Wellbrooke of Avon

In the surveyor’s words

From the most serious findings on record at Wellbrooke of Avon, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 25, 2022

  A. Based on observations, interviews, and record reviews, the facility failed to ensure a resident received appropriate care and services to prevent complications with his biliary drainage catheter (a thin, hollow tube which is inserted into the liver through the skin which collects bile that is drained from the liver), which resulted in actual harm when a full physician order set with care instructions for flushing the tube was not re-initiated after a hospital stay and the tube became obstructed for 1 of 1 resident reviewed for biliary drainage catheter (Resident 13). B.Based on interviews and record reviews, the facility failed to ensure neurochecks were assessed after a resident fell for 1 of 1 resident reviewed for post fall procedure (Resident 98). C. […]

• Actual harm, isolatedF689Oct 25, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident was not outside smoking at a smoke-free facility and did not sign out for a leave of absence when leaving the building for 1 of 1 resident reviewed for smoking (Resident 32) and failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents reviewed for accidents (Resident 14, 21, and 32). Findings include: 1. On 10/18/22 at 4:06 p.m., Resident 32 was observed outside the facility building smoking a cigarette. She was at the edge of the parking lot almost behind a car. No staff were with her. Resident 32 indicated she was a nurse and was alert and oriented x 4 (person, place, time, and event). […]

• Actual harm, isolatedF697Oct 25, 2022

  Based on observation, interview, and record review, the facility failed to ensure enough medication was administered to manage pain resulting in harm when the resident was in acute pain and yelling out during a wound treatment for 1 of 2 residents reviewed for pain management (Resident 98). Findings include: On 10/20/22 at 9:56 a.m., Resident 98 record was reviewed. She was admitted on [DATE]. A progress note, dated 10/6/22, indicated Resident 98 was seen by the Nurse Practitioner (NP) 28 at 10:41 a.m. Her findings included, but were not limited to, the resident was seen for an initial visit related to an infected sacral wound. The resident was in the hospital due to a fall and developed the sacral wound. […]

• No harm, potential for more than minimal, patternF711Mar 7, 2025

  Based on interview and record review, the facility failed to ensure Medical Providers entered their visit assessments, summaries, and/or progress notes into the resident's medical records timely for facility staff access. Theis deficient practice had the potential to effect of 6 of 13 residents records reviewed, (Residents 1, 9, 12, 14, 16, and 99). Findings include: On 3/6/25 at 9:17 a.m., Residents 1, 9, 12, 14, 16, and 99's records were reviewed related to Medical Provider documentation into the electronic health record (EHR) for timely submission and access to facility staff as a part of resident's continuity of care. The following pattern of more than 3 business days late were noted: 1. Resident 1 was a long-term care resident who had resided in the facility for more than a year. […]

• No harm, potential for more than minimal, patternF657Feb 2, 2024

  Based on record review and interview, the facility failed to implement complete, person centered care plans for 4 of 4 residents reviewed for advance directive care plans (Residents 19, 26, 33 and 146). Findings include: 1. On 1/31/24 at 1:51 p.m., a record review was completed for Resident 19. She had the following diagnoses which included but were not limited to encephalopathy, urinary tract infection, heart disease, obesity, dementia, and low back pain. Resident 19 had an order for DNR (do not resuscitate). Resident 19's care plan indicated .Resident/resident representative have chosen the following advanced directives, residents 2 daughters are her health care representatives, code status reviewed. The care plan lacked resident specific choices and person centered information. 2. […]