Avamere Rehabilitation at Park West

In the surveyor’s words

From the most serious findings on record at Avamere Rehabilitation at Park West, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 6, 2024

  Based on observation, interview, and record review, the facility failed to consistently implement Infection Control (IC) and Infection Prevention (IP) practices and initiate outbreak management interventions to prevent transmission of COVID-19 (a highly contagious infectious disease, causing respiratory illness with symptoms including cough, fever, malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) for 29 of 39 current sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, & 29) who tested positive for COVID-19 and some who had respiratory symptoms including cough, sore throat, headache,… […]

• Immediate jeopardy, isolatedF610Mar 21, 2023

  Based on observation, interview, and record review the facility failed to thoroughly investigate contributing factors, rule out abuse/neglect, and implement appropriate corrective actions after a resident elopement (unsafe exiting of the building to an unsecure area without direct supervision) for 1 of 5 Residents (Resident 1) reviewed for elopement. This failure placed Resident 1 in immediate jeopardy for failing to investigate and identify system failures that allowed the resident to elope without staff knowledge, and placed all residents identified as elopement risk at further risk for harm and injury related to leaving the facility unsupervised. […]

• Actual harm, isolatedF686Oct 7, 2024

  Based on interview and record review the facility failed to implement interventions to protect resident's skin from injury, accurately identify, assess, document, and report changes in skin integrity for 1 of 3 residents (Resident 1) reviewed for Pressure Ulcer/Pressure Injury (PU/PI). Resident 1 experienced harm when they developed five new PU/PIs and pain. This failed practice placed residents at risk for skin injuries, PUs/PIs, and diminished quality of life. Findings included . The National Institutes of Health (NIH) website showed a Pressure Injury (PI) was localized damage to the skin and underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury could present as intact skin or an open ulcer and may be painful. […]

• Actual harm, isolatedF689Mar 21, 2023

  Based on observations, interviews, and record review, the facility failed to maintain an environment free of hazards. The facility failed to ensure supervision, development and implementation of policies and procedures to ensure safety devices such as footrests (FR) were in place on residents' wheelchairs (W/C), which placed residents (3, 17, 2, & 18) at risk of injury and contributed to Resident 3's fall and significant injury when their foot hit the ground, when propelled in their W/C without FRs. The facility failed to ensure adequate supervision and monitoring for 2 of 5 residents (Resident 2 & Resident 10) who smoked and failed to ensure medications were secured on 1 of 6 medication carts which placed residents at risk for accidents, injury, and diminished quality of life. […]

• No harm, potential for more than minimal, widespreadF880Jul 10, 2023

  Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) to help prevent the transmission of communicable diseases, including COVID-19 (a highly transmissible infectious virus that causes respiratory illness, in severe cases can cause difficulty breathing, and could result in impairment or death) for 41 of 42 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, & 41) reviewed who tested positive for COVID-19 during an facility outbreak and 1 resident (Resident 42) who was reviewed for Transmission Based Precautions (TBP- specific protocols based on disease transmission to help… […]