Avalon Village

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF725Jan 26, 2023

  Based on observation, interview, and record review, the facility failed to ensure adequate staff were present to meet the physical needs of the residents. 50 residents resided in the building. During the initial tour of the building on 1/22/23 beginning at 10:47 AM, food trays from the breakfast meal were observed in rooms 305, 309, 313 and 314. Resident B was observed sitting in a recliner in the lounge area wearing a hospital gown that was not tied in the back. The gown was hanging down in the front exposing most of her chest, including her right breast. Registered Nurse 4 was observed walking past Resident B several times. RN4 made no attempt to interact with her or assist with covering her exposed areas. […]

• No harm, potential for more than minimal, isolatedF842Feb 25, 2026

  Based on interview and record review, the facility failed to ensure medical records were complete and accurately reflected the resident's clinical status for 1 of 3 residents reviewed (Resident E). Findings include:On 2/25/26 at 11:56 A.M., Resident E's record was reviewed. Diagnoses included end-stage kidney disease with dependence on renal dialysis, stage 4 pressure wound to the sacrum, and history of multiple type cancers. He was alert, oriented and able to make daily decisions as well as healthcare decisions for himself. A care plan, dated 7/23/25, indicated Resident E had dermatitis with a raised lesion on his left lower extremity suspicious for cancer. He was diagnosed with Lichenoid Keratosis (benign skin lesion) and treated with chemotherapy cream for 4 weeks. […]

• No harm, potential for more than minimal, isolatedF690Nov 6, 2024

  Based on observation, interview and record review, the facility failed to ensure nephrostomy care was provided for 2 of 2 residents reviewed (Resident 5 and Resident 41). Findings include: 1. Resident 5's record was reviewed on 11/1/24 at 10:51 AM. Diagnoses included chronic kidney disease and neuromuscular dysfunction of the bladder. Resident 5's Minimum Data Set (MDS), dated [DATE], indicated Resident 5's Quarterly Brief Interview for Mental Status (BIMS) score was 15 (no cognitive impairment). […]

• No harm, potential for more than minimal, isolatedF755Nov 6, 2024

  Based on observation, interview, and record review the facility failed to ensure medication disposition guidelines were followed for 1 of 5 residents reviewed (Resident 11). Findings include: During medication pass observation on 11/1/24 at 9:07 AM, Registered Nurse (RN) 3 prepared medication for Resident 11. During the preparation, RN 3 dropped a duloxetine 60 mg capsule on top of the medication cart. RN 3 picked up the capsule with ungloved fingers, placed it in the medication cup along with other medications due to be given that morning and administered them to Resident 11. During an interview on 11/1/24 at 9:25 AM, Licensed Practical Nurse (LPN) 2 indicated dropped pills should be placed in drug buster (a liquid chemical used to dissolve medications and render them unusable). […]

• No harm, potential for more than minimal, isolatedF842Nov 6, 2024

  Based on observation, interview, and record review the facility failed to ensure a wound assessment was accurately recorded for 1 of 11 residents reviewed (Resident 15). Findings include: During a wound care observation on 11/4/24 at 9:41 AM, Resident 15 was observed lying on his right side with a heavily padded heel boot secured with a Velcro closure. Licensed Practical Nurse (LPN) 4 held Resident 15's foot up about 6 inches off the bed. LPN 5 removed Resident 15's heel boot. Resident 15 had a gauze dressing wrapped around his right foot covering his ankle and up to the base of his toes. The dressing was secured with a piece of tape dated 11/3/24. […]