ElderGrade

Inspection citations at Avamere At Three Fountains

20 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 5 0
2024 3 2
2023 11 0
2022 1 0
D January 16, 2025 Tag F0947 Corrected Feb 2025

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

No actual harm, potential for more than minimal harm

D January 16, 2025 Tag F0881 Corrected Feb 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

D January 16, 2025 Tag F0688 Corrected Feb 2025

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D January 16, 2025 Tag F0554 Corrected Feb 2025

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

F January 16, 2025 Tag F0880 Corrected Feb 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D April 1, 2024 Tag F0602 Complaint investigation Corrected Nov 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

No actual harm, potential for more than minimal harm

G April 1, 2024 Tag F0760 Complaint investigation Corrected Aug 2023

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Actual harm to a resident

G April 1, 2024 Tag F0658 Complaint investigation Corrected Aug 2023

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Actual harm to a resident

D August 25, 2023 Tag F0919 Corrected Sep 2023

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

No actual harm, potential for more than minimal harm

D August 25, 2023 Tag F0791 Corrected Sep 2023

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

No actual harm, potential for more than minimal harm

D August 25, 2023 Tag F0758 Corrected Sep 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D August 25, 2023 Tag F0744 Corrected Sep 2023

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

No actual harm, potential for more than minimal harm

D August 25, 2023 Tag F0686 Corrected Sep 2023

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D August 25, 2023 Tag F0679 Corrected Sep 2023

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

No actual harm, potential for more than minimal harm

D August 25, 2023 Tag F0657 Corrected Sep 2023

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D August 25, 2023 Tag F0554 Corrected Sep 2023

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

E August 25, 2023 Tag F0921 Complaint investigation Corrected Sep 2023

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

E August 25, 2023 Tag F0880 Corrected Sep 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F August 25, 2023 Tag F0812 Corrected Sep 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

F July 15, 2022 Tag F0838 Corrected Aug 2022

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.