A list of the most recent deficiencies for Arbor Care Centers-Valhaven, LLC. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-05 | 2023-09-08 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-07-25 | 2023-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-25 | 2023-09-08 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-21 | 2023-09-08 | 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 | 2023-07-21 | 2023-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-18 | 2022-08-31 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-07 | 2022-04-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-07 | 2022-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-07 | 2022-04-29 | 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 | 2022-03-08 | 2022-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-08 | 2022-04-20 | 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 | 2022-03-08 | 2022-04-20 | 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 | 2022-03-08 | 2022-04-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-08 | 2022-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-08 | 2022-04-20 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-08 | 2022-04-20 | N |
| 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. | Health | 2022-03-08 | 2022-04-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-07 | 2022-04-20 | 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 | 2022-03-07 | 2022-04-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-07 | 2022-04-20 | 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 | 2022-03-07 | 2022-04-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-07 | 2022-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-12-03 | 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 | 2020-08-06 | 2020-09-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-08-06 | 2020-09-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-08-06 | 2020-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-06 | 2020-09-28 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2020-08-06 | 2020-09-28 | 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 | 2020-08-04 | 2020-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-08-04 | 2020-08-31 | N |
