Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Place during CMS and state inspections, most recent first.
Two residents had inaccurate MDS assessments: one was incorrectly marked as a non-smoker despite documentation and care planning for smoking, and another was documented as not having a colostomy when their care plan included interventions for colostomy care. These inaccuracies were confirmed by facility leadership.
Nursing staff did not properly assess or document care for two residents, including failing to record the rationale for a foot x-ray for one resident and not completing an assessment when another resident reported abdominal pain before hospital transfer. Leadership confirmed the lack of required documentation and assessment by nursing staff.
Failure to Provide Needed Mobility Device: A resident with diabetes, PVD, and an above-the-knee amputation was documented as using an electric scooter or manual wheelchair for mobility, but the scooter battery was not working and the facility did not provide replacement batteries. The resident stated he wanted a manual wheelchair in his room to get out of bed and move around, yet no manual wheelchair was available and the DON confirmed the resident had neither a manual wheelchair nor a working motorized wheelchair.
The facility did not notify the physician or resident representatives when two residents experienced significant changes in condition or were transferred to the hospital. In both cases, documentation confirming required notifications was missing, as verified by staff interviews and record reviews.
A resident with a colostomy did not receive or have documented colostomy care as ordered and per facility policy over several days. Required checks of the stoma site and colostomy bag changes were not documented, and the resident was later hospitalized with complications at the ostomy site, including abnormal bowel color and questionable gangrene.
A facility failed to transmit a resident’s significant change MDS to the state within the required timeframe. The record showed the assessment was not sent until during the survey, and the ADONs confirmed the delay and that one ADON was responsible for transmitting all MDS assessments into the state system.
A resident with multiple chronic conditions tested positive for COVID-19 and was placed on COVID isolation, with additional lab, imaging, and medication orders entered. However, the care plan contained no focus area, goals, or interventions for the COVID diagnosis, and the DON confirmed no plan of care had been developed.
A resident with dementia and other conditions was involved in an incident where she hit her head on a table. The LPN attempted to notify the resident's physician but was unable to due to outdated contact information, resulting in a failure to communicate the incident. The Interim DON confirmed the LPN should have notified the physician, indicating a deficiency in the notification process.
The facility failed to provide adequate pressure ulcer care for two residents. A resident with moderate cognitive impairment was found with an open pressure ulcer on her heel, without a pressure-relieving device in place, despite previous complaints of pain. Another resident with severe cognitive impairment and a Stage II pressure ulcer on the hip was observed sitting in a geri chair without a pressure-relieving device, risking further skin breakdown.
The facility failed to document and assess incidents involving assistive devices for two residents with severe cognitive impairments. One resident slid under a lap tray and fell, while another broke a lap tray and slid to the floor, resulting in a skin tear. Neither incident was documented in an Incident/Accident Report, nor were the residents assessed for the appropriateness of the assistive devices.
A facility failed to ensure proper dialysis care for a resident with end-stage renal disease by not monitoring fluid intake as per physician orders. Despite a 1000 cc fluid restriction, staff interviews revealed that no fluid intake log was maintained, and the ADON confirmed the lack of documentation.
The facility failed to assess the risk of entrapment from bed rails for four residents before installation, despite policy requirements. Observations revealed residents with cognitive impairments and mobility issues had bed rails raised without documented assessments. Interviews confirmed the lack of assessments.
The facility experienced a medication error rate of 10.71%, exceeding the acceptable threshold of 5%. An LPN administered incorrect dosages of Furosemide and Gabapentin to a resident, and another resident received an incorrect dosage of Fludrocortisone. These errors were confirmed by the ADON during an interview.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling medical devices, as required by their policy. Observations showed that these residents did not have EBP signage on their doors, despite having conditions that necessitated such precautions. Interviews confirmed the oversight in communicating and implementing the EBP policy.
The facility failed to notify the appropriate parties of changes in resident conditions. A resident with severe cognitive impairment experienced a fall, but the family was not informed by the LPN. In another case, a resident with moderate cognitive impairment was found with multiple bruises, but the nursing administration was not notified as required by policy.
