Inspection Results » Avamere at Three Fountains

Health Inspection on January 17, 2019 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Ensure that residents are free from significant medication errors. (Corrected 2019-02-28)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2019-03-05)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-02-28)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-02-28)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-02-28)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2019-02-28)
   • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (Corrected 2019-02-28)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-02-28)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-02-28)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-02-28)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2019-03-05)
   • Provide appropriate foot care. (Corrected 2019-02-28)
   • 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 ne (Corrected 2019-02-28)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-02-28)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2019-02-28)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2019-02-28)
   • Ensure meals and snacks are served at times in accordance with residentÂ’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of schedu (Corrected 2019-02-28)
   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2019-02-28)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-02-28)
   • Provide and implement an infection prevention and control program. (Corrected 2019-02-28)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2019-02-28)