Inspection Reports for
Ashley Manor Health &Amp; Rehabilitation
1630 RADIO HILL ROAD, BOONVILLE, MO, 65233-1957
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
21.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
291% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
87% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 6
Date: Jan 15, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with nursing staff sufficiency, infection prevention and control, and environmental safety standards at Ashley Manor Health & Rehabilitation.
Findings
The facility was found deficient in having sufficient nursing staff to meet resident needs, timely response to call lights, infection control procedures including incomplete TB testing for employees, and maintenance of wheelchair armrests. Multiple residents reported long wait times for staff assistance and call light responses.
Deficiencies (6)
F725 Sufficient Nursing Staff: The facility failed to have adequate nursing staff available to meet resident needs as evidenced by extended call light wait times and staff shortages reported by residents and staff.
F880 Infection Prevention & Control: The facility failed to ensure all employees completed two-step purified protein derivative (PPD) testing for tuberculosis as required by policy and regulation.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain wheelchair armrests in good repair, resulting in cracked and peeling vinyl that could cause skin tears or breakdown.
A3038 Furniture/Equip, Provide Comfort & Safety: The facility failed to maintain furniture and equipment in good condition, including wheelchair armrests with sharp edges and peeling vinyl.
A4031 Communicable Disease-Employees: The facility failed to implement policies ensuring employees are screened for communicable diseases and complete required TB testing.
A4046 Nursing Staff Sufficient/Qualified: The facility failed to employ sufficient nursing personnel to meet resident care needs on a 24-hour basis.
Report Facts
Facility census: 45
Call light response times: Multiple call light response times ranged from 30 minutes to over three hours as documented in wireless call light reports
Number of sampled employees for TB testing: 10
Number of interviewed residents reporting call light delays: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Reported short staffing and issues with resident care and wheelchair maintenance |
| CNA G | Certified Nurse Aide | Reported wheelchair damage and maintenance request procedures |
| Director of Nursing | DON | Acknowledged staffing shortages and call light issues |
| Administrator | Administrator | Reported staffing holes and impact on resident care |
Inspection Report
Life Safety
Census: 45
Capacity: 52
Deficiencies: 7
Date: Jan 15, 2025
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Ashley Manor Health & Rehabilitation.
Findings
The facility was found deficient in multiple areas including emergency preparedness communication, emergency lighting testing and documentation, kitchen range hood maintenance, sprinkler system inspection, fire drills, smoking regulations, and storage of combustible materials. Deficiencies had the potential to affect all residents and facility occupants.
Deficiencies (7)
E035: The facility failed to develop and implement a method for sharing the emergency preparedness plan with residents and their families or representatives. Documentation was missing in records and admissions packets.
K291: The facility failed to provide complete and verifiable documentation for annual 1.5-hour functional tests of emergency lighting equipment. Several emergency lights did not function during testing.
K324: The facility failed to maintain the kitchen range hood with a grease drip pan as required, increasing fire risk. Maintenance records and inspections were incomplete or missing.
K353: The facility failed to inspect, test, and maintain dry and wet pipe sprinkler systems properly, including monthly backflow prevention assembly inspections. Documentation was incomplete.
K712: The facility failed to conduct fire drills at various times and under varying conditions quarterly on each shift. Documentation of simulated fire conditions was missing.
K741: The facility failed to maintain two smoking areas free from fire hazards and ensure proper disposal of cigarette waste. Observations showed cigarette waste improperly stored and mixed.
K923: The facility failed to store oxygen cylinders and combustible materials in accordance with fire safety codes, including improper storage near oxygen and lack of fire resistance rating for wooden racks.
Report Facts
Facility census: 45
Total capacity: 52
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
Annual Inspection
Census: 49
Deficiencies: 24
Date: Nov 9, 2023
Visit Reason
Annual inspection survey conducted at Ashley Manor Health & Rehabilitation to assess compliance with federal and state regulations.
Findings
The facility was found to have multiple deficiencies including failure to maintain residents' dignity and privacy, inadequate reasonable accommodations, unsafe environment maintenance, incomplete abuse prevention policies, insufficient infection control, and lack of proper staffing and training documentation.
Deficiencies (24)
F550 Resident Rights/Exercise of Rights: Facility staff failed to maintain residents' dignity and privacy by not closing privacy curtains or doors during care, exposing residents to others.