The facility failed to ensure residents were free from physical restraints used for convenience, as three residents were observed with lap trays without proper documentation or physician orders. Despite severe cognitive impairments, these residents were not monitored for the release of restraints as required by policy, and staff confirmed these deficiencies.
A facility failed to notify a resident and their representative of hospital transfers and did not inform the Ombudsman. The resident was transferred twice without proper notification, as confirmed by the Ombudsman and facility records.
The facility failed to complete quarterly MDS assessments for two residents as required by CMS. One resident's last assessment was in late June, and the other in early June, with no subsequent assessments documented within the required three-month period. The ADON confirmed the oversight.
A facility failed to ensure accurate MDS documentation for a resident's discharge status. The MDS indicated a discharge to the hospital, but nurse's notes and staff interviews confirmed the resident was discharged to home, revealing a documentation inaccuracy.
A facility failed to document the required assessment of a resident's urine character every shift, as outlined in the care plan for a resident with an indwelling urinary catheter. Despite the resident's cognitive intactness and need for substantial assistance, the necessary documentation was absent, which was confirmed by the Assistant Director of Nursing.
A facility failed to maintain a resident's personal hygiene by not keeping their fingernails trimmed. The resident, with severe cognitive impairment and dependent on staff for daily living activities, had long and untrimmed nails despite a care plan for daily nail cleaning. Observations confirmed the deficiency, and the Activity Director addressed the issue after being notified.
A resident with severe cognitive impairment and hand contractures was observed without necessary hand rolls, which are crucial for maintaining range of motion. The LPN was unaware of this oversight, and the resident's care plan lacked documentation addressing the hand contractures, indicating a failure in providing appropriate care.
A facility failed to monitor edema in a resident who was prescribed Lasix, a diuretic, for edema management. The resident had multiple diagnoses, including depression, hypotension, and edema, and required assistance with daily activities. Despite a care plan that included monitoring for hypertension/hypotension and administering medications as ordered, there was no documentation of edema checks. This deficiency was confirmed by the ADON.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of three sampled residents. For one resident with multiple diagnoses including heart disease, dementia, and chronic obstructive pulmonary disease, the MDS assessment inaccurately documented the resident as a non-smoker. However, record reviews and staff interviews confirmed that the resident was identified as a smoker upon admission, had a smoking assessment completed, and had a care plan in place addressing smoking safety, with cigarettes and lighter kept at the nurse's station. Both the administrator and assistant directors of nursing confirmed the omission on the MDS assessment. For another resident with diagnoses including Parkinson's disease and chronic obstructive pulmonary disease, the MDS assessment inaccurately indicated the absence of an ostomy and dependence with toileting hygiene. In contrast, the resident's care plan documented a colostomy and included interventions for colostomy care and monitoring for skin breakdown. The director of nursing confirmed that the MDS assessment was inaccurate regarding the resident's colostomy status.
Failure to Ensure Nursing Staff Competency in Resident Assessment and Documentation
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skills in the assessment and documentation of care for two residents. For one resident with a history of cerebral infarction, biliary cirrhosis, heart failure, diabetes, and gout, there was no documented assessment or rationale in the medical record to support the completion of a left foot x-ray. Both the Director of Nursing and the Administrator confirmed that there was no evidence of an assessment or explanation for the x-ray performed. For another resident with diagnoses including Parkinson's Disease, COPD, hypertension, GERD, pain, and edema, nursing staff did not complete or record an assessment when the resident complained of abdominal pain prior to being transferred to a hospital. Interviews revealed that the LPN involved did not recall the resident's code status and believed the decision to transfer was made by hospice staff. Hospital records later showed the resident was diagnosed with a perforated sigmoid colon requiring surgery. The Director of Nursing confirmed there was no documentation to support that a competent assessment was performed by the LPN.
