The Springs of Avalon

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a smoking apron for 3 (Resident #44, Resident #6, Resident #45) of 4 residents on the secured unit who smoked.

Inspectors wroteBased on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure over the counter medications in medication cart #1 were not expired.

Inspectors wroteBased on observation, record review, and interview, and facility policy review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed.

Inspectors wroteBased on observation, facility document review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, interview, and facility policy review, the facility failed to ensure ceiling tiles, dish washing machine, and door frames were free of stains, rotten and chipped wood; cold food items were maintained at 41 degrees Fahrenheit or below; dietary staff washed their hands before handling food items; foods stored in the dry storage area, refrigerator, and freezer were covered, sealed and dated; and expired food items were promptly removed from stock for 2 of 2 meals observed.

Inspectors wroteBased on observation, record review, and interview, it is determined that the facility failed to ensure a resident who was on Transmission Based Precaution had a contact isolation sign in a conspicuous location outside the resident ' s room to alert and instruct staff and visitors to wear personal protective equipment (PPE) while entering the room for 1(Resident #4) of 1 sample mix resident reviewed for Transmission Based Precautions.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to initiate a care plan for elopement risk for 1 (Resident #3) of 1 resident reviewed for high risk elopement.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) of 3 residents reviewed for elopement.

Inspectors wroteBased on observation and interview, the facility failed to ensure foods stored in the dry storage area refrigerator, and freezer were covered, sealed and dated to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness, kitchen wall and door frames, ceiling tiles; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen, kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, dish washer and kitchen walls, door frames and baseboards were free of rotten wood, chipped floor tiles, chipped base board, debris, dirt, grease, grime, rust, stains, and spills; [...]

Inspectors wroteBased on observation, interview and policy review, he facility failed to post, in a form and manner accessible and understandable to residents, contact information for pertinent State agencies and advocacy groups for 20 residents residing in the facility's secure unit (500 Hall).

Inspectors wroteBased on interview, and record review the facility failed to ensure an advance directive were in the electronic record, and readily available for 2 (Resident #31, and Resident #47) of 15 (Resident #9, #17, #19, #23, #24, #28, #30, #31, #32, #46, #47, #49, #52, #57, #265) sampled residents.

Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain the building in good repair by (1) ensuring that bathroom sinks were properly affixed for the restrooms for resident rooms 513, 514, 515, 516, 517, 519 on the secure unit, (2) ensuring that window coverings were not damaged for room [ROOM NUMBER], and (3) ensured that molding remained attached to the wall for room [ROOM NUMBER].

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 (Resident 31) of 9 (Resident #9, #19, #23, #28, #31, #32, #46, #47, #265) sampled residents who depended on staff for shaving were shaved, and the facility failed to ensure nails were cleaned and trimmed for 2 (Resident #31, and Resident #47) of 15 (Resident #9, #17, #19, #23, #24, #28, #30, #31, #32, #46, #47, #49, #52, #57, #265) sampled residents whom depended on staff for nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment was free from accident hazards for two (Rooms 305-A, 306-B, 506, 514, 516, 517, 518, and 519) resident rooms, one whirlpool room, and one secure unit in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 4 (Resident #17, 46, #47, and #57) of 14 (Resident #9, #17, #19, #23, #24, #28, #30, #32, #46, #47, #49, #52, #57, #265) sampled residents received fresh water.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure that handrails were firmly secured and affixed to the walls in the hallway of the secure unit (500 Hall), which had the potential to affect 13 residents assessed as ambulatory residing on the unit.

Inspectors wroteBased on interview and record review the facility failed to perform a Neurological Assessment after an unwitnessed fall for 1 (Resident #264) of 6 (Resident's #3, #24, #47, #49, #264, #265) sample mix residents were reviewed for falls. The Administrator provided a list at 1:24 PM on 2/2/2024 titled, Resident's with an unwitnessed fall since 9/1/2023.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items stored in the refrigerator and/or freezer were covered and sealed; dietary staff washed their hands before handling clean equipment or food items; and hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and the ice machine was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 69 residents who received meals from the kitchen (total census: 72), as documented on a list provided by the Dietary Supervisor on 10/25/2022.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents' fingernails were cleaned to promote good personal hygiene and grooming for 2 (Residents #61 and #44) of 5 (Residents #17, #39, #44, #227 and #61) sampled residents who resided on the 500 hall and were dependent on staff for nail care and failed to ensure residents received showers and/or baths and were shaved regularly and consistently to maintain good personal hygiene and prevent odors for 1 (Resident #69) of 4 (Residents #69, #34, #14 and #50) sampled residents who resided on the 100 hall and were dependent on staff for personal hygiene/showers.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care and services to maintain acceptable parameters of nutritional status were maintained and nutritional interventions ordered by the physician were offered, to minimize further weight loss and maintain nutritional status for 2 (Residents #39 and #43) of 5 (Residents #17, #43, #22, #24 and #39) sampled residents who had a weight loss in the last six months.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 53 residents who received regular diets and 14 residents on mechanical soft diets from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 10/25/2021.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practice had potential to affect 19 residents who received meal trays in their rooms on the 100 Hall and 9 residents who received meal trays in their rooms on 300 Hall and 18 residents who received their meal trays in their rooms on 400 Hall, as documented on a list provided by Dietary Supervisor.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 2 residents who received pureed diets, as documented on a list provided by the Dietary Supervisor on 10/25/2022.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a dressing for a non-pressure-related skin condition was properly labeled for 1 (Resident #227) of 5 (Residents #17, #70, #43, #14 and #227) sampled residents who had physician orders for dressing changes.