A list of the most recent deficiencies for Arbor Grace Guest Care Center. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-29 | 2024-03-01 | Y |
| 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 | 2024-02-23 | 2024-02-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-20 | 2023-11-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-20 | 2023-11-21 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-11-20 | 2023-11-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-14 | 2023-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-10 | 2023-03-07 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-14 | 2023-03-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-08 | 2023-03-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-02-08 | 2023-03-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-08 | 2023-03-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-02-08 | 2023-03-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-08 | 2023-03-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-08 | 2023-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-08 | 2023-03-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-08 | 2023-03-03 | 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 | 2023-02-08 | 2023-03-03 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-02-08 | 2023-03-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-08 | 2023-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-08 | 2023-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-08 | 2023-03-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-08 | 2023-03-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-08 | 2023-03-03 | 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 | 2023-02-08 | 2023-03-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-08 | 2023-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-08 | 2023-03-03 | Y |
| 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 | 2023-02-08 | 2023-03-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-19 | 2022-09-15 | 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 | 2022-08-19 | 2022-09-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-19 | 2022-09-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-19 | 2022-09-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-28 | 2022-02-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-10 | 2021-12-13 | N |
| 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 | 2021-11-10 | 2021-12-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-10 | 2021-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-10 | 2021-12-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-10 | 2021-12-13 | 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 | 2021-11-10 | 2021-12-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-10 | 2021-12-13 | 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 | 2021-11-10 | 2021-12-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-10 | 2021-12-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-10 | 2021-12-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-01-08 | 2020-02-14 | 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 | 2020-01-08 | 2020-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-08 | 2020-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-08 | 2020-02-14 | 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 | 2020-01-08 | 2020-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-08 | 2020-02-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-08 | 2020-02-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-08 | 2020-02-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-08 | 2020-02-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-08 | 2020-02-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-10 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-08 | Not Fixed | N |
