Inspection Reports for
Avalon View Health and Wellness

The facility failed to implement contact precautions and infection control measures for three residents diagnosed with scabies, resulting in prophylactic treatment of all residents on the special care unit. Staff were unaware or did not follow proper isolation and PPE protocols despite documented scabies cases and physician orders.

The complaint investigation was substantiated. The resident slid out of the wheelchair during transport due to the driver not applying the seatbelt. The resident was assessed with no serious injury but some pain was reported. The driver was new to transportation duties and had not completed proper training prior to the incident. Corrective actions and re-education were implemented.

The facility failed to ensure the environment was free from accident hazards and did not follow its transportation policy, resulting in a resident sliding out of a wheelchair and sustaining minor injury during transport. Corrective actions included staff suspensions, re-education on transport safety, competency demonstrations, and implementation of audits and driving record validations.

The facility failed to ensure staff invoked the Durable Power of Attorney prior to allowing designated agents to make medical decisions for residents. Additionally, two residents were declared incapacitated by two physicians but had no guardianship or DPOA in place. This affected seven of eleven sampled residents.

The complaint investigation found that Resident #2 hit Resident #1 on the back on 3/24/25. Both residents were assessed; Resident #1 had redness on the back, Resident #2 had no injuries. Both residents reported feeling safe. The facility conducted an investigation, notified responsible parties, implemented environmental changes, provided trauma-informed care, reviewed medications, updated care plans, and provided staff education on de-escalation and abuse prevention.

The facility failed to protect Resident #1 from physical abuse by Resident #2, resulting in redness on Resident #1's back. The facility promptly investigated, implemented corrective actions, and updated care plans and staff education to prevent recurrence.

The facility failed to protect a resident from physical abuse during an altercation between two residents, resulting in redness on one resident's back. The facility conducted an investigation, implemented corrective actions, and completed staff education and environmental changes to prevent future incidents.

The facility failed to maintain confidentiality of resident records, ensure a safe and clean environment, provide adequate activities programming for residents, and maintain sufficient nursing staff to meet residents' basic care needs including hygiene, toileting, and timely call light response.

The facility had multiple deficiencies including failure to treat residents with dignity and respect, inadequate access to personal funds, inconsistent code status documentation, breaches in confidentiality, unsanitary environment and equipment, incomplete care plans, insufficient assistance with activities of daily living, lack of trauma informed care, insufficient staffing impacting resident care, medication management issues, food service deficiencies, and environmental safety hazards.

The facility failed to meet several fire safety requirements including maintaining fire-rated walls and ceilings, proper egress door locking mechanisms, kitchen range hood maintenance, sprinkler system maintenance, and electrical system inspections. Immediate jeopardy was identified and subsequently removed after corrective actions.

The facility failed to ensure call lights were within reach and responded to timely, moved residents' personal belongings without permission, maintained a clean environment, and provided adequate assistance with dressing, grooming, and bathing for several residents. Multiple residents reported unmet needs and dissatisfaction with care.

The facility failed to ensure residents' dignity by not keeping call lights within reach, delayed response to call lights, and moving residents' personal belongings without their presence. Additionally, the facility did not maintain a clean and comfortable environment, with issues such as dirty rooms, stained furniture, unemptied trash, and leftover food trays left in hallways. These deficiencies affected multiple residents and posed minimal harm or potential for actual harm.

The facility was found deficient in multiple areas including failure to ensure residents' dignity and timely response to call lights, inadequate maintenance of a clean and homelike environment, incomplete criminal background checks for staff, lack of PASARR screening for residents with mental disorders, medication administration errors, inadequate assistance with activities of daily living, improper use and assessment of bed rails, insufficient RN coverage, delayed meal service, unsafe food handling and storage practices, and failure to maintain an effective infection prevention and control program.

The facility was found not to meet several provisions of the Life Safety Code, including issues with building construction fire resistance, vertical openings, hazardous areas, cooking facilities, sprinkler system maintenance, fire watch policy, corridor wall construction, electrical equipment safety, and extension cord use. The facility had multiple deficiencies related to fire safety that could potentially affect residents.

