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 |