F558 Reasonable Accommodations Needs/Preferences: Facility staff failed to provide reasonable accommodations by not keeping call lights within reach and not accommodating bariatric needs for residents.
F584 Safe/Clean/Comfortable/Homelike Environment: Facility staff failed to maintain a clean, comfortable, and homelike environment, including unfinished repairs and poor room conditions.
F607 Develop/Implement Abuse/Neglect Policies: Facility staff failed to check CNA registry prior to hire for several employees and did not maintain proper documentation.
F636 Comprehensive Assessments & Timing: Facility staff failed to complete required comprehensive resident assessments within mandated timeframes.
F644 Coordination of PASARR and Assessments: Facility staff failed to coordinate assessments and referrals for residents with mental disorders as required.
F658 Services Provided Meet Professional Standards: Facility staff failed to maintain professional standards of care including physician orders and documentation for self-care and abuse prevention.
F679 Activities Meet Interest/Needs Each Resident: Facility staff failed to provide an ongoing program of activities meeting residents' interests and needs, especially on weekends.
F689 Free of Accident Hazards/Supervision/Devices: Facility staff failed to ensure accident hazards were minimized and residents were properly supervised, including wheelchair safety and access to razors.
F700 Bedrails: Facility staff failed to complete entrapment assessments and ensure proper use and maintenance of bed rails for residents.
F727 RN 8 Hrs/7 days/Wk, Full Time DON: Facility failed to provide a registered nurse for at least 8 consecutive hours 7 days a week as required.
F756 Drug Regimen Review: Facility staff failed to conduct monthly drug regimen reviews by a licensed pharmacist and document irregularities.
F801 Qualified Dietary Staff: Facility failed to employ a qualified dietitian or nutrition professional full-time and did not maintain proper documentation.
F868 QAA Committee: Facility failed to maintain a quality assessment and assurance committee with required members and proper documentation.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention and control program, including hand hygiene and isolation procedures.
F881 Antibiotic Stewardship Program: Facility failed to implement an antibiotic stewardship program with protocols and monitoring of antibiotic use.
A8030 Dignity/Privacy: Facility staff failed to ensure residents were treated with dignity and privacy during care and treatment.
A3001 Substantially Constructed/Maintained: Facility building was not maintained in good repair with unfinished patchwork and exposed pipes.
A4061 Drug regimen review-monthly: Facility failed to conduct monthly pharmacist reviews of residents' drug regimens and report irregularities.
A4074 Protective Oversight, Voluntary Leave: Facility failed to provide required protective oversight and supervision for residents on voluntary leave.
A4075 Nursing Care Per Res Condition: Facility failed to provide personal attention and consistent nursing care per residents' conditions.
A4086 Infection Control/Communicate Disease: Facility failed to use acceptable infection control procedures to prevent spread of infection.
A4108 Clinical Records-assessments/interventions: Facility clinical records lacked sufficient information on assessments and interventions.
A5014 Personal Sufficient, Trained: Facility failed to ensure sufficient trained personnel to assure adequate preparation and serving of food.
Report Facts
Facility census: 49
Deficiencies cited: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Named in privacy violation and wound care findings |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings including privacy, staffing, and infection control |
| Administrator | Administrator | Named in multiple findings including privacy, staffing, and infection control |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Named in privacy and infection control findings |
| Certified Nursing Assistant (CNA) B | Certified Nursing Assistant | Named in call light and activity findings |
| Certified Nursing Assistant (CNA) H | Certified Nursing Assistant | Named in privacy and hygiene findings |
| Certified Nursing Assistant (CNA) M | Certified Nursing Assistant | Named in hygiene and wound care findings |
Inspection Report
Life Safety
Census: 49
Capacity: 52
Deficiencies: 8
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Ashley Manor Health & Rehabilitation.
Findings
The facility failed to meet several Life Safety Code requirements including maintenance of fire barriers, sprinkler system deficiencies, fire alarm system testing, and fire drill documentation. The facility census was 49 with a capacity of 52.
Deficiencies (8)
K161 Building Construction Type and Height: The facility failed to maintain the Type V (111) protected wood-frame construction standard as required by NFPA 101 when staff failed to ensure there were no holes or penetrations in ceilings.
K321 Hazardous Areas - Enclosure: The facility failed to maintain the fire resistance rating of hazardous areas and ensure doors were self-closing and automatic-closing as required by NFPA 101.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to inspect, test, and maintain the fire alarm system in accordance with NFPA 72, including failure to secure the control panel and maintain documentation.
