A list of the most recent deficiencies for Arbor Grove Village. 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? |
|---|---|---|---|---|
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-06-07 | 2023-06-23 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-03-30 | 2023-04-14 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-03-30 | 2023-04-14 | 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 | 2023-03-30 | 2023-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-30 | 2023-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-30 | 2023-04-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-30 | 2023-04-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-30 | 2023-04-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-30 | 2023-04-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-16 | 2023-04-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-16 | 2023-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-16 | 2023-04-11 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-03-16 | 2023-04-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-03-16 | 2023-04-11 | 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 | 2023-03-16 | 2023-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-01 | 2022-11-30 | Y |
| Develop a communication plan. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-04 | 2022-05-22 | 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 | 2022-05-04 | 2022-05-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-04 | 2022-05-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-05-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-13 | 2022-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-02 | 2021-03-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Construct fire resistant interior walls. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-08-05 | 2020-09-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-24 | 2020-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-24 | 2020-03-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-24 | 2020-03-17 | 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 | 2020-02-24 | 2020-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-24 | 2020-03-17 | N |
