Service and Testing: fire alarm not documented as having been tested in the last five years for sensitivity; noted on fire alarm report.

.215.08 Procedures for Investigations: the facility did not ensure that investigation of incidents and accidents were completed by the administrator.

.215.09 Identify and Monitor Patterns of Incidents and Accidents: the administrator did not identify or monitor patterns of incidents and accident to develop interventions to prevent recurrences.

.260.04.a Insect and Rodent Control: the facility did not secure cleaning chemicals that were accessible to residents in the laundry room, in the bathroom across from room A and under the kitchen sink.

.320.02.e Key Elements of the Negotiated Service Agreement: 4 of 4 residents' NSAs did not specify the frequency of services for bathing, housekeeping or laundry services.

.320.03 Signature, Date and Approval of Agreement: 4 of 4 sampled residents' NSAs were not signed by the facility Administrator.

.330.03 Resident Record Confidentiality: the facility administrator did not ensure that resident information, contained in the laptop on the medication cart, was safeguarded from potential unauthorized use. This information was open and in view of visiting family on the first day of survey.

.711.08.e Care Notes: a facility caregiver neither notified the RN nor documented the open wound on Resident #1's coccyx when the caregiver was notified of the wound by an outside provider.

.725.01 Admission and Discharge Register: the facility did not maintain an up-to-date admission and discharge register.

.730.02.a Work Records: the facility work records failed to document the times the administrator and maintenance staff worked at the facility.

.730.02.b Work Records: the facility's work records did not contain the first and last names of each employee and their position, including the current administrator.

.405.07 Exit Door Locks: front door delayed egress locking arrangement would not release under applied force of 15 lbf for 15 seconds.