A list of the most recent deficiencies for Arbors West. 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 residents are free from significant medication errors. | Health | 2023-12-05 | 2023-12-19 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-11 | 2023-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-27 | 2022-06-23 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-04-12 | 2022-04-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-12 | 2022-04-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-12 | 2022-04-29 | N |
| 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 | 2022-04-12 | 2022-04-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-12 | 2022-04-29 | 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 | 2022-04-12 | 2022-04-29 | 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 | 2022-04-12 | 2022-04-29 | 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 | 2022-04-12 | 2022-04-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-12 | 2022-04-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-12 | 2022-04-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-04-05 | 2022-04-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-05 | 2022-04-29 | 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 | 2022-04-05 | 2022-04-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-05 | 2022-04-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-05 | 2022-04-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-05 | 2022-04-29 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-04-05 | 2022-04-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-05 | 2022-04-29 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-04-05 | 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 | 2022-04-05 | 2022-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-05 | 2022-04-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-05 | 2022-04-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-05 | 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 | 2022-02-28 | 2022-03-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-28 | 2022-03-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-08 | 2021-12-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-08 | 2021-12-31 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-08 | 2021-12-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-08 | 2021-12-31 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-12-08 | 2021-12-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-08 | 2021-12-31 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-09-22 | 2021-10-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-22 | 2021-10-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-22 | 2021-10-18 | 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 | 2021-07-06 | 2021-07-07 | Y |
| 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 | 2019-06-27 | 2019-07-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-06-27 | 2019-07-26 | 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 | 2019-06-27 | 2019-07-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-06-27 | 2019-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-27 | 2019-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-27 | 2019-07-26 | 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 | 2019-06-27 | 2019-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-25 | 2019-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-07-26 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-06-25 | 2019-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-03 | 2018-06-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-03 | 2018-06-05 | 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 | 2018-05-03 | 2018-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-03 | 2018-06-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-05-03 | 2018-06-05 | N |
| Use approved construction type or materials. | Fire Safety | 2018-05-01 | 2018-06-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-01 | 2018-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-01 | 2018-06-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-05-01 | 2018-06-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-01 | 2018-06-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-01 | 2018-06-05 | N |
