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Deficiency Records for Avina On Division

View the most recent health deficiencies and inspection results for Avina On Division. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Avina On Division. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2026-03-28 2026-04-23 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2026-03-28 2026-04-23 Y
Ensure that residents are free from significant medication errors. Health 2026-03-28 2026-04-23 Y
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 2026-03-28 2026-04-23 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2026-03-28 2026-04-23 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2026-03-28 2026-04-23 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2026-03-28 2026-04-23 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2025-05-21 2025-07-16 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2025-05-21 2025-07-07 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-05-21 2025-06-24 N
Provide and implement an infection prevention and control program. Health 2025-05-21 2025-06-13 N
Dispose of garbage and refuse properly. Health 2025-05-21 2025-06-12 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2025-05-21 2025-06-12 N
Reasonably accommodate the needs and preferences of each resident. Health 2025-05-21 2025-06-12 N
Conduct testing and exercise requirements. Fire Safety 2025-05-21 2025-06-12 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2025-05-21 2025-06-09 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2025-05-21 2025-06-09 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-05-21 2025-05-29 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2025-05-21 2025-05-23 N
Dispose of garbage and refuse properly. Health 2024-11-18 2024-11-21 Y
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-03-27 2024-09-30 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-03-27 2024-09-01 N
Conduct testing and exercise requirements. Fire Safety 2024-03-27 2024-05-09 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-03-27 2024-05-06 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2024-03-27 2024-05-06 N
Provide and implement an infection prevention and control program. Health 2024-03-27 2024-04-20 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-03-27 2024-04-20 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2024-03-27 2024-04-19 N
Post nurse staffing information every day. Health 2024-03-27 2024-04-18 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-03-27 2024-04-18 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2024-03-27 2024-04-18 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-03-27 2024-04-17 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-03-27 2024-04-17 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-03-27 2024-04-17 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-03-27 2024-04-17 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-27 2024-04-16 N
Give the resident's representative the ability to exercise the resident's rights. Health 2024-03-27 2024-04-16 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2024-03-27 2024-04-16 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-03-27 2024-03-29 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 2024-03-27 2024-03-28 N
Have restrictions on the use of portable space heaters. Fire Safety 2024-03-27 2024-03-28 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-03-27 2024-03-28 N
Have proper medical gas storage and administration areas. Fire Safety 2024-03-27 2024-03-28 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-03-27 2024-03-27 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-03-27 2024-03-27 N
Ensure each resident receives an accurate assessment. Health 2024-03-27 2024-03-27 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-03-07 2023-04-10 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-03-07 2023-04-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-03-07 2023-04-07 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-03-07 2023-04-07 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 2023-03-07 2023-04-07 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-03-07 2023-04-07 N
Provide activities to meet all resident's needs. Health 2023-03-07 2023-04-07 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-03-07 2023-04-07 N
Provide enough food/fluids to maintain a resident's health. Health 2023-03-07 2023-04-07 N
Provide care or services that was trauma informed and/or culturally competent. Health 2023-03-07 2023-04-07 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 2023-03-07 2023-04-07 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2023-03-07 2023-04-07 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 2023-03-07 2023-04-07 N
Give the resident's representative the ability to exercise the resident's rights. Health 2023-03-07 2023-04-07 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-03-07 2023-03-29 N
Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. Fire Safety 2023-03-07 2023-03-29 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2023-03-07 2023-03-29 N
Construct fire resistant interior walls. Fire Safety 2023-03-07 2023-03-24 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-03-07 2023-03-08 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-03-07 2023-03-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-03-07 2023-03-08 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 2026-04-30 Not Fixed Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2026-04-30 Not Fixed Y
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2026-04-30 Not Fixed Y
Provide and implement an infection prevention and control program. Health 2026-04-30 Not Fixed Y

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