Avalon Care Center: Dignity Violation for Catheter Bag - HI
When a federal inspector stopped to speak with him on June 1, the resident said he was concerned about it too, and that the bag should always be covered....
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When a federal inspector stopped to speak with him on June 1, the resident said he was concerned about it too, and that the bag should always be covered....
That's what federal inspectors found when they visited the facility on June 5, 2026....
The finding emerged from a June 4, 2026 inspection at the facility on West Broadway Avenue....
Federal inspectors documented the finding on June 2, 2026....
The facility's therapy contractor had been trying to work something out....
The residents both have morbid obesity....
A nurse told inspectors the medication had been discontinued and the oversight was simply that â it was overlooked....
One resident, identified in inspection records as Resident 71, told inspectors she saw roaches all over her room at night....
Physical therapists who worked with them wrote a clear discharge recommendation: begin a restorative range-of-motion program for both lower extremities....
The inspection was completed June 5, 2026....
Federal inspectors documented the sequence in detail during a June 9 visit to Gables of Boutwells Landing, a nursing facility in Oak Park Heights....
Inspectors visiting the facility on June 8, 2026, watched the morning meal get delivered to residents in rooms 9, 14, 15, and 18....
The April 23 event report noted a wrong dose on April 22....
Inspectors visited the laundry department twice, three days apart....
The patient, identified in inspection records only as Resident 7, was admitted to the facility with a history of stroke and left-side paralysis....
Inspectors reviewed two medication carts and one medication room at the facility....
The resident, identified in inspection records only as R54, had moderate cognitive impairment, used a walker, and depended on staff for most of his daily care....
The woman, identified in inspection records as Resident 34, has Alzheimer's disease....
A federal inspector watched the entire procedure on June 17, 2026....
Neither of those were the problem....