Avalon Springs Health Campus
Inspection Findings
F-Tag F0677
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, record review, and interview, the facility failed to ensure a resident who required maximum to dependent care received incontinence care in a timely manner, for 1 of 3 residents reviewed for incontinence care. (Resident B) Finding includes:During an observation on 10/27/25 at 10:27 a.m., Resident B was awake and lying in bed with the head of the bed elevated. The over the bed table was over
the bed and the breakfast tray was on the table. The food on the tray had all been eaten. The resident indicated she was waiting on the staff to come and assist out of bed into the chair. She indicated when they brought the breakfast tray to her, they said they would be back to help her get out of bed.During an
observation on 10/27/25 at 11:12 a.m., CNA 1 and CNA 2 entered the room. CNA 1 indicated the resident had incontinence care last completed at 7:30 a.m. and the resident was incontinent of large amounts of urine. The CNA's started morning care. The resident's incontinent brief was saturated, the lift sheet underneath her was soaked through to the bottom sheet on the bed and there was a large circle of wetness
on the bottom sheet. CNA 1 acknowledged the saturated brief and wetness of the sheets.Resident B's
record was reviewed on 10/27/25 at 10:41 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy, multiple UTI's (urinary tract infections), and sepsis.A Hospital Physician's Note, dated 10/15/25 at 5:12 p.m., indicated the resident had recurrent urinary tract infections.A Care Plan, dated 4/11/25 and revised on 9/2/25, indicated there was urinary incontinence. The interventions included the resident would be offered and provided assistance to the toilet as needed and/or requested.A Quarterly Minimum Data Set assessment, dated 9/4/25, indicated a moderately impaired cognitive status, dependent for toileting hygiene and transfers, maximum assistance for hygiene, moderate assistance for bed mobility and was always incontinent of bowel and bladder.A re-admission Observation Assessment, dated 10/23/25 at 8:24 p.m., indicated the resident was oriented to person, place, and time. There was no mental impairment. She was incontinent of bowel and bladder and was unable to recognize the need to void. The Baseline Care Plan, dated 10/23/25, indicated the toilet would be offered upon rising, before and after meals, and before bedtime. The resident would be checked for incontinence and the brief would be changed as needed.During an interview on 10/27/25 at 1:58 p.m., the Director of Nursing (DON) indicated there was no facility policy for how often a resident was to be checked for incontinence. She indicated if
they voided a lot, they should be checked more often. The residents were usually checked before and after meals and before bedtime.A Professional Resource, titled, Indiana State Department of Health Nurse Aide Curriculum, revised 11/19/15, Lesson #12, Activities of Daily Living (dressing and toileting), indicated residents with incontinence were to be monitored frequently for needed perineal care and change of brief.This citation relates to Intake 2645656.3.1-38(a)(3)
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
AVALON SPRINGS HEALTH CAMPUS in VALPARAISO, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in VALPARAISO, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVALON SPRINGS HEALTH CAMPUS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.