K355 Portable Fire Extinguishers: The facility failed to inspect and maintain portable fire extinguishers monthly as required by NFPA 10, including failure to maintain spare sprinklers free of obstruction.
K374 Smoke Barrier Doors: The facility failed to maintain one of three attic smoke and fire barrier doors with positive latching assembly and failed to maintain the gap under the door to less than 3/4 inch.
K511 Utilities - Gas and Electric: The facility failed to maintain electrical panels locked and clear of obstructions, and failed to maintain electrical systems in accordance with NFPA 70 and NFPA 99.
K712 Fire Drills: The facility failed to conduct fire drills quarterly on each shift and failed to document drills properly as required by NFPA 101.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to inspect and maintain fire doors and non-rated doors located within means of egress, and failed to document inspections as required by NFPA 101.
Report Facts
Facility census: 49
Total capacity: 52
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
Plan of Correction
Census: 47
Deficiencies: 2
Date: Nov 2, 2022
Visit Reason
The inspection was conducted to assess compliance with care requirements related to activities of daily living (ADLs) for dependent residents, focusing on grooming, hygiene, and assistance with personal care.
Findings
The facility failed to provide appropriate care and services to assist residents with ADLs, including grooming and hygiene. Multiple residents were observed with unkempt hair and clothing, and staff did not consistently assist residents as required.
Deficiencies (2)
F677 ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2). The facility failed to provide necessary services to maintain good nutrition, grooming, and personal hygiene for six residents, including assistance with brushing hair and changing soiled clothes.
A4077 19 CSR 30-85.042(68) Residents Groomed/Dressed Appropriately. The regulation was not met as residents were not consistently well-groomed or dressed appropriately for the time of day and environment.
Report Facts
Facility census: 47
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 |
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 11
Date: Jun 24, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Ashley Manor Care Center following a survey completed on 06/24/2022. It addresses multiple regulatory deficiencies identified during the inspection.
Findings
The facility was found deficient in providing adequate care related to activities of daily living, dialysis services, nutritional needs, food safety, sanitation, and immunizations. Specific failures included inadequate bathing assistance, failure to provide dialysis orders and communication, failure to serve food items according to nutritional requirements, unsanitary kitchen conditions, and incomplete immunization documentation.
Deficiencies (11)
F677 ADL Care Provided for Dependent Residents. Facility staff failed to provide care to meet basic hygiene needs for five residents and failed to answer call lights timely for two residents. The facility census was 43.
F698 Dialysis. Facility staff failed to provide orders for dialysis or maintain communication with the dialysis clinic for one resident receiving dialysis. The facility census was 43.
F803 Menus Meet Resident Needs/Prep in Advance/Followed. Facility staff failed to serve food items in accordance with nutritional calculated menus to four residents receiving pureed diets. The facility census was 43.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. Facility staff failed to maintain kitchen cleanliness, proper food storage, and sanitation, including uncovered food items and accumulation of dirt and grease. The facility census was 43.
F883 Influenza and Pneumococcal Immunizations. Facility staff failed to offer pneumococcal immunizations to four residents and did not maintain proper documentation of immunizations and refusals.
A4076 Clean, Dry, Odor Free. Each resident shall be clean, dry, and free of body and mouth odor that is offensive to others. This regulation was not met as evidenced by deficiencies referenced to F677.
A4105 Medical Record-Physician Documentation. Facility staff shall include physician entries in the medical record with required information. This regulation was not met as evidenced by deficiencies referenced to F698.
A5001 Nutritional Needs Met, Assess Res, Inform Dr. Each resident shall be served nutritious food prepared and seasoned appropriately. This regulation was not met as evidenced by deficiencies referenced to F803.
A6031 Kitchen Waste Containers Covered. Waste containers used in food-preparation and utensil-washing areas shall be kept covered when not in actual use. This regulation was not met as evidenced by deficiencies referenced to F812.
A7002 Wash Hands/Arms & Clean Fingernails. Employees shall thoroughly wash their hands and exposed arms with soap and warm water before starting work and as often as necessary. This regulation was not met as evidenced by deficiencies referenced to F812.
A7015 Food-Protected, Temp, Need to Contact DHSS. Food shall be protected from contamination and maintained at safe temperatures. This regulation was not met as evidenced by deficiencies referenced to F812.
