A list of the most recent deficiencies for Arbors at Pomeroy. 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? |
|---|---|---|---|---|
| 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 | 2023-12-04 | 2024-02-06 | 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 | 2023-12-04 | 2024-02-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-04 | 2024-02-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-04 | 2024-02-06 | 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 | 2023-12-04 | 2024-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-04 | 2024-02-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-04 | 2024-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-04 | 2024-02-06 | 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 | 2023-12-04 | 2024-02-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-04 | 2024-02-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-20 | 2024-02-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-20 | 2024-02-06 | 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 | 2023-10-16 | 2023-10-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-16 | 2023-10-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-16 | 2023-10-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-17 | 2023-07-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-30 | 2023-04-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-17 | 2022-12-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-07 | 2022-06-24 | 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 | 2022-04-13 | 2022-05-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-13 | 2022-05-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-13 | 2022-05-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-13 | 2022-05-10 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-04-13 | 2022-05-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-13 | 2022-05-10 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-13 | 2022-05-10 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-04-13 | 2022-05-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-13 | 2022-05-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-13 | 2022-05-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-13 | 2022-05-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-13 | 2022-05-10 | 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 | 2022-04-13 | 2022-05-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-13 | 2022-05-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-13 | 2022-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-05-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-13 | 2022-05-10 | 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 | 2022-04-13 | 2022-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-13 | 2022-05-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-13 | 2022-05-10 | 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 | 2022-04-13 | 2022-05-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-13 | 2022-05-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-04-13 | 2022-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-05-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-13 | 2022-05-10 | 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 | 2022-04-13 | 2022-05-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-04-13 | 2022-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-05-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-13 | 2022-05-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-13 | 2022-05-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-13 | 2022-05-10 | 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 | 2022-04-06 | 2022-05-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-06 | 2022-05-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-06 | 2022-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-06 | 2022-05-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-06 | 2022-05-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-06 | 2022-05-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-13 | 2021-12-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-16 | 2021-12-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-22 | 2019-09-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-22 | 2019-09-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-22 | 2019-09-24 | 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 | 2019-08-22 | 2019-09-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-22 | 2019-09-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-08-22 | 2019-09-24 | 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 | 2019-08-22 | 2019-09-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-22 | 2019-09-24 | 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 | 2019-08-22 | 2019-09-24 | 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 | 2019-08-22 | 2019-09-24 | N |
| Provide or obtain dental services for each resident. | Health | 2019-08-22 | 2019-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-22 | 2019-09-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-20 | 2019-09-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-20 | 2019-09-24 | N |
