A list of the most recent deficiencies for East Lake Arbor. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-04 | 2023-11-28 | 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 | 2023-10-04 | 2023-11-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-04 | 2023-11-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-04 | 2023-11-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-11-28 | 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 | 2023-10-04 | 2023-11-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-04 | 2023-11-28 | 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 | 2023-10-04 | 2023-11-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-04 | 2023-11-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-04 | 2023-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-04 | 2023-11-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-27 | 2023-11-28 | 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 | 2023-09-27 | 2023-11-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-27 | 2023-11-28 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-09-27 | 2023-11-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-27 | 2023-11-28 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-09-27 | 2023-11-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-27 | 2023-11-28 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-09-27 | 2023-11-28 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-09-27 | 2023-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-27 | 2023-11-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-08 | 2022-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-08 | 2022-03-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-08 | 2022-03-08 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-08 | 2022-03-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-08 | 2022-01-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-08 | 2022-01-22 | Y |
| 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 | 2021-12-08 | 2022-01-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-30 | 2021-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-30 | 2021-06-30 | Y |
| 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. | Health | 2021-04-30 | 2021-06-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-30 | 2021-06-30 | Y |
| 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. | Health | 2021-04-30 | 2021-06-30 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-04-30 | 2021-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-30 | 2021-06-30 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-30 | 2021-06-30 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-30 | 2021-06-30 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-04-30 | 2021-06-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-09-23 | 2018-10-16 | 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 | 2018-09-23 | 2018-10-16 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-09-23 | 2018-10-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-23 | 2018-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-23 | 2018-10-16 | N |