Report Facts
Facility census: 43
Call light response times: Multiple call light response times ranging from 25 to 85 minutes documented for various rooms
Dates of bathing assistance omissions: Multiple date ranges in 2022 where bathing assistance was not documented or provided
Inspection Report
Life Safety
Census: 43
Capacity: 52
Deficiencies: 5
Date: Jun 24, 2022
Visit Reason
The inspection was conducted to evaluate compliance with the Life Safety Code and fire safety regulations, including testing and maintenance of the fire alarm system, sprinkler system, fire drills, and electrical systems.
Findings
The facility failed to properly test and maintain the fire alarm system, resulting in communication failures with the supervising station and lack of fire watch during outages. The sprinkler system inspection documentation was incomplete, and fire drills were not fully documented or conducted as required. Electrical receptacle inspections were also incomplete.
Deficiencies (5)
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to test and maintain the fire alarm system monthly and promptly repair impairments, preventing communication with the supervising station. The facility census was 43 with a capacity of 52.
K346 Fire Alarm System - Out of Service: Facility staff failed to implement an approved fire watch and notify all applicable entities during fire alarm system impairments lasting more than four hours. The facility census was 43 with a capacity of 52.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to provide complete and verifiable documentation of monthly, quarterly, and annual sprinkler system inspections and testing. The facility census was 43 with a capacity of 52.
K712 Fire Drills: Facility staff failed to conduct fire drills at various times and under varying conditions on each shift quarterly for the months of July 2021 through June 2022. The facility census was 43 with a capacity of 52.
K914 Electrical Systems - Maintenance and Testing: Facility staff failed to provide complete and verifiable documentation of electrical receptacle inspections in resident care rooms during the 12-month period. The facility census was 43 with a capacity of 52.
Report Facts
Facility census: 43
Total capacity: 52
Deficiency counts: 5
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 4
Date: Jul 27, 2021
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident notification of changes and admission physician orders for immediate care at Ashley Manor Care Center.
Findings
The facility failed to notify the resident's physician in a timely manner about a resident's condition change and failed to obtain physician orders upon admission for immediate care. Documentation and communication deficiencies were identified related to resident care and medication administration.
Deficiencies (4)
F580 Notification of Changes. The facility failed to notify the resident's physician promptly about a resident's significant change in condition and obtain discharge orders. The facility census was 40 at the time of inspection.
F635 Admission Physician Orders for Immediate Care. The facility failed to obtain physician orders upon admission for immediate care of one resident. The facility census was 40.
A4050 Res Diagnosis/Orders Upon Admission. The facility did not obtain a physician's primary diagnosis and written orders for immediate care at admission.
A4074 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with the resident's condition.
Report Facts
Facility census: 40
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 26, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Mar 3, 2020
Visit Reason
The inspection was conducted due to an allegation of sexual abuse involving one resident (Resident #1). The investigation focused on whether the facility followed policies and procedures to prevent and report abuse.
Complaint Details
The complaint involved an allegation of sexual abuse of Resident #1. The allegation was not substantiated as staff failed to report the incident to the Department of Health and Senior Services. Interviews with staff and family members revealed conflicting accounts, and the facility did not follow proper reporting procedures.
Findings
The facility failed to follow its abuse and neglect policies and procedures by not properly investigating and reporting an allegation of sexual abuse. Interviews and record reviews showed staff did not report the incident to the Department of Health and Senior Services as required.
Deficiencies (2)
F607: The facility did not develop and implement policies and procedures to prohibit abuse, neglect, and exploitation of residents. Staff failed to investigate and report an allegation of sexual abuse for one resident as required by policy and regulation.
A8023: The facility did not meet the requirement to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents. This deficiency references F607.
Report Facts
Facility census: 37
Deficiency counts: 2
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 4
Date: Feb 7, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Ashley Manor Care Center.
Findings
The facility was found deficient in several areas including surety bond security for personal funds, required postings for resident rights and hotline information, catheter care and incontinence management, and food procurement and sanitation practices. Corrective actions were planned and submitted in a plan of correction.
Deficiencies (4)
F570 Surety Bond-Security of Personal Funds: Facility staff failed to purchase a surety bond in an amount sufficient to assure security of all personal funds held for residents.
F575 Required Postings: Facility staff failed to post the telephone number to the Department of Health and Senior Services hotline or a list of names, addresses, and phone numbers of the State Survey Agency.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to keep catheter bags positioned below the bladder to prevent backflow and failed to ensure catheter care and privacy for residents with catheters.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility staff failed to manually wash kitchenware to prevent cross-contamination and failed to rinse kitchenware with potable water between uses of soap and sanitizer.
