A list of the most recent deficiencies for Arbor Grace Wellness 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-11-01 | 2023-11-15 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-10-10 | 2023-11-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-10 | 2023-11-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-10 | 2023-11-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-10 | 2023-11-10 | 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 | 2023-10-10 | 2023-11-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-10 | 2023-11-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-10 | 2023-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-10 | 2023-11-10 | 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 | 2023-10-10 | 2023-11-10 | N |
| Post nurse staffing information every day. | Health | 2023-10-10 | 2023-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-10 | 2023-11-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-29 | 2023-10-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-29 | 2023-10-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-23 | 2023-06-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-23 | 2023-06-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-05-01 | 2023-06-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-01 | 2023-06-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-01 | 2023-06-01 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-11-09 | 2022-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-09 | 2022-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-09 | 2022-12-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-09 | 2022-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-09 | 2022-12-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-12 | 2022-09-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-12 | 2022-09-13 | 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 | 2022-08-12 | 2022-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-12 | 2022-09-13 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-31 | 2022-09-01 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-26 | 2022-07-27 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2022-07-26 | 2022-07-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-14 | 2022-02-28 | 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 | 2022-02-14 | 2022-02-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-07 | 2022-01-08 | 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 | 2022-01-07 | 2022-01-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-01-08 | Y |
| 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 | 2021-05-19 | 2021-06-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-19 | 2021-06-10 | 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 | 2021-05-19 | 2021-06-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-19 | 2021-06-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-19 | 2021-06-10 | 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 | 2021-05-19 | 2021-06-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-19 | 2021-06-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-19 | 2021-06-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-19 | 2021-06-10 | Y |
| 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 | 2021-05-19 | 2021-06-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-19 | 2021-06-10 | Y |
