Avalon Health Care Center at Stoneridge

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 27, 2024

  Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #3) reviewed for accidents, the facility failed to ensure the wheelchair leg rests were in place during resident transport resulting in a fall with injury. The findings include: Resident #3's diagnoses included Parkinson's disease, fibromyalgia, hypertension, and anemia. The care plan dated 4/19/24 identified Resident #3 was at risk for falls related to decreased mobility and history of falls. […]

• No harm, potential for more than minimal, isolatedF580May 5, 2026

  Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #8) reviewed for unnecessary medications, the facility failed to notify the physician when the resident was observed over several days with delayed processing, drowsiness and a reported concern by the resident representative of Resident #8's alertness. Subsequently, the resident exhibited low blood pressure and an oxygen saturation of 90 %. The findings include: Resident #8 was admitted to the facility in October 2025 with diagnoses that included spinal stenosis, dementia, and osteoarthritis of the right and left knees. […]

• No harm, potential for more than minimal, isolatedF656May 5, 2026

  Based on review of the clinical record, facility documentation, facility policies, and interviews for 1 of 4 residents (Resident #4) reviewed for accidents, the facility failed to develop a comprehensive care plan to include interventions to address observed behaviors during eating such as eating fast and putting too much food in his/her mouth. Subsequently, the resident choked while eating and required the Heimlich, transfer to the hospital and laryngoscopy to remove a 3-inch piece of lamb from the airway. The findings include: Resident #4 was admitted to the facility in June 2025 with diagnoses that included mild intellectual disabilities and obesity. […]

• No harm, potential for more than minimal, isolatedF600Mar 4, 2025

  Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident abuse, the facility failed to ensure Resident #1 was not verbally abused by a staff member. The findings include: Resident #1's diagnoses included cognitive impairment and anxiety. The admission Resident Care Plan (RCP) dated 2/6/25 identified Resident #1 had a mood disorder and received an antidepressant medication. Interventions directed to monitor targeted behaviors, provide routine and as needed psychiatric visits, and medications as ordered. […]

• No harm, potential for more than minimal, isolatedF609Mar 4, 2025

  Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident verbal abuse, the facility failed to ensure a witnessed allegation of verbal abuse was reported to the Administrator and/or designee within two (2) hours after the event occurred. The findings include: Resident #1's diagnoses included cognitive impairment and anxiety. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some short and long term memory recall deficits, exhibited verbal outbursts towards others, required staff assistance with activities of daily living, and utilized a wheelchair for mobility. […]