A list of the most recent deficiencies for Arbor Glen Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-01-29 | 2024-02-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-01-29 | 2024-02-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-01-29 | 2024-02-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-29 | 2024-02-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-01-29 | 2024-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-29 | 2024-02-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-29 | 2024-02-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-02-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-25 | 2024-02-15 | N |
| 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. | Health | 2024-01-25 | 2024-02-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-25 | 2024-02-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-25 | 2024-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-25 | 2024-02-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-25 | 2024-02-15 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-25 | 2024-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-25 | 2024-02-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-25 | 2024-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-25 | 2024-02-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-25 | 2024-02-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-25 | 2024-02-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-01-25 | 2024-02-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-25 | 2024-02-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-25 | 2024-02-15 | N |
| 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. | Health | 2024-01-25 | 2024-02-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-25 | 2024-02-15 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-01-25 | 2024-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-25 | 2024-02-15 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-30 | 2023-09-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-11 | 2023-09-18 | Y |
| Keep all essential equipment working safely. | Health | 2023-08-19 | 2023-09-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-17 | 2023-09-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-07-28 | 2023-08-25 | Y |
| Keep all essential equipment working safely. | Health | 2023-07-28 | 2023-08-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-11 | 2023-07-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-02 | 2023-06-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-29 | 2023-04-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-29 | 2023-04-30 | Y |
| 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. | Health | 2023-03-29 | 2023-04-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-04-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-29 | 2023-04-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-29 | 2023-04-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-07 | 2022-11-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-04 | 2022-11-18 | Y |
| Provide immediate access to any resident. | Health | 2022-08-22 | 2022-09-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-22 | 2022-09-19 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-22 | 2022-09-19 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-08-11 | 2022-09-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-06-08 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2022-04-05 | 2022-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-22 | 2022-04-25 | Y |
| 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. | Health | 2022-03-22 | 2022-04-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-10 | 2022-03-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-10 | 2022-03-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-14 | 2021-10-14 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-09-14 | 2021-10-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-12 | 2021-10-08 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-08-12 | 2021-10-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-12 | 2021-10-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-08-12 | 2021-10-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-12 | 2021-10-08 | N |
| 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. | Health | 2021-08-12 | 2021-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-12 | 2021-10-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-08-12 | 2021-10-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-12 | 2021-10-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-12 | 2021-10-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-08-12 | 2021-10-08 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-12 | 2021-10-08 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-08-12 | 2021-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-12 | 2021-10-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-12 | 2021-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-10-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-12 | 2021-10-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-12 | 2021-10-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-12 | 2021-10-08 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2021-08-11 | 2021-09-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-11 | 2021-09-09 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-08-11 | 2021-09-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-08-11 | 2021-09-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-11 | 2021-09-09 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-08-11 | 2021-09-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-11 | 2021-09-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-11 | 2021-09-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-14 | 2019-04-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-14 | 2019-04-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-03-14 | 2019-04-16 | N |
| Provide appropriate foot care. | Health | 2019-03-14 | 2019-04-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-14 | 2019-04-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-03-14 | 2019-04-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-14 | 2019-04-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-14 | 2019-04-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-14 | 2019-04-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-14 | 2019-04-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-03-14 | 2019-04-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-14 | 2019-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-14 | 2019-04-16 | N |
