Inspection visit
Health inspection
Citations
24 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F661 - Quality of life
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F678 - Personnel provide basic life support, including CPR, to a resident
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F837 - Governing body
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F848 - Arbitrator/Venue Selection and Retention of Agreements
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F941 - Training Requirements
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
F946 - Compliance and ethics
Provide training in compliance and ethics.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F949 - Training Requirements
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
FAQ · About this visit
Common questions about this visit
What happened during the November 1, 2024 survey of Ashley Rehabilitation and Health Care Center?
This was a inspection survey of Ashley Rehabilitation and Health Care Center on November 1, 2024. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Ashley Rehabilitation and Health Care Center on November 1, 2024?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.