Deficiency Records for Avamere Heritage Rehabilitation of Tacoma
Updated as of March 01, 2024
A list of the most recent deficiencies for Avamere Heritage Rehabilitation of Tacoma. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-26 | 2024-02-27 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-09 | 2023-12-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-09 | 2023-12-21 | 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 | 2023-11-09 | 2023-12-21 | 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 | 2023-11-09 | 2023-12-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-09 | 2023-12-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-09 | 2023-12-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-09 | 2023-12-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-09 | 2023-12-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-09 | 2023-12-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-09 | 2023-12-21 | N |
| Post nurse staffing information every day. | Health | 2023-11-09 | 2023-12-21 | 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 | 2023-11-09 | 2023-12-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-09 | 2023-12-21 | 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 | 2023-11-09 | 2023-12-21 | 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 | 2023-11-09 | 2023-12-21 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-11-09 | 2023-12-21 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-11-09 | 2023-12-21 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-08 | 2023-12-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-08 | 2023-12-06 | 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 | 2023-11-08 | 2023-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-08 | 2023-12-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-08 | 2023-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-08 | 2023-12-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-08 | 2023-12-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-08 | 2023-12-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-08 | 2023-12-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-08 | 2023-12-06 | 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 | 2023-11-03 | 2023-12-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-09-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-10 | 2023-03-15 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-07 | 2022-12-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-15 | 2022-10-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-15 | 2022-10-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-08-15 | 2022-10-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-15 | 2022-10-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-15 | 2022-10-03 | 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 | 2022-08-15 | 2022-10-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-15 | 2022-10-03 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-08-15 | 2022-10-03 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-15 | 2022-10-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-15 | 2022-10-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-15 | 2022-10-03 | N |
| Provide appropriate foot care. | Health | 2022-08-15 | 2022-10-03 | 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 | 2022-08-15 | 2022-10-03 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-15 | 2022-10-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-15 | 2022-10-03 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-08-15 | 2022-10-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-15 | 2022-10-03 | 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 | 2022-08-15 | 2022-10-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-15 | 2022-10-03 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-15 | 2022-10-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-15 | 2022-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-15 | 2022-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-15 | 2022-10-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-15 | 2022-10-03 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-15 | 2022-09-15 | 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 | 2022-08-15 | 2022-09-15 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-08-15 | 2022-09-15 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-06-16 | 2022-07-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-16 | 2022-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-07-27 | Y |
| Post nurse staffing information every day. | Health | 2021-12-02 | 2021-12-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-12 | 2021-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-22 | 2021-06-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-06 | 2019-11-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-06 | 2019-11-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-06 | 2019-11-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-06 | 2019-11-05 | N |
| Post nurse staffing information every day. | Health | 2019-08-06 | 2019-11-05 | 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 | 2019-08-06 | 2019-11-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-08-06 | 2019-11-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-06 | 2019-09-27 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-06 | 2019-09-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-06 | 2019-09-27 | 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 | 2019-08-06 | 2019-09-27 | 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 | 2019-08-06 | 2019-09-27 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-08-06 | 2019-09-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-06 | 2019-09-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-06 | 2019-09-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-06 | 2019-09-27 | 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 | 2019-08-06 | 2019-09-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-06 | 2019-09-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-06 | 2019-09-27 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-06 | 2019-09-27 | 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 | 2019-08-06 | 2019-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-06 | 2019-09-27 | 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 | 2019-08-06 | 2019-09-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-06 | 2019-09-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-06 | 2019-09-27 | 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 | 2019-08-06 | 2019-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-06 | 2019-09-27 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-06 | 2019-09-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-06 | 2019-09-27 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-08-06 | 2019-09-27 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-25 | 2019-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-25 | 2019-08-02 | N |
