A list of the most recent deficiencies for Arbor Post Acute. 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 | 2024-01-18 | 2024-02-20 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-01-18 | 2024-02-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-18 | 2024-02-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-18 | 2024-01-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | 2024-01-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-18 | 2024-01-30 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-29 | 2023-12-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-28 | 2023-12-13 | 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 | 2023-10-06 | 2023-10-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-06 | 2023-10-20 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-06 | 2023-10-20 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-10-06 | 2023-10-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-09 | 2023-10-09 | Y |
| 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 | 2023-10-06 | 2023-10-06 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-06 | 2023-10-06 | Y |
| Keep all essential equipment working safely. | Health | 2023-10-06 | 2023-10-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-21 | 2023-10-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-21 | 2023-10-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-14 | 2023-09-03 | Y |
| 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 | 2023-08-14 | 2023-09-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-14 | 2023-09-03 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-08-14 | 2023-09-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-17 | 2023-08-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-13 | 2023-07-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-13 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-25 | 2023-07-06 | Y |
| 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 | 2023-05-25 | 2023-07-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-23 | 2023-06-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-23 | 2023-06-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-15 | 2023-04-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-19 | 2023-02-06 | Y |
| 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 | 2022-12-28 | 2023-01-17 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Use approved construction type or materials. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-20 | 2022-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-15 | 2022-10-26 | 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 | 2022-09-15 | 2022-10-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-15 | 2022-10-26 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-09-15 | 2022-10-26 | N |
| 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 | 2022-09-15 | 2022-10-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-15 | 2022-10-26 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-09-15 | 2022-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-15 | 2022-10-26 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-15 | 2022-10-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-15 | 2022-10-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-10-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-16 | 2022-09-27 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-09-07 | 2022-09-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-07 | 2022-08-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-07 | 2022-08-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-11 | 2022-08-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-11 | 2022-08-08 | Y |
| 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 | 2022-06-09 | 2022-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-07-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-02 | 2022-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-28 | 2022-05-25 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-04-28 | 2022-05-25 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-07 | 2022-04-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-07 | 2022-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-04-28 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2022-03-02 | 2022-04-04 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-11-01 | 2021-11-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-01 | 2021-11-12 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-09-09 | 2021-10-04 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-01 | 2021-09-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-17 | 2021-09-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-01-13 | 2020-02-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-13 | 2020-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-13 | 2020-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-13 | 2020-02-20 | 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 | 2020-01-13 | 2020-02-20 | 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 | 2020-01-13 | 2020-02-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-13 | 2020-02-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-13 | 2020-02-20 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-01-13 | 2020-02-20 | 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 | 2020-01-13 | 2020-02-20 | N |
| Provide or obtain dental services for each resident. | Health | 2020-01-13 | 2020-02-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-13 | 2020-02-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-01-13 | 2020-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-13 | 2020-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-13 | 2020-02-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-16 | 2020-02-04 | 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 | 2020-01-16 | 2020-02-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-16 | 2020-02-04 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-01-11 | 2019-05-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-01-11 | 2019-05-14 | 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 | 2019-01-11 | 2019-05-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-11 | 2019-05-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-11 | 2019-05-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-01-11 | 2019-05-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-11 | 2019-05-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-01-11 | 2019-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-11 | 2019-05-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-01-11 | 2019-05-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-01-11 | 2019-04-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-11 | 2019-04-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-11 | 2019-04-25 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-01-11 | 2019-04-25 | 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 | 2019-01-11 | 2019-04-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-01-11 | 2019-04-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-11 | 2019-04-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-11 | 2019-04-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-11 | 2019-04-25 | 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 | 2019-01-11 | 2019-04-25 | 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 | 2019-01-11 | 2019-04-25 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-01-11 | 2019-04-25 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-01-11 | 2019-04-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-02-13 | 2019-03-11 | N |
