Deficiency Records for Avalon Villa Care Center

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Updated as of March 01, 2024

A list of the most recent deficiencies for Avalon Villa Care Center. 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 2023-12-29 2024-01-28 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-12-29 2024-01-28 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 2023-12-29 2024-01-28 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-12-29 2024-01-28 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2023-12-29 2024-01-28 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-12-29 2024-01-28 Y
Assist a resident in gaining access to vision and hearing services. Health 2023-12-29 2024-01-28 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-12-29 2024-01-28 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 2023-12-29 2024-01-28 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-12-29 2024-01-28 Y
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 2023-12-29 2024-01-28 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-12-29 2024-01-28 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 2023-12-29 2024-01-28 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 2023-12-29 2024-01-28 Y
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 2023-12-29 2024-01-28 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-12-29 2024-01-28 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2023-12-29 2024-01-28 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-12-29 2024-01-28 Y
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2023-12-29 2024-01-28 Y
Provide and implement an infection prevention and control program. Health 2023-12-29 2024-01-28 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-12-29 2024-01-28 Y
List the names and contact information of those in the facility. Fire Safety 2024-01-04 2024-01-23 N
Provide emergency officials' contact information. Fire Safety 2024-01-04 2024-01-23 N
Implement emergency and standby power systems. Fire Safety 2024-01-04 2024-01-23 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-01-04 2024-01-23 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 2024-01-04 2024-01-23 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2024-01-04 2024-01-23 N
Construct fire resistant interior walls. Fire Safety 2024-01-04 2024-01-23 N
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Fire Safety 2024-01-04 2024-01-23 N
Install an approved automatic sprinkler system. Fire Safety 2024-01-04 2024-01-23 N
Install properly constructed windows in hallway walls or doors. Fire Safety 2024-01-04 2024-01-23 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-01-04 2024-01-23 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-01-04 2024-01-23 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-01-04 2024-01-23 N
Ensure that sources of ignition are removed from patients receiving respiratory therapy. Fire Safety 2024-01-04 2024-01-23 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 2023-12-19 2024-01-17 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-12-01 2023-12-31 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-01 2023-11-30 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-10-19 2023-11-18 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-10-16 2023-11-16 Y
Provide and implement an infection prevention and control program. Health 2023-09-01 2023-09-30 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2023-08-21 2023-09-20 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-08-21 2023-09-20 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-08-16 2023-09-15 Y
Respond appropriately to all alleged violations. Health 2023-08-16 2023-09-15 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-02-16 2023-03-16 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-11-04 2022-12-06 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-09-08 2022-10-11 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-09-29 2022-10-09 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-09-02 2022-10-02 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-08-26 2022-09-14 Y
Provide and implement an infection prevention and control program. Health 2022-07-08 2022-08-19 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2022-07-08 2022-08-19 Y
Perform COVID19 testing on residents and staff. Health 2022-07-08 2022-08-19 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-07-01 2022-08-17 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2022-06-17 2022-08-15 Y
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2022-06-18 2022-07-08 Y
Reasonably accommodate the needs and preferences of each resident. Health 2022-06-18 2022-07-08 Y
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2022-06-18 2022-07-08 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 2022-06-18 2022-07-08 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 2022-04-08 2022-05-04 Y
Provide and implement an infection prevention and control program. Health 2022-04-08 2022-05-04 Y
Provide and implement an infection prevention and control program. Health 2022-02-02 2022-02-15 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-12-09 2022-01-21 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-12-22 2022-01-05 Y
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2021-12-07 2021-12-30 Y
Provide and implement an infection prevention and control program. Health 2021-11-01 2021-11-12 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-09-07 2021-10-19 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-09-18 2021-10-15 Y
Provide and implement an infection prevention and control program. Health 2021-09-18 2021-10-15 Y
Provide and implement an infection prevention and control program. Health 2021-08-05 2021-08-10 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-04-23 2021-06-03 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2021-04-23 2021-06-03 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-04-23 2021-06-03 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-04-23 2021-06-03 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 2021-04-23 2021-06-03 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-04-23 2021-06-03 N
Assist a resident in gaining access to vision and hearing services. Health 2021-04-23 2021-06-03 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 2021-04-23 2021-06-03 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-04-23 2021-06-03 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 2021-04-23 2021-06-03 N
Ensure medication error rates are not 5 percent or greater. Health 2021-04-23 2021-06-03 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 2021-04-23 2021-06-03 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 2021-04-23 2021-06-03 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-04-23 2021-06-03 N
Provide and implement an infection prevention and control program. Health 2021-04-23 2021-06-03 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 2021-04-23 2021-06-03 Y
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2021-04-23 2021-06-02 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-04-23 2021-06-02 N
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2019-10-29 2019-11-26 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-10-29 2019-11-26 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-10-29 2019-11-26 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 2019-10-29 2019-11-26 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2019-10-29 2019-11-26 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-10-29 2019-11-26 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-10-29 2019-11-26 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 2019-10-29 2019-11-26 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 2019-10-29 2019-11-26 N
Provide special eating equipment and utensils for residents who need them and appropriate assistance. Health 2019-10-29 2019-11-26 N
Provide and implement an infection prevention and control program. Health 2019-10-29 2019-11-26 N
Have proper medical gas storage and administration areas. Fire Safety 2019-10-25 2019-11-20 N