Deficiency Records for Grand Avenue Healthcare and Wellness Centre LP
Updated as of March 01, 2024
A list of the most recent deficiencies for Grand Avenue Healthcare and Wellness Centre LP. 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? |
|---|---|---|---|---|
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-01-29 | 2024-02-14 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-01-04 | 2024-01-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-12 | 2024-01-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-11-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-29 | 2023-07-28 | Y |
| 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 | 2023-06-14 | 2023-07-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-14 | 2023-07-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-24 | 2023-06-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-09 | 2023-06-09 | 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 | 2023-05-09 | 2023-06-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-30 | 2023-05-08 | Y |
| 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 | 2023-03-30 | 2023-05-08 | 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 | 2023-03-30 | 2023-05-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-10 | 2023-05-04 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-03-31 | 2023-04-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-17 | 2023-02-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-17 | 2023-02-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-01 | 2023-01-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-01 | 2023-01-18 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-11-30 | 2022-12-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-04 | 2022-12-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-09 | 2022-09-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-31 | 2022-05-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-10 | 2022-02-16 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-02-10 | 2022-02-16 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-12-28 | 2022-01-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-10-19 | 2021-11-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-13 | 2021-09-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-23 | 2021-09-14 | 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 | 2021-07-23 | 2021-09-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-23 | 2021-09-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-07-13 | 2021-08-19 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-07-13 | 2021-08-19 | 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 | 2021-07-13 | 2021-08-19 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-07-13 | 2021-08-19 | 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 | 2021-07-13 | 2021-08-19 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-13 | 2021-08-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-08-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-07-13 | 2021-08-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-13 | 2021-08-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-13 | 2021-08-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-13 | 2021-08-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-07-13 | 2021-08-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-13 | 2021-08-19 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-07-13 | 2021-08-19 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-07-13 | 2021-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-13 | 2021-08-19 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-13 | 2021-08-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-07-13 | 2021-08-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-13 | 2021-08-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-13 | 2021-08-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-23 | 2021-08-10 | 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 | 2021-07-23 | 2021-08-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-22 | 2021-08-10 | Y |
| 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 | 2021-07-22 | 2021-08-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-21 | 2021-08-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-21 | 2021-08-10 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-18 | 2021-05-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-18 | 2021-05-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-23 | 2021-05-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-23 | 2021-05-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-23 | 2021-05-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-05-25 | Y |
| 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 | 2021-04-23 | 2021-05-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-23 | 2021-05-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-23 | 2021-05-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-23 | 2021-05-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-04-23 | 2021-05-25 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-04-23 | 2021-05-25 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-04-23 | 2021-05-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-27 | 2021-05-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-30 | 2021-04-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-30 | 2021-04-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-30 | 2021-04-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-12 | 2021-04-27 | Y |
| 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 | 2021-03-12 | 2021-04-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-12 | 2021-04-27 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-03-12 | 2021-04-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-08 | 2021-04-16 | 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 | 2019-03-21 | 2019-04-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-21 | 2019-04-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-03-21 | 2019-04-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-03-21 | 2019-04-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-03-21 | 2019-04-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-21 | 2019-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-21 | 2019-04-16 | 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 | 2019-03-21 | 2019-04-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-21 | 2019-04-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-03-21 | 2019-04-16 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-21 | 2019-04-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-21 | 2019-04-16 | 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 | 2019-03-21 | 2019-04-16 | 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 | 2019-03-21 | 2019-04-16 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-03-21 | 2019-04-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-21 | 2019-04-16 | 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 | 2019-03-21 | 2019-04-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-03-21 | 2019-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-21 | 2019-04-16 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-03-20 | 2019-04-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-20 | 2019-04-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-04-02 | 2018-04-26 | 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 | 2018-04-02 | 2018-04-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-02 | 2018-04-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-04-02 | 2018-04-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-02 | 2018-04-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-02 | 2018-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-02 | 2018-04-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-02 | 2018-04-26 | 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 | 2018-04-02 | 2018-04-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-04-02 | 2018-04-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-02 | 2018-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-02 | 2018-04-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-30 | 2018-04-26 | 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 | 2018-03-30 | 2018-04-26 | 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 | 2018-03-30 | 2018-04-26 | 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 | 2018-03-30 | 2018-04-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-30 | 2018-04-26 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-03-30 | 2018-04-26 | 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 | 2018-04-02 | 2018-04-20 | N |
