Avalon View Health and Wellness

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 6, 2022

  Based on interview and record review, the facility failed to ensure residents are free from sexual abuse, when four residents (Resident #1, #2, #3 and #4), who are alert and oriented and independent with care, reported that the nurse would touch and rub their genitals using the excuse of providing incontinent care and treatments. The resident's reported that the actions of the nurse made them feel very uncomfortable and they felt violated. The facility census was 100. The Administrator was notified on 1/5/22 at 2:00 P.M. of an Immediate Jeopardy (IJ) which began on 1/2/22. The IJ was removed on 1/6/22 as confirmed by surveyor onsite verification. […]

• Immediate jeopardy, isolatedF689Dec 22, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate assistance devices to prevent accidents. The facility to ensure staff identified a bariatric resident who was unable to safely be evacuated from the facility in the event of an emergency (Resident #71), when the facility did not have a mechanical lift rated to safely transfer the resident. The facility census was 104. The Administrator was notified on 12/15/21 at 4:16 P.M. of an Immediate Jeopardy (IJ) which began on 9/22/21. The IJ was removed on 12/16/21 as confirmed by surveyor onsite verification. A review of the facility policy of Care and Treatment of Bariatric Residents, dated 11/1/21, showed: -Bariatric residents have special needs. […]

• Immediate jeopardy, isolatedF600Oct 27, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse when the facility failed to protect residents who reside on a Special Care Unit (SCU), when one resident (Resident#1) who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement interventions after the incident on 10/15/21 to protect other residents. On 10/23/21 Resident #1 abused another resident (Resident #3) causing injury to the resident. The facility failed to ensure staff were aware of Resident #1's aggression and failed to ensure staff had access and knowledge of the resident's plan of care. The facility census was 103. The Administrator was notified on 10/26/21 at 4:30 P.M. of an Immediate Jeopardy (IJ) which began on 10/15/21. […]

• Actual harm, isolatedF744Oct 18, 2022

  Based on observation, interview, and record review, the facility failed to implement interventions for two residents (Resident #1 and Resident #2) who displayed physically aggressive behaviors towards staff and other residents, when Resident #1 pushed another resident down (Resident #3) who sustained a fractured hip, and when Resident #2 pushed Resident #4 down causing a laceration to the residents forehead. The facility census was 87. Review of the facility's Dementia Care policy, dated 10/18/2022, showed: -It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. […]

• Actual harm, isolatedF760Jul 19, 2022

  Based on observation, interview, and record review, the facility failed to prevent significant medication errors when they failed to correctly administer dilantin (a medication used to treat and prevent seizures) for one sampled resident (Resident #1). The facility census was 78. Review of the facility's undated Medication Administration policy, showed: -Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. -10. Review Medication Administration Record (MAR) to identify medication to be administered. -11. […]