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Deficiency Records for Arbor Hills Nursing and Rehabilitation Center
A list of the most recent deficiencies for Arbor Hills Nursing and Rehabilitation Center. 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 Arbor Hills Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-05-17 | 2024-08-01 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-05-17 | 2024-07-31 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-05-17 | 2024-07-30 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-05-17 | 2024-07-30 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-05-17 | 2024-07-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-05-17 | 2024-07-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-17 | 2024-07-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-05-17 | 2024-07-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-30 | 2024-07-03 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2024-05-17 | 2024-07-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-17 | 2024-07-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-17 | 2024-07-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-17 | 2024-07-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-17 | 2024-07-01 | N |
| Respond appropriately to all alleged violations. | Health | 2024-05-17 | 2024-07-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-17 | 2024-07-01 | N |
| 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 | 2024-05-17 | 2024-07-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-17 | 2024-07-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-17 | 2024-07-01 | N |
| 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 | 2024-05-17 | 2024-07-01 | N |
| Post nurse staffing information every day. | Health | 2024-05-17 | 2024-07-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-05-17 | 2024-07-01 | 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 | 2024-05-17 | 2024-07-01 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-05-17 | 2024-07-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-17 | 2024-07-01 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-17 | 2024-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-30 | 2024-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-30 | 2024-05-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-30 | 2024-05-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-30 | 2024-05-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-30 | 2024-05-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-30 | 2024-05-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-23 | 2024-03-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-10 | 2024-02-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-20 | 2023-11-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-20 | 2023-11-10 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-04-12 | 2023-05-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-12 | 2023-05-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-12 | 2023-05-01 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-04-12 | 2023-05-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-10 | 2023-03-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-10 | 2023-03-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-03 | 2022-12-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-20 | 2022-12-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-20 | 2022-12-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-20 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-20 | 2022-12-02 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-20 | 2022-12-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-02 | 2022-12-02 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-09-02 | 2022-12-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-02 | 2022-12-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-02 | 2022-12-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-02 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-02 | 2022-12-02 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-02 | 2022-12-02 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2022-09-02 | 2022-09-23 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-09-02 | 2022-09-23 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-02 | 2022-09-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-22 | 2022-07-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-22 | 2022-07-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-22 | 2022-07-23 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-18 | 2022-05-12 | N |
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