Deficiency Records for Avondale Villa Post-Acute
Updated as of October 01, 2022
This is not the most recent data for Avondale Villa Post-Acute. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2020-12-23 | Not Fixed | N |
