Deficiency Records for Avalon Health and Rehabilitation Center - Pasco
Updated as of April 01, 2024
A list of the most recent deficiencies for Avalon Health and Rehabilitation Center - Pasco. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-14 | 2024-03-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-14 | 2024-03-11 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-02-14 | 2024-03-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-14 | 2024-03-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-23 | 2024-02-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-26 | 2023-11-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-23 | 2023-09-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-17 | 2023-06-23 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-05-17 | 2023-06-23 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-17 | 2023-06-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-17 | 2023-06-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-17 | 2023-06-23 | 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 | 2023-05-17 | 2023-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-17 | 2023-06-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-17 | 2023-06-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-17 | 2023-06-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Develop a communication plan. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Meet other general requirements. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-08 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-12 | 2023-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-31 | 2022-09-28 | Y |
| Report COVID19 data to residents and families. | Health | 2022-08-31 | 2022-09-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-11-02 | 2021-12-14 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-02 | 2021-12-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-02 | 2021-12-14 | 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 | 2021-11-02 | 2021-12-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-02 | 2021-12-14 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-02 | 2021-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-02 | 2021-12-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-02 | 2021-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-02 | 2021-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-02 | 2021-12-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-11-02 | 2021-12-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide or obtain dental services for each resident. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-11-02 | 2021-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-02 | 2021-12-14 | 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 | 2021-11-02 | 2021-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-02 | 2021-12-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-02 | 2021-12-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-02 | 2021-12-14 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-20 | 2021-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-27 | 2021-08-18 | Y |
| Report COVID19 data to residents and families. | Health | 2021-07-27 | 2021-08-18 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-07-27 | 2021-08-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-18 | 2021-07-07 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-05-13 | 2019-06-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-13 | 2019-06-10 | 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 | 2019-05-13 | 2019-06-10 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-13 | 2019-06-10 | 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 | 2019-05-13 | 2019-06-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-13 | 2019-06-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-13 | 2019-06-10 | 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 | 2019-05-13 | 2019-06-10 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-05-13 | 2019-06-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-05-13 | 2019-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-13 | 2019-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-15 | 2019-06-04 | N |
