Avondale Villa Post-Acute

In the surveyor’s words

From the most serious findings on record at Avondale Villa Post-Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Mar 1, 2024

  Based on observation, interview, and record review, the facility failed to employ a qualified nutrition professional to manage the food and nutrition services when; 1. The Dietary Services Supervisor (DSS) did not work in the facility on a full-time basis and the Registered Dietitian (RD) worked part-time. 2. DSS did not know the cool down method for a leftover meat sauce and Pozole soup. 3. DSS did not ensure that time and temperature monitoring was performed by kitchen staff during thawing of frozen food items. 4. DSS did not ensure residents were served palatable food when food was served at a low temperature, tasted bland, and was a poor texture. 5. DSS did not ensure food was fortified (adding protein, fat, and/or carbohydrate to foods) for 15 out of 15 residents on fortified diet. 6. […]

• No harm, potential for more than minimal, widespreadF802Mar 1, 2024

  Based on observation, interview, and record review the facility failed to ensure food and nutrition staff had the appropriate competencies and skills set when: 1. Staff did not follow correct procedure for thawing frozen food item. 2. Staff did not appropriately demonstrate how to check the sanitizer strength used for the dish machine. 3. Staff recorded dish wash machine temperature inaccurately. These failures had the potential for inappropriate food preparation and dishwashing procedure that could result in food borne illness. Findings: 1. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with Cook 1, an unlabeled plastic package of tan colored frozen meat was in the freezer. […]

• No harm, potential for more than minimal, widespreadF803Mar 1, 2024

  Based on observation and record review, the facility failed to provide food items according to the menu when nine of 30 sampled residents receiving a regular diet order (Residents 4, 6, 13, 15, 16,17, 29, 186, and 188) were not served with one teaspoon (tsp) of margarine at lunch. This failure had the potential for residents to receive and/or consume inadequate caloric intake. See also tag F 808. Findings: During a review of the facility document, Diet Type Report, dated 2/28/24, the document indicated Residents 4, 6, 13, 15, 16,17, 29, 186, and 188 were on a regular textured diet that allowed margarine consumption. […]

• No harm, potential for more than minimal, widespreadF804Mar 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were served palatable food when food was served at a low temperature, tasted bland, and had poor texture. These failures had the potential for 30 of 30 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Findings: During an interview on 2/26/24 at 10:28 a.m., Resident 1 stated the meals served at the facility were often cold and not palatable. Resident 1 stated the same menu was served repeatedly. Review of the Minimum Data Set (MDS), a Resident Assessment and care guide tool, dated 1/25/24, indicated Resident 1 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Mar 1, 2024

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve foods in a sanitary manner that prevents foodborne illness for the facility when: 1. Cool down method was not performed for a leftover meat sauce and Pozole soup in the refrigerator. 2. Frozen food items were incorrectly thawed and refrozen. 3. A box of cherry tomatoes in the refrigerator was covered with white fuzzy material and dark spots. 4. A bag of cooked chicken was stored together in the same compartment with frozen raw meat and poultry. 5. Multiple unlabeled and undated food items were found in the freezer. 6. Staff did not handle drinkware in a manner to protect the drinkware from contamination. 7. […]