Avantara Redfield

Based on interview, resident council meeting, resident council meeting minutes review, grievance forms review, and policy review, the provider failed to ensure that grievances regarding the food quality of residents' meals were addressed, and documentation reflecting the staff's efforts to resolve those grievances was communicated to the residents and approved as effective resolutions for:*Nine of nine residents (13, 18, 19, 22, 24, 36, 40, 50, and 51) who individually reported concerns in grievance records reviewed from July 2025 through January 2026.*Five of five residents (12, 19, 25, 32, and 44) who attended the resident council meeting on 1/26/26. Findings include:1. Interview on 1/25/26 at 12:19 p.m. with resident 4 revealed: *He preferred to eat meals in his room. *When his meal trays were delivered to his room, the food was not always as hot as he thought it should be. 2. Interview on 1/26/26 at 8:45 a.m. with resident 41 revealed: *He preferred to eat meals in his room. *When his meal trays were delivered to his room, the food was not always as hot as he thought it should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to develop a person-centered baseline care plan that included the minimum healthcare information necessary to provide care for four of five newly admitted residents (8, 18, 32, and 33) and failed to ensure the resident's baseline care plan was reviewed with the resident or resident representative within 48 hours of admission for three of five newly admitted residents (18, 32, and 33). Findings include:1. Review of resident 32's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Resident 32's representative and licensed practical nurse (LPN) G signed her baseline care plan on 8/13/25, nine days after she was admitted to the facility. *Resident 32's 8/4/25 baseline care plan did not indicate the level of assistance he required from staff to complete bathing tasks or what diet he should receive at meal times. -Resident requires assistance with ADL's [activities of daily living]: bed mobility, transfers, dressing, personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure staff members followed quality of care practices and professional standards that ensured:*A Roho cushion's (air filled cushion designed for high-level pressure ulcer prevention and treatment) were used and maintained according to manufacturer's instructions for one of one sampled resident (5) with a pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) to her buttocks and upper thighs.*Specialized compression garments had complete physician's orders for use and were applied according to the manufacturer's instructions for one of one sampled resident (5) with lymphedema (tissue swelling caused by blocked lymph node fluid drainage) who used Circaids (adjustable compression garments designed to treat lymphedema, venous insufficiency, and edema).*A urine sample was collected according to the facility's identified professional standard reference by registered nurse (RN) E for one of one sampled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and policy review the provider failed to monitor and document the temperatures for one of one commercial dishwashing machine according to the provider's policy to ensure it reached the minimum rinse cycle temperature of 180 degrees for sanitization of dishes and equipment used to prepare and serve residents' meals after every meal service.Findings include:1.Observation and interview on 1/25/26 at 11:41 a.m. in the main kitchen with dietary aide R revealed:*A clipboard hanging on the wall at the end of the dish machine tray line with dishwasher temperatures on it.*The January 2026 dishwashing machine temperature log did not have temperatures documented for:-Breakfast on 1/12/26, 1/14/26, 1/21/26, and 1/24/26.-Lunch on 1/12/26, 1/14/26, 1/21/26, and 1/24/26.-Dinner on 1/10/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, and 1/20/26.*The manufacturer's sign attached to the dish machine stated:-NSF Machine Operation Requirements as Manufactured by CMA Dish machines.Wash Temperature-Minimum 155 degrees F cycle.Wash cycle Time 49 seconds.Rinse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the provider failed to ensure the staff followed standard infection control practices regarding:*Hand hygiene (handwashing or hand sanitizer use) and gloves used by one of one certified medication aide (CMA) (H), and one of one licensed practical nurse (LPN) (G) while providing personal cares for resident 5.