Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avondale Villa Post-acute during CMS and state inspections, most recent first.
A severely cognitively impaired, highly dependent resident was found by CNAs and LVNs to have a new purplish bruise on the lower chin/near the lip, with staff consistently unable to identify a cause. The bruise was documented in clinical notes as a new skin discoloration, and internal notifications were made, but the administrator confirmed that the incident was not reported to CDPH, law enforcement, or the Ombudsman, despite facility policy requiring immediate external reporting of suspected injuries of unknown origin.
Surveyors found that the facility did not maintain proper infection control practices, including unclear cleaning status and improper storage of a shared Hoyer lift, failure to follow Enhanced Barrier Precautions for a resident with a stage 4 pressure ulcer and wound vac, and improper cleaning and disinfection of a shared glucometer between resident uses. Staff did not consistently follow manufacturer instructions or facility policy for cleaning and disinfection, and required personal protective equipment was not always used during high-contact care.
An LVN administered a hazardous drug, finasteride, to a resident without wearing gloves, despite the medication being labeled as hazardous and facility policy requiring PPE. The resident’s MAR did not indicate the need for precautions, and the DON confirmed that gloves should be used when handling such medications.
The facility did not maintain documentation or a witnessed process for the destruction of discontinued non-narcotic prescription medications. Nurses were allowed to destroy these medications without records, and there was no designated storage area for discontinued drugs. The policy did not address documentation requirements for non-narcotic medication destruction, and the consultant pharmacist was not involved in this process.
A resident with GERD, diabetes, kidney disease, and heart issues was given both pantoprazole and omeprazole, two PPIs, at the same time after a hospitalization. Nursing staff did not identify or address the duplicate therapy, and the facility's consultant pharmacist confirmed there was no benefit to this practice. Facility policies requiring medication review were not followed.
Three medication administration errors were observed, resulting in a facility-wide medication error rate of 9.52%. Errors included a nurse giving a resident Robitussin DM instead of plain Robitussin, another nurse administering Senna instead of the prescribed Senna-Docusate combination to a resident, and a nurse applying a 4% lidocaine patch instead of the ordered 5% strength to another resident. These errors occurred due to failure to follow prescriber orders and verify medication details as required by facility policy.
Surveyors found expired Covid-19 testing products, vaccines with unclear expiration dates, and co-mingled supplies for IV use and foley catheters in the medication room, along with expired swabs for throat infection. The treatment cart contained opened, single-use sterile wound care products and additional expired swabs. Facility staff acknowledged the findings, and interviews revealed that monthly checks were not detailed enough to prevent these deficiencies.
A resident's two bottles of apple juice, one expired and one undated, were found stored in the staff refrigerator instead of the designated resident food refrigerator, in violation of facility policy. The expired juice was not discarded as required, and the improper storage was confirmed by both the DSD and DON during interviews.
Two rooms were found to provide less than the required 80 square feet per resident, with each room housing four residents in spaces measuring 77.24 and 72.1 square feet per person. Despite residents and staff reporting no issues with space, privacy, or care delivery, the rooms did not meet regulatory size standards.
The facility failed to employ a qualified nutrition professional to manage food and nutrition services, leading to multiple issues such as improper food handling, serving cold and unpalatable food, not fortifying diets for residents who needed it, and not maintaining accurate resident food preferences. The DSS was not present full-time, and the RD worked part-time, contributing to these deficiencies.
The facility failed to ensure food and nutrition staff had the appropriate competencies and skills set, leading to improper thawing of frozen food, incorrect sanitizer strength checks, and inaccurate dish wash machine temperature recordings. Staff admitted to not monitoring time or temperature during thawing, and logs showed repeated temperatures for multiple cycles.
The facility failed to provide food items according to the menu when nine residents on a regular diet were not served with one teaspoon of margarine at lunch. This was observed during a lunch tray line observation, where no margarine was served on any resident lunch tray. The facility's Winter Menus indicated that one teaspoon of margarine should be included on the lunch tray for all regular textured diets, excluding the low/fat, low cholesterol diet. This failure had the potential for residents to receive inadequate caloric intake.
The facility failed to serve palatable food at the appropriate temperature. Residents reported receiving cold, bland, and poorly textured meals. Observations confirmed that food temperatures were below the required standards, and the kitchen lacked proper equipment to maintain hot food during service.
