A list of the most recent deficiencies for Advena Living at Fountainview. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-15 | 2023-12-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-15 | 2023-12-22 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-14 | 2023-09-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-14 | 2023-08-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-14 | 2023-07-03 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-14 | 2023-07-03 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-03-14 | 2023-07-03 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2023-03-14 | 2023-07-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-14 | 2023-07-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-14 | 2023-07-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-14 | 2023-07-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-14 | 2023-07-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-14 | 2023-06-26 | 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 | 2023-03-14 | 2023-06-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-14 | 2023-06-26 | 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 | 2023-03-14 | 2023-06-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-14 | 2023-06-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-14 | 2023-06-26 | 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 | 2023-04-24 | 2023-05-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-24 | 2023-05-31 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-04-24 | 2023-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-31 | 2023-05-24 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-14 | 2023-03-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-23 | 2023-02-21 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-23 | 2023-02-21 | Y |
| 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 | 2023-01-23 | 2023-02-21 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-23 | 2023-02-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-23 | 2023-02-21 | 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 | 2023-01-23 | 2023-02-21 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-01-23 | 2023-02-21 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-23 | 2023-02-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-23 | 2023-02-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-23 | 2023-02-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-23 | 2023-02-21 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-23 | 2023-02-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-23 | 2023-02-21 | Y |
| 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 | 2023-01-23 | 2023-02-21 | 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 | 2023-01-23 | 2023-02-21 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-01-23 | 2023-02-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-23 | 2023-02-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-23 | 2023-02-21 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-01-23 | 2023-02-21 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-23 | 2023-02-21 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-23 | 2023-02-21 | 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 | 2022-09-15 | 2022-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-15 | 2022-10-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-15 | 2022-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-29 | 2022-04-29 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-29 | 2022-04-29 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-14 | 2021-08-23 | 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 | 2021-07-14 | 2021-08-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-14 | 2021-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-14 | 2021-07-14 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-06-16 | 2021-07-12 | 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 | 2021-06-16 | 2021-07-12 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-06-16 | 2021-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-16 | 2021-07-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-16 | 2021-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-16 | 2021-07-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-20 | 2019-12-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-20 | 2019-12-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-11-20 | 2019-12-23 | 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 | 2019-11-20 | 2019-12-23 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-20 | 2019-12-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-20 | 2019-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-20 | 2019-12-23 | 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 | 2019-11-20 | 2019-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-20 | 2019-12-23 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-20 | 2019-12-23 | N |
| Post nurse staffing information every day. | Health | 2019-11-20 | 2019-12-23 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-11-20 | 2019-12-23 | 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 | 2019-11-20 | 2019-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-20 | 2019-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-20 | 2019-12-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-20 | 2019-12-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-20 | 2019-10-30 | 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 | 2019-08-20 | 2019-10-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-20 | 2019-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-20 | 2019-08-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-20 | 2019-08-20 | N |
