The Avenues Transitional Care Center

In the surveyor’s words

From the most serious findings on record at The Avenues Transitional Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 2, 2025

  Based on interview and record review, the facility failed to prevent an avoidable fall for one (Resident 1) of four sampled resident when Resident 1 fell from bed to the floor.This failure resulted in Resident1 fall with injury, hospitalization, and subsequent death. Record review of Resident1's Clinical admission Record, admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, affecting both arms and legs, usually due to a spinal cord injury), a personal history of physical injury and trauma, and dementia (a progressive decline in mental abilities). At the time of the incident, Resident 1 was in room [ROOM NUMBER] bed A. […]

• No harm, potential for more than minimal, widespreadF812Mar 24, 2025

  Based on observations, interviews and record reviews, the facility failed to ensure food safety requirements in accordance with professional standards for food service when: 1. A dirty frying pan was found stacked in between clean frying pans under the food preparation counter. 2. Large metal pans and trays for serving were stacked wet under the food preparation counter. 3. A large can of mushroom was found dented among the undented canned products in the dry storage room. The failure to store clean cooking utensils, wet serving trays and dented canned products has the potential to contaminate other clean cooking utensils and promote growth of food borne illnesses to 133 residents. Findings: 1. […]

• No harm, potential for more than minimal, patternF684Mar 24, 2025

  Based on observation, interview, and record review, the facility failed to identify and provide needed care and treatment for two of 25 sampled residents (Resident 32 and Resident 78) when: 1. The facility failed to follow physician's order to obtain monthly measurements of mid upper arm circumference (MUAC, a tool used to assess nutritional status and help identify people at risk for malnutrition or weight loss, allowing for early intervention) for Resident 32 and Resident 78 who were refusing monthly weights. This failure had the potential to result in Resident 32 and Resident 78 to experience unplanned and undesirable weight loss. 2. […]

• No harm, potential for more than minimal, patternF755Mar 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (medications with high potential for abuse and addiction), appropriate preparation and accurate administration of medications when: 1. The Controlled Drug Records (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for five of seven sampled residents (Residents 105, 119, 81,30 and 36) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications. 2. Nursing staff did not administer correct prescribed medication to one of five residents (Resident 28). 3. […]

• No harm, potential for more than minimal, patternF761Mar 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure medications (drug or medicine, used to diagnose, cure, treat, or prevent disease) and biologicals were properly stored when: 1.The temperature in one of two sampled medication storage rooms did not follow the manufacturer's labeling for proper medication storage. 2.One of two sampled medication storage room refrigerator contained an open and undated multi dose vial (a small bottle of medication that contains more than one dose). 3.Three expired lidocaine (medication that reduces pain) 5% patches were stored in one of three medication carts for Resident 105, readily available for use. […]