The facility failed to store, prepare, distribute, and serve foods in a sanitary manner, leading to potential foodborne illness risks. Issues included improper cool down methods, incorrect thawing and refreezing of food, spoiled cherry tomatoes, improper storage of cooked and raw meats, unlabeled and undated food items, improper handling of drinkware, and inadequate cleaning of the ice machine.
A resident with a history of stroke and dementia experienced repeated unwitnessed falls due to inadequate supervision and lack of necessary safety equipment. Despite being identified as high risk for falls, the facility did not consistently implement the required stand-by assistance during transfers, leading to multiple incidents where the resident was found on the floor after attempting to transfer without help.
The facility failed to ensure that pureed food was prepared to the appropriate consistency for six residents. Observations revealed that pureed chili, cornbread, beef roast, and zesty spinach were too thin and runny, not adhering to the Registered Dietician's guidelines for pureed food to be smooth, moist, and able to hold its shape.
The facility failed to offer a substitute when milk was not provided as per the planned menu and did not maintain an accurate system for recording residents' food preferences. One resident reported receiving cold food and having lactose intolerance, but her preferences were not accurately reflected. The facility's administrative documents were outdated and not maintained within the licensed building.
The facility failed to provide physician-prescribed therapeutic diets to residents, as observed during multiple lunch tray line observations. Six residents on a Fortified diet did not receive supplemental food items, three residents on a Consistent Carbohydrate diet received regular diet items, and one resident with a diet order for extra protein did not receive additional meat as prescribed.
The facility failed to document medication administration for three residents on multiple occasions in February 2024. Both the DON and an LVN admitted to administering the medications but did not document them due to being too busy and, in one case, falling ill and forgetting to document upon return to work.
The facility failed to maintain the dishwashing machine's water temperature within the manufacturer's recommended range, risking insufficient sanitization of dishware. Observations and records showed discrepancies in recorded and actual temperatures, indicating non-compliance with sanitation standards.
The facility failed to complete baseline care plans within 48 hours of admission for three residents and did not provide them or their representatives with a summary of the baseline care plan. The DON confirmed that the baseline care plans were not developed within the required timeframe and that summaries were not provided.
The facility failed to implement a care plan for a resident at risk of aspiration due to dysphagia. Despite a physician's order for a provale cup, staff used a regular plastic cup, leading to frequent coughing. The change was not communicated to the speech therapist, and no care plan addressed the resident's risk.
The facility failed to assess a resident who experienced severe weight loss, despite the resident's multiple diagnoses and significant weight changes. The last nutrition-related documentation by an RD was several months old, and the care plan was not updated in a timely manner. Interviews with staff revealed that the required assessment and intervention process was not followed.
The facility failed to ensure that two residents were free from unnecessary drugs when psychotropic medications were administered without adequate clinical indication and monitoring. One resident received Ziprasidone without documented behavioral symptoms or side effect monitoring, while another received Zyprexa and Trazodone without adequate monitoring and PRN Lorazepam without non-pharmacological interventions first. The facility did not follow its policy on psychotropic medication use and PRN orders.
The facility failed to use a prescribed provale cup for a resident at risk for aspiration and did not consult the Speech Therapist for alternative recommendations when the resident refused the cup. This led to the resident being given water from a plain plastic cup, resulting in frequent coughing during meals.
The facility had two resident rooms with multiple beds that did not meet the required 80 square feet per resident. Staff and residents reported no issues with space for care or belongings, but the rooms did not comply with regulatory space requirements. No negative consequences were observed, and a room size waiver was recommended.
Failure to Report Injury of Unknown Origin to Required External Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin for a severely cognitively impaired resident as required by law and by the facility’s own abuse reporting policy. The resident’s MDS indicated severe cognitive impairment and dependence on staff for most ADLs, including toileting, showering, transferring, and substantial assistance with eating, oral hygiene, and bed mobility. Multiple CNAs and LVNs observed a new bruise on the resident’s lower left chin/near the lip on or around 2/4/26, described as purple or purplish-blue, small, round or irregular, and approximately 1/4 to 1/2 inch in size. CNAs reported the bruise to charge nurses/LVNs, and documentation in the SBAR and skin assessment on 2/4/26 noted a new skin discoloration on the left chin area, with no complaints of pain or distress and the resident sleeping during the shift. Staff consistently stated they did not know what caused the bruise, and one CNA believed no one knew how it happened. Despite the unknown cause of the facial bruise and the resident’s severe cognitive impairment and dependence on staff, the administrator acknowledged that the bruise was not reported to CDPH, local law enforcement, or the Ombudsman. The facility’s written policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised September 2022, states that all reports of resident abuse, including injuries of unknown origin, must be reported to local, state, and federal agencies as required by regulations, and that suspected injuries of unknown source must be reported immediately to the administrator and appropriate external agencies, including the state licensing/certification agency, the ombudsman, and law enforcement. Although the physician and resident representative were notified, the required external reporting to regulatory and protective agencies did not occur, resulting in the failure to ensure the injury of unknown origin was reported as required by law.