The complaint investigation found that the facility did not properly investigate resident to resident altercations involving four residents, failed to interview other residents about their feelings of safety, and did not notify physicians or law enforcement as required. The facility also failed to maintain a safe environment with broken windows and unsecured air conditioning units.

The facility failed to conduct thorough investigations of resident to resident altercations, including not interviewing involved residents or notifying physicians and law enforcement. Additionally, the facility failed to maintain a safe environment by not replacing broken or missing window panes and leaving air conditioning units unsecured on the secure community.

The complaint investigation found that the facility did not properly investigate resident-to-resident altercations involving Residents #1, #2, #3, and #4, with missing interviews of involved residents and witnesses, and failure to notify physicians and law enforcement. The facility also failed to maintain a safe environment with broken windows and unsecured air conditioning units.

The facility failed to conduct thorough investigations of resident-to-resident altercations, including inadequate interviews of involved residents and witnesses, and failure to notify physicians or law enforcement. Additionally, the facility failed to maintain a safe environment by not replacing broken or missing window panes and not securing air conditioning unit covers on the secure community.

The investigation was triggered by allegations of abuse, neglect, exploitation, or mistreatment involving resident altercations. The complaint was substantiated as the facility failed to properly investigate and follow policy, and failed to maintain a safe environment.

The facility failed to conduct thorough investigations and follow their policy regarding resident altercations involving four sampled residents. Additionally, the facility did not maintain a safe, functional, sanitary, and comfortable environment due to broken or missing window panes and unsecured air conditioning units on the secure community.

The facility failed to maintain the grounds properly, with grass approximately eighteen inches tall and overgrown due to lapses in lawn maintenance services. Interviews confirmed the facility was between lawn service providers and lacked some equipment, such as a weedeater.

The facility failed to maintain a safe, functional, sanitary, and comfortable environment as the grounds were not mowed and the grass was approximately eighteen inches tall. Observations and interviews confirmed the lawn had not been maintained as required by facility policy.

The facility was found deficient in maintaining a safe, clean, and homelike environment, providing adequate personal care including grooming and showering, and ensuring food was served at safe and appetizing temperatures. Multiple residents reported issues with lost personal belongings, inadequate showering, and cold food service.

The facility failed to maintain their construction rating due to holes in the ceilings of shower rooms and attic areas, which compromised the fire safety rating. Repairs were made to the ceilings and shower rooms to address these issues.

The facility failed to provide appropriate treatment and services to residents with dementia who displayed aggressive behaviors, resulting in physical harm to other residents. The report details multiple incidents involving residents pushing others causing injuries, and inadequate staff interventions and behavior management.

The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a diagnosis of convulsion and failed to prevent significant medication errors related to dilantin administration. Deficiencies were cited related to care planning and medication administration policies and procedures.

The facility failed to provide professional services by not scheduling a physician-ordered MRI for Resident #1, resulting in incomplete diagnostic imaging. Interviews revealed communication failures between nursing staff and imaging centers, and lack of follow-up on physician orders.

The complaint involved an injury of unknown origin to Resident #1. The investigation was found to be insufficient and incomplete, with failure to prevent further harm and failure to report timely to authorities. The complaint was substantiated based on the findings.

The facility failed to conduct a thorough investigation and follow their policy regarding alleged abuse, neglect, and exploitation. The facility also failed to obtain timely physician orders for x-rays related to a resident's injury and did not follow professional standards of care.

The complaint investigation found the violation to be at an imminent danger class I level due to sexual abuse by an LPN. The facility implemented corrective actions during the onsite visit to remove the immediate jeopardy.

The facility failed to ensure residents were free from sexual abuse by an LPN who inappropriately touched multiple residents. The facility also failed to perform proper background checks on the LPN prior to employment and did not have adequate abuse prevention policies in place.