Avalon Care Center: Stage 4 Pressure Ulcer Missed - WA

The resident's representative told inspectors the wound was "black" and staff had been "circling the area with a marker." They said a wound consultation had been requested but "nobody followed up on it."

Federal inspectors found the facility failed to identify the pressure ulcer until January 27, 2025, when weekly skin documentation suddenly recorded an "unstageable pressure ulcer" measuring five centimeters by three centimeters on the resident's left heel. Just three days later, a wound evaluation revealed it was actually a stage 4 pressure ulcer measuring 7.9 centimeters by 5 centimeters with a depth of 2.1 centimeters.

The wound was facility-acquired and had been present for one to three months, according to the evaluation.

Resident 54 had a documented history of heel wounds dating back to 2022. Care plans showed interventions including air mattresses, heel boots, and twice-daily treatments. A July 2024 skin review noted the heel wound had "healed," and an October review stated the wound was "resolved."

But the January 21, 2025 weekly skin check documented "no skin concerns."

Staff N, a registered nurse, told inspectors she was "unsure when it developed" and thought "it was acting up again but would have to check." Staff C, the resident care manager, said the family brought the pressure ulcer to their attention on January 27 and they placed a referral to United Wound Healing that day.

The resident told inspectors they had acquired the sore at the facility.

Another resident sustained a fall that highlighted gaps in post-fall monitoring protocols. Resident 30 had undergone brain surgery in December after an unwitnessed fall at home caused a head injury requiring a craniotomy to remove a blood clot.

On January 18 at 1:15 AM, just weeks after admission to the nursing home, Resident 30 fell again while reaching for their call light. Staff found a bump on the back of the resident's head in the same location as the previous injury.

The neurological assessment form required vital signs and checks every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for four hours, then every four hours for 24 hours. Staff completed the required 15-minute checks until 2:15 AM, then no documentation appeared until 6:00 AM — nearly four hours later.

At 7:04 AM, the resident received medication for a headache. When family visited that afternoon, they were "unhappy with cares" and had to insist the resident be sent to the hospital for evaluation, according to progress notes.

"Resident 30 was on blood thinners and experienced a brain bleed before," the family member told inspectors. "Resident 30's family member had to insist Resident 30 be sent to the hospital for further evaluation because the facility was not monitoring them."

The provider's note documented the resident hit "the same location on their head as the previous fall that occurred on 12/23/2024 that resulted in a craniotomy." The resident reported 5 out of 10 pain and was transferred to the hospital.

Multiple residents experienced repeated falls with inadequate safety interventions. Resident 90, who had severe cognitive impairment, sustained 11 documented falls between November 2024 and January 2025, including three falls before one-on-one supervision was implemented and additional falls even after constant monitoring began.

During the resident's initial admission attempt on November 18, transportation staff had to pull over three times because the resident "repeatedly attempted to get out of their wheelchair while the vehicle was in motion." Once at the facility, the resident was "too impulsive to participate in the admission process" and required transport back to the hospital for safer placement.

Progress notes stated the resident "was unaware of their safety needs and required constant supervision as they would transfer in less than a minute and seemingly required one on one supervision as Resident 90's safety would be compromised if left alone at any time."

The resident's power of attorney expressed concern that falls continued "even after 1:1 monitoring was implemented and wondered how that was possible."

Fall incident summaries showed interventions were often implemented days after they were supposedly initiated. A November 22 fall summary listed a "new intervention" of activities to promote exercise and strength building, but the care plan showed this intervention was initiated November 20 — four days before the fall occurred.

Resident 4's case revealed another implementation failure. The resident's care plan documented a fall mat should be placed on the floor, initiated October 10, 2022. But when the resident fell on October 23, 2024, hitting their head and developing a hematoma, the incident investigation noted the resident "was supposed to have a fall mat in place as care planned on 10/10/2022, but that had not occurred."

