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Deficiency Records for Archer Heights Healthcare
A list of the most recent deficiencies for Archer Heights Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Archer Heights Healthcare. 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? |
|---|---|---|---|---|
| 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 | 2024-08-26 | 2024-09-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-26 | 2024-09-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-26 | 2024-09-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-15 | 2024-08-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-15 | 2024-08-28 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-08-15 | 2024-08-28 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-08-15 | 2024-08-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-15 | 2024-08-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-15 | 2024-08-28 | Y |
| 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 | 2024-08-15 | 2024-08-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-08-15 | 2024-08-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-31 | 2024-06-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-31 | 2024-06-20 | 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 | 2024-05-31 | 2024-06-20 | 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 | 2024-05-31 | 2024-06-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-05-31 | 2024-06-20 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-05-31 | 2024-06-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-31 | 2024-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-31 | 2024-06-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-05-31 | 2024-06-20 | 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 | 2024-05-31 | 2024-06-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-31 | 2024-06-20 | 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 | 2024-05-31 | 2024-06-20 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-05-31 | 2024-06-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-31 | 2024-06-20 | 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 | 2024-05-31 | 2024-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-31 | 2024-06-20 | N |
| Dispose of garbage and refuse properly. | Health | 2024-05-31 | 2024-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-31 | 2024-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-31 | 2024-06-20 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-05-31 | 2024-06-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-05-31 | 2024-06-20 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-05-31 | 2024-06-20 | 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 | 2024-05-30 | 2024-06-12 | 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 | 2024-05-30 | 2024-06-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-05-30 | 2024-06-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-16 | 2024-05-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-16 | 2024-05-24 | 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 | 2024-05-16 | 2024-05-24 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-05-16 | 2024-05-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-16 | 2024-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-16 | 2024-05-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-04 | 2024-04-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-04 | 2024-04-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-22 | 2024-03-01 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-26 | 2024-02-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-24 | 2023-12-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-24 | 2023-12-29 | 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 | 2023-11-09 | 2023-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-09 | 2023-11-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-09 | 2023-11-16 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-11-09 | 2023-11-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-25 | 2023-10-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-25 | 2023-10-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-25 | 2023-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-25 | 2023-10-11 | 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 | 2023-09-25 | 2023-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-25 | 2023-10-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-25 | 2023-10-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-26 | 2023-06-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-26 | 2023-06-30 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-25 | 2023-05-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-25 | 2023-05-12 | 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 | 2023-04-25 | 2023-05-12 | 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 | 2023-04-25 | 2023-05-12 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-25 | 2023-05-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-25 | 2023-05-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-25 | 2023-05-12 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-04-25 | 2023-05-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-25 | 2023-05-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-25 | 2023-05-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-25 | 2023-05-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-26 | 2023-05-10 | 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 | 2023-04-26 | 2023-05-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-26 | 2023-05-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-26 | 2023-05-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-26 | 2023-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-05-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-04-26 | 2023-05-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-26 | 2023-05-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-26 | 2023-05-10 | N |
| Post nurse staffing information every day. | Health | 2023-04-26 | 2023-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-26 | 2023-05-10 | 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 | 2023-04-26 | 2023-05-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-26 | 2023-05-10 | 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 | 2023-04-26 | 2023-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-05-10 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-26 | 2023-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-05-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-26 | 2023-05-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-13 | 2023-04-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-24 | 2023-03-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-24 | 2023-03-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-27 | 2023-03-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-27 | 2023-03-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-27 | 2023-03-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-27 | 2023-03-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-27 | 2023-03-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-27 | 2023-03-16 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-02-27 | 2023-03-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-30 | 2022-10-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-19 | 2022-10-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-08 | 2022-08-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-01 | 2022-07-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-01 | 2022-07-08 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-25 | 2022-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-25 | 2022-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-25 | 2022-06-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-25 | 2022-06-09 | 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 | 2022-05-25 | 2022-06-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-05-25 | 2022-06-09 | 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 | 2022-05-25 | 2022-06-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-05-25 | 2022-06-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-20 | 2022-06-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-20 | 2022-06-06 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-20 | 2022-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-20 | 2022-06-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-20 | 2022-06-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-20 | 2022-06-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-20 | 2022-06-06 | 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 | 2022-05-20 | 2022-06-06 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-05-20 | 2022-06-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-20 | 2022-06-06 | 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 | 2022-05-20 | 2022-06-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-20 | 2022-06-06 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-25 | 2022-06-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-25 | 2022-05-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-29 | 2022-04-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-06 | 2022-03-11 | 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 | 2022-03-06 | 2022-03-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-16 | 2022-03-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-16 | 2022-03-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-07 | 2021-10-18 | Y |
| Provide appropriate foot care. | Health | 2021-10-07 | 2021-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-07 | 2021-10-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-07 | 2021-10-18 | Y |
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