Failure to Provide Needed Mobility Device
Penalty
Summary
The facility failed to reasonably accommodate Resident #28’s needs and preferences by not providing a manual wheelchair when the resident’s electric scooter was not functioning. Resident #28 was admitted with diagnoses including diabetes, peripheral vascular disease, and acquired absence of the left leg above the knee. The resident’s quarterly MDS showed a BIMS score of 15, indicating no cognitive impairment, and the annual MDS indicated the resident used an electric scooter or manual wheelchair for mobility. During an observation and interview in the resident’s room, an electric scooter was present, and the resident stated the scooter did not have a working battery and the facility did not provide replacement batteries. The resident also stated he wanted a manual wheelchair in his room so he could get out of bed and move around. A later observation showed there was no manual wheelchair available in the room, and the DON confirmed the resident did not have a manual wheelchair or a working motorized wheelchair in the room and needed a wheelchair for mobility.
Failure to Notify Physician and Representative of Resident Status Changes and Transfers
Penalty
Summary
The facility failed to notify the physician and/or the resident's representative when there was a significant change in the resident's condition or when a transfer to the hospital occurred. For one resident with multiple chronic conditions, including diabetes, chronic kidney disease, atrial fibrillation, gout, and hypertension, there was no documented evidence that the physician or the resident's representative was notified when the resident was transferred to the emergency room. This was confirmed through record review and staff interview, which verified the absence of documentation regarding the required notifications at the time of transfer. In another case, a resident with diagnoses including Parkinson's disease, COPD, hypertension, GERD, pain, and edema experienced a significant change in condition that led to a hospital transfer and subsequent surgery for a perforated sigmoid colon. The responsible party had voiced concerns about the resident's status, and hospice staff were notified, but there was no documentation that the physician was informed of the change in condition prior to the transfer. Staff interviews confirmed the lack of physician notification and documentation regarding the resident's status change.
Failure to Provide and Document Colostomy Care per Orders and Policy
Penalty
Summary
The facility failed to provide colostomy care in accordance with physician orders, professional standards, and the resident's comprehensive plan of care for one resident. The facility's policy required documentation of colostomy care, including the date and time care was provided, the name and title of the caregiver, any skin issues or signs of infection, how the resident tolerated the procedure, and notification of the supervisor for refusals or abnormal findings. For the resident in question, who had multiple diagnoses including Parkinson's Disease and a colostomy, the care plan and physician orders specified that the stoma site should be checked every shift for swelling and redness, and the colostomy bag changed as needed every shift. However, a review of the medical record, medication administration record (MAR), and nursing notes revealed no documentation that colostomy care was performed or that the stoma site was checked from June 28 to July 7. During this period, the resident was later transferred to the emergency department, where hospital records noted abnormal bowel color at the ostomy site and questionable gangrene, requiring surgical consultation. The facility's Director of Nursing confirmed the absence of documentation for the required colostomy care during the specified timeframe.
Delayed Transmission of MDS Assessment
Penalty
Summary
The facility failed to ensure MDS assessments were transmitted to the state within 7 days of assessment for 1 of 3 sampled residents reviewed. Resident #2 was admitted on 05/06/2025, and the record showed a significant change MDS assessment dated [DATE]. Review of the MDS history showed that this assessment was not transmitted to the state until 12/03/2025, during the survey. During an interview on 12/03/2025 at 10:00 a.m., the S5 ADON stated the significant change MDS for Resident #2 had not been transmitted until that date. The S5 ADON reported she was not responsible for MDS transmission, and an interview at 10:10 a.m. with the S4 ADON confirmed she was responsible for transmitting all MDS assessments for the facility into the state system and confirmed she failed to transmit Resident #2's significant change MDS assessment in a timely manner.
No Care Plan Developed for Resident with COVID-19
Penalty
Summary
The facility failed to ensure a comprehensive plan of care was developed for Resident 20 after the resident tested positive for COVID-19. Resident 20 had admitting diagnoses including polyosteoarthritis, seborrheic dermatitis, major depressive disorder, hypertension, history of colon cancer with colostomy placement, and atrial fibrillation. The record showed orders for COVID testing, and laboratory results dated 11/10/2025 confirmed the resident was positive for COVID-19. Additional physician orders dated 11/11/2025 included CBC, CMP, D-dimer twice weekly for 3 weeks, chest x-ray twice weekly for 3 weeks, Vitamin C, Zinc Sulfate, Augmentin, and Azithromycin, and the resident was placed on COVID isolation. Review of the care plan showed no focus area, goals, or interventions were developed for the resident’s COVID diagnosis, and the DON confirmed on interview that no plan of care had been developed when the resident tested positive.
