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Deficiency Records for Avalon View Health and Wellness

A list of the most recent deficiencies for Avalon View Health and Wellness. 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 View Health and Wellness. 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?
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2024-02-12 2024-03-14 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 2024-02-12 2024-03-14 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2024-02-12 2024-03-14 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2023-12-14 2024-03-14 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-12-14 2024-03-14 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-12-14 2024-03-14 N
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2023-12-14 2024-03-14 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 2023-12-14 2024-03-14 Y
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2023-12-14 2024-02-12 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-12-14 2024-01-16 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-12-14 2024-01-16 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-12-14 2024-01-16 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-12-14 2024-01-16 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 2023-12-14 2024-01-16 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 2023-12-14 2024-01-16 N
Ensure medication error rates are not 5 percent or greater. Health 2023-12-14 2024-01-16 N
Ensure that residents are free from significant medication errors. Health 2023-12-14 2024-01-16 N
Provide or obtain dental services for each resident. Health 2023-12-14 2024-01-16 N
Provide and implement an infection prevention and control program. Health 2023-12-14 2024-01-16 N
Use approved construction type or materials. Fire Safety 2023-12-14 2024-01-16 N
Have an enclosure around a vertical opening shaft. Fire Safety 2023-12-14 2024-01-16 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 2023-12-14 2024-01-16 N
Provide properly protected cooking facilities. Fire Safety 2023-12-14 2024-01-16 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-12-14 2024-01-16 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2023-12-14 2024-01-16 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2023-12-14 2024-01-16 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-12-14 2024-01-16 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-12-14 2024-01-16 N
Respond appropriately to all alleged violations. Health 2023-07-28 2023-08-18 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-07-28 2023-08-18 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-05-23 2023-05-23 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 2023-02-03 2023-03-15 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-02-03 2023-03-15 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-02-03 2023-03-15 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-12-02 2022-12-30 Y
Use approved construction type or materials. Fire Safety 2022-12-02 2022-12-30 Y
Reasonably accommodate the needs and preferences of each resident. Health 2022-12-02 2022-12-29 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2022-10-18 2022-12-29 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-07-19 2022-08-31 Y
Ensure that residents are free from significant medication errors. Health 2022-07-19 2022-08-31 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-06-08 2022-07-15 Y
Install corridor and hallway doors that block smoke. Fire Safety 2021-12-22 2022-06-22 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2021-12-22 2022-04-08 N
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 2021-12-22 2022-04-05 N
Provide activities to meet all resident's needs. Health 2021-12-22 2022-04-05 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2021-12-22 2022-04-05 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-12-22 2022-04-05 N
Perform COVID19 testing on residents and staff. Health 2021-12-22 2022-04-05 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2021-12-22 2022-04-05 N
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2021-12-22 2022-04-05 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-12-22 2022-04-05 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2021-12-22 2022-04-05 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-12-22 2022-04-05 Y
Respond appropriately to all alleged violations. Health 2021-12-22 2022-04-05 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-12-22 2022-04-05 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-03-24 2022-04-05 Y
Respond appropriately to all alleged violations. Health 2022-02-08 2022-04-05 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-12-22 2022-04-05 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2021-12-22 2022-04-05 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2021-12-22 2022-04-05 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 2021-12-22 2022-03-15 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-12-22 2022-03-15 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 2021-12-22 2022-03-15 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-12-22 2022-03-15 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 2021-12-22 2022-03-15 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-12-22 2022-03-15 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-12-22 2022-03-15 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 2021-12-22 2022-03-15 Y
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2021-12-22 2022-03-15 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-12-22 2022-03-15 Y
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2021-12-22 2022-03-08 N
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2021-12-22 2022-03-08 N
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 2021-12-22 2022-03-08 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2021-12-22 2022-03-08 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2021-12-22 2022-03-08 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-12-22 2022-03-08 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 2021-12-22 2022-03-08 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-12-22 2022-03-08 N
Plan the resident's discharge to meet the resident's goals and needs. Health 2021-12-22 2022-03-08 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-12-22 2022-03-08 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 2021-12-22 2022-03-08 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 2021-12-22 2022-03-08 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-12-22 2022-03-08 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 2021-12-22 2022-03-08 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 2021-12-22 2022-03-08 N
