Avalon Care Center

In the surveyor’s words

From the most serious findings on record at Avalon Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 1, 2025

  Based on review of clinical records, facility policy and documentation, and staff and resident interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for one of one residents reviewed who eloped from the facility (Resident R1). Findings include: Review of the facility policy entitled, Safety and supervision of residents, with a policy review date of 1/20/2025, revealed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. […]

• Actual harm, isolatedF689May 8, 2026

  Based on review of facility policy, clinical records, facility incident reports, facility documents, and staff interviews, it was determined that the facility failed to provide necessary precautionary measures to maintain resident safety and prevent injury during transport in a wheelchair resulting in harm of a fractured orbital bone (a bony cavity in the skull that houses and protects the eyeball) for one resident reviewed (Resident R1). Findings include: Review of facility policy entitled Abuse and Neglect dated 4/16/26, revealed Neglect.means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• Actual harm, isolatedF689Feb 29, 2024

  Based on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury during a transfer, and resulted in actual harm when the resident received rib fractures that required medical treatment at a hospital for one of one residents reviewed (Resident R1). Findings include: Review of the facility policy, SRC-Safety-17.35 Transfers-ABC, dated 5/12/23, indicated to assist residents with movement from one surface to another .(1) verify resident's mobility needs .(3) determine the necessary amount of assistance needed in accordance with the plan of care. […]

• No harm, potential for more than minimal, patternF695Jun 12, 2026

  Based on review of facility policy and clinical records, observations, and staff and resident interviews, it was determined that the facility failed to administer supplemental oxygen as ordered for one resident and promote cleanliness and prevent the spread of infection regarding respiratory care equipment for three of 25 residents reviewed (Residents R32, R53, and R72).Findings include:Review of facility policy entitled Oxygen Administration, dated 4/16/26, revealed Set the flow rate as ordered by physician; Oxygen shall be humidified as indicated by physician; Humidifier bottle shall be connected to the oxygen concentrator prior to setting flow rate.Review of facility policy entitled Continuous Positive Airway Pressure/ Bilevel Positive Airway Pressure [CPAP (therapy that keeps your… […]

• No harm, potential for more than minimal, patternF725Jun 12, 2026

  Based on review of facility policy, clinical records, and staff and resident interviews it was determined that the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for four of 21 residents reviewed for showers/bathing (residents R2, R43, R53, and R77), and eight of 21 residents reviewed for call bell response times (Residents R21, R23, R29, R32, R42, R44, R65, and R66) Findings include:A Facility policy entitled Activities of Daily Living (ADL), Supporting dated 4/16/26, indicated that: residents who… […]