Inspection Reports for
Ashley Manor Health &Amp; Rehabilitation
1630 RADIO HILL ROAD, BOONVILLE, MO, 65233-1957
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
45 residents
Based on a January 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 45
Deficiencies: 3
Date: Jan 15, 2025
Visit Reason
The inspection was conducted to assess compliance with nursing staff adequacy, infection control, wheelchair maintenance, and other regulatory requirements at Ashley Manor Health & Rehabilitation.
Findings
The facility was found to have inadequate nursing staff to meet resident needs, resulting in extended call light response times and resident complaints. Additionally, four employees lacked required two-step TB testing documentation, and several residents' wheelchairs were in disrepair with cracked and peeling armrests that posed potential harm.
Deficiencies (3)
Failure to provide enough nursing staff every day to meet the needs of every resident, resulting in extended call light wait times.
Failure to ensure two-step purified protein derivative (PPD) testing was completed for four employees.
Failure to maintain wheelchairs in good repair, with cracked and peeling armrests posing risk of skin tears and discomfort.
Report Facts
Facility census: 45
Staffing needs per shift: 12
Staffing levels observed: 7
Staffing levels observed: 11
Call light response times: 227
Employees missing two-step PPD: 4
Residents with wheelchair issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide G | Certified Nurse Aide | Named in relation to call light response times and resident care delays |
| Director of Nursing | Director of Nursing (DON) | Named in relation to staffing adequacy and call light response issues |
| LPN C | Licensed Practical Nurse | Named in relation to staffing and wheelchair maintenance |
| Staffing Coordinator | Staffing Coordinator | Named in relation to staffing shortages and call light response times |
| Administrator | Administrator | Named in relation to staffing issues and facility oversight |
| Business Office Manager | Business Office Manager | Named in relation to employee TB screening oversight |
| Therapy Director | Therapy Director | Named in relation to wheelchair maintenance procedures |
| Maintenance Director | Maintenance Director | Named in relation to wheelchair maintenance and repair |
Inspection Report
Routine
Census: 49
Deficiencies: 17
Date: Nov 9, 2023
Visit Reason
Routine inspection of Ashley Manor Health & Rehabilitation to assess compliance with regulatory requirements including resident rights, accommodations, environment, staffing, infection control, and medication management.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity and privacy, inadequate accommodations for residents' needs, poor maintenance of the environment, incomplete background checks for employees, untimely resident assessments, failure to update PASARR documentation, lack of physician orders for self-care, incomplete post-fall assessments, insufficient weekend activities, unsafe wheelchair propulsion and storage of razors, incomplete entrapment assessments for bed rails, insufficient RN coverage, missing documentation of medication regimen reviews and gradual dose reductions, unqualified dietary manager, incomplete QAA committee membership, lapses in infection control practices, failure to maintain transmission-based precautions, incomplete TB screening, and lack of antibiotic stewardship documentation.
Deficiencies (17)
Failure to maintain residents' dignity and privacy during care by not closing curtains or doors, exposing residents to hallway view.
Failure to provide reasonable accommodations including call lights within reach and bariatric equipment.
Failure to maintain a clean, comfortable, homelike environment with unfinished repairs and mold issues.
Failure to conduct CNA registry checks for all employees prior to hire.
Failure to complete required Minimum Data Set (MDS) assessments within required timeframes.
Failure to update PASARR documentation with new diagnoses for residents.
Failure to maintain professional standards of care including lack of physician orders for self-care and incomplete post-fall assessments.
Failure to provide ongoing weekend activities meeting residents' interests.
Failure to safely propel residents in wheelchairs and failure to properly store razors.
Failure to complete entrapment assessments for bed rails for multiple residents.
Failure to provide RN coverage for eight consecutive hours seven days a week.
Failure to maintain documentation of monthly Medication Regimen Reviews and gradual dose reductions for psychotropic medications.
Failure to employ a qualified dietary manager or clinically qualified nutrition professional full-time.
