Avoca Specialty Care

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications for 5 of 5 sampled residents reviewed (Resident #4, #8, #25, #23, and #33). The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for 4 of 6 Residents (Resident #4, #25, #23, and #33) reviewed. The facility reported a census of 33.

Inspectors wroteBased on facility document review, clinical record review, resident interview, family interview and staff interviews, the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner and not responding to a request for toileting in a timely manner for 3 of 16 resident reviewed (Resident #10, #33, and #34). The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to verify the resident's advanced directive choice documented accurately for 1(Resident #7) of 16 residents reviewed. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, observations, resident interview, and staff interviews, the facility failed to provide the residents with a comfortable / clean homelike environment by not changing soiled sheets for 1 for 20 residents reviewed (Resident #3). The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) for 3 of 5 residents (Resident #25, #5, #33) reviewed. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to Incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination and the PASRR evaluation report into a resident's care plan for 1 (Resident #13) of 3 resident reviewed. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to revise and implement care plans for 1 of 4 residents (Resident #4) reviewed. The facility reported a census of 33 residents.

Inspectors wroteBased on observation, prescription package insert review, clinical record review, staff interviews, and policy review the facility failed to meet professional standards of care when administering insulin to one (Resident #24) of one residents reviewed. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review the facility failed to ensure residents received showers to maintain good personal hygiene for 2 (Residents #7 and #34) of 3 residents reviewed. The facility reported a census of 33 residents.

Inspectors wroteBased on observations, clinical record review, resident interview, staff interviews and policy review the facility failed to provide respiratory services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #34) who required the use of a Continuous Positive Airway Pressure (CPAP) machine. The facility failed to have an order for the CPAP and failed to clean the CPAP. The facility reported a census of 33 residents.

Inspectors wroteBased on observation, clinical record review, staff interview and policy review the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter for 1 of 3 reviewed (Resident #10). The facility reported a census of 33 residents.

Inspectors wroteBased on interviews, record reviews, and policy review the facility failed to provide services meeting professional standards for 1 of 3 residents (Resident #2). The facility failed to follow physician orders for completion of labs. The facility had a census of 31.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to provide bathing assistance for 2 of 4 residents reviewed for bathing (Residents #1 and #2). The facility reported a census of 35 residents.

Inspectors wroteBased on observations, clinical record review, resident council notes, grievances, staff and resident interviews, and facility policy review, the facility failed to ensure residents received baths twice a week or per their requested amount a week for 6 of 6 residents reviewed (Resident #2, #4, #5, #6, #7, and #8). The facility also failed to offer toileting assistance for 2 of 4 resident reviewed (Resident #5 and #8). The facility reported a census of 31 residents.

Inspectors wroteBased on observations, review of resident council notes, review of grievances and resident and staff interviews the facility failed to ensure they had adequate staff members to answer resident's call lights, provide baths, and assist with toileting needs. The facility reported a census of 31 residents. Findings Include: 1. According to the quarterly MDS assessment tool with a reference date of 4/11/2025, Resident #8 had a BIMS score of 15. A BIMS of 15 suggested no cognitive impairment. The MDS documented he had an impairment on one side of his lower extremity and utilized a wheelchair. Resident #8 required partial/moderate assistance with upper body dressing, was dependent of staff for lower body dressing and required substantial/maximal assistance with personal hygiene. The MDS documented a toilet transfer was not attempted due to his medical condition. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review the facility failed to maintain complete and accurate records for 7 of 7 residents reviewed (Resident #2, #3, #4, #5, #6, #7, #8). The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, staff interviews and policy review the facility failed to implement their abuse policies. The facility's staff member with concerns about the treatment of Resident #3 was not reported within two hours of the concerns. The facility also failed to complete a thorough investigation. The facility reported a census of 31 residents.

Inspectors wroteBased on record review, facility investigative file review, staff interviews and policy review the facility failed to report concerns about the treatment of Resident #3 within two hours of the alleged concerns observed. The facility reported a census of 31 residents.