Infection Control Failures in Equipment Cleaning, Enhanced Barrier Precautions, and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several key areas. During an observation in the utility room, two Hoyer lifts were found, with one positioned in a red-taped area labeled as 'DIRTY AREA' and a nearby cabinet labeled 'CLEAN AREA' containing unopened medical supplies. The Infection Preventionist (IP) stated uncertainty about whether the Hoyer lift was clean or dirty and acknowledged that the lift did not fit in the designated dirty area, raising concerns about potential cross-contamination. Review of records showed that seven residents used the Hoyer lift, and facility policy required cleaning and disinfecting reusable equipment between residents, in accordance with CDC guidelines. In another instance, the facility did not follow Enhanced Barrier Precautions (EBP) protocol for a resident with a stage 4 sacral pressure ulcer and a wound vac. The resident's care plan and physician order required staff to use gowns and gloves during high-contact care activities. However, a Certified Nursing Assistant (CNA) was observed providing direct care to the resident without wearing a gown, despite signage indicating the need for EBP. The CNA later confirmed awareness of the precautions but admitted to not following them during care, and the Director of Nursing (DON) confirmed that the required precautions were not followed during the incident. Additionally, the facility failed to properly clean and disinfect a shared glucometer between resident uses. During a medication pass, a Registered Nurse (RN) was observed wiping the glucometer with a single disinfecting wipe for less than ten seconds before returning it to the medication cart. Manufacturer instructions and facility policy required a two-step process using two wipes, with the device remaining wet for a specified contact time. The RN acknowledged not following the correct procedure, and both the DON and IP confirmed the expectation for staff to adhere to the two-step cleaning and disinfection process.
Failure to Use PPE During Hazardous Drug Administration
Penalty
Summary
Nursing staff failed to follow professional standards and facility policy for the safe handling of hazardous drugs during medication administration. During a medication pass observation, an LVN administered a tablet of finasteride, which was clearly labeled as a hazardous drug, to a resident without wearing gloves. The LVN removed the tablet from the bubble pack with bare hands and placed it into a medication cup before giving it to the resident. The resident’s Medication Administration Record did not indicate the need for gloves or other precautions when administering the drug. The facility’s policy required the use of appropriate personal protective equipment, including gloves, when handling hazardous drugs. Additionally, CDC and NIOSH guidelines specify that gloves should be used when handling intact tablets of hazardous medications such as finasteride. The DON confirmed that nurses are expected to wear gloves to minimize contact and protect themselves when handling these medications. This failure to adhere to established guidelines and facility policy had the potential to pose health risks to both staff and residents.
Lack of Documentation for Non-Narcotic Medication Destruction
Penalty
Summary
The facility failed to document the disposition and destruction of non-narcotic prescription medications for its residents. During an inspection of the medication room, a nurse was unable to locate any records of prescription drug destruction and was unsure about the procedures for storing or destroying discontinued non-narcotic medications. The medication room did not have a designated storage area for discontinued medications. The Director of Nursing confirmed that nurses were allowed to destroy discontinued prescription medications without any system of documentation or witnessed signatures, and there was no option to return unused drugs to the pharmacy. The Consultant Pharmacist stated she was only involved in the destruction of narcotic drugs and not non-narcotic medications, and indicated that the facility should follow its policy for discontinued drug disposition. A review of the facility's policy on discarding and destroying medications revealed that while it referenced compliance with federal, state, and local regulations for the disposal of non-hazardous pharmaceuticals and controlled substances, it did not address the need for documentation or accountability in the destruction of non-narcotic medications. This lack of documentation and clear procedures for non-narcotic medication destruction was observed in a facility with a resident census of 35.
