The Springs of Avalon

In the surveyor’s words

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

• Actual harm, isolatedF600Aug 13, 2026

  Based on interviews, record review, and facility policy review, it was determined that the facility failed to a keep a resident free from physical abuse for one (Resident #75) of one resident reviewed for resident-to-resident altercations. Specifically, Resident #75 was physically assaulted by Resident #97, after Resident #97 did not receive indicated medication for dementia and delusions. The findings include: Resident #75 A review of the admission Record revealed that the facility admitted Resident #75 on 05/17/2024, with diagnoses that included dementia, malnutrition, anorexia, depression, anxiety, insomnia, restlessness and agitation, altered mental status, and muscle weakness and atrophy. […]

• No harm, potential for more than minimal, widespreadF812Feb 2, 2024

  37634 Based on observation and interview, the facility failed to ensure foods stored in the dry storage area refrigerator, and freezer were covered, sealed and dated to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness, kitchen wall and door frames, ceiling tiles; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen, kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, dish washer and kitchen walls, door frames and baseboards were free of rotten wood, chipped floor tiles, chipped… […]

• No harm, potential for more than minimal, widespreadF812Oct 28, 2022

  Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and/or freezer were covered and sealed; dietary staff washed their hands before handling clean equipment or food items; and hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and the ice machine was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 69 residents who received meals from the kitchen (total census: 72), as documented on a list provided by the Dietary Supervisor on 10/25/2022. […]

• No harm, potential for more than minimal, widespreadF812Jul 9, 2021

  Based on observation and interview, the facility failed to ensure kitchen employees washed their hands before handling clean equipment or food items, failed to ensure beverage cups were stored in a sanitary manner, on the secure unit, failed to ensure 1 of 1 ice machine was maintained in a clean condition, failed to ensure food items stored in the freezer and /or refrigerator were covered or sealed; failed to ensure kitchen floor and doors and window frames were clean and sanitary; failed to ensure hot food items were maintained at or above 135 degrees Fahrenheit on the counter while awaiting the meal service, to prevent potential cross contamination and or food borne illnesses for residents who received meal from 1 on 1 kitchen. […]

• No harm, potential for more than minimal, patternF689Feb 27, 2025

  Based on observations, interviews, and record review the facility failed to provide a smoking apron for 3 (Resident #44, Resident #6, Resident #45) of 4 residents on the secured unit who smoked. The findings are: A review of the facility policy Smoking Policy-Resident with a revision date of July 2024, indicated 7. The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. […]