Avalon Villa Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF812Sep 7, 2021

  Based on observation, interview, and record review the facility dietary staff failed to prepare, distribute, and serve food in accordance with acceptable and safe temperatures based on professional standards for food service safety for six of six sampled residents (Residents 1, 2, 3, 4, 5 and 6) who received hot foods served at cold temperatures. The milk was served at a temperature 53.4 degrees Fahrenheit ([F] temperature scale based on 32° for the freezing point of water and 212° for the boiling point of water) and the chicken salad sandwiches were served at of 62.8 degrees F. […]

• Immediate jeopardy, isolatedF689Jan 31, 2025

  Based on interview and record review the facility failed to ensure five of eight sampled residents (Resident 118, 319, 55, 99, and 117) were free of accidents and hazards by failing to: 1. Follow its policy and procedure (P&P) titled, Wandering, Unsafe Resident, which indicated the facility would identify residents at risk for harm due to unsafe wandering and elopement by failing to ensure: a. Resident 118, who was assessed as high risk for wandering (the act of roaming around and becoming lost or confused about their location) and elopement (the act of leaving a facility unsupervised and without prior authorization), did not elope from the facility on 10/13/2024 and 11/24/2024 (42 days after the first elopement). b. Staff were aware of all residents at risk for wandering and elopement. c. […]

• Immediate jeopardy, isolatedF880Sep 18, 2021

  Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program for one of three sampled residents (Resident 1) by failing to place Resident 1 who was positive for [CONDITION(S)]-resistant staphylococcus aureus ([CONDITION(S)]- A bacteria that causes infections in different parts of the body and is resistant to most antibiotics) of the nares (nose), and the right lower leg on contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the residents or the resident's environment), which included cohorting (the practice of grouping residents infected or colonized with the same infectious agent together and prevent contact with susceptible… […]

• Actual harm, isolatedF688Jan 8, 2026

  Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for five of six sampled residents (Resident 37, 35, 5, 110, 114) with positioning, mobility, and restorative nursing ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) concerns.a. For Resident 37, the facility failed to:1. Measure Resident 37's ROM in the joints of both arms during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 9/17/2025. 2. […]

• Actual harm, isolatedF656Jan 24, 2024

  Based on observation, interview, and record review, the facility failed to implement the care plan after a resident's refusal of Levetiracetam (medication used to treat seizures [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness]) and implement interventions to monitor for seizure activity for one of six sampled residents (Resident 2) as per the resident's care plan. As a result, Resident 2 had an unwitnessed fall in the bathroom during a seizure activity and sustained a right ankle fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. […]