Avalon Place

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received reasonable accommodation of needs in accordance with preferences for 1(#28) of 1 sampled residents reviewed for accommodation of needs by failing to provide a manual wheelchair for Resident #28 for mobility when the resident's electric scooter was not functioning.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure accuracy of the MDS assessment for 2 (#76 and #77) of 3 sampled residents reviewed.

Inspectors wroteBased on record review and interview the facility failed to provide nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (#55 & #77) sampled residents. The facility failed to ensure: 1) Nursing staff had a documented assessment or rationale for Resident #55 having an x-ray of her foot in the medical record prior to the x-ray being completed 2) Nursing staff completed and recorded an assessment for Resident #77 on 06/17/2025 when she complained of abdominal pain before being transferred to a local hospital on [DATE] for treatment of the abdominal pain.

Inspectors wroteBased on record reviews and interviews, the facility failed to inform the resident's physician and /or the resident's representative when a significant change in the resident's physical, mental, or psychosocial status or a decision to transfer or discharge a resident from the facility. The facility failed to:1.) notify the resident's physician and the resident's representative of a change in condition on 09/26/2025 when Resident #72 was transferred to the emergency room, and2.) notify the resident's physician of a change in condition for Resident #77.

Inspectors wroteBased on record reviews and interviews, the provider failed to ensure the MDS assessments were transmitted to the state in a timely manner for 1 (#2) of 3 sampled residents reviewed.

Inspectors wroteBased on record review and interview the facility failed to ensure a comprehensive plan of care was developed for 1 (#20) of 1 resident that developed COVID-19.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive plan of care for 1 (#77) of 2 (#20, #77) reviewed for colostomy care.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure notifications of changes in resident conditions were made, as evidenced by the facility failing to ensure the resident's physician was notified of an incident for 1 (#1) of 3 (#1, #2, and #4) residents reviewed for notification of change.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident with pressure ulcers recieved the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 (#6 and #52) of 5 (#5, #6, #18, #52, and #125) residents investigated for pressure ulcers. The facility failed to ensure that a pressure relieving device was implemented for resident #52, who currently had a new, unidentified pressure to her left heel.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (#25 and #70) of 9 (#5, #12, #17, #25, #38, #52, #69, #70 and #175) residents reviewed for accident hazards. The facility failed to 1) complete an Incident/Accident report after residents #25 and #70 had an incident, and 2) assess resident #70 to determine if the lap tray was appropriate after he slid under the lap tray.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice by failing to ensure fluid restrictions were followed and implemented as ordered for 1 (#3) of 1 sampled residents who were reviewed for dialysis.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to the installation of bed rails for 4 (#5, #12, #17, and #38) of 5 (#5, #12, #17, #38 and #52) residents reviewed for bed rails.

Inspectors wroteBased on observations of medication administration, record review, and interview, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 10.71% medication error rate with 3 medication errors out of 28 opportunities.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 3 (#18, #28, and #35) of 3 (#18, #28, and #35) residents reviewed for enhanced barrier precautions.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure notifications of changes in resident conditions were made, as evidenced by the facility failing to ensure 1) the resident's representative was notified after resident #69 had a fall, and 2) staff notified the nurse when resident #6 was found to have bruises for 2 (#6 and #69) of 2 residents reviewed for notification of change.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#25, #52 and #70) of 3 residents reviewed for restraints. The facility failed to have documented evidence of monitoring the release of the lap trays for residents #25, #52 and #70 and failed to have physician orders for the lap trays for residents #25 and #70.

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and send a copy of the notice to a representative at the Office of the State Long-Term Care Ombudsman for 1 (#12) of 1 (#12) reviewed for hospitalizations.

Inspectors wroteBased on record reviews and interview, the facility failed to assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 2 (#25 and #27) of 2 residents sampled for Minimum Data Set (MDS) Assessments.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 1 (#72) of 3 (#72, 73, 74) residents selected for closed record reviews.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's needs by not having documentation of the character of urine every shift for 1 (#18) of 1 residents reviewed for urinary catheters.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (#52) of 5 (#6, #28, #30, #52, and #67) residents investigated for activities of daily living. The facility failed to ensure resident #52's fingernails were kept trimmed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that a resident with limited range of motion receives appropriate treament and services to increase range of motion and /or to prevent further decrease in range of motion for 1 (#52) of 1 residents reviewed for Position/Mobility. The facility failed to ensure hand rolls were provided for resident #52's hand contractures.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor edema for a resident who received a diuretic for 1 (#17) of 5 (#17, #35, #38, #52, and #68) residents reviewed for unnecessary medications.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 5 (#4, #49, #57, #80 and #82) of 6 (#4, #7, #49, #57, #80, and #82) residents reviewed for unnecessary medications. The pharmacist failed to address no monitoring for side effects for residents #4, #49, #57, #80 and #82 while receiving psychotropic medications.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs for 2 (#4 and #80) of 6 (#4, #7, #49, #57, #80, and #82) sampled residents reviewed for unnecessary medications. The facility failed to monitor resident #80 for edema while receiving a diuretic and failed to monitor lab for resident #4 while taking Keppra and Divalproex.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that each resident was free from unnecessary medication use for 5 (#4, #49, #57, #80 and #82) of 6 (#4, #7, #49, #57, #80, and #82) residents reviewed for unnecessary medications. The facility failed to monitor side effects for residents #4, #49, #57, #80 and #82 that received psychotropic medications. Findings Resident #82 Review of the Facility's Behavioral Assessment, Intervention and Monitoring Policy revealed in part: The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, and or recurrent falling. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance wtih professional standards for food service safety by storing resident and staff's personal belonging in the kitchen food preparation and supply storage areas.

Inspectors wroteBased on record review and interview the facility failed to coordinate and evaluate activities under the Quality Assessment and Assurance QAA / Quality Assurance Performance Improvement (QAPI) program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

Inspectors wroteBased on observation and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition, by having a grease build-up on the internal components of the deep fryer.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#18) of 2 (#8, #18) residents reviewed for limited range of motion. The facility failed to ensure staff placed a splint device to resident #18's contracted right hand.

Inspectors wroteBased on record reviews and interviews, the provider failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical specialist of laboratory results that fall outside of clinical reference ranges for 1 (#1) of 1 (#1) residents who received seizure medications.