*Hand hygiene and use of personal protective equipment (PPE) (such as a gown, gloves, and mask) by one of one certified nursing assistant (CNA) (S) observed while delivering meal trays to four of four sampled residents (10, 14, 20, and 22) with COVID-19 (a contagious disease that can spread quickly) and on enhanced droplet precautions (which need and a N95 mask (a mask that filters 95 percent of airborne particles), gown, gloves, and eye protection to be worn when entering those rooms) according to the provider's policy. Findings include:1. Observation on 1/25/26 at 11:58 a.m. of CNA S passing lunch trays to residents in their rooms revealed:*On the door of resident 10's room was a sign for enhanced droplet precautions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure two of two sampled resident's (25 and 43) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the Pre-admission Screening and Resident Review (PASRR). Findings include: 1. Review of resident 25's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included major depressive disorder, obsessive compulsive disorder (reoccurring thoughts and repetitive behaviors), anxiety disorder (anticipation of future danger or misfortune with symptoms such as restlessness or irritability), and paranoid schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a distorted sense of reality). *Her 5/9/23 level II [2] PASRR which stated, This PASRR approval is not time limit [does not have a time limit] there is no need to re-submit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and policy review, the provider failed to follow food safety standard pratices to ensure resident food temperatures were monitored and recorded according to the provider's policy for all meals prepared and served in one of one kitchen. Findings include: 1. Observation and interview on 4/14/25 at 4:45 p.m. with cook C in the kitchen revealed: *He was checking the temperature of the food for the evening meal. *He took the temperature of each food item five to fifteen minutes before it was served. *Staff were to document food temperatures on the food temperature chart for all meals. 2. Interview and record review on 4/15/25 at 9:50 a.m. with dietary manager B regarding food temperatures revealed: *Staff were instructed to take food temperatures for all meals. *The food temperatures were to be documented in the food temperature chart. *He stated it had been a struggle to get some staff to document the food temperatures. *He had implemented a new food temperature system on 4/1/25 to try to improve charting by the dietary staff. *In March…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the provider failed to ensure food items were appropriately labeled, stored, handled, prepared, and served to residents in a safe and sanitary manner in one of one kitchen and one of one dining rooms for the following: *One of one kitchen was not maintained in a safe and sanitary manner. *One of one commercial refrigerator contained beverage items that were not labeled, dated, or discarded by the use-by date. *Unsafe meat thawing practices. *Inappropriate glove use and hand hygiene by four of four observed dietary staff (dietary manager C, cook D, cook E, and dietary aide (DA) I) while preparing and serving residents' food. *Inappropriate glove use and hand hygiene by four of four observed staff (certified nursing assistant (CNA) K, CNA L, CNA N, and restorative aide (RA) J) while assisting residents in the dining room. Findings include: 1. Observation on 12/3/24 at 7:47 a.m. of CNA K and CNA N in the main dining room revealed: *CNA K and CNA N were seated at a table with four residents who had not yet been identified. *CNA K and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to maintain a clean and homelike environment for 5 of 49 sampled residents (6, 7, 13, 16, and 19) and for the residents who ate their meals in the main dining room. Findings include: 1. Observation on 12/3/24 at 9:00 a.m. in the bathroom shared by residents 16 and 19 revealed: *The floor at the base of the toilet was wet. -There were areas of an unidentified black substance. -The caulking at the base of the toilet was peeling and missing in several areas. 2. Observation on 12/3/24 at 9:29 a.m. in resident 17's room revealed: *The faucet on the sink in that room had a white and green, thick, unidentified build-up, and areas of the faucet were missing. -This was not a cleanable surface. -The handle spun around in a circle and the surveyor was unable to get hot water at that sink. 3. Observation on 12/3/24 at 9:25 a.m. revealed a wall-mounted hand sanitizer outside of residents 16 and 19's room that did not dispense hand sanitizer and flopped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure that essential dietary department kitchen equipment was in safe working condition including: *Five of the eight stove-top burners on the commercial gas stove that did not ignite. *Two of the two ovens in the commercial gas stove that were not in working condition. *One of one flattop grill that leaked oil down