Avery Nursing Home/Noble Building

In the surveyor’s words

From the most serious findings on record at Avery Nursing Home/Noble Building, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 12, 2023

  Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for mechanical lift transfers, the facility neglected to utilize two staff members while operating the mechanical lift in accordance with physician orders and facility policy resulting in Resident #1 falling from the lift on [DATE] and [DATE]. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included quadriplegia (partial or total loss of function in the arms, legs, trunk, and pelvis) due to a history of right cerebellar infarct stroke and right femoral neck fracture. a. Physician orders dated [DATE] directed (2) assist with mechanical lift transfers. […]

• Immediate jeopardy, isolatedF689Dec 12, 2023

  Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate assistance was provided when operating a mechanical lift in accordance with the plan of care and facility policy, resulting in the resident falling to the floor on [DATE] and [DATE]. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1 diagnoses included quadriplegia (partial or total loss of function in the arms, legs, trunk, and pelvis) due to a history of right cerebellar infarct stroke and right femoral neck fracture. a. Physician orders dated [DATE] directed (2) assist with mechanical lift transfers. […]

• Actual harm, isolatedF689Oct 6, 2025

  Based on review of the clinical record review, facility documentation, and facility policy, and interviews for one of three residents (Resident #1) reviewed for wandering, the facility failed to ensure adequate supervision for a resident with known wandering behaviors to ensure Resident #1 could not leave the unit without staff knowledge resulting in a fall outside the building (last seen 2 hours prior to observed outside). These failures resulted in a finding of immediate jeopardy. […]

• Actual harm, isolatedF684Apr 8, 2025

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls with major injuries, the facility failed to ensure a timely assessment pertaining to bed mobility during provisions of care. As a result, Resident #1 sustained a fall out of bed resulting in multiple subsequent fractures. The findings include: Resident #1's diagnoses included muscle weakness, repeated falls, anxiety disorder and type 2 diabetes with neuropathy (nerve damage affecting the feet and legs that can cause numbness, tingling, pain and loss of sensation). […]

• Actual harm, isolatedF686Aug 8, 2023

  Based on clinical record review, observation, facility policy review, and interviews for one of two sampled residents (Resident #105) reviewed for facility acquired pressure ulcers, the facility failed to ensure interventions were implemented to prevent the development and worsening of a pressure ulcers/injury. The findings include: Resident #105 had diagnoses that included dementia, venous insufficiency, mood disturbance, dysphagia, anxiety, and type II diabetes mellitus. The admission MDS assessment dated [DATE] identified Resident #105 had severe cognitive impairment, required extensive assistance for bed mobility and eating, was non-ambulatory, required total assistance for transfers, hygiene, and toilet use. […]