Avalon Place

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF558Dec 3, 2025

  Based on observation, interview and record review, the facility failed to ensure residents received reasonable accommodation of needs in accordance with preferences for 1(#28) of 1 sampled residents reviewed for accommodation of needs by failing to provide a manual wheelchair for Resident #28 for mobility when the resident's electric scooter was not functioning. Findings: Record review revealed Resident #28 was admitted to the facility on [DATE]. Resident #28 had diagnoses that included diabetes, peripheral vascular disease, and acquired absence of left leg above the knee. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. […]

• No harm, potential for more than minimal, patternF641Dec 3, 2025

  Based on record reviews and interviews, the facility failed to ensure accuracy of the MDS assessment for 2 (#76 and #77) of 3 sampled residents reviewed.Findings:Resident #76 Review of Resident #76's record revealed an admission date of 11/10/2025 with diagnoses including atherosclerotic heart disease of native coronary without angina pectoris, polyneuropathy, chronic systolic (congestive) heart failure, unspecified dementia unspecified severity with other behavioral disturbance, hypertension, and chronic obstructive pulmonary disease. Review of Resident #76's MDS assessments revealed an admission/Medicare 5 day MDS assessment with an ARD of 11/17/2025. […]

• No harm, potential for more than minimal, patternF726Dec 3, 2025

  Based on record review and interview the facility failed to provide 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 for 2 (#55 & #77) sampled residents. The facility failed to ensure: 1) Nursing staff had a documented assessment or rationale for Resident #55 having an x-ray of her foot in the medical record prior to the x-ray being completed 2) Nursing staff completed and recorded an assessment for Resident #77 on 06/17/2025 when she complained of abdominal pain before being transferred to a local hospital on [DATE] for treatment of the abdominal pain.Findings:Resident #55 Review of the record for… […]

• No harm, potential for more than minimal, patternF686Oct 16, 2024

  Based on observations, record reviews, and interviews, the facility failed to ensure a resident with pressure ulcers recieved the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 (#6 and #52) of 5 (#5, #6, #18, #52, and #125) residents investigated for pressure ulcers. The facility failed to ensure that a pressure relieving device was implemented for resident #52, who currently had a new, unidentified pressure to her left heel. Findings: Resident #6 Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF689Oct 16, 2024

  Based on observations, record reviews and interviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (#25 and #70) of 9 (#5, #12, #17, #25, #38, #52, #69, #70 and #175) residents reviewed for accident hazards. The facility failed to 1) complete an Incident/Accident report after residents #25 and #70 had an incident, and 2) assess resident #70 to determine if the lap tray was appropriate after he slid under the lap tray. Findings: Resident #70 Review of the medical record for resident #70 revealed an admitted [DATE] with diagnoses of edema, depression, muscle weakness, seizures, hypertension and lack of coordination. […]