the side of the equipment and onto the floor beneath. *The two-compartment food preparation sink leaked and was not used to prepare food. *The air conditioning unit in the kitchen ceiling had condensation tubing attached to the faucet and drained into the handwashing sink. Findings include: 1. Observation on 12/3/24 at 7:50 a.m. during the initial tour of the kitchen revealed: *The floor under the commercial gas stove and flattop grill had a thick brown oily substance on the left side that extended behind the stove. A large can containing grease was on the floor to the left of the stove and appeared to be catching grease as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure: *The foam filter was replaced on one of one sampled resident's (34) oxygen concentrator machine. *One of one sampled resident (34) had current physician's orders to receive oxygen therapy. *Facility policy had been followed regarding documenting oxygen tubing and foam filter replacement in one of one sampled resident's (34) electronic medical record (EMR). Findings include: 1. Observation and interview on 12/3/24 at 3:11 p.m. with resident 34 in her room revealed: *She was receiving oxygen through a nasal cannula (flexible tubing with prongs to deliver oxygen through the nose). *There was no foam filter on the back of the oxygen concentrator machine. *She said the staff gave her new oxygen tubing that morning. *The oxygen concentrator machine was delivering oxygen at a rate of 3L (liters per minute). 2. Review of resident 34's EMR revealed: *There was no current physician's order for supplemental oxygen. *Three of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure wound care treatments were completed per physician orders and documented for one of one resident (2). Findings include: 1. Observation and interview on 7/16/24 at 1:58 p.m. with resident 2 and licensed practical nurse (LPN) D revealed: *He was seated in his recliner with the footrest in the up position. *There was a wound dressing on his left foot. *LPN D removed the wound dressing and stated it was a vascular wound. *Resident 2 stated he had a scheduled appointment the next day with a vascular surgeon for possible amputation of his left foot. *Resident 2 stated that a nurse who worked the night shift had not completed his dressings a couple of times. Review of resident 2's medical record revealed: *He was admitted on [DATE]. *His diagnoses included: peripheral vascular disease, vitamin D deficiency (Vitamin D deficiency can lead to delayed or chronic wounds), major depressive disorder, low back pain, varicose veins…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and a cleaning checklist for housekeepers the provided failed to ensure a clean and homelike environment that included the following: *A handwashing sink in the dining room that had noticeable water damage and one of the doors were hanging off the hinge. *A cracked half-wall located in the resident's shower room. *A resident's door opening only halfway and leaving grooves in the floor. *Paint on a heating unit in a resident's room is peeling away. *A wall heating unit in the dining room was that pulling away from the wall. *Spider webs around a non-exit door. *Multiple non-used screws in the wall. *Wallpaper in multiple places throughout the facility was bubbling and peeling away from the wall. 1. Observation on 8/29/23 8:32 a.m. in the main dining room revealed: *A handwashing sink was located next to the entrance to the kitchen. -It had noticeable water damage located at the bottom front and side. -The right-side door had fallen off the hinge and was hanging down. Observation on 8/29/23 at 9:00 a.m. in the resident's shower room revealed: *A wheeled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, email communication review, and policy review, the provider failed to ensure: *A functional whirlpool tub was available to all residents who preferred a tub bath. *Scheduled showers were offered and given to 16 of 40 sampled residents (3, 5, 6, 10, 12, 15, 17, 20, 23, 24, 25, 30, 32, 33, 38, and 40). Findings include: 1. Observation on 8/29/23 at 9:35 a.m. of the resident's shower room revealed: *A wheeled high-back chair was sitting against a wall and a handheld shower-head with a long hose was connected to the wall. -Bottles of shampoo, conditioner, and body wash were on top of the half-wall located next to the chair. *A whirlpool tub was in the corner covered with plastic. *There were no other whirlpool tub visible in the shower room. 2. Interview on 8/29/23 at 2:32 p.m. with maintenance director C regarding the non-functional whirlpool tub revealed: *They had a whirlpool tub, but it leaked, had draining and electrical issues. -He was not aware the last time it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.