Failure to Notify Physician of Resident Incident
Penalty
Summary
The facility failed to ensure proper notification of a change in a resident's condition, as evidenced by the lack of communication with the resident's physician following an incident. A resident with diagnoses including unspecified dementia, depression, and hypothyroidism was involved in an incident where she hit her head on a table in the day room. The Incident/Accident Reporting Form indicated that the resident was assessed for injuries, and a knot was found on the left side of her head. However, the report inaccurately documented the object as a chair instead of a table. The LPN attempted to notify the resident's physician but was unable to do so because the contact information in the system was outdated, and the phone number was disconnected. Despite efforts to find the correct number, the LPN was unsuccessful, resulting in the physician not being notified of the incident. The Interim Director of Nursing confirmed that the LPN should have notified the physician about the incident, highlighting a deficiency in the facility's notification process.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers for two residents. Resident #6, who had a history of pressure ulcers and moderate cognitive impairment, was observed with her feet pressed against the footboard of her bed, complaining of pain. A CNA discovered an open area with drainage on her left heel, indicating a pressure ulcer. Despite previous complaints of foot pain, the LPN had not assessed the resident's feet, and no pressure-relieving device was in place to prevent further skin breakdown. Resident #52, with severe cognitive impairment and dependent on staff for daily living activities, was observed sitting in a geri chair without a pressure-relieving device. The resident had a Stage II facility-acquired pressure ulcer on the right hip. The absence of a pressure-relieving device in the geri chair was confirmed by the ADON, indicating a failure to prevent further skin breakdown.
Failure to Document and Assess Incidents Involving Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and appropriate use of assistive devices for two residents, leading to incidents that were not properly documented or assessed. Resident #70, who has severe cognitive impairment and multiple medical conditions, was observed using a geri chair with a lap tray. Despite documented behaviors indicating distress and attempts to remove the lap tray, no Incident/Accident Report was completed when the resident slid under the tray and fell to the floor. Additionally, there was no assessment conducted to determine if the lap tray was an appropriate assistive device for this resident. Similarly, Resident #25, also with severe cognitive impairment and dependent on staff for daily activities, experienced an incident where he broke his lap tray and slid to the floor, resulting in a skin tear. This incident was not documented in an Incident/Accident Report, and the resident's care plan was not updated to reflect the fall. These oversights indicate a failure in the facility's processes for monitoring and documenting incidents involving assistive devices, potentially compromising resident safety.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease, hypertensive heart disease, and unspecified psychosis. The resident was admitted with physician orders for dialysis on Monday, Wednesday, and Friday, along with a 1000 cc fluid restriction. However, there was no documentation in the medical record indicating that the resident's fluid intake was being monitored. Interviews with staff, including a Certified Nurse Aid (CNA) and the Assistant Director of Nursing (ADON), confirmed that the staff were not documenting the resident's fluid intake to ensure compliance with the fluid restriction.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails prior to their installation for four out of five residents reviewed. The facility's policy requires an assessment to determine the resident's symptoms, risk of entrapment, and reason for using side rails. However, there was no documented evidence of such assessments for residents #5, #12, #17, and #38. Resident #17, with intact cognition and requiring assistance with activities of daily living, was observed with bed rails raised on both sides of the bed. Despite the facility's policy, there was no documented assessment for the risk of entrapment. Similarly, resident #38, who had moderate cognitive impairment and a history of falling, was observed with bed rails raised, but no assessment for entrapment risk was documented. Resident #12, with moderate cognitive impairment and a history of repeated falls, was observed with bed rails in a locked position, yet there was no documented assessment for entrapment risk. Resident #5, with severe cognitive impairment and requiring substantial assistance, also had bed rails raised without a documented assessment for entrapment risk. Interviews with the Assistant Director of Nursing confirmed the lack of documented assessments for these residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.71% error rate during a medication administration observation. Three medication errors were identified out of 28 opportunities. For one resident, the LPN administered incorrect dosages of Furosemide and Gabapentin, providing 20 mg of Furosemide instead of the prescribed 40 mg, and 100 mg of Gabapentin instead of the prescribed 300 mg. Another resident received only one tablet of Fludrocortisone 0.1 mg instead of the prescribed two tablets, totaling 0.2 mg. These errors were confirmed by the Assistant Director of Nursing during an interview, acknowledging the discrepancies in medication administration as observed during the morning medication pass.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy and procedures for three residents who required such precautions due to their medical conditions. The EBP policy, dated April 1, 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. This policy applies to residents with indwelling medical devices or those colonized with targeted multidrug-resistant organisms. However, observations revealed that residents with indwelling catheters and dialysis access did not have the required EBP signage posted on their doors, indicating a lapse in communication and implementation of the policy. Resident #18, who had a urinary catheter, did not have an EBP sign posted on her door, despite physician orders for EBP during high-contact care activities. Similarly, Resident #28, who had a dialysis access, also lacked the necessary signage. Resident #35, with an indwelling catheter, was observed multiple times without the EBP sign on his door. Interviews with the Assistant Director of Nursing confirmed these oversights, acknowledging that the facility failed to communicate the need for EBP as per their policy.
