Avon Nursing Home L L C

In the surveyor’s words

From the most serious findings on record at Avon Nursing Home L L C, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 29, 2023

  Based on observations, interviews and record review conducted during an Abbreviated Survey (#NY00313057) the facility did not ensure the resident environment remained free of accident hazards and each resident received adequate supervision to prevent accidents for one (Resident #1) of six residents reviewed for accidents and hazards. Specifically, the facility did not know at what operating temperatures the in-room heating system should function, had no system or policy in place to monitor operating temperatures or the distance of residents from the in-room heating units required to prevent injury. Subsequently, Resident #1 sustained multiple second-degree thermal injuries on bilateral legs, right shoulder, and right hand from falling out of bed and onto the baseboard heater in their room. […]

• Actual harm, isolatedF692Oct 2, 2024

  Based on observations, interviews, and record reviews conducted during the Recertification Survey from 09/26/2024 to 10/02/2024, the facility failed to ensure services were provided to maintain acceptable parameters of nutritional status for one (Resident #27) of two residents reviewed for nutrition. Specifically, Resident #27 had multiple meal refusals and decreased intakes (less than 50%) for approximately two months resulting in a 31 pound (14.4%) unplanned, severe weight loss. The facility could not provide evidence that nursing leadership, dietary or the medical team had been notified or any supplemental interventions had been implemented. […]

• No harm, potential for more than minimal, isolatedF554Oct 2, 2024

  Based on observations, interviews, and record review conducted during the Recertification Survey from 09/26/2024 to 10/02/2024, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer a medication for one (Resident #7) of six residents reviewed. Specifically, Resident #7 was observed with a prescribed inhaler kept at the beside with no documented evidence that an assessment had been completed to determine their ability to safely self-administer the medication or a physician's order for self-administration. This was evidenced by the following: Review of the facility policy Administering Medications, dated April 2019, revealed that medications are administered in accordance with prescribed orders. […]

• No harm, potential for more than minimal, isolatedF656Oct 2, 2024

  Based on observation, interviews, and record review conducted during the Recertification Survey from 09/26/2024 to 10/02/2024, the facility did not develop and implement a comprehensive plan of care (including measurable goals and interventions) for one (Resident #14) of two residents reviewed for communication and sensory. Specifically, Resident #14's Comprehensive Care Plan did not include that the resident had profound hearing loss, used of an amplifier (hearing aid), or was able to read lips. […]

• No harm, potential for more than minimal, isolatedF641Sep 30, 2021

  Based on interviews and record reviews conducted during a Recertification Survey, completed on 9/30/21, it was determined for 1 (Resident #7) of 14 residents, the facility did not ensure that staff who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's status, needs, strengths and areas of decline, accurately complete the resident assessment. Specifically, Resident #7's Minimum Data Set (MDS) Assessments, dated 5/7/21 and 7/6/21, were incorrectly coded or did not include the resident's Level II Preadmission Screening and Resident Review (PASRR) conditions. […]