A list of the most recent deficiencies for Avalon Care Center - Sonora. 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 implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-09 | 2024-02-09 | Y |
| 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 | 2024-01-09 | 2024-02-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-06 | 2024-01-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-20 | 2023-11-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-11 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-17 | 2023-10-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-22 | 2023-07-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-22 | 2023-07-19 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-06-22 | 2023-07-19 | 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 | 2023-06-22 | 2023-07-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-22 | 2023-07-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-22 | 2023-07-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide appropriate foot care. | Health | 2023-06-22 | 2023-07-19 | 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 | 2023-06-22 | 2023-07-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-22 | 2023-07-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-22 | 2023-07-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-22 | 2023-07-19 | 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 | 2023-06-22 | 2023-07-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-22 | 2023-07-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-22 | 2023-07-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-22 | 2023-07-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-22 | 2023-07-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-22 | 2023-07-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-06-29 | 2023-07-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-05-31 | 2023-06-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-10 | 2023-05-30 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-10 | 2023-05-30 | Y |
| 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 | 2023-05-10 | 2023-05-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-04 | 2023-04-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-27 | 2023-01-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-27 | 2023-01-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-27 | 2023-01-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-27 | 2023-01-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-29 | 2023-01-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-26 | 2023-01-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-15 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-22 | 2022-09-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-25 | 2022-08-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-18 | 2022-07-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-12 | 2022-05-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-15 | 2022-03-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-15 | 2022-03-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-27 | 2022-02-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-15 | 2021-12-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-15 | 2021-12-31 | Y |
| 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 | 2021-12-15 | 2021-12-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-15 | 2021-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-11-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-20 | 2021-11-04 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-20 | 2021-11-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-16 | 2021-10-13 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-26 | 2021-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-26 | 2021-08-06 | 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 | 2021-07-22 | 2021-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-06 | 2021-05-21 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-23 | 2021-05-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-05-11 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-04-14 | 2021-05-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-14 | 2021-05-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-15 | 2021-05-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-06 | 2021-04-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-01 | 2021-04-26 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-04-07 | 2021-04-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-17 | 2021-03-24 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-03-17 | 2021-03-24 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-19 | 2019-12-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-29 | 2019-11-26 | 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 | 2019-10-29 | 2019-11-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-29 | 2019-11-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-10-29 | 2019-11-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-29 | 2019-11-26 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-10-29 | 2019-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-29 | 2019-11-26 | 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 | 2019-10-29 | 2019-11-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-29 | 2019-11-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-29 | 2019-11-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-29 | 2019-11-26 | 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 | 2019-10-29 | 2019-11-26 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-10-29 | 2019-11-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-29 | 2019-11-26 | 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 | 2019-10-29 | 2019-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-29 | 2019-11-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-29 | 2019-11-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-29 | 2019-02-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-29 | 2019-02-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-29 | 2019-02-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-29 | 2019-02-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-29 | 2019-02-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-11 | 2019-01-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-12-11 | 2019-01-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-11 | 2019-01-18 | 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 | 2018-12-11 | 2019-01-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-11 | 2019-01-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-11 | 2019-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-11 | 2019-01-18 | 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 | 2018-12-11 | 2019-01-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-11 | 2019-01-18 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2018-12-11 | 2019-01-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-11 | 2019-01-18 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-12-11 | 2019-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-11 | 2019-01-18 | N |
