All citations for Ashley Manor Health & Rehabilitation

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Ashley Manor Health & Rehabilitation

Last standard health inspection on record

January 15, 2025

Showing 1 to 25 of 27 citations

  1. No harm, with potential for more than minimal harm

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

    Widespread (many residents). CMS level F.

    Health citation F-0801, Nutrition and Dietary Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  2. No harm, with potential for more than minimal harm

    Establish staff and initial training requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  3. No harm, with potential for more than minimal harm

    Conduct testing and exercise requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  4. No harm, with potential for more than minimal harm

    Use approved construction type or materials.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0161, Construction Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  5. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  6. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  7. No harm, with potential for more than minimal harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0355, Smoke Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  8. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  9. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0511, Services Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  10. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  11. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  12. No harm, with potential for more than minimal harm

    Reasonably accommodate the needs and preferences of each resident.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0558, Resident Rights Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  13. No harm, with potential for more than minimal harm

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0607, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  14. No harm, with potential for more than minimal harm

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0636, Resident Assessment and Care Planning Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  15. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  16. No harm, with potential for more than minimal harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  17. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0700, Quality of Life and Care Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  18. No harm, with potential for more than minimal harm

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0727, Nursing and Physician Services Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  19. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  20. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  21. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  22. No harm, with potential for more than minimal harm

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  23. No harm, with potential for more than minimal harm

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0644, Resident Assessment and Care Planning Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  24. No harm, with potential for minimal harm

    Provide activities to meet all resident's needs.

    Widespread (many residents). CMS level C.

    Health citation F-0679, Quality of Life and Care Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

  25. No harm, with potential for minimal harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    Widespread (many residents). CMS level C.

    Health citation F-0756, Pharmacy Service Deficiencies. Inspection of November 9, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 15, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.