A list of the most recent deficiencies for Arleigh Burke Pavilion. 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? |
|---|---|---|---|---|
| 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 | 2022-08-15 | 2022-10-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-15 | 2022-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-15 | 2022-10-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-11 | 2022-08-26 | N |
| 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 | 2022-08-11 | 2022-08-26 | 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 | 2021-08-03 | 2021-09-09 | 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 | 2021-08-03 | 2021-09-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-03 | 2021-09-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-08-03 | 2021-09-09 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-08 | 2021-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-08 | 2021-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-08 | 2021-08-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-02-10 | 2021-03-08 | 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 | 2021-02-10 | 2021-03-08 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-03-12 | 2020-04-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-03-12 | 2020-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-12 | 2020-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-12 | 2020-04-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-12 | 2020-04-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-03-12 | 2020-04-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-03-12 | 2020-04-20 | N |
| Dispose of garbage and refuse properly. | Health | 2020-03-12 | 2020-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-03-12 | 2020-04-20 | N |
