Avalon Village

Based on interview and record review, the facility failed to ensure medical records were complete and accurately reflected the resident's clinical status for 1 of 3 residents reviewed (Resident E). Findings include:On 2/25/26 at 11:56 A.M., Resident E's record was reviewed. Diagnoses included end-stage kidney disease with dependence on renal dialysis, stage 4 pressure wound to the sacrum, and history of multiple type cancers. He was alert, oriented and able to make daily decisions as well as healthcare decisions for himself. A care plan, dated 7/23/25, indicated Resident E had dermatitis with a raised lesion on his left lower extremity suspicious for cancer. He was diagnosed with Lichenoid Keratosis (benign skin lesion) and treated with chemotherapy cream for 4 weeks. Interventions included to assess and document the skin condition weekly and as needed; and observe for signs of infection. A dermatology note, dated 10/9/25, indicated the resident had been seen for a non-healing lesion to his left lower extremity. At his appointment, the area around the lesion was numbed and with a…

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 record review, the facility failed to ensure nephrostomy care was provided for 2 of 2 residents reviewed (Resident 5 and Resident 41). Findings include: 1. Resident 5's record was reviewed on 11/1/24 at 10:51 AM. Diagnoses included chronic kidney disease and neuromuscular dysfunction of the bladder. Resident 5's Minimum Data Set (MDS), dated [DATE], indicated Resident 5's Quarterly Brief Interview for Mental Status (BIMS) score was 15 (no cognitive impairment). The MDS indicated Resident 5 had an indwelling urinary catheter. A physician order, dated 3/14/22, indicated the nephrostomy urine collection bags were to be changed monthly and as needed. A physician order, dated 7/29/22, indicated the nephrostomy tubes should be irrigated with 10 milliliters of normal saline every shift. A physician order, dated 10/2/24, indicated nephrostomy output should be recorded every shift. Resident 5's physician orders did not include directions for cleansing the nephrostomy tube sites or…

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 record review the facility failed to ensure medication disposition guidelines were followed for 1 of 5 residents reviewed (Resident 11). Findings include: During medication pass observation on 11/1/24 at 9:07 AM, Registered Nurse (RN) 3 prepared medication for Resident 11. During the preparation, RN 3 dropped a duloxetine 60 mg capsule on top of the medication cart. RN 3 picked up the capsule with ungloved fingers, placed it in the medication cup along with other medications due to be given that morning and administered them to Resident 11. During an interview on 11/1/24 at 9:25 AM, Licensed Practical Nurse (LPN) 2 indicated dropped pills should be placed in drug buster (a liquid chemical used to dissolve medications and render them unusable). She indicated drug buster should be available in the medication room. During an observation on 11/1/24 at 9:26 AM, LPN 2 opened all cabinets in the medication room and no drug buster was found. The 300-hall medication cart was inspected…

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 record review the facility failed to ensure a wound assessment was accurately recorded for 1 of 11 residents reviewed (Resident 15). Findings include: During a wound care observation on 11/4/24 at 9:41 AM, Resident 15 was observed lying on his right side with a heavily padded heel boot secured with a Velcro closure. Licensed Practical Nurse (LPN) 4 held Resident 15's foot up about 6 inches off the bed. LPN 5 removed Resident 15's heel boot. Resident 15 had a gauze dressing wrapped around his right foot covering his ankle and up to the base of his toes. The dressing was secured with a piece of tape dated 11/3/24. LPN 5 removed the dressing from his right ankle, placing it in a plastic bag on the bed next to his left leg and performed wound care, assessment and application of a new dressing. Resident 15's record was reviewed on 10/31/24 at 11:03 AM. Diagnoses included peripheral vascular disease, type 2 diabetes mellitus with diabetic nephropathy, and essential hypertension.…

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 record review the facility failed to ensure infection control practices were implemented regarding hair restraint during wound care for of 1 of 11 residents reviewed (Resident 15). Findings include: During a wound care observation on 10/4/24 at 9:41 AM, Resident 15 was observed lying on his right side. Licensed Practical Nurse (LPN) 4 held Resident 15's foot up about 6 inches off the bed while LPN 5 removed Resident 15's dressing from his right ankle, placing it in a plastic bag on the bed next to his left leg. LPN 5 leaned her head down to observe the wounds on the inner aspect of the right foot and ankle. LPN 5's shoulder length hair was not restrained and touched Resident 15's bedding and the top of the plastic bag containing the soiled dressing. LPN 5's hair touched the bedding and plastic bag during the loosening of a patch of HydroFera blue wound treatment (an antibacterial wound care application), during the cleansing of the wound, during the wound assessment, 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.

