Deficiency Records for Avamere Heritage Rehabilitation of Tacoma
Updated as of August 01, 2022
This is not the most recent data for Avamere Heritage Rehabilitation of Tacoma. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-01-26 | 2021-02-26 | 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 |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-08-31 | 2018-10-16 | 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 | 2018-08-31 | 2018-10-16 | 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 | 2018-08-31 | 2018-10-16 | N |
| 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 | 2018-08-31 | 2018-10-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-31 | 2018-10-16 | 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 | 2018-08-31 | 2018-10-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-08-31 | 2018-10-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-08-31 | 2018-10-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-31 | 2018-10-16 | 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 | 2018-08-31 | 2018-10-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-08-31 | 2018-10-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-31 | 2018-10-16 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-31 | 2018-10-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-31 | 2018-10-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-08-31 | 2018-10-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-31 | 2018-10-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-31 | 2018-10-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-31 | 2018-10-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-31 | 2018-10-16 | 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 | 2018-08-31 | 2018-10-16 | 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 | 2018-08-31 | 2018-10-16 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-08-31 | 2018-10-16 | 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 | 2018-08-31 | 2018-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-31 | 2018-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-23 | 2018-09-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-23 | 2018-09-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-23 | 2018-09-07 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-14 | 2017-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-14 | 2017-10-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-08-14 | 2017-09-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-08-14 | 2017-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-14 | 2017-09-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-08-14 | 2017-09-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-08-14 | 2017-09-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-14 | 2017-09-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-08-14 | 2017-09-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-08-14 | 2017-09-21 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-08-14 | 2017-09-15 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-08-14 | 2017-09-15 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-08-14 | 2017-09-15 | N |
