A list of the most recent deficiencies for Arbors at Carroll. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-24 | 2023-10-16 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-24 | 2023-10-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-23 | 2023-09-06 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-17 | 2023-08-01 | Y |
| 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 | 2023-07-17 | 2023-08-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-23 | 2023-07-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-07 | 2022-12-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-07 | 2022-12-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-07 | 2022-12-27 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-07 | 2022-12-27 | 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 | 2022-06-22 | 2022-07-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-22 | 2022-07-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-22 | 2022-07-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-03 | 2022-07-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-05-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-16 | 2022-05-26 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-12 | 2022-04-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-12 | 2022-04-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-12 | 2022-04-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-12 | 2022-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-12 | 2022-04-01 | 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 | 2022-02-12 | 2022-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-12 | 2022-04-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-12 | 2022-04-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-12 | 2022-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-12 | 2022-04-01 | 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 | 2022-02-12 | 2022-04-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-12 | 2022-04-01 | 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 | 2022-02-12 | 2022-04-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-12 | 2022-04-01 | 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 | 2022-02-12 | 2022-04-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-02-12 | 2022-04-01 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-12 | 2022-04-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-12 | 2022-04-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-12 | 2022-04-01 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-08 | 2022-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-08 | 2022-04-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-08 | 2022-04-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-08 | 2022-04-01 | 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 | 2021-10-21 | 2021-11-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-21 | 2021-11-10 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-21 | 2021-11-10 | Y |
| 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 | 2021-10-21 | 2021-11-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-30 | 2021-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-30 | 2021-11-10 | Y |
| Provide appropriate foot care. | Health | 2021-08-30 | 2021-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-30 | 2021-11-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-30 | 2021-11-10 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-30 | 2021-11-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-08 | 2021-07-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-08 | 2021-07-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-22 | 2021-07-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-31 | 2021-04-14 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-31 | 2021-04-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-30 | 2019-06-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-05-30 | 2019-06-28 | 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 | 2019-05-30 | 2019-06-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-29 | 2019-06-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-04-02 | 2018-04-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-04-02 | 2018-04-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-02 | 2018-04-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-02 | 2018-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-02 | 2018-04-26 | 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 | 2018-04-02 | 2018-04-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-02 | 2018-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-02 | 2018-04-26 | 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 | 2018-04-02 | 2018-04-26 | N |
| Post nurse staffing information every day. | Health | 2018-04-02 | 2018-04-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-02 | 2018-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-02 | 2018-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-02 | 2018-04-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-03-27 | 2018-04-26 | N |
