Inspection Report
Follow-Up
Deficiencies: 0
Jun 25, 2025
Visit Reason
A follow-up to a previous recertification survey and a follow-up to a previous Life Safety survey were conducted at the facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 30
Capacity: 31
Deficiencies: 12
May 30, 2025
Visit Reason
A recertification and complaint survey was conducted at Avalon Nursing Home from 05/27/2025 through 05/30/2025 to determine compliance with federal regulations for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified in multiple areas including resident rights, comprehensive care plans, nutrition and hydration, medication labeling and storage, immunizations, personnel background checks, emergency preparedness, and life safety code compliance. The facility failed to protect resident identifying information, maintain acceptable nutritional status, ensure proper medication management, and maintain a safe and functional environment.
Complaint Details
The survey included a complaint investigation referenced by ACTS number 100587.
Deficiencies (12)
| Description |
|---|
| Facility failed to protect identifying information for 3 of 4 residents reviewed. |
| Facility failed to ensure residents received treatment and care according to professional standards related to oxygen administration, offloading heels, and splint use. |
| Facility failed to maintain acceptable nutritional status for 1 resident with severe weight loss and failed to obtain timely reweighs and notify dietitian or physician. |
| Facility failed to properly label and store drugs and biologics, including expired medications and improperly dated vials. |
| Facility failed to ensure residents received required influenza and pneumococcal immunizations and documentation. |
| Facility failed to perform criminal background checks within one week of employment for 3 of 8 staff reviewed. |
| Facility failed to maintain effective in-service training program for nurse aides. |
| Facility failed to ensure quarterly evaluations for medication technicians were completed. |
| Facility failed to maintain emergency preparedness compliance with 42 CFR §483.73. |
| Facility failed to maintain fire alarm system, sprinkler system, and electrical systems in accordance with NFPA Life Safety Code requirements. |
| Facility failed to maintain safe, functional, and comfortable environment including air conditioning units and oxygen cylinder storage. |
| Facility failed to maintain required in-service training for nurse aides. |
Report Facts
Capacity: 31
Census: 30
Weight loss percentage: 7.82
Staff reviewed: 8
Staff with late background checks: 3
Nurse aides reviewed: 4
Nurse aides without required training: 2
Medication technicians reviewed: 1
Inspection Report
Follow-Up
Deficiencies: 0
Jul 10, 2024
Visit Reason
An off-site desk audit was conducted on July 10, 2024, to review all previous deficiencies cited on May 31, 2024, and a follow-up Life Safety Code survey was conducted on July 5, 2024 to verify correction of previous deficiencies.
Findings
All previous deficiencies cited in the May 31, 2024 inspection were corrected based on acceptable plans of correction and supporting documentation. No new deficiencies were identified during the follow-up Life Safety Code survey.
Inspection Report
Annual Inspection
Census: 30
Capacity: 31
Deficiencies: 9
May 31, 2024
Visit Reason
A recertification survey was conducted at Avalon Nursing Home from 5/29/2024 through 5/31/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to failure to provide written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman, dialysis services, nutritional adequacy, food safety, infection prevention and control, training requirements, employee immunization and screening, and life safety code compliance including fire alarm system and sprinkler system maintenance.
Severity Breakdown
Level B: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to provide written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for 2 residents discharged to hospital. | Level B |
| Facility failed to ensure dialysis services were provided consistent with professional standards for 1 resident. | — |
| Facility failed to meet nutritional needs related to increased protein for 1 dialysis resident. | — |
| Facility failed to ensure food safety requirements including dated food items and clean equipment in kitchen. | — |
| Facility failed to maintain an infection prevention and control program to prevent transmission of communicable diseases for multiple residents. | — |
| Facility failed to develop and maintain an effective training program for all new and existing staff including mandatory education and performance evaluations. | — |
| Facility failed to obtain evidence of immunity for all health care workers as required by regulations. | — |
| Facility failed to maintain fire alarm system and sprinkler system maintenance and testing as required by NFPA codes. | — |
| Facility failed to maintain emergency power supply system in accordance with NFPA standards. | — |
Report Facts
Census: 30
Total Capacity: 31
Residents reviewed for dialysis: 1
Residents reviewed for infection control: 3
Staff reviewed for immunization: 6
Residents impacted by fire alarm deficiency: 30
Residents impacted by sprinkler system deficiency: 30
Residents impacted by emergency power supply deficiency: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to oversight of dialysis services and plan of correction |
| Administrator | Administrator | Named in relation to oversight of deficiencies and plans of correction |
| Registered Nurse Staff A | Registered Nurse | Interviewed regarding dialysis services and infection control practices |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding dialysis services and infection control |
| Cook Staff B | Cook | Interviewed regarding food safety and immunization records |
| Staff C | Registered Nurse | Interviewed regarding infection control and immunization records |
| Staff F | Certified Medication Technician | Named in relation to immunization record deficiency |
| Staff G | Nursing Assistant | Named in relation to immunization record deficiency |
Inspection Report
Plan of Correction
Deficiencies: 0
May 2, 2022
Visit Reason
An off-site desk audit was conducted on May 2, 2022, to review all previous deficiencies cited on April 7, 2022.
Findings
Based on an acceptable plan of correction, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 29
Capacity: 31
Deficiencies: 6
Apr 7, 2022
Visit Reason
A Recertification of hour & Complaints Investigation Survey was conducted from 04/03/2022 to 04/07/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to baseline care plans, food service and safety, employee immunization and screening, personnel records, and in-service education. The facility failed to develop baseline care plans within 48 hours for residents, ensure food was prepared and served properly, maintain required immunization records for employees, and provide adequate staff training.
Complaint Details
This visit was triggered by complaints and a recertification survey to investigate compliance with federal and state regulations.
Deficiencies (6)
| Description |
|---|
| Facility failed to develop and implement a baseline care plan within 48 hours of admission for 2 residents. |
| Facility failed to assure residents receive and consume food in the appropriate form for 4 of 12 residents observed. |
| Facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. |
| Facility failed to obtain evidence of immunity for 3 of 8 employees reviewed. |
| Facility failed to obtain evidence of active licensing for 1 of 8 employees reviewed. |
| Facility failed to provide evidence of in-service training for staff related to infection control, food services and sanitation, fire safety, confidentiality, and residents' rights. |
Report Facts
Census/bed count: 29
Total licensed capacity: 31
Employees lacking immunization evidence: 3
Employees lacking active license: 1
Residents observed with food form issues: 4
Residents reviewed for baseline care plans: 2
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