Avalon Springs Care Center
AVALON SPRINGS CARE CENTER in MERCER, PA — inspection on December 31, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 12/30/25, at 1:47 p.m.
Licensed Practical Nurse Assessment Coordinator (LPNAC) confirmed that Resident R2's 9/26/25, MDS was coded incorrectly and Resident R2's Section M0300 G2 should have been coded as a two.
Resident R4's clinical record revealed an admission date of 7/21/25, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), GERD, and fractured left femur (a break in the thigh bone).
Resident R4's quarterly MDS with an ARD of 10/8/25, revealed section N Medications, Subsection N0415 High [NAME] Drug Classes E Anticoagulant (medication used to thin the blood) was coded as currently taking.
Resident R4's clinical record revealed a physician's order dated 7/21/25, for Lovenox (anticoagulant medication) 30 milligrams (mg) subcutaneous (sq - injection into the fatty tissue just beneath the skin) daily for 21-days.
Review of the October 2025 Medication Administration Record (MAR) revealed no evidence of Resident R4 receiving any anticoagulant during the seven-day look-back period for the 10/8/25 MDS.
During an interview on 12/30/25, at 1:39 p.m. the LPNAC confirmed that Resident R4's 10/8/25, MDS was coded incorrectly and Resident R4's Section N0415E should not have been coded as receiving during the last seven days. 28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa.
Code 211.5(f)(ix) Medical records
396058 12/31/2025
Avalon Springs Care Center 745 Greenville Road Mercer, PA 16137
During an interview on 12/30/25, at 11:10 a.m. the Director of Nursing confirmed that a care plan had not been developed to address Resident R3's usage of an anticoagulant; diabetes and usage of insulin; and usage and monitoring of an antipsychotic and antidepressant medication. 28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa.
Code 211.12(d)(3)(5) Nursing services
During an interview on 12/30/25, at 11:10 a.m. the Director of Nursing (DON) confirmed that the care plans for Residents R5 and Resident R49 were not reviewed and revised to reflect current resident care and services regarding code status.
Resident R2's clinical record revealed an admission date of 9/3/25, with diagnoses that included GERD, Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure.
Resident R2's clinical record revealed a POLST dated 7/22/25, that revealed DNR / Do Not Attempt Resuscitation (Allow Natural Death), Limited Additional Interventions.
Resident R2's physician's order dated 9/16/25, revealed an order for DNR / Do Not Attempt Resuscitation (allow natural death).
Resident R2's comprehensive care plan dated 9/5/25, with revision date of 10/1/25, revealed Advance Directive: Full Code.
During an interview on 12/30/25, at 2:21 p.m. the DON confirmed that the care plan for Resident R2 was not reviewed and revised to reflect current resident care and services regarding code status. 28 Pa.
Code 211.5(f)(i) Medical records 28 Pa.
Code 211.10(c)(d) Resident care policies 28 Pa.
Code 211.12(d)(1)(5) Nursing services
396058 12/31/2025
Avalon Springs Care Center 745 Greenville Road Mercer, PA 16137