Inspection Reports for
Ashley Manor – Mountain Home

.260.07 Toxic Chemicals: toxic chemicals, such as disinfectants and other cleaning agents were observed to be stored in an unlocked laundry room in the memory care unit accessible to cognitively impaired residents on multiple occasions (previously cited 4/3/2025).

.320 Negotiated Service Agreement (NSA) requirements: NSAs were not updated to accurately reflect residents' current needs, including wound care, medication management, emergency evacuation, and personal care instructions for multiple residents.

.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: fire suppression wet system pressure gauges and valves lacked monthly inspection documentation, and sprinkler pendants in room #10 had non-factory applied paint covering the frangible bulb and pin requiring replacement.

.405.01.a Electrical installations and equipment: a mini fridge in room #8 was supplied power by a prohibited 6-2 multi-plug adapter.

.405.02.a Prohibited applications: an oxygen concentrator in room #8 was powered by a relocatable power tab, which is prohibited for medical devices.

.260.07 Toxic chemicals: toxic cleaning chemicals in the laundry room of Building #3 were unsecured with the door unlocked and open, allowing access to cognitively impaired residents; a female resident was observed in the laundry room at the time.

.305.02.b. Current Medication Orders and Treatment Orders: the facility did not ensure residents received their medications as ordered; Resident #2 was not given 22 doses of mirtazapine in March 2023 and Resident #3's scheduled amphetamine-dextroamphetamine was unavailable from April 7 to April 11, 2023.

.310.01.g. Medication Distribution System: not all residents' as-needed (PRN) medications were available at the facility; Resident #5 did not have ordered PRN acetaminophen, ibuprofen, or benzocaine 10% mucosal gel and Resident #2 did not have ordered PRN acetaminophen or albuterol available (previously cited 7/21/22).

.330.14.a. As Worked Schedules: the facility's as-worked schedule did not document the actual times the facility nurse and on-call facility nurse were at the facility.

.451.01.d. Menu: the facility did not ensure the dietitian-approved menus were served consistently; substitutions occurred routinely from February to April 2023, residents were served leftovers often at month end and resorted to ordering pizza; the house manager was not properly trained to purchase groceries to meet the menu (previously cited 7/21/22).

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: emergency lighting was not functioning over door to room 6 in House 3, fire suppression quick response heads in Houses 1 and 2 were over 20 years old and past due for replacement or sampling, sprinkler head in House 2 storage closet had insufficient clearance, and a prohibited transfer grille was cut into the header above door at room 8 of House 2.

.405.01. Electrical installations and equipment: the main breaker panel of House 1 was duct-taped closed instead of having approved covers installed.

.405.01.a. Electrical installations and equipment: extension cords and multiple plug adapters were prohibited but found in use in Room 8 House 2 using 6-2 MPA.

.405.03. Medical gases: no policy or procedure existed for the elimination of sources of ignition and the misuse of flammable substances as outlined in NFPA 99, Chapter 11, Section 11.5.

.151. Activity requirements: no activities were offered to residents in Buildings #1 and #2, and multiple residents complained about the lack of activities; the administrator acknowledged inconsistent activity offerings.

.215.08.b. Investigation within thirty days: the facility failed to investigate incidents and accidents for 5 of 7 sampled residents, including multiple falls with no investigations completed.

.215.08.e. Corrective action: the facility did not ensure appropriate corrective actions to prevent recurrence of residents' falls; interventions were not added or changed despite multiple falls for residents.

.260.06. Housekeeping and maintenance services: the facility was not maintained in a clean, safe, and orderly manner with dirty windows, decaying screens, dirty furniture and floors, weeds, and trip hazards; residents reported rooms and bathrooms were not cleaned regularly.

.305.03. Resident health status: residents were not consistently assessed after condition changes, including falls and unresponsiveness; assessments were missing for several residents after significant events.

