A list of the most recent deficiencies for Avalon Springs Health Campus. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-11 | 2024-01-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-04 | 2023-12-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-04 | 2023-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-04 | 2023-12-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-04 | 2023-12-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-10 | 2023-01-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-01-10 | 2023-01-25 | N |
| Develop a communication plan. | Fire Safety | 2023-01-10 | 2023-01-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-01-10 | 2023-01-25 | 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 | 2023-01-10 | 2023-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-10 | 2023-01-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-10 | 2023-01-25 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-12-19 | 2023-01-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-12-19 | 2023-01-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-19 | 2023-01-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-19 | 2023-01-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-19 | 2023-01-13 | N |
| Post nurse staffing information every day. | Health | 2022-12-19 | 2023-01-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-19 | 2023-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-19 | 2023-01-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-09-30 | 2021-10-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-30 | 2021-10-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-09-30 | 2021-10-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-30 | 2021-10-27 | N |
| Have an externally vented heating system. | Fire Safety | 2021-09-30 | 2021-10-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-20 | 2021-10-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-20 | 2021-10-15 | 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 | 2021-09-20 | 2021-10-15 | N |
