Avon Place Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF761Jul 7, 2026

  Based on observation, interview, record review, and review of manufacturer instructions, the facility failed to ensure medications were stored in a safe and sanitary manner. This affected two residents (Residents #21 and #38) out of four residents reviewed for insulin pen storage and had the potential to affect all 80 residents residing in the facility who could use house stock medications. The total census was 80.Findings include:1. Observation of the East Hall medication refrigerator on 06/29/26 at 5:00 P.M. revealed the freezer section was completely filled by white and brown frost built up to such a degree that it pressed against the shelf in the freezer door and appeared to have damaged it. […]

• No harm, potential for more than minimal, widespreadF812Jul 7, 2026

  Based on observation, interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen area and ensure appropriate labeling and dating of food items. This had the potential to affect all 80 residents receiving meals from the facility kitchen. The facility identified no residents who received a nothing by mouth diet. The facility census was 80.Findings include:Observations on 06/28/26 at 8:43 A.M. of the main kitchen area revealed in the walk-in freezer there were containers of sherbet ice cream on the floor. The microwave had food splatters on the inside ceiling of the microwave and dried brown food splatters on the door of the microwave. The deep fryer had floating food debris covering the entire top of the fryer. […]

• No harm, potential for more than minimal, widespreadF880Nov 29, 2021

  Based on observations,, medical record review, staff interviews, review of in-services, review of facility policy, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19 and review of the CDC COVID tracker website , the facility failed to maintain proper infection control procedures to prevent the spread of infection, as well as isolation precautions. This had the potential to affect 85 of 85 residents residing in the facility. The facility census was 85. Findings include: Review of Resident #85's medical records revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Aug 31, 2021

  Based on observations, interviews with staff, review of in-services, review of facility screening checklist, review of facility employee, vendor and visitor log, review of the facility Coronavirus Disease 2019 (COVID-19) policy, review of Centers for Medicare and Medicaid Services (CMS) guidance, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore masks while in the facility and the facility failed to ensure individuals entering the facility were screened as required to potentially prevent the spread of COVID-19. This had the potential to affect all 79 residents currently residing in the facility. The facility census was 79. Findings include: Observations on 08/26/21 from 4:57 A.M. to 5:24 A.M. […]

• No harm, potential for more than minimal, patternF755Jul 7, 2026

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure controlled medications were accounted and dispensed appropriately. This affected two residents (Residents #32 and #62) out of three residents reviewed for controlled medication tracking and had the potential to affect all 80 residents residing in the facility who could use house stock medications. The total census was 80.1. Observation of the East Hall medication cart on 06/29/26 at 4:27 P.M. and record review of its narcotic count sheet and affected residents revealed three of Resident #62's oxycodone (a pain reliever) doses were documented as removed on 06/28/26, with the first dose being removed at an illegibly written time, the second at 12:30 P.M., and the third at 5:00 P.M. […]