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Deficiency Records for Avamere Rehabilitation at Park West
A list of the most recent deficiencies for Avamere Rehabilitation at Park West. 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 Avamere Rehabilitation at Park West. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-04-22 | 2024-06-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-22 | 2024-06-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-04-22 | 2024-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-22 | 2024-06-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | 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 | 2024-04-22 | 2024-06-01 | N |
| Provide or obtain dental services for each resident. | Health | 2024-04-22 | 2024-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-22 | 2024-06-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-04-22 | 2024-06-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-04-22 | 2024-05-25 | 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 | 2024-04-22 | 2024-05-25 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-04-22 | 2024-05-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-06 | 2024-02-24 | Y |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2023-10-20 | 2023-11-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-20 | 2023-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-10 | 2023-10-10 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-07-10 | 2023-08-18 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-10 | 2023-08-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-21 | 2023-04-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-04-03 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-21 | 2023-04-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-03 | 2023-04-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Meet other general requirements. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-02 | 2023-03-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-03 | 2023-03-03 | 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 | 2023-02-03 | 2023-03-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-03 | 2023-03-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-03 | 2023-03-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-02-03 | 2023-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-03 | 2023-03-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-02-03 | 2023-03-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-02 | 2019-08-30 | 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 | 2019-08-02 | 2019-08-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-02 | 2019-08-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-08-02 | 2019-08-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-02 | 2019-08-30 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-02 | 2019-08-30 | 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 | 2019-08-02 | 2019-08-30 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-08-02 | 2019-08-30 | N |
| Provide or obtain dental services for each resident. | Health | 2019-08-02 | 2019-08-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-02 | 2019-08-30 | N |
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