Report Facts
Facility census: 37
Surety bond amount requested: 15000
Number of residents with catheters: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Perry Clemmons | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Life Safety
Census: 37
Capacity: 52
Deficiencies: 6
Date: Feb 7, 2020
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety regulations and related requirements at Ashley Manor Care Center.
Findings
The facility failed to maintain two smoking areas free from fire hazards and ensure proper disposal of cigarette waste. Additionally, the facility did not maintain one oxygen storage room according to fire safety codes and failed to provide adequate education and training on medical gas safety to staff.
Deficiencies (6)
K741 Smoking Regulations: Facility staff failed to maintain two smoking areas free from fire hazards and ensure proper disposal of cigarette waste in self-closing metal containers. This deficient practice could affect all residents and staff using the smoking areas.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to maintain one oxygen storage room in accordance with NFPA 99, including improper storage of combustibles within five feet of oxygen cylinders. This failure has the potential to affect all facility occupants.
K926 Gas Equipment - Qualifications and Training: Facility staff failed to provide education regarding safety guidelines and usage requirements for medical gases and cylinders to all staff involved. This failure poses an increased risk of fire and injury to residents and staff.
A2010 Oxygen Storage: Facility did not comply with NFPA 99 requirements for oxygen storage, including proper racks or fasteners and safety caps. Refer to K923 for details.
A2057 Ashtrays Noncombustibles/Safe Disposal: Designated smoking areas lacked ashtrays made of noncombustible material and safe design. Refer to K741 for details.
A4022 Employee Orientation/Continuing Education: Facility failed to provide in-service orientation and continuing education on infection control, emergency protocol, and resident rights for all personnel. Refer to K926 for details.
Report Facts
Facility census: 37
Total capacity: 52
Number of employees lacking training documentation: 19
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 7
Date: Nov 9, 2018
Visit Reason
Annual survey conducted to assess compliance with federal regulations for Ashley Manor Care Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, professional standards of care related to pressure ulcers, infection prevention and control, psychotropic medication management, and dining and resident activities. Multiple environmental and care-related deficiencies were documented.
Deficiencies (7)
F584 Safe/Clean/Comfortable/Homelike Environment: Facility failed to provide routine maintenance and cleaning resulting in chipped paint, dirt accumulation, damaged flooring, and other environmental hazards.
F658 Services Provided Meet Professional Standards: Facility staff failed to stage pressure ulcers according to guidelines and provide adequate care for residents with pressure ulcers.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: Facility failed to ensure proper treatment and prevention of pressure ulcers including proper use of air cushions and wound care documentation.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: Facility failed to obtain gradual dose reductions and proper documentation for psychotropic medications for several residents.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection control program including water management and tuberculosis screening.
F883 Influenza and Pneumococcal Immunizations: Facility failed to ensure residents received recommended vaccinations and proper documentation.
F920 Requirements for Dining and Resident Activities: Facility failed to accommodate dining needs of residents with appropriate table height and seating.
Report Facts
Facility census: 29
Residents sampled for pressure ulcers: 2
Residents sampled for psychotropic medication review: 5
Residents sampled for vaccination review: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN G | Registered Nurse | Provided wound care and vaccination information, interviewed regarding wound staging and pressure ulcer care |
| CNA F | Certified Nurse Assistant | Provided incontinence care and resident observations |
| CNA/RA E | Certified Nurse Assistant/Restorative Aide | Provided incontinence care and resident observations |
| Dietary Manager | Interviewed regarding maintenance and cleaning of kitchen areas | |
| Maintenance Director | Interviewed regarding facility maintenance and repairs | |
| Administrator | Interviewed regarding facility policies and renovation plans | |
| DON | Director of Nursing | Interviewed regarding vaccination review and infection control |
Inspection Report
Life Safety
Census: 29
Capacity: 52
Deficiencies: 11
Date: Nov 9, 2018
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and egress requirements at Ashley Manor Care Center.
Findings
The facility failed to meet several Life Safety Code requirements including egress door locking mechanisms, corridor door integrity, smoke barrier penetrations, fire drill compliance, electrical receptacle testing, oxygen storage, and fire drill/emergency preparedness plans. Deficiencies were documented with specific observations and interviews.
