A list of the most recent deficiencies for Avondale Villa Post-Acute. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-21 | 2024-01-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-18 | 2023-09-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-18 | 2023-09-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-18 | 2023-09-15 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-22 | 2023-02-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Use approved construction type or materials. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-28 | 2022-04-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-25 | 2022-04-11 | 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 | 2022-03-25 | 2022-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-25 | 2022-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-25 | 2022-04-11 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-25 | 2022-04-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-25 | 2019-10-23 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-08-22 | 2019-08-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Develop a communication plan. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-11-15 | 2018-12-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-09-26 | 2018-10-26 | 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 | 2018-09-26 | 2018-10-26 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-09-26 | 2018-10-26 | N |
