A list of the most recent deficiencies for Arbor Court. 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? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2023-09-07 | 2023-10-05 | 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 | 2023-09-07 | 2023-10-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-07 | 2023-10-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-10-05 | 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 | 2023-09-07 | 2023-10-05 | 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 | 2023-09-07 | 2023-10-05 | 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 | 2023-09-07 | 2023-10-05 | N |
| 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. | Health | 2023-09-07 | 2023-10-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-07 | 2023-10-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-07 | 2023-10-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-07 | 2023-10-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-09-07 | 2023-10-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-07 | 2023-10-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-07 | 2023-10-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-07 | 2023-10-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-07 | 2023-10-05 | Y |
| 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 | 2023-09-07 | 2023-10-05 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-31 | 2023-09-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-08-31 | 2023-09-07 | 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 | 2023-08-31 | 2023-09-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-31 | 2023-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-31 | 2023-08-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-15 | 2023-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-15 | 2023-06-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-15 | 2023-06-14 | Y |
| 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. | Health | 2023-05-15 | 2023-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-15 | 2023-06-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-02 | 2023-06-14 | N |
| 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. | Health | 2023-03-02 | 2023-06-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-02 | 2023-05-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-03-02 | 2023-05-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-02 | 2023-05-15 | 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 | 2023-03-02 | 2023-05-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-03-02 | 2023-05-15 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-03-02 | 2023-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-02 | 2023-05-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-02 | 2023-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-02 | 2023-05-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-02 | 2023-05-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-02 | 2023-05-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-02 | 2023-05-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-02 | 2023-05-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-02 | 2023-05-15 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-03-02 | 2023-05-15 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-24 | 2023-03-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-24 | 2023-03-10 | N |
| Use approved construction type or materials. | Fire Safety | 2023-02-24 | 2023-03-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-24 | 2023-03-06 | 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 | 2023-02-24 | 2023-03-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-24 | 2023-02-27 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-02-24 | 2023-02-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-24 | 2023-02-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-19 | 2022-12-20 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-10-05 | 2022-11-11 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-05 | 2022-11-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-05 | 2022-11-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-05 | 2022-11-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-05 | 2022-11-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-04 | 2022-02-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-03 | 2022-02-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-03 | 2022-01-04 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-03 | 2022-01-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-03 | 2022-01-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-03 | 2022-01-04 | Y |
| Provide appropriate foot care. | Health | 2022-01-03 | 2022-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-03 | 2022-01-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-03 | 2022-01-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-03 | 2022-01-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2022-01-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-13 | 2022-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-13 | 2022-01-04 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-11-03 | 2021-11-16 | Y |
| Post nurse staffing information every day. | Health | 2021-09-13 | 2021-10-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-13 | 2021-10-11 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-06-03 | 2021-07-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-03 | 2021-07-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-03 | 2021-07-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-03 | 2021-07-02 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-06-03 | 2021-07-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-03 | 2021-07-02 | 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 | 2021-06-03 | 2021-07-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-06-03 | 2021-07-02 | N |
| Post nurse staffing information every day. | Health | 2021-06-03 | 2021-07-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-03 | 2021-07-02 | 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 | 2021-06-03 | 2021-07-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-03 | 2021-07-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-06-03 | 2021-07-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-03 | 2021-07-02 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-03 | 2021-07-02 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-26 | 2021-06-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-26 | 2021-06-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-26 | 2021-06-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-05-26 | 2021-06-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-05-26 | 2021-06-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-26 | 2021-06-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-26 | 2021-06-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-03 | Not Fixed | Y |
