Avon Place Healthcare Center

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure controlled medications were accounted and dispensed appropriately. This affected two residents (Residents #32 and #62) out of three residents reviewed for controlled medication tracking and had the potential to affect all 80 residents residing in the facility who could use house stock medications. The total census was 80.1. Observation of the East Hall medication cart on 06/29/26 at 4:27 A.M. and record review of its narcotic count sheet and affected residents revealed three of Resident #62's oxycodone (a pain reliever) doses were documented as removed on 06/28/26, with the first dose being removed at an illegibly written time, the second at 12:30 P.M., and the third at 5:00 P.M. Only two doses were documented in the resident's record as given to Resident #62 that day at 8:11 A.M. [...]

Inspectors wroteBased on observation, interview, record review, and review of manufacturer instructions, the facility failed to ensure medications were stored in a safe and sanitary manner. This affected two residents (Residents #21 and #38) out of four residents reviewed for insulin pen storage and had the potential to affect all 80 residents residing in the facility who could use house stock medications. The total census was 80.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen area and ensure appropriate labeling and dating of food items. This had the potential to affect all 80 residents receiving meals from the facility kitchen. The facility identified no residents who received a nothing by mouth diet. The facility census was 80.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to accommodate resident needs and preferences by providing access to beautician services which were available to others and ensuring call lights were within reach. This affected two residents (Residents #5 and #10) out of two residents reviewed for accommodation of needs. The facility census was 80.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure accurate advanced directive information was present throughout a resident's medical record. This affected two residents (Residents #3 and #60) out of two residents reviewed for advanced directives. The facility census was 80.

Inspectors wroteBased on record review and interviews, the facility failed to maintain a clean safe homelike environment for its residents. This affected one resident (Resident #46) of one resident reviewed for homelike environment. The facility census was 80.

Inspectors wroteBased on medical record review, interview, and review of witness statements, a personnel file, and facility policy, the facility failed to implement abuse policy and procedure by not timely reporting and investigating an allegation of abuse. This affected one resident (Resident #45) of four residents reviewed for abuse. The facility census was 80.

Inspectors wroteBased on medical record review, interview, and review of witness statements, a personnel file, and facility policy, the facility failed to timely report an allegation of sexual abuse to the state agency as required. This affected one resident (Resident #45) of four residents reviewed for abuse. The facility census was 80.

Inspectors wroteBased on medical record review, interview, and review of witness statements, a personnel file, and facility policy, the facility failed to complete a thorough investigation for an allegation of sexual abuse. This affected one resident (Resident #45) of four residents reviewed for abuse. The facility census was 80.

Inspectors wroteBased on record review and staff interview, the facility failed to timely complete a required pre-admission screen and resident review (PASRR) prior to admission or upon the expiration of a 30-day hospital exemption. This affected three residents (Residents #20, #37 and #75) out of three residents reviewed for PASRR. The facility census was 80.

Inspectors wroteBased on resident record review and staff interview, the facility failed to develop and implement an individualized comprehensive care plan to address elopement risk. This affected one resident (Resident #72) of one resident reviewed for elopement risk. The facility census was 80.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to coordinate a resident's orthopedic care. This affected one resident (Resident #10) out of two residents reviewed for quality of care. The facility census was 80.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide residents with timely incontinence care. This affected two residents (Residents #7 and #45) of two residents reviewed for incontinence care. The facility census was 80.

Inspectors wroteBased on medical record review, interview, and review of dialysis contract and facility policy, the facility failed to ensure there was ongoing monitoring for signs and symptoms of infection for Resident #69's dialysis catheter. This affected one resident (Resident #69) out of two residents reviewed for dialysis. The facility census was 80.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure behaviors were managed and addressed appropriately including personal property being taken, behavior addressed during therapy, and psychological services offered for depressive symptoms. This affected three residents (Residents #5, #11 and #52) out of three residents reviewed for behavior management. The facility census was 80.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to release one former resident (#95) medical records timely to her family and their legal representative. This affected one (#95) of two Former Residents (#95, #96) reviewed for medical record release. The facility census was 84.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility staff failed to ensure medications were administered as ordered and failed to ensure the medications were properly stored until administered. This affected one (#62) of one resident observed for medication storage and had the potential to affect Resident #64 who the facility identified as cognitively impaired and independently mobile. The facility census was 84.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility staff failed to accurately document on a resident's condition. This affected one resident (#94) of three medical records reviewed. The facility census was 84.

Inspectors wroteBased on review of the medical record, staff interviews, and review of facility policy, the facility failed to ensure changes in resident condition were reported. This affected one resident (#77) of three residents reviewed for changes in condition. The facility census was 76.

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to ensure a resident was accurately assessed for additional injuries after being found with bruising with no known cause at the time of discovery. This affected one (#77) of three residents reviewed for abuse. The facility census was 76.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident was assessed and monitored while administered oxygen after a change in condition. This affected one (#77) of three residents reviewed for change in condition. The facility identified nine residents receiving oxygen therapy. The facility census was 76.

