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Deficiency Records for Avita Health and Rehab at Reeds Cove
A list of the most recent deficiencies for Avita Health and Rehab at Reeds Cove. 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 Avita Health and Rehab at Reeds Cove. 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? |
|---|---|---|---|---|
| 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 | 2024-09-09 | 2024-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-09 | 2024-09-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-09 | 2024-09-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-09-09 | 2024-09-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-09 | 2024-09-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-09 | 2024-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-09-09 | 2024-09-20 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-08-19 | 2024-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-19 | 2024-09-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-19 | 2024-09-16 | 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 | 2024-08-19 | 2024-09-16 | 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 | 2024-08-19 | 2024-09-16 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-08-19 | 2024-09-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-19 | 2024-09-16 | 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 | 2024-08-19 | 2024-09-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-19 | 2024-09-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-19 | 2024-09-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-19 | 2024-09-16 | 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 | 2024-08-19 | 2024-09-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-19 | 2024-09-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-19 | 2024-09-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-19 | 2024-09-16 | 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 | 2024-08-19 | 2024-09-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-19 | 2024-09-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-19 | 2024-09-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-19 | 2024-09-16 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-23 | 2023-03-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-23 | 2023-01-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-30 | 2023-01-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-30 | 2023-01-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-30 | 2023-01-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2023-01-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-30 | 2023-01-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-30 | 2023-01-01 | 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 | 2022-11-30 | 2023-01-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-30 | 2023-01-01 | 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 | 2022-11-30 | 2023-01-01 | Y |
| Post nurse staffing information every day. | Health | 2022-11-30 | 2023-01-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-30 | 2023-01-01 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-11-30 | 2023-01-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-30 | 2023-01-01 | Y |
| 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 | 2022-11-30 | 2023-01-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-30 | 2023-01-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-30 | 2023-01-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-16 | 2022-03-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-05-03 | 2021-05-13 | 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 | 2021-05-03 | 2021-05-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-03 | 2021-05-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-05 | 2021-04-30 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-04-05 | 2021-04-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-05 | 2021-04-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-05 | 2021-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-05 | 2021-04-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-05 | 2021-04-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-05 | 2021-04-30 | 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 | 2021-04-05 | 2021-04-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-05 | 2021-04-30 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-04-05 | 2021-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-05 | 2021-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-05 | 2021-04-30 | N |
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