Failure to Prevent Duplicate PPI Therapy in a Resident with GERD
Penalty
Summary
A deficiency occurred when a resident with a history of GERD, diabetes, kidney disease, and heart issues was prescribed and administered two proton pump inhibitors (PPIs), pantoprazole (Protonix) and omeprazole (Prilosec), at the same time. The resident's medical record showed that Prilosec had been prescribed for GERD and continued after a recent hospitalization, while Protonix was added upon the resident's return from the hospital. Nursing staff did not identify or address the duplicate therapy, and the duplicate medications were not flagged in the electronic medical record system. The Licensed Vocational Nurse acknowledged that Prilosec should have been discontinued and that the physician should have been notified about the duplicate PPI therapy. The facility's consultant pharmacist confirmed that there was no clinical justification for the resident to be on both PPIs simultaneously and that this practice would not provide additional benefit. The facility's policies required ongoing review of medication regimens for indications, doses, duration, and potential adverse consequences, but these procedures were not followed in this case. The medical director was not reached for comment during the survey.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 9.52%, which exceeds the acceptable threshold of 5%. During medication administration observations, three errors were identified out of 43 opportunities involving three residents. In one instance, a nurse administered Robitussin DM, which contains both guaifenesin and dextromethorphan, instead of the prescribed plain Robitussin (guaifenesin only) to a resident with allergy and cough symptoms. The nurse could not locate the correct medication and used a similar product from another unit without clarifying the order with the physician. Another error involved the administration of a laxative containing only Senna to a resident, despite the physician's order specifying a combination of Senna and Docusate. The nurse attributed the mistake to the similar appearance of the medication bottles. In a third case, a nurse applied a lidocaine 4% patch to a resident for pain management, although the order specified a 5% strength patch. The nurse documented the administration as 5% on the Medication Administration Record. The facility's policy requires medications to be administered according to prescriber orders and verified for the correct resident, medication, and dosage, but these procedures were not followed in the observed cases.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of drugs and biologicals in both the medication room and the treatment cart. In the medication room, expired Covid-19 testing products and vaccines with unclear expiration dates were found. The Covid-19 vaccine syringes were stored in the refrigerator with labels that did not clearly indicate the beyond use date or when the product was thawed, and the storage instructions were inconsistent. Additionally, a plastic drawer contained expired swabs for throat infection and supplies for IV use, including items for residents no longer in the facility, co-mingled with other supplies. The treatment cart, located in the main hallway, contained multiple opened wound care products that were labeled as sterile and for one-time use only. These included opened sterile Iodoform Packing strips, non-adherent pads, calcium alginate dressings, and comfort foam dressings, all marked as sterile and not for reuse. Expired swabs for throat infection were also found in the cart's active storage area. These items were accessible in areas where they could be used for resident care. Interviews with the Director of Staff Development and the Director of Nursing confirmed the findings. The DON acknowledged the need for continuous re-organization of the small medication room and stated that monthly checks by nurses and the pharmacy consultant were not detailed enough to catch these issues in the active storage areas. Facility policies reviewed indicated requirements for safe, secure, and orderly storage of medications and supplies, as well as proper labeling and removal of outdated or deteriorated items.
Failure to Follow Policy for Storage and Discarding of Resident Food Brought by Family
Penalty
Summary
The facility failed to implement its policy regarding the storage and handling of food and beverages brought in by family or visitors for residents. Specifically, two frozen bottles of apple juice belonging to a resident were found stored in the staff refrigerator, rather than in the designated resident food refrigerator. One of the bottles was past its expiration date, and the other had no expiration date marked. According to the facility's policy, expired food or beverages should be discarded, and items without a manufacturer's expiration date should be dated upon arrival and discarded after three days if refrigerated or thirty days if frozen. The Director of Staff Development confirmed that the bottles belonged to the resident and acknowledged the improper storage and failure to discard the expired item. The resident involved had a regular diet order with thin liquids and had been admitted to the facility prior to the incident. The Director of Nursing also confirmed that the bottles should have been stored in the appropriate refrigerator and that the expired juice should have been discarded, as per facility policy. The improper storage and failure to discard the expired juice were identified during an observation and interview, and the deficiency was limited to this one resident among the sampled group.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
Two resident rooms were found to be non-compliant with space requirements, as each room provided less than 80 square feet per resident. Specifically, one room measured 308.95 square feet and was occupied by four residents, resulting in 77.24 square feet per resident. Another room measured 288.4 square feet and was also occupied by four residents, giving each resident 72.1 square feet of living space. These measurements were confirmed during an observation and interview with the Maintenance Director, who stated that no residents in these rooms had complained about the room size or requested transfers. Interviews with residents and observations of care revealed that residents did not express concerns about the room size, and staff were able to provide necessary care and services without obstruction. There was sufficient space for movement, privacy, and storage of personal belongings, and no heavy equipment was present in the rooms that could interfere with care. Despite these observations, the rooms did not meet the required minimum square footage per resident.