Failure to Notify of Changes in Resident Conditions
Penalty
Summary
The facility failed to ensure proper notification of changes in resident conditions, as evidenced by two separate incidents involving residents. In the first case, a resident with severe cognitive impairment, as indicated by a BIMS score of 5, experienced a fall. Despite the facility's policy requiring prompt notification of the resident's representative, the attending physician, and the resident themselves, the family of the resident was not informed of the fall by the LPN responsible. This oversight was confirmed through interviews with the LPN and the Assistant Director of Nursing. In the second incident, another resident with moderately impaired cognitive skills, as indicated by a BIMS score of 9, was found to have multiple bruises on her body. The staff failed to notify the nursing administration upon discovering these injuries, which were of unknown origin. The bruises were observed during an inspection by the Assistant Directors of Nursing, who confirmed they were unaware of the injuries prior to the inspection. The facility's policy mandates that staff notify the administration of any injuries of unknown origin, which was not adhered to in this case.
Failure to Monitor and Document Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience. Specifically, three residents were observed using lap trays as restraints without proper documentation or physician orders. The facility's policy requires that restraints only be used with a physician's order and informed consent, and that residents be monitored and the restraints released regularly. However, the facility did not adhere to these requirements for the residents in question. Resident #70, who has severe cognitive impairment and requires assistance with activities of daily living, was observed multiple times sitting in a geri chair with a lap tray. Despite the use of the lap tray being documented as a physical restraint for trunk control, there was no physician's order for its use, nor was there documentation of monitoring the release of the lap tray every two hours as required. The Assistant Director of Nursing confirmed these deficiencies during an interview. Similarly, Resident #52, who also has severe cognitive impairment and is dependent on staff for all activities of daily living, was observed with a lap tray in place without documentation of monitoring for its release. The resident's hands were contracted, indicating an inability to remove the tray independently. Resident #25, with severe cognitive impairment and multiple diagnoses, was also observed with a lap tray without a physician's order or documentation of monitoring. Interviews with staff confirmed these lapses in compliance with the facility's restraint policy.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to a resident and the resident's representative regarding the transfer or discharge to a hospital, as well as the reasons for the move, in writing. Additionally, the facility did not send a copy of the notice to a representative at the Office of the State Long-Term Care Ombudsman. This deficiency was identified for a resident who was transferred to the hospital on two separate occasions. A review of the Emergency Transfer Logs for June and July 2024 revealed that there was no documented evidence of the Ombudsman being notified of the resident's transfers on the specified dates. During a telephone interview, the local Ombudsman confirmed that she had not been notified of these transfers. The facility administrators were informed of these findings.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to conduct quarterly assessments for two residents, as required by the Centers for Medicare and Medicaid Services (CMS). Resident #25 was admitted on an unspecified date, and their last documented Quarterly Minimum Data Set (MDS) Assessment had an Assessment Reference Date (ARD) of 06/25/2024. However, there was no subsequent Quarterly MDS Assessment recorded for this resident. Similarly, Resident #27, also admitted on an unspecified date, had their last Quarterly MDS Assessment with an ARD of 06/04/2024, but no further assessment was documented within the required three-month period. An interview with the Assistant Director of Nursing (ADON) confirmed that the Quarterly MDS Assessments for both residents were not completed within the mandated timeframe. This oversight indicates a failure to adhere to the regulatory requirement of updating each resident's assessment at least once every three months.