Based on observation, interview and record review, the facility failed to ensure fall interventions were followed for 1 of 3 residents reviewed for accidents (Resident J). Findings include: On 7/11/24 at 11:38 A.M., Resident J's record was reviewed. Diagnoses included dementia, Alzheimer's disease with late onset, and generalized anxiety disorder. A quarterly MDS (Minimum Data Set) assessment, dated 5/14/24, indicated the resident had severely impaired cognition with fluctuating behaviors of inattentiveness and disorganized thinking. She had no verbal or physical behaviors and no rejection of care. She required maximal assistance with her activities of daily living. A care plan, revised 7/1/24, indicated Resident J was at risk for falls with a goal of reducing her fall risk factors to avoid significant fall related injuries. An intervention, dated 12/27/2022 was for 2 persons to assist with transfers via the hoyer mechanical lift. A physician order, dated 5/31/24, was for the resident to be transferred with the mechanical lift and assistance of 2 staff members. A Fall Event form,…

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 record review the facility failed to ensure an adaptive call light was available and within reach for 1 of 15 residents reviewed (Resident 30). Findings include: During an observation on 11/12/23 at 10:13 AM, Resident 30 was observed lying in bed in her room. Resident 30 had severe contractures of her bilateral upper arms. Her elbows were bent at a tight angle and her hands were in a tight fist position. Her hands were positioned near her face. Her call light cord was observed against the wall behind the bed. The call light activation handle was observed lying on the floor. The call light was observed to be a standard call light. Resident 30 indicated she could not reach her call light. During an interview on 11/12/23 at 10:35 AM, Certified Nurse Aide (CNA) 4 indicated the call light should be within Resident 30's reach. CNA 4 placed the call light on resident's upper torso. When asked to have Resident 30 demonstrate activation of her call light, CNA 4 placed the call light…

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 record review the facility failed to ensure self-determination of visitors for 2 of 15 residents reviewed (Resident 30 and Resident 35). Findings include: 1) During an observation on 11/12/23 at 10:13 AM, Resident 30 was observed lying in bed in her room. Resident 35 was observed standing beside her bed speaking nonsensically to Resident 30 and dancing to music playing on her radio. Resident 30 had severe contractures of her bilateral upper arms. Her elbows were bent at a tight angle and her hands were in a tight fist position. Her hands were positioned near her face. Her call light cord was observed against the wall behind the bed. The call light activation handle was observed lying on the floor. Resident 30 indicated she could not reach her call light. Resident 30 indicated Resident 35 had not touched her, but she did not invite him into the room and his presence made her uncomfortable. She indicated he had been in her room the prior night also. Resident 30's record was…

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 record review the facility failed to ensure direct care staff was made aware of the identified triggers for a resident with a history of trauma for 1 of 2 residents reviewed. (Resident 48) Findings include: On 11/12/23 at 11:59 AM, Resident 48 was observed ambulating with bare feet in the hallway . Resident 48 had their arms folded tightly across their chest. Resident 48's lips were turned downward at the corners. Resident 48 grabbed a container of applesauce from a medication cart and clutched the container to their chest. A Certified Nurse Aide (CNA) was overheard stating the resident was combative. Resident 48's record was reviewed on 11/14/23 at 10:33 AM. Diagnoses included hallucinations, unspecified dementia with psychotic disturbances and anxiety disorder. Resident 48's current Comprehensive Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 48's communication was rarely or never understood. The MDS…

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 record review the facility failed to ensure behavioral care plan interventions were followed for 1 of 5 residents reviewed. (Resident 35) Findings include: During an observation on 11/12/23 at 10:13 AM, Resident 30 was observed lying in bed in her room. Resident 35 was observed standing beside her bed speaking nonsensically to Resident 30 and dancing to music playing on her radio. Resident 35 placed Resident 30's trash can on top of her overbed table and pushed it around the room while mumbling non-sensical words. Resident 35 walked out to the hallway and grabbed a hoyer (a large mechanical device used to lift dependent residents) lift device that was sitting in the hallway and began pushing it down the hallway. An unidentified CNA approached Resident 35 and redirected him away from the hoyer lift device. Resident 35's record was reviewed on 11/15/23 at 1:31 PM. Diagnoses included Diagnoses included Alzheimer's disease with late onset, cognitive communication deficit, 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 record review the facility failed to ensure resident specific, non-pharmacological interventions were attempted for 1 of 2 residents reviewed. (Resident 48) Findings include: On 11/12/23 at 11:59 AM, Resident 48 was observed ambulating in the hallway with bare feet. Resident 48 had their arms folded tightly across their chest. Resident 48's lips were turned downward at the corners. Resident 48 grabbed a container of applesauce from a medication cart and clutched the container to their chest. A Certified Nurse Aide (CNA) was overheard stating the resident was combative. Resident 48's record was reviewed on 11/14/23 at 10:33 AM. Diagnoses included hallucinations, unspecified dementia with psychotic disturbances and anxiety disorder. Resident 48's current Comprehensive Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 48's communication was rarely or never understood. The MDS indicated Resident 48 had exhibited…

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 record review the facility failed to ensure a clean call light and a clean urinal were provided to 2 of 15 residents reviewed (Resident 1, and Resident 30). Findings include: 1) During an observation on 11/13/23 at 9:47 AM Resident 1 was lying in bed with a urinal on the left side of his bed. The urinal was a whitish translucent plastic with brown debris around the opening. A 3mm and a 2 mm round pieces of brown debris were noted on the side of the urinal. During an observation on 11/14/23 at 9:34 AM, the urinal was observed in about the same place beside the resident with the debris appearing unchanged from the previous day's observation. During an interview and observation on 11/14/23 at 9:37 AM Nurse Aide in Training (NAIT) 3 indicated Resident 1 could use his urinal, but staff managed the emptying task due to Resident 1's mobility limitations. NAIT 3 indicated the urinal at Resident 1's bedside was dirty and the staff member who emptied his urinal after the last use…

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.