Inspectors wroteBased on record review, facility investigative file review, staff interviews and policy review the facility failed to complete a thorough investigation. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to ensure 1 of 9 resident's care plans (Resident #3) was revised once her transfer assistance requirement was changed to the use of a mechanical lift. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to implement additional individualized interventions for 1 of 3 residents (Resident #3) related to behaviors to assist residents with dementia in the completion of a task. Resident #3 refused staff to assist her to the bathroom and refused staff to check her for incontinence and change her when she was incontinent. The facility reported a census of 31 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to ensure medications and supplies stored in the medication room and medication carts were stored and held within their expiration dates. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, resident interviews, observations, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 16 resident reviewed (Resident #15, #20,#21 and #37). The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interviews and policy review the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of an anticoagulant for 1 of 5 residents reviewed (Resident #6). The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review, observation, staff interview and policy review the facility failed to provide appropriate infection prevention practices when administering medications for 1 of 4 residents reviewed (Resident #15). The facility reported a census of 38 residents.

Inspectors wroteBased on observations, clinical record review, resident, family, and staff interviews, and facility policy review the facility failed to provide baths for 3 of 4 residents (Resident #5, #8 and #9) reviewed. The facility also failed to provide personal hygiene for 2 of 4 residents (Resident #8 and #11) reviewed. The facility reported a census of 30 residents.

Inspectors wroteBased on observations, resident council meeting notes, grievance/concerns investigation forms, resident and staff interviews, and facility policy review the facility failed to ensure the facility had sufficient staffing to meet the needs of residents that included answering resident's call lights in a timely manner. The facility reported a census of 30 residents.

Inspectors wroteBased on grievance/concern investigation forms, staff interviews, employee file review, and review of job descriptions the facility failed to ensure qualified staff assisted in the kitchen when they did not have adequate staff working. The facility reported a census of 30 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to store and serve food in a sanitary manner. The facility also failed to maintain infection control practices while in the dish area when going from the dirty area to the clean area. The facility reported a census of 30 residents.

Inspectors wroteBased on clinical record review, resident interviews, staff interviews, and facility policy review the facility failed to speak in a dignified manner around residents and failed to speak to residents in a dignified manner to 3 of 4 (Resident #5, #6 and #8) residents reviewed. The facility reported a census of 30 residents.

Inspectors wroteBased on observations, clinical record review, facility investigation review, staff interviews and facility policy review the facility failed to supervise 1 of 3 cognitively impaired residents (Resident #1). Staff were unaware Resident #1 had left the building on 5/26/24 at approximately 4:50 PM. Staff responded to an alarmed door, looked out the door window, disarmed the door alarm and went back to work. The staff member failed to go outside to visually check to see if a resident had left the building. The staff member assumed he saw another staff member in the vicinity. The staff member also failed to initiate a head count to ensure all residents were accounted for. The facility reported a census of 30 residents.

Inspectors wroteBased on observations, resident and staff interviews and facility policy review the facility failed to properly dispose of room trays with left-over food in a timely manner. The facility reported a census of 30 residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and facility policy review the facility failed to ensure 2 of 2 residents' (Resident #6 and #7) vape pens were properly stored. The facility also failed to ensure 1 of 2 residents (Resident #7) used her vape pen outside in the designated smoking areas. The facility reported a census of 30 residents.

Inspectors wroteBased on personnel document review, staff interviews and facility policy review the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 40 residents.

Inspectors wroteBased on facility document review, policy review and staff interview the facility failed to have the minimum members of the quality assessment and assurance committee meet quarterly. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to fully review and revise the comprehensive care plan for 4 of 4 residents reviewed (#3, #15, #20, & #23) and failed to include family representatives of 1 of 1 resident reviewed (#15). The facility reported a census of 40 residents.

