Avalon Springs Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Apr 15, 2021

  Based on observations, review of facility policies and documentation, and staff interviews, it was determined that the facility failed prevent the potential for cross contamination (transfer of harmful substances or disease causing organisms to food from unclean hands or objects) in one of two nutrition refrigerators (Second Floor) and during food preparation in the main kitchen; and failed to consistently monitor/document final food temperatures and the chemical sanitizing levels in the main kitchen's three compartment sink. […]

• No harm, potential for more than minimal, widespreadF908Apr 15, 2021

  Based on observations, review of facility records and staff interviews, it was determined that the facility failed to maintain kitchen equipment (dishwasher and three compartment sink) in safe, operating condition. Findings include: Observations of the facility's main kitchen on 4/12/21, between 11:15 a.m. and 11:25 a.m., revealed the dishwasher, not in use, but with an audible sound of running water and heat escaping from the open areas on both sides of the machine. During an interview at the time of the observation, the Certified Dietary Manager (CDM) indicated that the running water was from a broken valve in the dishwasher, identified on 3/29/21, that needed replaced and that the facility was still awaiting the replacement part (14 days later). […]

• No harm, potential for more than minimal, patternF657Dec 31, 2025

  Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for three of 17 residents reviewed (Residents R5, R49, and R2). Findings include: Review of facility policy entitled, Care Plans, Comprehensive Person-Centered dated 3/1/25, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. […]

• No harm, potential for more than minimal, isolatedF641Dec 31, 2025

  Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of two of 17 residents reviewed (Residents R2 and R4). Findings include: MDS instructions for section M Skin Conditions, Subsection M0300 Current number of unhealed pressure ulcers/injuries at each stage indicated For each pressure ulcer, determine the deepest anatomical stage and For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission / entry or reentry and not acquired while the resident was in the care of the nursing home. […]

• No harm, potential for more than minimal, isolatedF656Dec 31, 2025

  Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 17 residents reviewed (Resident R3).Findings include: Review of facility policy entitled, Care Plans, Comprehensive Person-Centered dated 3/1/25, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. […]