Avalon Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Avalon Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 27, 2026

  Based on staff interviews, record review, and review of the facility's policy titled Abuse Prohibition, the facility failed to protect one of 42 sampled residents (R) (R81) right to be free from physical abuse by another resident. Actual harm was identified to have occurred on July 6, 2026, when R87 physically assaulted R81, causing a laceration of the left palm and an open displaced fracture of the proximal phalanx of the right ring finger. Findings include:Review of the facility's undated policy titled Abuse Prohibition revealed the Intent section included, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. The Guidelines section included, . […]

• No harm, potential for more than minimal, widespreadF812Apr 10, 2025

  Based on observations, staff interviews, and review of the facility policy titled, Labeling and Dating, the facility failed to discard food and seasonings by the expiration date. The deficient practice had the potential to promote foodborne illnesses associated with bacterial growth for 74 of 77 residents receiving an oral diet. Findings include: Review of the facility's policy titled Labeling and Dating dated [DATE] revealed in paragraph two, Upon receipt all items should be inspected and marked with the date it was received into your facility and the date it should be discarded or expired. Further review revealed in paragraph three, After opening any item, the date it was opened must be clearly labeled on the front of the package and a new use by date should also be noted. […]

• No harm, potential for more than minimal, patternF761Jul 27, 2026

  Based on observations, staff interviews, and review of the facility's policy titled Medication Storage in the Care Center, the facility failed to ensure that medications were stored securely on two of two units (West Unit and the Secured Memory Unit). In addition, the facility failed to ensure opened insulin pens were labeled with an open and discard date on one of three medication carts. These deficient practices created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart and had the potential to place the residents at risk of receiving medications with altered effectiveness. […]

• No harm, potential for more than minimal, isolatedF690Jul 27, 2026

  Based on observations, staff interviews, record review, and review of the facility's policy titled Foley Catheter Care, the facility failed to provide appropriate care and services to manage an indwelling catheter when staff did not clean the genitalia for one of five residents (R) (R6) with an indwelling urinary catheter. This deficient practice had the potential to cause health problems, including urinary tract infections, skin breakdown, and tissue damage to R6.Findings include:Review of the facility's policy titled Foley Catheter Care, reviewed 12/27/2025, revealed the Intent section included, To promote hygiene, comfort and decrease risk of infection for patients with an indwelling catheter and is performed daily and PRN (as needed) for soiling.Review of the facility's electronic… […]

• No harm, potential for more than minimal, isolatedF880Jul 27, 2026

  Based on observations, staff interviews, record review, and review of the facility's policy titled Hand Hygiene, the facility failed to ensure infection control processes were followed during indwelling urinary catheter care for one of five residents (R) (R6) with an indwelling urinary catheter. This deficient practice had the potential to place R6 at increased risk of infection due to cross-contamination. Findings include:Review of the facility's policy titled Hand Hygiene, reviewed 12/27/2025, revealed the Intent section stated, It is the intent of this facility to promote and facilitate appropriate hand washing as set forth by the guidelines of CDC. The Purpose section included, Hand Hygiene is the single most important means of preventing the spread of infection. […]