Avantara Norton

In the surveyor’s words

From the most serious findings on record at Avantara Norton, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 9, 2023

  A. Based on observation, interview, record review, and policy review, the provider failed to ensure staff were competent to safely use the mechanical lift equipment and provided with accurate information about each resident's transfer equipment needs, including sling size, for eight of twelve sampled residents (1, 9, 24, 32, 33, 77, 79, 244). Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 10/31/23 at 7:03 p.m. to administrator A for F689 Accidents related to accurate assessment and care planning for the use of mechanical lifts and body slings: *Multiple staff interviews revealed staff were unable to state where they would find the transfer recommendations for residents, which included the appropriate mechanical lift and the… […]

• Immediate jeopardy, isolatedF692Oct 4, 2022

  Based on observation, interview, and record review, the provider failed to ensure maintenance of hydration status for one of one resident (16). Findings include: 1. Observation and interview on 9/27/22 at 9:59 a.m. revealed resident 16: *Was in bed with the head of the bed raised and an overbed table on wheels positioned in front of her. A big water mug with a straw was on the overbed table. *Had patches of flaky skin on her lips and teeth appeared dull with yellow build-up and dry. *Moved her arms about in uncontrollable jerking movements. *Spoke with a muffled sound and moved her lips only slightly when she confirmed that she received enough to drink throughout each day. Observation on 9/27/22 at 12:10 p.m. […]

• Actual harm, patternF675Mar 5, 2025

  Based on observation, interview, record review, resident council interview, and policy review, the provider failed to ensure prompt response to call lights and necessary care and services were provided for eight sampled residents (4, 6, 12, 47, 51, 64, 65, and 349) and four additional council meeting residents (3, 10, 61, and 62) to maintain their physical, mental, and emotional well-being. Residents reported frustration, sadness, incontinence, and pain related to the delay in staff's response to their call lights and requests for assistance. Findings include: 1. Interview on 2/25/25 at 6:57 a.m. […]

• Actual harm, patternF686Nov 9, 2023

  Based on observation, interview, record review, and policy review, the provider failed to ensure interventions that had been put in place were consistently implemented and documentation was consistent for four of four sampled residents (3, 37, 39, and 193) who developed pressure ulcers after admission to the facility. Findings include: 1. Interview on 10/31/23 at 10:30 a.m. with resident 193's wife revealed she had found a large blister on his right heel the previous night. She was surprised staff had not found it. She had informed the nurse at that time. The nurse had placed a foam dressing over his right heel the morning of 10/31/23. They had given him heel protector boots. He had told her his heels were causing him pain. Observation and interview on 10/31/23 at 10:30 a.m. […]

• Actual harm, patternF725Nov 9, 2023

  45383 Based on observation, interview, record review, and policy review, the facility failed to ensure sufficient nursing staff to provide care or complete/accurate documentation for 41 of 54 residents reviewed during the survey (1, 3, 5, 6, 7, 9, 10, 11, 12, 19, 23, 24, 26, 28, 32, 33, 36, 37, 38, 39, 46, 53, 58, 60, 62, 64, 67, 71, 72, 73, 74, 75, 77, 79, 81, 84, 87, 91, 193, 244, and 253). The census of the facility was 95 at the time of the survey. These failures placed residents at risk for unmet care needs and negative outcomes. Findings include: 1. […]