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Deficiency Records for Avalon Villa Care Center
A list of the most recent deficiencies for Avalon Villa Care 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 Avalon Villa 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-03-06 | 2024-04-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-24 | 2024-02-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-24 | 2024-02-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-24 | 2024-02-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-29 | 2024-01-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-29 | 2024-01-28 | 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 | 2023-12-29 | 2024-01-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-29 | 2024-01-28 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-12-29 | 2024-01-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-29 | 2024-01-28 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-12-29 | 2024-01-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-29 | 2024-01-28 | Y |
| 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 | 2023-12-29 | 2024-01-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-29 | 2024-01-28 | Y |
| 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 | 2023-12-29 | 2024-01-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-29 | 2024-01-28 | 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 | 2023-12-29 | 2024-01-28 | 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 | 2023-12-29 | 2024-01-28 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-12-29 | 2024-01-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-29 | 2024-01-28 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-29 | 2024-01-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-29 | 2024-01-28 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-12-29 | 2024-01-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-29 | 2024-01-28 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-29 | 2024-01-28 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-04 | 2024-01-23 | 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 | 2024-01-04 | 2024-01-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-01-04 | 2024-01-23 | 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 | 2024-01-04 | 2024-01-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-04 | 2024-01-23 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-01-04 | 2024-01-23 | 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 | 2023-12-19 | 2024-01-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-01 | 2023-12-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-01 | 2023-11-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-19 | 2023-11-18 | 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 | 2023-10-16 | 2023-11-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-09-30 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-08-21 | 2023-09-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-21 | 2023-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-16 | 2023-09-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-16 | 2023-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-16 | 2023-03-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-04 | 2022-12-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-08 | 2022-10-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-29 | 2022-10-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-02 | 2022-10-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-26 | 2022-09-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-08 | 2022-08-19 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-07-08 | 2022-08-19 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-08 | 2022-08-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-01 | 2022-08-17 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-17 | 2022-08-15 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-06-18 | 2022-07-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-18 | 2022-07-08 | 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 | 2022-06-18 | 2022-07-08 | Y |
| 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 | 2022-06-18 | 2022-07-08 | 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 | 2022-04-08 | 2022-05-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-08 | 2022-05-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-09 | 2022-01-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-22 | 2022-01-05 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-12-07 | 2021-12-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-01 | 2021-11-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-23 | 2021-06-03 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-04-23 | 2021-06-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-23 | 2021-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-23 | 2021-06-03 | 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 | 2021-04-23 | 2021-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-06-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-04-23 | 2021-06-03 | 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 | 2021-04-23 | 2021-06-03 | 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 | 2021-04-23 | 2021-06-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-23 | 2021-06-03 | 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 | 2021-04-23 | 2021-06-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-23 | 2021-06-03 | 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 | 2021-04-23 | 2021-06-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-23 | 2021-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-23 | 2021-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-23 | 2021-06-03 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-04-23 | 2021-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-23 | 2021-06-02 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-10-29 | 2019-11-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-29 | 2019-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-29 | 2019-11-26 | 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 | 2019-10-29 | 2019-11-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-29 | 2019-11-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-29 | 2019-11-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-29 | 2019-11-26 | 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 | 2019-10-29 | 2019-11-26 | 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 | 2019-10-29 | 2019-11-26 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-10-29 | 2019-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-29 | 2019-11-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-25 | 2019-11-20 | N |
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