CMS Inspection Results for ASHLAND CONVALESCENT CENTER

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.

• 06/16/2008 Fire Safety Survey for ASHLAND CONVALESCENT CENTER

Exits and Egress
Deficiency	Scope	Level of Harm
resident room doors of proper design and width.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
properly sized and located compartments to protect residents from smoke.	Isolated	Minimal harm or potential for actual harm

 

• 06/12/2008 Health Survey for ASHLAND CONVALESCENT CENTER

Administration
Deficiency	Scope	Level of Harm
Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	Pattern	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.	Widespread	Minimal harm or potential for actual harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	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 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
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

 

• 06/14/2007 Health Survey for ASHLAND CONVALESCENT CENTER

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
post nurse staffing information.	Widespread	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	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.	Widespread	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.	Isolated	Minimal harm or potential for actual harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	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
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	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
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	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
Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	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
Resident Rights
Deficiency	Scope	Level of Harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Isolated	Minimal harm or potential for actual harm
Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm

 

• 06/13/2007 Fire Safety Survey for ASHLAND CONVALESCENT CENTER

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
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm

 

• 04/26/2006 Fire Safety Survey for ASHLAND CONVALESCENT CENTER

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
Electrical
Deficiency	Scope	Level of Harm
a separate and independent backup electrical power source.	Widespread	Minimal harm or potential for actual harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	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.	Widespread	Minimal harm or potential for actual harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	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.	Widespread	Minimal harm or potential for actual harm

 

• 04/14/2006 Health Survey for ASHLAND CONVALESCENT CENTER

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.	Pattern	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	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	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 professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure that a doctor approves a resident's admission in writing and that each resident has a doctor.	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
Resident Rights
Deficiency	Scope	Level of Harm
Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Isolated	Minimal harm or potential for actual harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm