The Avenues Transitional Care Center

Inspectors wroteBased on interview and record review, the facility failed to prevent an avoidable fall for one (Resident 1) of four sampled resident when Resident 1 fell from bed to the floor. This failure resulted in Resident1 fall with injury, hospitalization, and subsequent death. Record review of Resident1's Clinical admission Record, admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, affecting both arms and legs, usually due to a spinal cord injury), a personal history of physical injury and trauma, and dementia (a progressive decline in mental abilities). At the time of the incident, Resident 1 was in room [ROOM NUMBER] bed A. During an observation on [DATE] at 2:05PM in room [ROOM NUMBER], there were three beds (39A, 39B and 39C). Bed A was the first bed near the door, bed with side table beside it. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food safety requirements in accordance with professional standards for food service when: 1. A dirty frying pan was found stacked in between clean frying pans under the food preparation counter. 2. Large metal pans and trays for serving were stacked wet under the food preparation counter. 3. A large can of mushroom was found dented among the undented canned products in the dry storage room. The failure to store clean cooking utensils, wet serving trays and dented canned products has the potential to contaminate other clean cooking utensils and promote growth of food borne illnesses to 133 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide needed care and treatment for two of 25 sampled residents (Resident 32 and Resident 78) when: 1. The facility failed to follow physician's order to obtain monthly measurements of mid upper arm circumference (MUAC, a tool used to assess nutritional status and help identify people at risk for malnutrition or weight loss, allowing for early intervention) for Resident 32 and Resident 78 who were refusing monthly weights. This failure had the potential to result in Resident 32 and Resident 78 to experience unplanned and undesirable weight loss. 2. The facility failed to implement interventions to monitor Resident 78's injection sites for bruising (skin discoloration from damaged, leaking blood vessels underneath your skin). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (medications with high potential for abuse and addiction), appropriate preparation and accurate administration of medications when: 1. The Controlled Drug Records (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for five of seven sampled residents (Residents 105, 119, 81,30 and 36) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications. 2. Nursing staff did not administer correct prescribed medication to one of five residents (Resident 28). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications (drug or medicine, used to diagnose, cure, treat, or prevent disease) and biologicals were properly stored when: 1. The temperature in one of two sampled medication storage rooms did not follow the manufacturer's labeling for proper medication storage. 2. One of two sampled medication storage room refrigerator contained an open and undated multi dose vial (a small bottle of medication that contains more than one dose). 3. Three expired lidocaine (medication that reduces pain) 5% patches were stored in one of three medication carts for Resident 105, readily available for use. These failures had the potential for medications to be ineffective, unsafe for unknown usage timelines and expired that can harm residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control program when: 1. The urinal used by Resident 45 was stowed inside the trash bin at bedside. 2. During collection of soiled linen on the second floor, the janitor did not perform hand hygiene (the practice of cleaning hands to remove germs, dirt, and other contaminants) before and after glove use. 3. Nursing staff did not perform hand hygiene prior to medication preparation and administration for two of five residents (Resident 432 and Resident 28) and did not disinfect the blood pressure cuff (a device used to measure the force of blood against the artery walls) before and after use for one of one resident (Resident 432). 4. Nursing staff did not wear gloves during medication administration for one of five residents (Resident 433). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 25 sampled residents (Resident 92 and Resident 7) were treated with dignity and respect when Certified Nursing Assistants (CNA 1 and CNA 2) were standing over residents while assisting them to eat. This failure resulted in the potential for Resident 92 and Resident 7 to feel disrespected and the potential to affect the resident's psychosocial (mental, emotional, social, and spiritual effects) well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe self-administration of medications for one of 25 sampled residents (Resident 78) when: a. Multiple prescription medications were left at Resident 78's overbed table. b. The interdisciplinary team (IDT- a group of professionals from different disciplines who work together to achieve a common goal) did not determine if the prescription medications left on the overbed table may be self-administered by Resident 78. These failures resulted in the potential for medication error and may place residents on self-administration of medication at risk for adverse health reactions which could negatively impact the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents reviewed (Resident 28) was free from unnecessary medication when Resident 28 has no evidence of monitoring for bleeding for the use of heparin (anticoagulant-commonly known as a blood thinner, a medication that prevents blood clots from forming in the heart and blood vessels). This failure had the potential to result in undetected medication adverse effects, such as bleeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents reviewed (Residents 32 and 121) were free from unnecessary antipsychotic (drug that affects brain activities associated with mental process and behavior) medications when: 1. There was no evidence of non-pharmacological interventions and PRN (as needed) Seroquel (quetiapine, an antipsychotic medication) was ordered for more than 14 days for Resident 32; 2. There was no evidence of specific behavioral monitoring for Seroquel use for Resident 121. These failures had the potential to result in unnecessary use of medications that could cause somnolence (sleepiness), dry mouth and dizziness. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences for two out of 133 residents (Residents 36 and Resident 68) were honored when: 1. Resident 36 was served hard carrots with order of SOFT VEGETABLES. Texture: Mechanical Soft. 2. Resident 68 was plated the regular menu of fried rice, mixed veggies, and pork slices, when his meal ticket indicated, Serve Chow Mein with chicken OR potstickers. This failure had the potential for residents not receiving their food preferences that will result to poor appetite, and missing the nutritive value of their food leading to weight loss and/or malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 47 of 48 residents' rooms met the required minimum of 80 square feet (sq ft) per resident. This failure has the potential affecting residents' comfort, privacy and overall quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment was completed within the required period of 14 days of admission for Resident 1. Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plan was developed within 48 hours of admission for Resident 1. A Baseline Care Plan (BCP) includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Failure to complete the baseline care plan within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 1.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure resident food preferences were provided for 1 (Resident #115) of 4 sampled residents reviewed for food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff verified that the physician obtained informed consent for administering psychotropic medications before administering psychotropic medications (medications that affected residents' mood and behavior) to one out of 24 sampled residents, and one un-sampled resident, Resident 42, and 54. 1. For Resident 42, the facility failed to verify that the physician and the resident's representative signed the psychotropic medication informed consent form. 2. For Resident 54, the facility failed to verify that the physician signed the psychotropic medication informed consent form. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to verify resident's ability to self-administer medication, and did not ensure that interdisciplinary team (IDT) evaluated the safety of resident's self-administration of the medication, for one un-sampled resident, Resident 93. This failure had a potential to expose all residents requesting to self-administer medications to the risk of adverse drug events (medication related harm during care activities), with the potential to result in residents' injuries, and compromising their health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medication according to nationally recognized professional standards of practice for two out of 24 sampled residents, and five un-sampled residents, Resident 26, 27, 42, 63, 73, 91, and Resident 93. This failure had potential to expose all residents receiving medication at the facility to the risk of adverse drug events (harm resulting from medication related care activities), with the potential to result in residents' medication related harm, and compromising their health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident (Resident 59), prescribed enteral tube feeding was followed when: a) Resident 59 received the wrong prescribed enteral nutrition (known as tube feeding [TF]- a way of delivering nutrition/food directly to the stomach or small intestine) formula . b)The TF site dressing was not changed on 4/8/21. This deficient practice has the potential for Resident 59 to receive low caloric requirement resulting in malnutrition, dehydration, and weight loss. This deficient practice has the potential for Resident 59's TF site to develop growth of organisms that will cause infection. Resident had history of sepsis. Resident 59 was observed receiving enteral nutrition through his gastric tube (G-tube - a medical device used to provide nutrition to people who are unable to swallow. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications labeling included current expiration dates, and staff followed cautionary instructions documented on medication labels, for one of 24 sampled residents, in one out of six medication carts, and one out of three refrigerators. 1. For Resident 91, the facility failed to ensure staff followed cautionary instructions documented on medication label before administering medication to her. 2. For Second Floor Medication Room Refrigerator and Third Floor Medication Cart 2, the facility failed to ensure that staff did not store medication with expired dates. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 48 of 48 residents' rooms measured at least 80 square feet (sq ft) per resident. This failure had the potential to negatively impact residents' provision of care and quality of life.