A list of the most recent deficiencies for Grand Avenue Rest Home. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-26 | 2023-12-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-26 | 2023-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-26 | 2023-12-08 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-08-31 | 2023-11-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-31 | 2023-11-15 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-08-31 | 2023-11-15 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2023-08-31 | 2023-11-15 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-09-01 | 2023-10-31 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-09-01 | 2023-10-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-01 | 2023-10-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-01 | 2023-10-31 | 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 | 2023-09-01 | 2023-10-31 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-09-01 | 2023-10-31 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-01 | 2023-10-31 | 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 | 2023-09-01 | 2023-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-01 | 2023-10-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-01 | 2023-10-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-01 | 2023-10-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-09-01 | 2023-10-31 | 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 | 2023-09-01 | 2023-10-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-10-31 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-09-01 | 2023-10-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-09-01 | 2023-10-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-01 | 2023-10-31 | N |
| Develop a communication plan. | Fire Safety | 2023-09-01 | 2023-10-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-09-01 | 2023-10-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-09-01 | 2023-10-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-31 | 2023-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-31 | 2023-10-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-31 | 2023-10-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-31 | 2023-10-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-31 | 2023-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-31 | 2023-10-31 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-08-31 | 2023-10-31 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-07 | 2023-08-18 | 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 | 2023-07-07 | 2023-08-18 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-07 | 2023-08-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-07 | 2023-08-18 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-09-22 | 2022-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-22 | 2022-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-22 | 2022-11-01 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-09-22 | 2022-11-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-22 | 2022-11-01 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-22 | 2022-11-01 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-22 | 2022-11-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-22 | 2022-11-01 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-10 | 2022-10-27 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-10-10 | 2022-10-27 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-10 | 2022-10-27 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-09-22 | 2022-10-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-16 | 2022-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-16 | 2022-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-13 | 2022-04-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-25 | 2019-09-30 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-25 | 2019-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-25 | 2019-09-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-07-25 | 2019-09-30 | N |
