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🔎 Ashley Rehabilitation And Health Care Center

Inspection Results


Inspection Overview

Ashley Rehabilitation And Health Care Center has been cited for a total of 64 deficiencies since we began saving each survey.

In Arkansas, the average facility has **38.45 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

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.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Provide training in compliance and ethics.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Implement a program that monitors antibiotic use.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Survey Date: 2024-11-01
Correction Date: 2025-01-01
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Post nurse staffing information every day.

Survey Date: 2024-11-01
Correction Date: 2025-01-01
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: J

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: F

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Survey Date: 2024-11-01
Correction Date: 2024-12-31
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2024-01-09
Correction Date: 2024-02-01
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-09-29
Correction Date: 2023-10-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: C

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Survey Date: 2023-09-29
Correction Date: 2023-09-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-09-29
Correction Date: 2023-10-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2023-09-29
Correction Date: 2023-10-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

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.

Survey Date: 2023-09-29
Correction Date: 2023-10-29
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2023-09-29
Correction Date: 2023-10-29
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-09-29
Correction Date: 2023-10-29
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-09-29
Correction Date: 2023-10-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Survey Date: 2023-09-29
Correction Date: 2023-10-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-08-11
Correction Date: 2023-09-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-08-11
Correction Date: 2023-09-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-06-24
Correction Date: 2022-07-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-06-24
Correction Date: 2022-07-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2022-06-24
Correction Date: 2022-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-06-24
Correction Date: 2022-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2022-06-24
Correction Date: 2022-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-06-24
Correction Date: 2022-07-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2021-09-10
Correction Date: 2021-10-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Report COVID19 data to residents and families.

Survey Date: 2021-09-10
Correction Date: 2021-10-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Survey Date: 2021-09-10
Correction Date: 2021-10-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2021-09-10
Correction Date: 2021-10-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2021-04-09
Correction Date: 2021-05-09
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-04-09
Correction Date: 2021-05-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-04-09
Correction Date: 2021-05-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2021-04-09
Correction Date: 2021-05-09
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2021-04-09
Correction Date: 2021-05-09
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2021-04-09
Correction Date: 2021-05-09
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-04-09
Correction Date: 2021-05-09
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-01-15
Correction Date: 2021-02-14
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2020-08-06
Correction Date: 2020-08-23
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2019-10-18
Correction Date: 2019-11-12
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2019-10-18
Correction Date: 2019-11-12
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2019-10-18
Correction Date: 2019-11-12
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: B

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2019-10-18
Correction Date: 2019-10-18
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2019-10-18
Correction Date: 2019-11-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-10-18
Correction Date: 2019-11-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2019-10-18
Correction Date: 2019-11-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-10-18
Correction Date: 2019-11-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-10-18
Correction Date: 2019-11-12
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**