Avoca Specialty Care

In the surveyor’s words

From the most serious findings on record at Avoca Specialty Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Mar 30, 2022

  Based on observations, clinical record review, and staff, resident and family interviews, the facility failed to ensure that based on a comprehensive assessment, staff provided care consistent with professional standards to prevent pressure ulcers from developing unless the individual's clinical condition demonstrated that they were unavoidable. The facility also failed to ensure residents with existing pressure sores received necessary treatment, care, and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 4 residents reviewed (Resident #1, #5, #9, and #15). […]

• Actual harm, isolatedF686Aug 8, 2023

  Based on observations, interviews and record review the facility failed to monitor and prevent the worsening of pressure sores for 1 of 2 residents. Resident #9 was admitted on [DATE] with a chronic skin issue on his left heel. It wasn't identified or documented until 6/20 and staff failed to get an order for treatment until 8/3. He also had an open sore on his right foot that had not been identified or documented until 8/3. The facility also failed to implement preventative interventions to facilitate healing. The facility reported a census of 36 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• Actual harm, isolatedF684Mar 30, 2022

  Based on clinical record review, staff and physician interview, and facility policy review, the facility failed to provide the necessary assessments and timely interventions for 2 of 5 residents reviewed that experienced a significant change in their physical, mental, or psychosocial condition (Resident #5 & #8). The facility identified a census of 39 residents. Findings include: According to the MDS assessment tool dated 1/21/22 Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident demonstrated severe cognitive impairment by scoring 0 of 15 possible points on the Brief Interview for Mental Status (BIMS) test. The MDS also documented Resident #8 required extensive assistance of 2 staff members for bed mobility, transfers and dressing. […]

• No harm, potential for more than minimal, widespreadF801Feb 1, 2024

  Based on personnel document review, staff interviews and facility policy review the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 40 residents. Findings include: On 1/30/24 a request for documentation from Staff O Dietary Manager, of qualifications for dietary manager revealed no certification or documentation. Interview on 1/30/24 at 9:02 AM, with Staff O revealed she was currently in charge of running the kitchen. […]

• No harm, potential for more than minimal, widespreadF868Feb 1, 2024

  Based on facility document review, policy review and staff interview the facility failed to have the minimum members of the quality assessment and assurance committee meet quarterly. The facility reported a census of 40 residents. Findings include: Review of documents titled, Quality Assurance Committee Meeting sign-in from 2/23 through 1/24 revealed 3/23 no DON or Infection Preventionist present, 4/23 no DON present, 5/23 no DON present, 7/23 no DON present, 8/23 no DON or Infection Preventionist present, 9/23 no DON or Infection Preventionist present, 10/23 no Infection Preventionist and only 5 members, and 1/24 only 5 members present for meetings. […]