Deficiencies (11)
K222 Egress Doors: Facility staff failed to maintain doors in a means of egress that did not contain more than one locking mechanism, violating NFPA 101 requirements.
K363 Corridor Doors: Facility staff failed to ensure corridor doors were solid, resisted smoke passage, and had positive latching, exposing gaps and damage in multiple doors.
K372 Smoke Barrier: Facility staff failed to maintain smoke barrier walls free of openings and penetrations, including unsealed holes and gaps around pipes and wiring.
K712 Fire Drills: Facility staff failed to conduct required fire drills quarterly on each shift and failed to conduct a simulated resident evacuation drill.
K914 Electrical Systems: Facility staff failed to assess electrical receptacles in resident care rooms for physical integrity, grounding, polarity, and retention force as required.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to store oxygen cylinders in accordance with NFPA 99, including separation of full and empty cylinders and proper signage.
A2010 Oxygen Storage: Oxygen storage was not maintained properly with full and empty cylinders stored separately and safety caps intact, violating NFPA 99 standards.
A2041 Door Locks: Door locks did not meet NFPA 101 requirements for egress doors, allowing only one lock per door and proper release mechanisms.
A2054 Smoke Section Walls/Doors: Smoke sections were not properly separated by one-hour fire-rated walls and doors, and some doors did not close automatically upon fire alarm activation.
A2058 Fire Drill/Emergency Preparedness Plans: Facility failed to request consultation and assistance from local fire unit for review of fire and evacuation plans, delaying emergency preparedness.
A2061 Fire Drill Requirements, Evacuation: Facility failed to conduct required annual fire drills including unannounced drills and simulated resident evacuation involving local fire department.
Report Facts
Facility census: 29
Total capacity: 52
Fire drills required: 12
Fire drills conducted: 8
Inspection Report
Life Safety
Census: 34
Capacity: 52
Deficiencies: 2
Date: Jan 31, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association, focusing on fire drill requirements and emergency preparedness.
Findings
The facility failed to meet fire drill requirements as staff did not conduct fire drills at various times and under various conditions, potentially delaying emergency response. Documentation of simulated conditions for fire drills was also incomplete for the 12-month period.
Deficiencies (2)
K712 Fire Drills: The facility failed to conduct fire drills at various times and under various conditions as required by NFPA 101. Records showed incomplete documentation of simulated conditions for the 12-month period.
A2061 Fire Drill Requirements, Evacuation: The facility did not meet the requirement to conduct a minimum of twelve fire drills annually with at least one every three months on each shift, including unannounced drills and simulated resident evacuation.
Report Facts
Facility census: 34
Total capacity: 52
Fire drills conducted: 3
Fire drills conducted: 2
Fire drills conducted: 2
Fire drills conducted: 2
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 5
Date: Jan 31, 2018
Visit Reason
The inspection was conducted to investigate complaints related to care plan timeliness, wound care, medication administration, and restorative nursing services at Ashley Manor Care Center.
Complaint Details
The visit was complaint-related focusing on care plan updates, wound care, medication administration, and restorative nursing services. Specific complaints included failure to update care plans for residents with UTIs and pressure ulcers, inadequate wound documentation, medication errors, and failure to provide restorative nursing care. The complaint was substantiated based on the findings.
Findings
The facility failed to update comprehensive care plans timely, did not consistently assess and document wound care, had a medication error rate above the acceptable threshold, and failed to provide adequate restorative nursing services as ordered by physicians.
Deficiencies (5)
F657 Care Plan Timing and Revision: The facility failed to update the plan of care with changes in residents' needs for two sampled residents, including failure to address urinary tract infections and pressure relieving devices.
F658 Services Provided Meet Professional Standards: Facility staff failed to meet professional standards by not consistently assessing, documenting, and maintaining proper wound documentation for a resident with a pressure ulcer.
F688 Increase/Prevent Decrease in ROM/Mobility: Facility staff failed to provide restorative nursing services as ordered for a resident with limited range of motion and mobility impairments.
F693 Tube Feeding Management/Restore Eating Skills: Facility staff failed to provide appropriate care and services for a resident with a gastrostomy tube, including proper medication administration and flushing procedures.
F759 Free of Medication Error Rates 5 Percent or More: The facility had a medication error rate of 16%, exceeding the 5% threshold, affecting one resident out of 12 sampled.
Report Facts
Facility census: 34
Medication error rate: 16
Medication error opportunities observed: 25
Residents sampled: 12
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