A list of the most recent deficiencies for Avamere at Three Fountains. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-25 | 2023-09-30 | 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 | 2023-08-25 | 2023-09-30 | N |
| Provide activities to meet all resident's needs. | Health | 2023-08-25 | 2023-09-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-25 | 2023-09-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-08-25 | 2023-09-30 | 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 | 2023-08-25 | 2023-09-30 | N |
| Provide or obtain dental services for each resident. | Health | 2023-08-25 | 2023-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-25 | 2023-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-25 | 2023-09-30 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-25 | 2023-09-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-25 | 2023-09-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-22 | 2023-09-30 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-07-15 | 2022-08-17 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2022-07-12 | 2022-08-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-12 | 2022-08-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-12 | 2022-08-17 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-07-12 | 2022-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-12 | 2022-08-17 | N |
| Meet other general requirements. | Fire Safety | 2022-07-12 | 2022-08-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-11 | 2022-04-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-03-11 | 2022-04-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-11 | 2022-04-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-10 | 2022-01-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-10 | 2021-10-15 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-09-10 | 2021-10-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-17 | 2019-03-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-17 | 2019-03-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-17 | 2019-02-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-01-17 | 2019-02-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-01-17 | 2019-02-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-01-17 | 2019-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-17 | 2019-02-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-17 | 2019-02-28 | N |
| Provide appropriate foot care. | Health | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-17 | 2019-02-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-17 | 2019-02-28 | 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 | 2019-01-17 | 2019-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-17 | 2019-02-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-17 | 2019-02-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-01-17 | 2019-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-17 | 2019-02-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-01-09 | 2019-02-28 | N |
