Avalon Springs Health Campus

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to appropriate signage posted during a respiratory outbreak, lack of monitoring for a resident that was COVID-19 positive and lack of COVID-19 testing for a symptomatic resident for 2 of 3 residents reviewed for infection control and random infection control observations. (Residents 19 and 44)

Inspectors wroteBased on record review and interview, the facility failed to ensure complete and accurate information was included in Indiana Department of Health (IDOH) Reportable Incidents related to abuse allegations for 2 of 3 IDOH Reportable Incidents reviewed. (Residents 11 and 42)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 1 residents reviewed for accidents. (Resident 6)

Inspectors wroteBased on record review and interview, the facility failed to ensure a peripherally inserted central catheter (PICC) intravenous (IV) access site was assessed and monitored accurately as ordered for 1 of 3 residents reviewed for parenteral/IV fluids. (Resident 41)

Inspectors wroteBased on observation, record review, and interview, the facility failed to document care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 2 of 3 residents reviewed for intravenous care. (Residents 14 and 59)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who required maximum to dependent care received incontinence care in a timely manner, for 1 of 3 residents reviewed for incontinence care. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to residents who were in EBP and failed to ensure a staff member (CNA 2) completed hand hygiene after the removal of soiled gloves for 2 of 3 residents reviewed for infection control. (Residents F and D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall interventions were in place to prevent injury for a resident with multiple falls for 1 of 3 residents reviewed for accidents. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had Physician's Order to self-administer their own medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 38)

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician was notified of abnormal vital signs for 1 of 5 residents reviewed for unnecessary medications. (Resident 5)

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's privacy was maintained related to the electronic medication record (EMR) left open and unlocked in the hallway during medication pass for 1 of 8 residents observed during medication pass. (Resident 363)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were involved in decisions about their care related to new medications and ensuring a resident attended and participated in care planning conferences for 2 of 2 residents reviewed for participation in care planning. (Residents 38 and 49)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure blood pressure medication was administered as ordered according to parameters for 1 of 1 resident reviewed for blood pressure parameters and for 1 of 5 residents reviewed for unnecessary medications. (Residents 38 and 5)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure urinary output was documented as ordered and an indwelling Foley (urinary) catheter collection bag was off of the floor for a resident with a history of infection for 3 of 3 residents reviewed for urinary catheters. (Residents 6, 216, and 13)

Inspectors wroteBased on record review and interview, the facility failed to monitor weekly weights and nutritional intake for meals and supplements as ordered for a resident with significant weight loss for 1 of 2 residents reviewed for nutrition. (Resident 38)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a peripherally inserted central catheter (PICC) line was maintained related to bandage changes for 1 of 1 resident reviewed for infections. (Resident 363)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen concentrators were set at the correct flow rate for 1 of 2 residents reviewed for oxygen therapy. (Resident 38)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's pain was managed and monitored for 1 of 2 residents reviewed for pain. (Resident 157)

Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented, related to the correct medication administration route for 1 of 1 resident reviewed for tube feeding. (Resident 41)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to enhanced barrier precautions (EBP) not in use for a resident with pressure ulcers during a wound treatment and for a resident with a peripherally inserted central catheter (PICC) line during medication pass. The facility also failed to change gloves in between pressure ulcer treatments and perform hand hygiene after glove removal during medication pass for 1 of 2 residents observed during a pressure ulcer treatment and for 1 of 8 residents observed during medication administration. (Residents 41 and 363) (Hospice CNA 1, Hospice RN 1, and RN 1)

Inspectors wroteBased on record review and interview, the facility failed to follow up on a notification of a change of condition with a resident's physician, for 1 of 4 residents reviewed for physician notification. (Resident F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to care for peripherally inserted central catheter (PICC line - long catheter inserted through a peripheral vein for intravenous treatments) in accordance with professional standards of practice, related to lack of measurement of the catheter length and arm circumference above the site, dressing changes to the sites, assessments of the site, and flushes of the catheters, for 3 of 3 residents with PICC lines. (Residents E, F, and C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were aware of which residents were in Enhanced Barrier Precautions (EBP), failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 3 and LPN 2) when providing care to a resident who was in EBP, and failed to ensure staff removed soiled gloves and washed hands after touching contaminated surfaces, for 1 of 3 residents observed for infection control and EBP (Resident F) This had the potential to affect 2 residents with PICC lines (peripherally inserted central catheter - long catheter inserted through a peripheral vein for intravenous treatments). (Residents E and F).

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were given as ordered to prevent significant medication errors for 1 of 3 residents reviewed for medication errors. (Resident B) The deficient practice was corrected by [DATE], prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the medication error. The facility's plan of action included staff education related to counseling and education on medication administration and dosage calculations. Medication administration competencies were completed for nurses and QMAs. Audits began for as needed (PRN) injectable medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 1 of 1 residents reviewed for hospitalization. (Resident 45) The closed record for Resident 45 was reviewed on 11/30/23 at 10:40 a.m. Diagnoses included, but were not limited to, chronic kidney disease and congestive heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 9/22/23, indicated the resident was cognitively intact. A Progress Note, dated 10/10/23, indicated the resident was lethargic, her heart rate was 44, and her oxygen saturation was 60%. The resident's blood pressure was not able to be assessed. The resident was put on a rebreather mask. The Nurse Practitioner checked on the resident. The family and Physician were notified and the resident was sent to the hospital. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a baseline care plan was developed and implemented that included an assistive device within 48 hours of admission for 1 of 19 residents reviewed for care plans. (Resident 97)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of Physician's Orders in place for a wound treatment for 1 of 2 residents reviewed for non-pressure skin conditions and for a back brace for 1 of 3 residents reviewed for positioning and limited range of motion. (Residents 102 and 97)

Inspectors wroteBased on record review and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 42)