Dispose of garbage and refuse properly. Health 2021-12-22 2022-03-08 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2021-12-22 2022-03-08 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2021-12-22 2022-03-08 N
Hire a qualified full-time social worker in a facility with more than 120 beds. Health 2021-12-22 2022-03-08 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2021-12-22 2022-03-08 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2021-12-22 2022-03-08 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2021-12-22 2022-03-08 N
Provide and implement an infection prevention and control program. Health 2021-12-22 2022-03-08 N
Implement a program that monitors antibiotic use. Health 2021-12-22 2022-03-08 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2021-12-22 2022-03-08 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2021-12-22 2022-03-08 N
Report COVID19 data to residents and families. Health 2021-12-22 2022-03-08 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2021-12-22 2022-03-08 Y
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2021-12-22 2022-03-08 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2021-12-22 2022-03-08 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-02-08 2022-03-08 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-01-06 2022-03-08 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-01-06 2022-03-08 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-12-22 2022-03-08 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2021-12-22 2022-03-08 N
Conduct testing and exercise requirements. Fire Safety 2021-12-22 2022-03-08 N
Use approved construction type or materials. Fire Safety 2021-12-22 2022-03-08 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2021-12-22 2022-03-08 N
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 2021-12-22 2022-03-08 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2021-12-22 2022-03-08 N
Meet other general requirements that are deficient. Fire Safety 2021-12-22 2022-03-08 N
Provide properly protected cooking facilities. Fire Safety 2021-12-22 2022-03-08 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-12-22 2022-03-08 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-12-22 2022-03-08 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2021-12-22 2022-03-08 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-12-22 2022-03-08 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2021-12-22 2022-03-08 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-12-22 2022-03-08 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-12-22 2022-03-08 N
Have proper medical gas storage and administration areas. Fire Safety 2021-12-22 2022-03-08 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2021-11-23 2021-12-30 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-03-02 2021-04-30 N
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. Health 2021-03-02 2021-04-30 N
Assure the security of all personal funds of residents deposited with the facility. Health 2021-03-02 2021-04-30 N
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 2021-03-02 2021-04-30 N
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 2021-03-02 2021-04-30 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2021-03-02 2021-04-30 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-03-02 2021-04-30 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 2021-03-02 2021-04-30 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-03-02 2021-04-30 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-03-02 2021-04-30 N
Provide activities to meet all resident's needs. Health 2021-03-02 2021-04-30 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-03-02 2021-04-30 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-03-02 2021-04-30 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-03-02 2021-04-30 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2021-03-02 2021-04-30 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2021-03-02 2021-04-30 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2021-03-02 2021-04-30 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 2021-03-02 2021-04-30 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 2021-03-02 2021-04-30 N
Ensure medication error rates are not 5 percent or greater. Health 2021-03-02 2021-04-30 N
Ensure that residents are free from significant medication errors. Health 2021-03-02 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 2021-03-02 2021-04-30 N
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2021-03-02 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 2021-03-02 2021-04-30 N
Provide and implement an infection prevention and control program. Health 2021-03-02 2021-04-30 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2021-03-02 2021-04-30 N
Have enough outside ventilation via a window or mechanical ventilation, or both. Health 2021-03-02 2021-04-30 N
Put firmly secured handrails on each side of hallways. Health 2021-03-02 2021-04-30 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-03-02 2021-04-30 N
Address patient/client population and determine types of services needed. Fire Safety 2021-03-02 2021-04-30 N
Address subsistence needs for staff and patients. Fire Safety 2021-03-02 2021-04-30 N
Establish policies and procedures including evacuation. Fire Safety 2021-03-02 2021-04-30 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-03-02 2021-04-30 N
Implement emergency and standby power systems. Fire Safety 2021-03-02 2021-04-30 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2021-03-02 2021-04-30 N
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 2021-03-02 2021-04-30 N
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. Fire Safety 2021-03-02 2021-04-30 N
Have exits that are accessible at all times. Fire Safety 2021-03-02 2021-04-30 N
Have properly located and lighted "Exit" signs. Fire Safety 2021-03-02 2021-04-30 N
Meet other general requirements that are deficient. Fire Safety 2021-03-02 2021-04-30 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 2021-03-02 2021-04-30 N
Provide properly protected cooking facilities. Fire Safety 2021-03-02 2021-04-30 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2021-03-02 2021-04-30 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-03-02 2021-04-30 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2021-03-02 2021-04-30 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-03-02 2021-04-30 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-03-02 2021-04-30 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-03-02 2021-04-30 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-03-02 2021-04-30 N
Have restrictions on the use of portable space heaters. Fire Safety 2021-03-02 2021-04-30 N
Have proper medical gas storage and administration areas. Fire Safety 2021-03-02 2021-04-30 N

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