ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2026

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2026

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 16, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2026

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2026

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2026

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2026

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2026

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 10, 2026

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Administration Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 30, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 10, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Implement a program that monitors antibiotic use.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

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.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Provide routine and 24-hour emergency dental care for each resident.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 30, 2025

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2024

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 18, 2022

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 18, 2022

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 18, 2022

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 18, 2022

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 18, 2022

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 26, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 18, 2022

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 18, 2022