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Deficiency Records for Avalon Health and Rehabilitation Center - Pasco
A list of the most recent deficiencies for Avalon Health and Rehabilitation Center - Pasco. 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 Health and Rehabilitation Center - Pasco. 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? |
|---|---|---|---|---|
| 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 | 2024-09-25 | 2024-10-11 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-23 | 2024-05-15 | N |
| Honor the resident's right to choose his or her attending physician. | Health | 2024-04-23 | 2024-05-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-04-23 | 2024-05-15 | 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 | 2024-04-23 | 2024-05-15 | 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 | 2024-04-23 | 2024-05-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-04-23 | 2024-05-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-04-23 | 2024-05-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-04-23 | 2024-05-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-04-23 | 2024-05-15 | 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 | 2024-04-23 | 2024-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-23 | 2024-05-15 | 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 | 2024-04-23 | 2024-05-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-04-23 | 2024-05-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-04-23 | 2024-05-15 | 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 | 2024-04-23 | 2024-05-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-23 | 2024-05-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-23 | 2024-05-15 | 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 | 2024-04-23 | 2024-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-23 | 2024-05-15 | 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 | 2024-04-23 | 2024-05-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-04-23 | 2024-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-23 | 2024-05-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-04-23 | 2024-05-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-23 | 2024-05-15 | N |
| 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. | Health | 2024-04-23 | 2024-05-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-04-23 | 2024-05-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Meet other general requirements. | Fire Safety | 2024-04-15 | 2024-05-15 | 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 | 2024-04-15 | 2024-05-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Have an externally vented heating system. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-04-15 | 2024-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-28 | 2024-04-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-28 | 2024-04-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-15 | 2024-04-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-15 | 2024-04-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-15 | 2024-04-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-14 | 2024-03-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-14 | 2024-03-11 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-02-14 | 2024-03-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-14 | 2024-03-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-23 | 2024-02-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-26 | 2023-11-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-23 | 2023-09-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-17 | 2023-06-23 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-05-17 | 2023-06-23 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-17 | 2023-06-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-17 | 2023-06-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-17 | 2023-06-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-17 | 2023-06-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-17 | 2023-06-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Develop a communication plan. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Meet other general requirements. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-08 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-12 | 2023-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-31 | 2022-09-28 | Y |
| Report COVID19 data to residents and families. | Health | 2022-08-31 | 2022-09-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-11-02 | 2021-12-14 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-02 | 2021-12-14 | 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 | 2021-11-02 | 2021-12-14 | 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 | 2021-11-02 | 2021-12-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-02 | 2021-12-14 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-02 | 2021-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-02 | 2021-12-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-02 | 2021-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-02 | 2021-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-02 | 2021-12-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-11-02 | 2021-12-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide or obtain dental services for each resident. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-11-02 | 2021-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-02 | 2021-12-14 | 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 | 2021-11-02 | 2021-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-02 | 2021-12-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-02 | 2021-12-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-02 | 2021-12-14 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-20 | 2021-11-08 | N |
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