.310.01.c. Medication distribution system: medication refrigerator temperatures were not documented multiple times and were out of range on several occasions in Buildings #1 and #2.

.310.01.g. Medication distribution system: the facility did not ensure all residents' as-needed medications were available at all times; some residents lacked Tylenol, Lidocaine patches, and other PRN medications.

.310.04.e. Psychotropic or behavior modifying medication: behavior updates were not included in six-month psychotropic medication reviews for 6 of 7 sampled residents taking these medications longer than six months.

.330.06.a. Behavior documentation: the facility did not evaluate certain residents' behaviors including pushing, yelling, hypersexual behaviors, refusal to use call light, and refusal of medical care; evaluations were not completed.

.330.06.b. Behavior documentation: the facility did not develop behavior plans with specific interventions for residents with documented behaviors.

.330.13.e. Personnel records: two of seven staff members did not have documentation of completing 16 hours of orientation and specialized training, though the administrator stated training was completed.

.451.01.d. Menu: the facility did not ensure dietitian-approved menus were served; observed meals did not follow the approved menus on multiple days.

.455. Food supply: the facility's three buildings had different menus and inadequate perishable food supplies to meet planned menus; residents were served meals missing required ingredients.

.645.02. Delegation: three of seven staff who passed medications were not delegated by the current facility nurse; the administrator was unaware re-delegation was needed after nurse changes.

.403 Fire and life safety standards for existing buildings licensed for three through sixteen residents: the facility had a non-operational emergency light, lacked documentation for monthly emergency lighting tests, used unsafe electrical devices including multi-plug adapters and daisy-chained power taps, and had exit doors with non-single operational locks.

.410 Requirements for emergency actions and fire drills: the facility's documentation did not show bi-monthly drills were completed in the third and fourth quarters of 2021, failed to document resident evacuation during drills, and lacked an assembly point in the emergency action plan.

.405.04 Fuel-fired heating: the facility could not produce documentation for annual inspections of fuel-fired systems in buildings #1 and #3; the last known inspection of the gas fireplace in building #3 was on 8/19/20.

.405.03 Medical gases: resident room #3 in building #2 had an unsecured oxygen cylinder in the bathroom.

.155.01 Relocation agreements: the facility had only one relocation agreement instead of the required two, and the existing agreement had not been updated since 2/27/2017.

.250.12.j Resident sleeping rooms: resident room #1 in building #2 would not latch due to an 'over the door' hanging shelf unit preventing the door from closing.

.415.02 Fuel-Fired Heating: no documentation for an annual inspection of the fuel fired systems; last known inspection was 7/22/2016.

.415.04 Fire Alarm Smoke Detection System Service and Testing: no documentation for a 5 year sensitivity test of the smoke detectors.

.415.05 Automatic Fire Extinguishing System Service and Testing: Building #1 had only 4 spare fire sprinklers, not the required 6; Building #3 had only 3 spare fire sprinklers, not the required 6.

.405.01.b Electrical Installations and Equipment: Building #1, Room #6 had a Multi-Plug Adapter (MPA); Building #2, office had a daisy chain, Relocatable Power Tap (RPT) to RPT; Building #2, Room #9 had a medical bed plugged into a RPT; Building #2 had a full sized washing machine plugged into a RPT.

.405.02 Fire Alarm Smoke Detection System: facility fire alarm smoke detection system is not electrically supervised.

.215.09 Identify and monitor patterns of incidents and accidents: the administrator did not develop interventions to prevent recurrences after Resident #2 fell twice, resulting in multiple bruises and a large skin tear.

.300.01 Licensed professional nurse (RN): the facility nurse did not conduct an assessment after Residents #2 and #3 sustained wounds.

.310.01.f Medication distribution system: three residents were observed taking their medications unsupervised.

.320.01 Use of negotiated service agreement: NSAs did not clearly describe care needs and services for 2 of 7 sampled residents; Resident #2's and #3's wound care needs were not identified.