Avon Health & Rehabilitation Center

A nursing admission assessment, dated 2/6/26, the baseline care plan section of the assessment

She had a fall risk assessment, dated 2/6/26, which indicated she was at risk for falls.

A care plan for her risk of falls was not implemented with interventions the following Monday, 2/9/26.

On 2/24/25 at 11:15 a.m., the DON provided a copy of the policy titled, Baseline Care Plan, dated 11/1/23. It indicated, .The baseline care plan will be developed within 48 hours of a resident's admission .A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

155236 02/26/2026

Avon Health & Rehabilitation Center 4171 Forest Pointe Circle Avon, IN 46123

and wheezes in lungs.

diagnosis which included, but was not limited to, congestive heart failure (CHF).

He had a current physician's order, dated 12/30/25, for daily weights related to CHF.

A nutrition progress note, dated 1/12/26 at 2:19 p.m., indicated Resident 70 triggered for a 5% weight gain since December, a 7.5% weight loss since October, and a 10% weight loss since September.

Resident's weight fluctuated due to diagnosis of heart failure and recent illnesses.

On 1/13/26 he was re-started on a daily diuretic, Torsemide 20 milligrams a day, for CHF and bilateral lower edema.

A nursing progress note, dated 1/15/26 at 10:17 p.m., indicated he continued on his diuretic and edema was still noted in his bilateral lower extremities. Resident 70's daily weights were noted missing on the following dates: January 8, 12, 16, 17, 21, and 30; and February 3, 5, 6, 9, 12, 13, 17, and 21, 2026.

The policy titled, Following Physician Orders/Parameters, dated 5/2018 and revised 4/2024, indicated, .To administer resident care in a safe and effective manner and following physician orders and ordered parameters.All licensed healthcare providers shall consult the resident's medical orders for the appropriate physician/clinician order prior to administering or performing a resident procedure.check MAR/TAR for physician/clinician order.Licensed healthcare personnel will consult and follow the physician/clinician order when performing any resident procedures.Note any contraindications the resident may have prior to performing a procedure.Check for vitals signs, other tests to be done as prescribed by resident's physician/clinician.evaluate resident for appropriate or accurate response to orders.Notification of Physician/Clinician will be made with resident refusals of physicians order.

This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-37(a).

155236 02/26/2026

Avon Health & Rehabilitation Center 4171 Forest Pointe Circle Avon, IN 46123

During our discussion, he confirmed that the device had been quarantined, fully inspected, and fixed to return to working condition and put back on the floor. He also provided documentation showing completed and passed audits for the facility's Hoyer lifts for the prior 3 months.

The Regional Director of Property Management conducted an onsite investigation to assess the circumstances surrounding the reported malfunction.

During the visit, a comprehensive inspection was performed on all mechanical lifts within the facility to verify their operational integrity and ensure that all equipment met safety and compliance standards.

This review included evaluating maintenance practices, confirming documentation of recent inspections, and identifying any areas requiring corrective action. -A teachable moment, dated 2/3/26, was signed by the maintenance staff.

The teachable moment indicated, .Upon reviewing the incident, it was noted that the missing lock nut on the sling attachment was not identified during the regular inspections.

While issues like this can sometimes be difficult to detect, it is important that our inspection forms and procedures allow for clear, consistent documentation and close attention to all critical parts of the equipment, such as bolts, nuts, and sling attachments. -The Hoyer lift manufacturer's guidance for cleaning and maintenance, dated 1/13/25, indicated functional checks should be periodically performed, at least once a year, including checks of the control of mechanical parts such as hooks, pins, and screws.

During an interview, on 2/24/26 at 10:11 a.m., the DON indicated a bolt came out of the hydraulic arm of the Hoyer lift during the resident's transfer, and the Hoyer lift broke.

When the bolt came out, the resident fell down.

The staff member was alone performing the Hoyer lift transfer, which was not consistent with the facility's policy.

Two people actively participating in the transfer were required per their facility policy for Hoyer lift transfers. On 2/24/26 at 10:46 a.m., the DON provided a document titled, Safe Resident Handling/Transfers, dated 2/28/24.

The policy indicated, .Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and promote a safe, secure and comfortable experience for the resident.Compliance Guidelines.6.

The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly.8.

Two staff members must be utilized when transferring residents with a mechanical lift.

The deficient practice was corrected by 2/13/26 after the facility implemented a systemic plan that included the following actions: immediate assessment by the charge nurse of the effected resident for follow-up care, transfer status audit for all residents completed by 2/6/26, staff members who provided assistance to residents with mechanical lift transfers received education on proper mechanical lift use completed prior to their next scheduled shift, ongoing maintenance processes updated and implemented by 2/13/26, and a Quality Assurance and Performance Improvement (QAPI) plan implemented with the completion of an audit tool for scaled ongoing monitoring.

The plan was fully implemented by 2/13/26.

This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-45(a)(2).

Trelegy and Incrusa, expired 42 days after they were opened.

This deficiency reflects State Findings

155236 02/26/2026

Avon Health & Rehabilitation Center 4171 Forest Pointe Circle Avon, IN 46123