Failure to Employ Qualified Nutrition Professional and Ensure Food Safety
Penalty
Summary
The facility failed to employ a qualified nutrition professional to manage the food and nutrition services. The Dietary Services Supervisor (DSS) did not work in the facility on a full-time basis, and the Registered Dietitian (RD) worked part-time. This led to multiple issues, including the DSS not knowing the cool-down method for leftover meat sauce and Pozole soup, not ensuring time and temperature monitoring during the thawing of frozen food items, and not ensuring residents were served palatable food. Additionally, the DSS did not ensure food was fortified for residents on a fortified diet and did not ensure residents on a Consistent Carbohydrate (CCHO) diet received the correct diet. The DSS also failed to communicate to the RD that most residents did not like milk, resulting in the facility not providing a substitute of equal nutritive value. Furthermore, the DSS did not effectively maintain a system to ensure that residents' food preferences were accurately recorded on individual tray cards. During a kitchen observation, multiple unlabeled and undated food items, thawed and refrozen food items, and moldy tomatoes were found in the freezer and refrigerator. The DSS admitted that cooks were responsible for checking food items, but she should also be monitoring the refrigerator and freezer. The DSS was not present full-time and was also working in a neighboring facility. The RD confirmed that she worked only 8 hours a week in the facility. The facility's policy and procedure on sanitation and the DSS job description indicated that the DSS was responsible for instructing employees in food safety and sanitation and for monitoring food temperatures and cool-down logs. However, the DSS failed to provide documented staff training related to food safety. The facility's policy on meal service indicated that meals should be served at the appropriate temperature and that hot food should be at or above 140°F. However, during tray line observations, pureed foods were found to be runny and not holding their shape, and regular textured foods were served at temperatures below the recommended levels. Residents complained about receiving cold food, and the DSS admitted to providing education to kitchen staff but did not follow up. The RD was not aware of the residents' complaints about cold food. Additionally, the facility's policy on fortification of food was not followed, as residents on a fortified diet did not receive additional items to increase the nutrient content of the food served. The DSS also failed to ensure that residents on a CCHO diet received the correct diet, as regular desserts and bread portions were served instead of the diet versions. The DSS did not communicate with the RD about residents' preferences for milk, resulting in no substitutions being made. The DSS also failed to maintain accurate resident profile cards, leading to incorrect food preferences being recorded and outdated profile cards being used.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure food and nutrition staff had the appropriate competencies and skills set, leading to several deficiencies. Staff did not follow the correct procedure for thawing frozen food items. During observations, it was noted that frozen meat was being thawed inappropriately without time or temperature monitoring, which is against the 2022 Federal Food Code. This improper thawing process was acknowledged by the staff, who admitted there was no oversight of temperature monitoring to ensure food safety. Additionally, staff demonstrated a lack of knowledge in checking the sanitizer strength used for the dish machine, using the incorrect sanitizer strip initially. Furthermore, the dish wash machine temperature was recorded inaccurately, with logs showing the same temperature for multiple cycles on multiple days, even before the lunch service had begun. The facility's policies and job descriptions indicated that staff should be trained and knowledgeable in these areas, but the surveyor found no documented staff training related to food safety.
