Ashley Manor Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ashley Manor Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Nov 9, 2023

  Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 49. 1. Review of the dietary manager's (DM) personnel records, showed a hire date of 10/15/23. Review showed the records did not contain documentation of prior dietary manager experience in a long-term care facility and certification or other education required for the director of nutritional services position. […]

• No harm, potential for more than minimal, widespreadF812Jun 24, 2022

  Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent cross-contamination and out dated use. Facility staff failed to maintain kitchen floors and equipment in a clean and sanitary manner to prevent the growth of bacteria. Facility staff failed to wash their hands as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to cover waste containers used in food-preparation and utensil-washing areas when not in actual use. The facility census was 43. 1. Review of facility's Food Storage (Dry, Refrigerated, and Frozen) policy dated 2020, showed All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded. […]

• No harm, potential for more than minimal, patternF725Jan 15, 2025

  Reviewed AT Based on interview and record review, the facility failed to have adequate nursing staff available to meet the needs of the residents as determined by their facility assessment and extended call light wait times. The facility census was 45. 1. Review of the facility policy titled, Answering the Call Light, undated, showed the purpose of this procedure is to ensure timely responses to the resident's requests and needs. Staff are directed: -If the resident needs assistance, indicate the approximate time it will take for you to respond; -If the resident's task is something you can fulfill, complete the task within five minutes if possible; -If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse… […]

• No harm, potential for more than minimal, patternF880Jan 15, 2025

  Reviewed AT Based on interview and record review, facility staff failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was completed for four employees (Staffing coordinator, Dietary Assistant L, Minimum Data Set (MDS) Coordinator, and Licensed practical nurse (LPN) K,) out of ten sampled employees. The facility census was 45. 1. Review of the facility's policy titled Tuberculosis (TB) Employee Screening, not dated, showed all employees are screened for Latent Tuberculosis Infection (LTBI) and active TB disease using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment. […]

• No harm, potential for more than minimal, patternF558Nov 9, 2023

  Based on observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of the residents by failing to keep the call lights within reach for three residents (Resident #5, #14, and #41) and failed to accommodate a resident with bariatric needs for one resident (Resident #6) The facility census was 49. 1. Review of facility's Call Light policy, revised March 2021, showed, when a resident is in bed or confined to a chair that the call light is within easy reach of the resident. 2. […]