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Deficiency Records for Avir at Western Hills

View the most recent health deficiencies and inspection results for Avir at Western Hills. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Avir at Western Hills. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
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 2025-12-29 2026-01-23 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2025-12-29 2026-01-23 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-11-20 2025-11-14 Y
Provide and implement an infection prevention and control program. Health 2025-05-08 2025-05-09 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-05-08 2025-05-09 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2025-05-08 2025-05-09 N
Post nurse staffing information every day. Health 2025-05-08 2025-05-09 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2025-04-30 2025-04-28 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-01-22 2025-02-08 Y
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 2025-01-22 2025-01-31 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2025-01-22 2025-01-30 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2025-01-22 2025-01-30 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 2025-01-22 2025-01-23 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-10-16 2024-11-04 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2024-03-21 2024-04-18 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-03-21 2024-04-18 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 2024-03-21 2024-04-18 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 2024-03-21 2024-04-18 N
Post nurse staffing information every day. Health 2024-03-21 2024-04-18 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 2024-03-21 2024-04-18 N
Ensure medication error rates are not 5 percent or greater. Health 2024-03-21 2024-04-18 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 2024-03-21 2024-04-18 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-03-21 2024-04-18 N
Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Fire Safety 2023-02-08 2023-07-14 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-06-20 2023-07-14 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-06-20 2023-07-14 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-02-08 2023-06-27 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-02-08 2023-06-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-02-08 2023-06-15 N
Meet Health Care Facilities Code mechanical requirements. Fire Safety 2023-02-08 2023-06-15 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-02-08 2023-06-15 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 2023-02-08 2023-06-15 N
Keep residents' personal and medical records private and confidential. Health 2023-02-08 2023-03-10 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-02-08 2023-03-10 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-02-08 2023-03-10 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-02-08 2023-03-10 N
Provide and implement an infection prevention and control program. Health 2023-02-08 2023-03-10 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2023-02-08 2023-03-03 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-07-02 Not Fixed Y

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