Failure to maintain a Quality Assessment and Assurance committee with required members including Medical Director.
Failure to implement infection prevention and control program including hand hygiene, glove use, wound care procedures, and transmission-based precautions.
Failure to ensure residents were screened for Tuberculosis with two-step PPD testing as per facility policy.
Failure to implement an Antibiotic Stewardship Program with protocols and monitoring of antibiotic use.
Report Facts
Facility census: 49
Dates without RN coverage for 8 consecutive hours: 20
Residents with missing MDS assessments: 4
Residents with missing PASARR updates: 2
Residents with incomplete post-fall assessments: 6
Residents with missing entrapment assessments: 4
Residents on psychotropic medications without GDR: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in multiple findings related to hand hygiene, wound care, TB screening, and infection control |
| CNA B | Certified Nursing Assistant | Named in findings related to call light accessibility and infection control |
| Director of Nursing | Interim Director of Nursing | Named in findings related to RN coverage, infection control, MDS assessments, and antibiotic stewardship |
| Administrator | Facility Administrator | Named in findings related to staffing, infection control, environmental maintenance, and antibiotic stewardship |
| Maintenance Director | Maintenance Director | Named in findings related to entrapment assessments and employee background checks |
| Dietary Manager | Dietary Manager | Named in findings related to qualifications for dietary services |
| Activities Director | Activities Director | Named in findings related to weekend activities |
| Social Services Director | Social Services Director | Named in findings related to PASARR documentation |
Inspection Report
Routine
Census: 43
Deficiencies: 5
Date: Jun 24, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, dialysis services, dietary services, kitchen sanitation, hand hygiene, waste management, and vaccination policies.
Findings
The facility failed to provide adequate bathing assistance and timely call light responses to several residents, lacked proper dialysis orders and communication for a resident receiving dialysis, failed to serve pureed diets according to planned menus, had unsanitary kitchen conditions and poor food storage practices, demonstrated inadequate hand hygiene and glove use among dietary staff, failed to cover waste containers properly, and did not offer pneumococcal vaccinations to several residents as required.
Deficiencies (5)
Failure to provide care to meet basic hygiene needs for five residents and failure to answer call lights timely for two residents.
Failure to provide orders for dialysis or have a system for communication with dialysis clinic for one resident.
Failure to serve food items in accordance with nutritionally calculated menus for residents on pureed diets.
Failure to store food properly, maintain kitchen cleanliness, perform proper hand hygiene, and cover waste containers.
Failure to offer pneumococcal immunization to four residents as per facility policy and national standards.
Report Facts
Residents affected by hygiene deficiency: 5
Residents affected by call light response deficiency: 2
Facility census: 43
Residents affected by dialysis deficiency: 1
Residents affected by pureed diet deficiency: 4
Residents affected by pneumococcal vaccine deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse D | Charge Nurse | Named in dialysis communication and call light response findings |
| Director of Nursing | Director of Nursing | Provided statements regarding bathing, call light response, dialysis, and vaccination policies |
| Administrator | Administrator | Provided statements regarding bathing, call light response, dialysis, dietary service, kitchen sanitation, hand hygiene, and vaccination policies |
| Certified Nurses Aide F | CNA | Provided statements regarding shower frequency and responsibilities |
| Certified Nurses Aide H | CNA | Provided statements regarding call light response and shower frequency |
| Certified Nurses Aide G | CNA | Provided statements regarding call light response and shower frequency |
| Licensed Practical Nurse D | LPN | Provided statements regarding call light response and shower frequency |
| Dietary Manager | Dietary Manager | Named in pureed diet and kitchen sanitation findings |
| Dietary Aide A | Dietary Aide | Observed and named in hand hygiene and food handling deficiencies |
| Infection Preventionist in training | Infection Preventionist | Named in vaccination deficiency |
| Interim Infection Preventionist/Corporate RN | Registered Nurse | Named in vaccination deficiency |
| Regional Nurse | Regional Nurse | Named in dialysis communication deficiency |
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