A list of the most recent deficiencies for Majestic Care of Avon. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-17 | 2023-08-17 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-06-30 | 2023-08-04 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-06-30 | 2023-08-04 | 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 | 2023-06-30 | 2023-08-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-30 | 2023-08-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-30 | 2023-08-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-30 | 2023-08-04 | 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 | 2023-06-30 | 2023-08-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-30 | 2023-08-04 | N |
| Post nurse staffing information every day. | Health | 2023-06-30 | 2023-08-04 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-06-30 | 2023-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-30 | 2023-08-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-30 | 2023-08-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-17 | 2023-08-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-17 | 2023-08-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-28 | 2023-05-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-17 | 2023-03-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-17 | 2023-03-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-14 | 2022-10-01 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-28 | 2022-05-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-28 | 2022-05-25 | 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 | 2022-03-28 | 2022-05-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-28 | 2022-05-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-28 | 2022-05-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-15 | 2022-04-04 | 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 | 2022-03-15 | 2022-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-15 | 2022-04-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-15 | 2022-04-04 | N |
| 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 | 2022-03-15 | 2022-04-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-15 | 2022-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-15 | 2022-04-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-15 | 2022-04-04 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-02-08 | 2022-02-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-04 | 2021-10-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-04 | 2021-10-06 | 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 | 2021-07-02 | 2021-07-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-02 | 2021-07-21 | 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 | 2021-07-02 | 2021-07-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-02 | 2021-07-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Develop a communication plan. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-02 | 2019-10-16 | 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 | 2019-10-02 | 2019-10-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-02 | 2019-10-16 | 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 | 2019-10-02 | 2019-10-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-10-02 | 2019-10-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-07-25 | 2019-08-17 | N |
| 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 | 2019-07-25 | 2019-08-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-07-25 | 2019-08-17 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-25 | 2019-08-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-25 | 2019-08-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-25 | 2019-08-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-25 | 2019-08-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-25 | 2019-08-17 | 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 | 2019-07-25 | 2019-08-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-25 | 2019-08-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-25 | 2019-08-17 | 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 | 2019-07-25 | 2019-08-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-25 | 2019-08-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-25 | 2019-08-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-25 | 2019-08-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-25 | 2019-08-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-25 | 2019-08-17 | N |
