Avita Health and Rehab at Reeds Cove

In the surveyor’s words

From the most serious findings on record at Avita Health and Rehab at Reeds Cove, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Nov 14, 2024

  The facility reported a census of 29 residents. The sample included three residents reviewed for medications. Based on observation, interview, and record review, the facility failed to prevent the significant medication error of cognitively impaired Resident (R) 1. On 10/11/24, Certified Medication Aide (CMA) R incorrectly administered R2's medications to R1, which included clopidogrel (antiplatelet medication) 75 mg (milligram), morphine (opioid medication used to treat severe pain) extended release (ER) 15 mg, as well as acetaminophen (analgesic) 650 mg. […]

• Actual harm, isolatedF686Apr 24, 2025

  The facility identified a census of 66 residents, with 10 residents sampled. Based on observation, interview, and record review, the facility failed to prevent the development of facility-acquired pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) on Resident (R)1's right and left buttock when staff failed to adequately monitor wounds after the initial development including measurements, presence of infection, drainage and effectiveness of treatments, failed to implement routine repositioning in the bed and the wheelchair until after the wounds progressed, and did not implement standard interventions such as low air loss mattress (a medical-grade mattress… […]

• Actual harm, isolatedF686Nov 30, 2022

  The facility identified a census of 49 residents. The sample included 15 residents, with five residents reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to prevent the redevelopment of a pressure related injury for Resident (R) 33 and failed to ensure pressure reducing measures were in place for R9. […]

• No harm, potential for more than minimal, widespreadF812May 7, 2026

  Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria.Findings included:- The initial kitchen tour of [NAME] house on 05/05/26 at 08:25 AM revealed a plate of food in the refrigerator with no date, ketchup and mustard which lacked an open date, a container of liquid eggs opened half of the container used with no open date. Freezer had an open bag of hotdogs open with no date and crystals on the hotdogs. […]

• No harm, potential for more than minimal, widespreadF812Aug 19, 2024

  The facility reported a census of 57 residents. The facility identified three kitchen/food service areas. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. This placed the affected residents at risk for decreased palatability of food and food-borne illness. Findings included: - Observation of the [NAME] House kitchen, on 08/12/24 at 12:50 PM, with Dietary Staff EE, revealed the following areas of concerns: 1. Dietary Staff EE was unable to locate the thermometers in the upright refrigerator and freezer. 2. In the stand-alone refrigerator; a large zipper style plastic bag of macaroni salad lacked a preparation date, an expirations date, or a label of contents. 3. […]