Inspection Reports for
Avantara Redfield

The provider failed to ensure that food temperatures were consistently monitored and documented according to policy. Documentation was missing for many meals in March and April 2025 despite staff instructions and a new system implemented to improve compliance.

The visit was complaint-related based on a facility-reported incident involving a resident served a food item with a documented allergy. The complaint was substantiated as the resident experienced an allergic reaction requiring emergency care.

The provider failed to ensure the safety of a resident by serving a food item containing strawberries despite a documented allergy. Corrective actions included staff education, audits, and policy reinforcement, leading to the non-compliance being considered past.

The facility failed to maintain a clean and homelike environment, ensure safe respiratory care, and uphold food safety standards. Several kitchen equipment items were not in safe working condition, and multiple hygiene and sanitation deficiencies were observed.

The investigation was triggered by complaints regarding two residents who eloped from the facility. The incidents were substantiated based on facility-reported incidents, record reviews, observations, and staff interviews confirming failures in supervision and safety protocols.

The provider failed to ensure the safety of two residents who eloped and were outside the facility unsupervised for extended periods. Deficiencies included staff not supervising residents properly, failure to reactivate door alarms, and inadequate monitoring of Wanderguard devices. Corrective actions and education were implemented after the incidents.

The complaint investigation found that wound care treatments for resident 2 were not consistently completed or documented as ordered. The resident reported missed dressings by night shift nurses. The provider confirmed missed documentation and lack of physician notification. Interviews with staff revealed inconsistent communication and documentation practices. The resident did not refuse care as per staff interviews.

The provider failed to ensure wound care treatments were completed and documented as ordered for one resident. Documentation gaps and missed treatments were identified, and communication failures regarding missed treatments and physician notification were noted.

The investigation was complaint-driven, focusing on allegations that residents were not receiving tub baths due to a non-functional whirlpool tub and that showers were not consistently offered or given. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to provide a functional whirlpool tub for residents who preferred tub baths and did not consistently offer scheduled showers to residents, resulting in some residents going weeks without showers. Multiple residents were observed with greasy, unkempt hair and body odor, and staff documentation of showers was inconsistent.

The facility failed to maintain a safe, clean, and homelike environment with multiple physical deficiencies such as spider webs, peeling wallpaper, damaged doors, and non-functional equipment. Additionally, the provider failed to ensure all residents received scheduled showers or baths due to a non-functional whirlpool tub and staffing issues.

The facility was found deficient in multiple areas including failure to meet individual resident needs such as lack of appropriate bariatric equipment, incomplete advance directive documentation, unclean and cluttered environment with strong urine odors, inadequate care plans addressing resident needs, medication administration errors, insufficient activity programming, pressure ulcer prevention failures, unsanitary kitchen conditions, and lapses in infection prevention and control practices.