Inspectors wroteBased on facility document review, and staff interview the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not having a staff on duty at the facility trained in cardiopulmonary resuscitation (CPR) for 5 days in the month of [DATE]. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, clinical record review, policy review, and staff interviews, the facility failed to secure medications in a locked compartment for to 1 of 3 residents reviewed (Residents #33). The facility also failed to label open medication with the date the medication was opened for 27 of 30 medications reviewed. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, facility document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the resident for 1 of 19 residents reviewed (Resident #9). The facility reported a census of 19 residents.

Inspectors wroteBased on observation, clinical record review, resident interview, staff interviews, and policy review, the facility failed to serve the appropriate diet type to 4 of 4 resident reviewed (#1, #8, #10, & #11). The facility reported a census of 40 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal preparation and service of a meal. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review the facility failed to implement appropriate infection control practices to prevent infection and/or cross contamination. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, staff interview, visitor interview, and facility policy review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, clinical record review, resident interview, staff interviews, and facility policy review the facility failed to ensure that residents have the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 5 residents reviewed (Resident #37). The facility reported a census of 40 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE], documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15 (no cognitive impairment). The MDS documented the resident required substantial assistance for toileting hygiene, personal hygiene, footwear, and functional transfers. Resident #37 completed transfers with the use of dependent weight bearing lift. The MDS documented Resident #37 had diagnoses including: [...]

Inspectors wroteBased on clinical record review, family interviews, staff interviews, and policy review, the facility failed to provide timely notification to the physician or family when changes occurred in the resident's physical or mental condition for 2 of 2 residents reviewed (Resident #15 & #17). The facility reported a census of 40 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review the facility failed to ensure that residents' equipment was kept clean and in good repair for 1 of 5 residents reviewed (Resident #4). The facility census was 40 residents. Findings Include: Resident #4's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #4 required the use of a wheelchair (w/c), and required partial/moderate assistance for transfers. The MDS documented the Resident #4 had diagnoses of syncope and collapse, gastrointestinal hemorrhage, other secondary Parkinsons, chronic atrial fibrillation, essential (primary) hypertension, moderate protein-calorie malnutrition, metabolic disorder, hypothyroidism, allergy, depression, and melena. [...]

Inspectors wroteBased on clinical record review, family and staff interviews, and policy review, the facility failed to ensure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 12 residents (Resident #15) reviewed. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to implement a comprehensive, person-centered care plan for 3 of 3 residents reviewed (#15, #17, & #20). The facility reported a census of 40 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and reviews of policy the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice regarding respiratory treatments, oxygen administration and insulin administration per orders for 2 of 3 residents reviewed. The facility census was 40. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE], documented that Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The resident required substantial assistance for toileting hygiene, personal hygiene, footwear, and functional transfers. Resident #37 completed transfers with the use of dependent weight bearing lift. Resident #37 had diagnoses to include: [...]

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to provide restorative activities for 2 of 2 residents reviewed (#15 & #23). The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview, and policy review the facility failed to provide an opportunity for bath or shower to 1 of 5 residents (Residents #3) reviewed. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, and policy review, the facility failed to prevent a resident from developing a preventable pressure ulcer for 1 of 1 resident reviewed (Resident #15). The facility reported a census of 40 residents.

Inspectors wroteBased on family interview, clinical record review, staff interview and policy review, the facility failed to maintain acceptable parameters of nutritional and hydration status by failing to prevent excessive weight loss and dehydration for 1 of 1 resident (#15). The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, observation, staff interviews, and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not verifying gastrostomy tube (G-tube) is functioning properly before administering medications for 1 of 1 residents (Resident #18) reviewed. The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide dialysis services consistent with professional standards by not completing a pre and post dialysis assessments for 1 of 1 residents (Resident #30) reviewed. The facility reported a census of 40 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews and facility policy review the facility failed to ensure medication error rates are not 5 percent or greater by having a medication error rate of 7.41%. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, staff interviews and policy review the facility failed to ensure the residents were free of significant medication errors to 1 of 4 residents reviewed (Resident #37). The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, observations, resident interviews, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents ( Residents #6, #8, and #9) reviewed. The facility reported a census of 40 residents.