Inspectors wroteBased on record review, resident interview, staff interview, observation, and policy review, the facility failed to provide wound care per the physician's orders. Furthermore, the facility failed to initial and date wound dressings per the facility policy. This affected one (#44) of four residents reviewed for wound care and six (#32, #38, #39, #44, #64, #66) of six residents reviewed for wound dressings. The facility census was 73. Review of Resident #44's medical record revealed an admission date of 01/04/25. Diagnoses included multiple sclerosis, muscle weakness, severe protein calorie malnutrition, hyperlipidemia, and hypertension. Review of Resident #44's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had intact cognition and required substantial or maximal assistance to roll from side to side. [...]

Inspectors wroteBased on record review, staff interview, resident interview, and policy review, the facility failed to ensure suprapubic catheters were secured. This affected two (#15 and #44) of two residents reviewed for catheter securement devices. The facility census was 73.1. Review of Resident #44's medical record revealed an admission date of 01/04/25. Diagnoses included multiple sclerosis, muscle weakness, severe protein calorie malnutrition, hyperlipidemia, and hypertension. Review of Resident #44's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had intact cognition and had an indwelling catheter. Review of Resident #44's care plan for alteration in elimination, revised date of 09/17/25 revealed Resident #44 had a supra pubic catheter. [...]

Inspectors wroteBased on record review, observation, staff interview, resident interview, and policy review, the facility failed to ensure the medical record was accurate and was not falsified. This affected one resident (#15) of three residents reviewed for an accurate medical record. The facility census was 73. Review of Resident #15 ' s medical record revealed an admission date of 12/23/25. Diagnoses included paraplegia, diabetes mellitus due to underlying condition with diabetic neuropathy, morbid obesity, hyperlipidemia, hypothyroidism, chronic kidney disease stage four, anemia, and delusional disorders. Review of Resident #15 ' s quarterly MDS assessment dated [DATE] revealed Resident #15 had intact cognition and had an indwelling catheter. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to post the required Enhanced Barrier Precautions (EBP) signage outside of one resident's room who required EBP, and further the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when caring for residents requiring EBP. This affected two (#32 and #44) of four residents reviewed for infection control. The facility census was 73. 1. Review of the medical record for Resident #32 revealed an admission date of 08/05/25. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of the left middle cerebral artery, unspecified protein-calorie malnutrition, type II diabetes mellitus, and hypertension. [...]

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure Resident #44's call light was within reach to be able to call for assistance as needed. This affected one resident (#44) of three residents reviewed for call lights. The facility census was 73. Review of Resident #44's medical record revealed an admission date of 01/04/25. Diagnoses included multiple sclerosis, muscle weakness, severe protein calorie malnutrition, hyperlipidemia, and hypertension. Review of Resident #44's care plan with a last revision date of 09/17/25 revealed Resident #44 had an alteration in skin integrity as evidenced by pressure ulcers present on his sacrum, right and left gluteal fold, and right and left heel. [...]

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were administered and were not left at the resident bedside. This affected one resident (Resident #20) of one resident observed. The facility census was 79.

Inspectors wroteBased on medical record review, staff and resident interview, review of the activity calendar, and policy review, the facility failed to ensure evening activities were provided. This affected three resident (#03, #16, and #47) out of 10 residents and three families interviewed for activities. The facility census was 73. Findings Include: Review of the medical record for Resident #16 revealed an admission date of 08/18/22. Diagnoses included schizoaffective disorder, bipolar, anxiety, epilepsy, and alcohol induced dementia. Review of the quarterly Minimum Set (MDS) 3.0 dated 06/13/23, revealed she had intact cognition and was independent with transfers, ambulation, and hygiene. Review of the plan of care dated 06/12/23 revealed the resident is a sociable person and likes to participate in various activities. Intervention included to participate in group activities at least twice a week. [...]

Inspectors wroteBased on observation, medical record review, staff interview and review of material safety and data sheets (MSDS), the facility failed to ensure a safe environment for residents residing on the secured memory care unit, when Resident #54 was able to have direct access to chemicals (spray can air freshener). This affected one resident (#54) of one resident reviewed for accident hazards. This had the potential to affect the 31 Residents (Residents #02, #04, #05, #06, #08, #13, #15, #16, #18, #23, #28, #30, #31, #33, #34, #36, #39, #40, #42, #44, #48, #49, #51, #56, #57, #64, #66, #67 #68, #71 and #125) who resided on the facilitys' secured dementia care unit. The facility census was 73. Findings Include: Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, dementia and psychosis. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were given to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit. This affected one (Resident #46) of three residents review of appropriate beneficiary notices. The facility census was 80.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure care planned interventions for falls were implemented for Resident #28. This affected one (#28) of two residents reviewed for falls. The facility census was 80.

Inspectors wroteBased on record review, review of facility policy, resident interview and staff interview, the facility failed to provide physician ordered medications to one (#67) of five residents reviewed for unnecessary medications. The facility identified 18 residents whom received physician ordered eye drops. The facility census was 80.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary manner. This had the potential to affect all 80 residents residing in the facility.