Inaccurate MDS Documentation of Resident Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for one of the residents selected for closed record reviews. Specifically, the discharge MDS assessment for a resident indicated that the resident was discharged to the hospital, while a review of the nurse's notes and interviews with the Assistant Director of Nursing and a Licensed Practical Nurse confirmed that the resident was actually discharged to home. This discrepancy highlights an inaccuracy in the documentation of the resident's discharge status.
Failure to Document Urine Assessment for Resident with Catheter
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with an indwelling urinary catheter. The care plan required documentation of the character of the resident's urine, including color, clarity, and odor, every shift. However, a review of the resident's medical records, including the Medication Administration Record (MAR) for September and October 2024, revealed no documented evidence of staff assessing these aspects of the resident's urine as required. The resident, who was cognitively intact and required substantial assistance with activities of daily living, had diagnoses including urinary retention and chronic urinary tract infection. Despite the care plan's directive to assess the urine's character every shift, observations confirmed the presence of the indwelling catheter, but the necessary documentation was missing. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the failure to document the required assessments.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain good personal hygiene. Specifically, the facility did not keep the resident's fingernails trimmed. The resident, who was admitted with diagnoses including dementia, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect, had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene. Despite a care plan that included daily nail cleaning, there was no documented evidence of nail care being provided during the 30-day look-back period. Observations on October 14, 2024, revealed the resident sitting in a geri chair with long and untrimmed fingernails. Later that day, the Activity Director trimmed the resident's fingernails after being notified of their condition. The Activity Director confirmed that the resident's nails needed trimming. The facility's failure to document and provide regular nail care for the resident was noted during the survey, and the Corporate Administrator and Administrator were informed of these findings.
Failure to Provide Hand Rolls for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically in addressing hand contractures. Resident #52, who was admitted with diagnoses including dementia, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect, was observed without hand rolls in place, which are necessary to prevent further decrease in range of motion. The resident had severe cognitive impairment and was dependent on staff for all activities of daily living, including personal hygiene. Despite these needs, there was no documented evidence in the plan of care to address the resident's hand contractures. During an observation, it was noted that the resident was sitting in a geri chair with both hands contracted and closed, without any hand rolls present. When notified, the LPN was unaware of the absence of hand rolls and confirmed that they were supposed to be in place at all times. This oversight indicates a failure in the facility's responsibility to ensure that the resident received the necessary treatment and services to maintain or improve range of motion, as there was no plan of care addressing this specific need.
Failure to Monitor Edema in Resident on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not monitoring edema for a resident who was prescribed a diuretic. The medical record review for the resident revealed an admission with diagnoses including depression, hypotension, edema, hypokalemia, muscle weakness, and anemia. The resident's annual Minimum Data Set (MDS) assessment indicated intact cognition for daily decision-making, and the resident required assistance with activities of daily living. The care plan noted a potential for hypertension/hypotension related to medication use, with interventions to monitor blood pressure, administer medications as ordered, and obtain labs and diagnostic tests as ordered. However, despite a physician's order for Lasix, a diuretic, to be administered every other day for edema, there was no documented evidence of edema checks being performed. This was confirmed in an interview with the Assistant Director of Nursing.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Skilled Nursing And Rehabilitation | 2.5 mi | ★★★★★ | 11 | 0 |
| Mary Goss Nursing Home | 4.1 mi | ★★★★★ | 12 | 0 |
| The Oaks | 4.7 mi | ★★★★★ | 2 | 0 |
| Ouachita Healthcare And Rehabilitation Center | 5.9 mi | ★★★★★ | 5 | 0 |
| Delta Grande Skilled Nursing And Rehabilitation | 6.6 mi | ★★★★★ | 5 | 0 |
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