Avon Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Avon Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 21, 2022

  Based on observation, interview, and record review, the facility failed to prevent falls with injuries for residents with histories of numerous falls which resulted in harm when Resident E was admitted to the hospital with a subarachnoid hemorrhage; and the facility failed ensure fall interventions were personalized, updated, effective, and followed for 4 of 4 residents reviewed for accidents (Residents E, C, D, and P). Findings include: 1. During an interview on 4/19/22 at 10:06 a.m., Resident E's Power of Attorney (POA) indicated she was angry and upset with the facility staff. Resident E had multiple falls during her short time in the facility after being admitted for rehabilitation and diagnoses to include seizures. […]

• No harm, potential for more than minimal, patternF761Feb 26, 2026

  Based on observations and interviews, the facility failed to ensure medications and topical gels were labeled and stored appropriately in medication carts and failed to ensure expired medications were not stored on medication carts or in the medication storage room refrigerator. This deficient practice had the potential to affect 60 of 60 residents residing on 100, 300, and 400 halls (Residents 128, 127, 74, 26, 132, 75, and 80). Findings include:On 2/23/26 at 10:00 a.m. the 100-hall medication cart was reviewed with Licensed Practical Nurse (LPN) 5. The findings were as follows: 1. Resident 128 had an Incruse Ellipta (a once-daily, long-acting inhaler) 62.5 micrograms (mcg) that had no open date. […]

• No harm, potential for more than minimal, patternF558Jun 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 7 of 13 residents randomly observed for call light placement (Residents D, F, H, L, M, P, and Q). Findings include: 1. During an initial pool interview on 6/19/23 at 10:45 a.m., Resident D was observed lying in bed watching television, her call light button was on her right side down between the bed and mattress out of sight of the resident. Resident D requested assistance with her the call light button as she could not find it. Resident D's record was reviewed on 6/20/23 at 8:42 a.m. Diagnoses on Resident D's profile included, but were not limited to, hemiplegia (paralysis) affecting the right side. […]

• No harm, potential for more than minimal, patternF607Aug 22, 2022

  Based on interview and record review, the facility failed to follow their policy to ensure all newly hired employees had a criminal background check completed and reviewed before starting work at the facility for 1 of 5 randomly selected new hire employees reviewed for criminal background checks (Housekeeper 25). This deficient practice had the potential to effect 120 of 120 residents who resided in the facility. Findings include: On 8/15/22 during the entrance conference State Form 5440, employee records was provided to the Executive Director for completion. On 8/18/22 at 10:15 a.m., the employee record form and 5 new hire employee files, randomly selected, were reviewed. The file for Housekeeper 25, hired on 6/14/22, did not contain a criminal background check. […]

• No harm, potential for more than minimal, patternF684Apr 21, 2022

  Based on observation, interview, and record review, the facility failed to assess, notify of change of condition, and ensure fall interventions were personalized, updated, effective, and followed for 4 of 4 residents reviewed for quality of care (Residents D, P, C, and E). Findings include: 1. Resident D's record was reviewed on [DATE] at 2:01 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS, completed on [DATE], assessed Resident D as having the ability to make himself understood and to understand others. A BIMS score 15 indicated cognitively intact. No signs or symptoms of [CONDITION(S)], behaviors, rejection of care, or wandering were observed. Extensive assistance of two or more persons physical assist required for bed mobility, transfers, toilet use. […]