Inspection Reports for
The Avenues Transitional Care Center

The complaint investigation substantiated that Resident 1 fell from bed due to staff leaving the resident unattended in an unsafe position without proper fall prevention measures. The fall resulted in injury, hospitalization, and death. Staff interviews and record reviews confirmed failure to use a low air loss mattress and inadequate training of CNA 1.

The facility failed to prevent an avoidable fall for Resident 1, who was left unattended in a high bed position with bed rails down. The fall caused serious injuries including a traumatic brain injury leading to death. The investigation revealed inadequate supervision, failure to use a low air loss mattress, and lack of proper staff training on fall prevention.

The facility failed to prevent an avoidable fall of a resident resulting in injury, hospitalization, and subsequent death. The investigation revealed inadequate supervision and failure to use a low air loss mattress as ordered, contributing to the fall and injury.

The facility was found deficient in multiple areas including failure to ensure resident dignity during feeding, unsafe medication self-administration practices, failure to monitor nutritional status and injection sites, medication accountability issues, medication errors, improper medication storage, failure to honor food preferences, infection control lapses, and inadequate resident room sizes.

The facility had multiple deficiencies including failure to ensure resident dignity during feeding, unsafe medication self-administration, failure to monitor nutritional status and injection sites, medication accountability issues, improper medication storage, failure to honor food preferences, infection control lapses, and inadequate room sizes.

The facility failed to complete the Minimum Data Set comprehensive assessment within the required 14-day period for Resident 1, completing it 23 days after admission. Additionally, the baseline care plan was not developed within 48 hours of admission as required, being completed on day 8 instead. These delays could result in delayed identification of resident needs affecting their physical, mental, and psychosocial well-being.

The facility failed to complete the Minimum Data Set (MDS) comprehensive assessment within the required 14-day period for a newly admitted resident and also failed to develop a baseline care plan within 48 hours of admission for the same resident.

The facility failed to ensure that resident food preferences were consistently honored, specifically for Resident #115 who requested ice cream with lunch and dinner but did not receive it as documented. Interviews and record reviews confirmed the failure to provide requested food items despite documented orders and facility policies.

The complaint was substantiated. Resident #115 and family reported the resident did not receive ice cream as requested. Staff interviews confirmed lack of awareness of the resident's food preferences. The Dietary Manager and facility leadership acknowledged the failure to document and honor the resident's food preferences on tray tickets.

The facility failed to ensure Resident #115 received requested food items such as ice cream with lunch and dinner as documented in the care plan and dietary orders. Interviews and observations confirmed the resident was not served ice cream as requested, and staff were unaware of the resident's food preferences not being honored.

The facility failed to ensure medication carts were locked when unattended, lacked required oxygen use signage, and did not maintain proper hand hygiene among staff, increasing risks of medication access by unauthorized persons, fire hazards, and infection spread.

The facility failed to ensure a safe environment by leaving a medication cart unlocked and unattended, lacking fire safety signage for oxygen use in a resident's room, and failing to maintain proper infection prevention practices as multiple staff did not perform hand hygiene between tasks.

The facility failed to update the care plan to include a Low Air Loss mattress as an intervention for a resident with a Stage III pressure injury, delayed implementation of the physician's order for the mattress by 14 days, and did not ensure that two registered nurses had the necessary training and competency to accurately assess and stage the pressure injury. These deficiencies had the potential to delay wound healing and place the resident at risk of further harm.

The facility failed to update the care plan to include a Low Air Loss mattress for a resident with a Stage III pressure injury, delayed implementation of the physician's order for the mattress by 14 days, and did not ensure that two registered nurses had the competency to accurately assess and stage the pressure injury.

The facility failed to verify informed consent for psychotropic medications for two residents, did not properly assess and educate a resident self-administering eye drops, staff signed medication administration records before giving medications, medications with expired dates were found in storage, a resident received the wrong enteral feeding formula and had an outdated feeding tube dressing, and all resident rooms measured less than the required minimum square footage.

The facility failed to ensure informed consent for psychotropic medications was properly obtained and verified, failed to verify resident ability to self-administer medication safely, failed to administer medications according to professional standards, failed to follow prescribed enteral feeding protocols, failed to ensure medication labeling and storage compliance, and did not meet minimum room size requirements for residents.