The facility also failed to assess substance use risks for residents with documented drug and alcohol histories. Resident 110 admitted with a history of using methamphetamine and alcohol — "1 ball and two cans of beer per day" according to hospital records — but had no care plan addressing substance use disorder risks.

The resident eloped from the facility on January 26, just one day after admission. Staff discovered them missing at 8:00 PM during medication rounds. Police were notified at 8:30 PM. The resident was found the next morning at a local hospital after "drinking alcohol and did not know how to get back to the facility."

Hospital records showed the resident had previously left another hospital against medical advice and noted "concerns of underlying psychotic illness contributed to Resident 110's recent AGAINST MEDICAL ADVICE discharge and possibly interfering with their medical decision-making capacity."

The facility's wander risk assessment rated the resident as "low risk for wandering or elopement," contrary to the hospital documentation of elopement history.

Staff interviews revealed confusion about substance use protocols. Staff P, a nursing assistant, was "unsure what staff were trained to recognize signs and/or symptoms of substance use, how the facility dealt with potential emergencies related to substance use or how the facility assessed for potential risks."

Staff Q, a licensed practical nurse, acknowledged Resident 110 "had a SUD with a history of smoking a ball of meth a day but no care plan was implemented."

Another resident with marijuana use documented in hospital records also lacked appropriate assessments. Resident 46's hospital intake showed they used marijuana seven days per week and tested positive for cannabinoids, but no substance use interventions appeared in their care plan.

Staff noted the resident had "glossed eyes and slurred speech" on January 19 and admitted to marijuana use, stating they "would hide it outside." Staff C said there was "no assessment to assess for marijuana use" and they were "unsure" if counseling was offered.

The facility's smoking policies created additional safety concerns. Administrator Staff A acknowledged they were "a non-smoking facility but they had smokers" who had to be "25 feet away from the building." However, Staff A also stated they "did not have a fire blanket because they were a non-smoking facility and to get a blanket would say they were a smoking facility."

Resident 46's August 2024 smoking assessment documented they were "unable to demonstrate a safe technique for extinguishing matches/lighter and dispose of ashes safely" and "unable to retrieve a cigarette if it were dropped." The assessment concluded the resident "would not smoke without supervision."

But Staff A admitted "the facility did not provide supervision for smokers and they could not stop them from going outside to smoke." Staff C acknowledged the resident "needed supervision and was unsafe to smoke independently" but said they "have not provided supervision for any of the smokers because they have never had anyone that needed it."

Basic care failures compounded safety risks. Resident 109, who was severely cognitively impaired and required two staff members and a mechanical lift for bathroom assistance, was dropped off at a medical appointment without any caregiver accompaniment. The resident began "exhibiting behaviors and screaming" during the appointment and needed help using the bathroom.

Staff O confirmed the facility "sometimes scheduled a nursing assistant to go to appointments with a resident" but acknowledged this hadn't occurred. The Director of Nursing confirmed Resident 109 "should have had a staff member and/or family member with them at the appointment due to needing assistance for ADLS."

Bathing documentation for Resident 54 showed sporadic care over five months. September 2024 showed one entry marked "non applicable" with no other bathing documented. October had two entries for "activity did not occur" and two refusals. November through January each showed only one or two bed baths per month, far below the care plan requirement of one to two showers weekly.

The resident's representative said they were "told they had no one to bathe them or the facility had not hired anyone to do bathing."

Staff N said if residents "continued to refuse their showers management would be notified to see what interventions could be implemented." But the Director of Nursing said they were aware the resident "had refused bathing and stated they preferred bed baths in the evening," though no such preference appeared in the care plan.

The inspection findings paint a picture of systematic failures in basic resident safety and care at Avalon Care Center at Northpointe, where a stage 4 pressure ulcer went undetected for months and a resident with recent brain surgery fell without proper monitoring protocols being followed.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Avalon Care Center At Northpointe from 2025-02-07 including all violations, facility responses, and corrective action plans.

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