Failure to Provide Margarine as Per Menu
Penalty
Summary
The facility failed to provide food items according to the menu when nine of 30 sampled residents receiving a regular diet order were not served with one teaspoon of margarine at lunch. This was observed during a lunch tray line observation, where no margarine was served on any resident lunch tray, including those of the nine affected residents. The facility's Winter Menus indicated that one teaspoon of margarine should be included on the lunch tray for all regular textured diets, excluding the low/fat, low cholesterol diet. Additionally, the facility's policy and procedure titled 'Diet Orders' stated that diet orders as prescribed by the physician would be provided by the Food & Nutrition Services Department. This failure had the potential for residents to receive and/or consume inadequate caloric intake.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure residents were served palatable food when food was served at a low temperature, tasted bland, and had poor texture. Resident 1 reported that meals were often cold and not palatable, and the same menu was served repeatedly. The Minimum Data Set (MDS) indicated Resident 1 was cognitively intact and had hypothyroidism. Resident council meetings also documented complaints about cold food and repetitive menus. The Activity Director confirmed that residents had complained about cold food and dietary issues, which were reported to the Dietary Supervisor. The Dietary Services Supervisor acknowledged awareness of the complaints but did not follow up on food temperature checks. During a tray line observation, the Registered Dietitian (RD) measured food temperatures and found them below the required 141°F. The pureed and regular textured food on a resident's tray was also below the recommended temperature, with the pureed fish at 121.8°F, pureed broccoli at 119.3°F, and pureed risotto at 106.5°F. The kitchen lacked equipment to hold food hot during tray line service. The RD sampled the food and found it cold, bland, and with a sticky texture. The facility's policy indicated that hot food should be served at or above 140°F, but this standard was not met. The facility's Diet Manual also specified that pureed food should be smooth and moist, which was not the case in this instance.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve foods in a sanitary manner, leading to potential foodborne illness risks. Observations revealed that the cool down method was not performed for leftover meat sauce and Pozole soup in the refrigerator, and the Cool Down Log had no entries. The Dietary Services Supervisor (DSS) admitted that no temperature monitoring was completed during the cool down process because the meat was mixed with other ingredients. The facility's policy required proper documentation and temperature monitoring during the cooling process, which was not followed. Frozen food items were incorrectly thawed and refrozen without proper time and temperature monitoring. Cook 1 and Cook 2 admitted to thawing frozen meat under running water and then refreezing it without documentation. The facility's policy required thawing meat in the refrigerator and monitoring the temperature to ensure it did not remain in the danger zone for more than four hours. Additionally, a box of cherry tomatoes in the refrigerator was found covered with white fuzzy material and dark spots, indicating spoilage. The DSS acknowledged that the tomatoes were past their shelf life and should have been discarded. Other deficiencies included storing a bag of cooked chicken together with frozen raw meat and poultry, multiple unlabeled and undated food items in the freezer, and improper handling of drinkware by staff. The ice machine was also found to have black build-up residue and white mineral build-up, and the cleaning and sanitizing procedures were not followed according to the manufacturer's instructions. The Maintenance staff admitted to using an unapproved cleaner and not following the detailed cleaning steps provided by the ice machine manufacturer. These failures had the potential to expose residents to foodborne illness.
Failure to Provide Adequate Supervision and Interventions for Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and implement appropriate interventions for a resident who had repeated unwitnessed falls. Resident 16, who had a history of stroke and Non-Alzheimer's Dementia, required extensive assistance and one-person physical assistance for transfers and movements. Despite being identified as high risk for falls, the facility did not provide necessary supervision or alert devices to prevent unassisted transfers. This led to multiple incidents where Resident 16 was found on the floor after attempting to transfer without assistance, including falls in the dining/activity room, hallways, and his room. Observations and interviews revealed that Resident 16 was often left unsupervised and without necessary safety equipment, such as cushions or alert devices, to prevent falls. The care plan indicated the need for stand-by assistance during transfers, but this was not consistently implemented. The facility's policy on managing fall risks was not adequately followed, as evidenced by the repeated falls and lack of effective interventions to address Resident 16's specific needs. The Director of Nursing acknowledged concerns about the resident's repeated falls, but appropriate measures were not in place to prevent them.
Inappropriate Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the appropriate consistency for six out of 30 residents. During tray line observations on two consecutive days, pureed chili and cornbread were found to be too thin, resembling thickened cream soup and thin pudding, respectively. Similarly, pureed beef roast and zesty spinach were observed to be runny and spread out on the plate. A review of the Diet Type Report confirmed that six residents were on a pureed diet order. According to the facility's Registered Dietician's manual, pureed food should be smooth, moist, and able to hold its shape, which was not adhered to in these instances.
