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Deficiency Records for Avalon Place
A list of the most recent deficiencies for Avalon Place. 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 Place. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-10-16 | 2024-11-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-10-16 | 2024-11-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-16 | 2024-11-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-10-16 | 2024-11-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-16 | 2024-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-16 | 2024-11-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-10-16 | 2024-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-10-16 | 2024-11-22 | 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 | 2024-10-16 | 2024-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-16 | 2024-11-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-10-16 | 2024-11-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-10-16 | 2024-11-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-10-16 | 2024-11-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-10-16 | 2024-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-16 | 2024-11-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-10-18 | 2024-10-29 | 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 | 2023-10-11 | 2023-11-21 | 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 | 2023-10-11 | 2023-11-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-11 | 2023-11-21 | 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 | 2023-10-11 | 2023-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-11 | 2023-11-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-11 | 2023-11-21 | N |
| Keep all essential equipment working safely. | Health | 2023-10-11 | 2023-11-21 | 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 | 2023-10-19 | 2023-11-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-19 | 2023-11-21 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-10-19 | 2023-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-19 | 2023-11-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-19 | 2023-11-21 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-10-19 | 2023-11-21 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-09-27 | 2023-11-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-30 | 2023-01-06 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-30 | 2023-01-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-30 | 2023-01-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-30 | 2023-01-06 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-10-27 | 2022-11-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-27 | 2022-11-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-27 | 2022-11-27 | Y |
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