A list of the most recent deficiencies for Avalon Care Center at Northpointe. 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 timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-12-12 | 2024-01-03 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-09 | 2023-12-20 | 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 | 2023-11-09 | 2023-12-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-09 | 2023-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-09 | 2023-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-09 | 2023-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-09 | 2023-12-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-09 | 2023-12-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-09 | 2023-12-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-09 | 2023-12-20 | 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 | 2023-12-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-11-09 | 2023-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-09 | 2023-12-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-09 | 2023-12-20 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-08 | 2023-12-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-08 | 2023-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-08 | 2023-12-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-08 | 2023-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-08 | 2023-12-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-08 | 2023-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-08 | 2023-12-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-08 | 2023-12-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-08 | 2023-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-12 | 2023-06-28 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-23 | 2023-06-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-23 | 2023-06-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-23 | 2023-06-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-14 | 2022-09-07 | Y |
| 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 | 2022-07-14 | 2022-08-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-14 | 2022-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-14 | 2022-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-14 | 2022-08-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-14 | 2022-08-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-07-14 | 2022-08-16 | 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 | 2022-07-14 | 2022-08-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-07-14 | 2022-08-16 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-07-14 | 2022-08-16 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-13 | 2022-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-26 | 2022-05-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-01 | 2022-03-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-17 | 2019-06-17 | 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 | 2019-05-17 | 2019-06-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-17 | 2019-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-17 | 2019-06-17 | 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 | 2019-05-17 | 2019-06-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-17 | 2019-06-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-17 | 2019-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-17 | 2019-06-17 | 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 | 2019-05-17 | 2019-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-17 | 2019-06-17 | 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 | 2019-05-17 | 2019-06-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-17 | 2019-06-17 | 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 | 2019-05-17 | 2019-06-17 | 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 | 2019-05-17 | 2019-06-17 | 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 | 2019-05-17 | 2019-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-17 | 2019-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-17 | 2019-06-05 | N |
