CMS Inspection Results for ASHFORD GARDENS

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 04/24/2008 Health Survey for ASHFORD GARDENS

Environmental
Deficiency	Scope	Level of Harm
Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Keep assessments completed in the preceding 15 months in the resident's active record.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Protect the resident from a transfer or discharge that is not wanted or needed.	Isolated	Minimal harm or potential for actual harm

 

• 04/23/2008 Fire Safety Survey for ASHFORD GARDENS

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
an externally vented heating system.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exit stairways and towers that are smoke proof.	Isolated	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
properly located and lighted Exit signs.	Isolated	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm

 

• 05/11/2007 Health Survey for ASHFORD GARDENS

Administration
Deficiency	Scope	Level of Harm
Make sure that nurse aides show they have the skills to be able to care for residents.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm

 

• 05/10/2007 Fire Safety Survey for ASHFORD GARDENS

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
a properly installed and maintained dumbwaiter or escalator.	Isolated	Minimal harm or potential for actual harm
an externally vented heating system.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
properly located and lighted Exit signs.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm

 

• 05/04/2006 Health Survey for ASHFORD GARDENS

Environmental
Deficiency	Scope	Level of Harm
Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Minimal harm or potential for actual harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm

 

• 05/04/2006 Fire Safety Survey for ASHFORD GARDENS

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
properly working sprinkler alarm system.	Widespread	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Potential for minimal harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
proper construction of ducts through walls designed to prevent smoke passage.	Isolated	Minimal harm or potential for actual harm
Vertical Openings
Deficiency	Scope	Level of Harm
proper stairway enclosures and vertical shafts.	Isolated	Minimal harm or potential for actual harm