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Avalon Care Center: Fungal Infection Treatment Delayed - HI
During this five-day period, the resident's condition deteriorated significantly....
Latest reports, citations, and penalties from CMS data
During this five-day period, the resident's condition deteriorated significantly....
The review process evaluated insulin administration protocols, physician orders, and compliance with prescribed treatment regimens....
These residents had feeding tubes, urinary catheters, and tracheostomies - medical devices that significantly increase infection risk....
When this system fails, residents face increased risks as facilities cannot effectively identify and address dangerous patterns....
Inspectors determined the facility failed to properly implement these safety protocols....
The resident, who had been discharged from the hospital with orders to be placed on fall precautions, was left alone in her room despite her high-risk status....
This citation represents a significant finding where the facility's practices directly impacted resident safety and wellbeing....
This safety protocol was clearly outlined on the CNA Assignment Sheet and in the resident's care plan dated April 28, 2023....
Federal surveyors documented that residents consistently waited **30 to 60 minutes** for staff to respond to call lights, creating serious safety risks....
**Resident 40** faced similar risks while taking apixaban for deep vein thrombosis prevention....
The Memory Care Coordinator reported working despite feeling ill, having "spent the weekend in bed sick" with chills and diarrhea....
The resident was ordered to receive 4 liters of oxygen per minute via nasal cannula to maintain blood oxygen levels above 88%....
## Critical Staffing Shortages Documented Federal inspectors found the facility operating with dangerously low staffing levels across multiple shifts....
Federal regulators classified the violation as affecting "few" residents but requiring urgent corrective action....
## Critical Safety Assessment Gaps The inspection centered on Resident #47, whose bed was equipped with turning bars for positioning purposes....
Within days, nursing staff reported the resident had become unusually lethargic and sleepy....
## Poor Appetite and Inadequate Nutrition Monitoring Daily intake records revealed consistently low food consumption....
The citations affected residents who experienced falls resulting in serious injuries, including ankle and hip fractures....
When food service employees fail to wash hands adequately, they can transfer harmful bacteria, viruses, and parasites directly to foods consumed by residents....
## Delayed Implementation of Safety Protocols The January 17, 2025 inspection revealed that the 700 S....