Inspection Report
Complaint Investigation
Deficiencies: 12
Aug 13, 2025
Visit Reason
The inspection was conducted as a health care licensure and follow-up visit combined with a complaint investigation to assess compliance with regulatory requirements and investigate specific complaints.
Findings
The facility was found deficient in multiple areas including lack of resident activities, absence of designated smoking areas, poor housekeeping and maintenance, medication administration failures, incomplete psychotropic medication reviews, missing nursing assessments prior to admission, unsigned negotiated service agreements, incomplete admission records, insufficient personnel, and failure to report resident falls.
Complaint Details
The complaint investigation included substantiated issues such as failure to provide medications, incomplete psychotropic medication reviews, insufficient staffing, and failure to report resident falls.
Deficiencies (12)
| Description |
|---|
| No activities were offered to residents due to staff time constraints. |
| Facility lacked clearly marked designated smoking areas; residents observed vaping without signage. |
| Facility was not maintained in a clean, safe, and orderly manner with multiple environmental issues observed. |
| Residents did not receive medications and treatments as ordered; documented missed doses for Resident #3. |
| Psychotropic medication reviews for Residents #2 and #3 lacked required behavioral updates. |
| Comprehensive nursing assessments were not completed prior to admission for Residents #1, #2, and #3. |
| Negotiated Service Agreements were not signed and dated by Residents #1, #3, and #5 or their legal guardians. |
| Admission records lacked history and physical results for Residents #4, #5, and two unsampled residents. |
| Two of five employees lacked documented dementia and mental illness training in personnel files. |
| Snacks were not offered or served three times a day; residents had to request snacks. |
| Insufficient personnel scheduled to meet resident needs; only one care staff observed on duty unable to provide all care. |
| Former administrator failed to notify licensing and certification of resident falls resulting in injury. |
Report Facts
Missed medication doses: 3
Missed medication doses: 6
Admission dates: May 15, 2023
Admission dates: Jan 20, 2025
Staff reviewed: 5
Staff lacking training documentation: 2
Resident falls: 1
Resident falls: 2
Inspection Report
Life Safety
Deficiencies: 3
Jan 30, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for Ashley Manor - Arlington.
Findings
The facility failed to produce required documentation for monthly and annual emergency lighting tests, monthly visual inspections of the wet suppression system, and bi-monthly emergency egress and relocation drills including night drills when residents were sleeping. These deficiencies were repeat and three-peat citations from previous inspections.
Deficiencies (3)
| Description |
|---|
| Failure to produce documentation for emergency lighting testing monthly and annually. |
| Failure to produce documentation for monthly visual inspections of wet suppression system gauges and secured control valves. |
| Failure to produce documentation for bi-monthly emergency egress and relocation drills including night drills. |
Report Facts
Number of required emergency drills per year: 6
Number of night drills required per year: 2
Inspection Report
Life Safety
Deficiencies: 9
Nov 7, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Ashley Manor - Arlington to assess compliance with fire and life safety standards and sanitation requirements.
Findings
Multiple deficiencies were identified including lack of documentation for the designated point of assembly in the emergency plan, inadequate monthly inspection of fire extinguishers, incomplete emergency lighting testing, insufficient staff emergency response training, and missing fire alarm sensitivity testing. Additional repeated deficiencies included lack of documented continuing education on medical gases, missing policies on medical gas safety, insufficient emergency drills, and missing fire and life safety documentation.
Deficiencies (9)
| Description |
|---|
| Facility emergency plan does not document the designated point of assembly in accordance with NFPA 101, Chapter 33, Section 33.7.3.3. |
| Fire extinguishers were not inspected monthly as required; one extinguisher was covered in grease-laden dust and lacked inspection tags. |
| Emergency lighting testing was incomplete with no documented 90-minute annual testing. |
| Staff training for emergency response was not conducted bi-monthly as required (REPEAT deficiency). |
| Fire alarm smoke detection sensitivity testing was incomplete, with only four of eleven detectors tested. |
| No documented continuing education program for staff on risks associated with oxygen (REPEAT deficiency). |
| No documented policy for medical gas elimination of ignition sources or misuse of flammable substances. |
| Emergency egress and relocation drills were insufficient; only four documented drills in twelve months with only one during evening shift and no drills evacuating to a designated assembly point (REPEAT deficiency). |
| Missing fire and life safety documentation including annual fire alarm report, sprinkler inspection report, and sensitivity testing within past five years. |
Report Facts
Number of fire extinguishers inspected: 2
Number of smoke detectors tested for sensitivity: 4
Number of documented emergency drills: 4
Number of documented evening shift drills: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilyn Mills | Administrator | Named as facility administrator in report header |
| Sam Burbank | Survey Team Leader | Named as survey team leader conducting the inspection |
Inspection Report
Follow-Up
Deficiencies: 3
Mar 24, 2022
Visit Reason
The visit was conducted as a health care licensure and follow-up survey to assess compliance with previously cited deficiencies.
Findings
The facility was found to have unresolved issues including failure to monitor incident patterns, excessively high water temperatures, and unsafe storage of toxic chemicals accessible to cognitively impaired residents.
Deficiencies (3)
| Description |
|---|
| The administrator did not monitor patterns of incidents and accidents nor develop interventions to prevent recurrences. |
| Water temperature was found to be between 125 and 132 degrees Fahrenheit, exceeding safe limits. |
| Toxic chemicals were stored in an unlocked cabinet accessible to cognitively impaired residents. |
Report Facts
Water temperature degrees Fahrenheit: 132
Inspection Report
Life Safety
Deficiencies: 4
Dec 9, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for Ashley Manor - Arlington.
Findings
The facility was found to have multiple deficiencies including lack of documented inservice training for staff and residents on disaster roles, missing documentation for testing special locking arrangements and monthly control valve inspections, use of prohibited multiple plug adapters, unsecured oxygen cylinders, missing oxygen usage signage, and insufficient documentation of fire drills.
Deficiencies (4)
| Description |
|---|
| No documented inservice for staff and residents on disaster plan roles and responsibilities; no documentation for testing special locking arrangements at front door; no documentation for monthly control valve and wet gauge inspections. |
| Use of multiple plug adapters prohibited: Christmas tree and television plugged into MPA (corrected on site). |
| No documented inservice on risks associated with oxygen; unsecured oxygen cylinders in room 4 and office; missing oxygen usage signage in room 1 (corrected on site). |
| Only five fire drills documented, with last drill in May 2021; drills for 2020 not available for review. |
Report Facts
Fire drills documented: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Garcia | Administrator | Named as facility administrator in report header. |
| Sam Burbank | Survey Team Leader | Named as survey team leader conducting the fire life safety and sanitation licensure survey. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 4, 2021
Visit Reason
The inspection was conducted as a health care complaint investigation regarding the facility's compliance with licensing requirements.
Findings
The facility did not have a licensed administrator from June 6, 2021 to June 27, 2021, totaling 20 days. The current administrator confirmed there was no record of a licensed administrator during that period.
Complaint Details
The visit was triggered by a health care complaint investigation. No substantiation status is provided.
Deficiencies (1)
| Description |
|---|
| The facility did not have a licensed administrator from 6/6/2021 to 6/27/2021, for a total of 20 days. |
Report Facts
Days without licensed administrator: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Garcia | Administrator | Confirmed no record of a licensed administrator for the specified time frame |
| Veronica LeMaster | Survey Team Leader | Led the health care complaint investigation survey |
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