Failure to Provide Substitutes and Maintain Accurate Food Preferences
Penalty
Summary
The facility failed to offer a substitute of equal nutritive value when milk on the planned menu was routinely not provided for all diets. During tray line observations, it was noted that over 20 trays did not include milk, despite it being listed on the winter menus. The Dietary Services Supervisor (DSS) stated that most residents do not like milk for lunch and other meals, and no substitution was made when milk was not provided. The Registered Dietitian (RD) was unaware of this issue and did not ensure a substitution was provided when residents preferred not to drink milk as per the planned menu. Additionally, the facility did not effectively maintain a system to ensure residents' food preferences were accurately recorded on their individual tray cards. One resident reported receiving cold food and being lactose intolerant, yet her preferences were not accurately reflected on her tray card. The DSS demonstrated that the facility's administrative documents, including resident profile cards, were not maintained within the licensed building and were outdated. A review of the resident profile cards showed multiple inaccuracies and missing information regarding food preferences and dislikes. The facility's policy indicated that the Food and Nutrition Services Director or designated personnel should update the profile cards, but this was not being done accurately or consistently.
Failure to Provide Physician-Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide physician-prescribed therapeutic diets to residents, as observed during multiple lunch tray line observations. Six residents on a Fortified diet did not receive supplemental food items such as margarine and extra gravy as ordered. Additionally, three residents on a Consistent Carbohydrate diet received regular diet items instead of the modified versions specified in their diet orders, such as Diet Citrus Chiffon Delight and half portions of cornbread and garlic sticks. One resident with a diet order for extra protein did not receive the additional meat as prescribed. During the observations, it was noted that the lunch trays for residents on therapeutic diets were identical to those on regular diets, lacking the necessary modifications. The facility's Winter Menus and recipes indicated specific changes for therapeutic diets, but these were not followed. For example, residents on a CCHO diet were supposed to receive diet gelatin and omit brown sugar from desserts, but these modifications were not made. The facility's policy and procedure documents also outlined the requirements for fortifying food to increase calorie and protein intake, which were not adhered to. The deficiencies were confirmed through interviews with the facility's cooks, who admitted to not preparing separate diet desserts and using regular recipes for all residents. The facility's policies clearly stated that diet orders prescribed by physicians should be provided by the Food & Nutrition Services Department, but this was not implemented, leading to potential risks for the residents involved.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for three residents (Residents 5, 13, and 16) on four separate days in February 2024. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN 3) did not document the administration of multiple medications, including those for high blood pressure, high blood sugar, depression, and blood clot prevention. The missing entries were identified during a review of the Medication Administration Records (MARs) for the specified dates. Both the DON and LVN 3 admitted to administering the medications but failing to document them due to being too busy and, in the case of LVN 3, falling ill and forgetting to document upon return to work. The lack of documentation was confirmed during interviews and record reviews with both the DON and LVN 3. The DON acknowledged that the expectation was for medications to be charted immediately after administration. The failure to document these medications could lead to unnecessary duplication of medication administration and hinder accurate analysis of the medications' effectiveness. The report references a nursing textbook that emphasizes the importance of recording each dose of medication as soon as possible after it is given, as the medication record is a legal document.
Dishwashing Machine Temperature Maintenance Failure
Penalty
Summary
The facility failed to ensure that the dishwashing machine maintained the manufacturer's recommended water temperature range during the wash and rinse cycles. During an observation, the dishwashing machine's water temperature gauge reached a maximum of 106 degrees Fahrenheit during both the wash and rinse cycles, which is below the required minimum of 120 degrees Fahrenheit. Dietary Aide 2 recorded incorrect temperatures in the Dish Machine Temperature Log, indicating that the machine was operating within the required range when it was not. A subsequent test with a water-proof digital holding thermometer showed a maximum temperature of 147.8 degrees Fahrenheit and a minimum of 74 degrees Fahrenheit, further confirming the inconsistency in temperature maintenance. The facility's policy and procedure on sanitation, as well as the dishwashing machine manufacturer guidelines, were not adhered to, as the equipment was not maintained in proper working order. The failure to maintain the correct water temperatures during the dishwashing cycles had the potential to result in insufficient sanitization of dishware, posing a risk of foodborne illness to residents. The deficiency was identified through a combination of observation, interview, and record review, highlighting a significant lapse in the facility's adherence to sanitation standards.
Failure to Complete Baseline Care Plans and Provide Summaries
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for three residents (Residents 187, 185, and 188) and did not provide them or their representatives with a summary of the baseline care plan. Resident 187, who was admitted with hemiplegia and hemiparesis, was discharged without a baseline care plan. The Director of Nursing (DON) confirmed that the baseline care plan was not developed within the required timeframe. Resident 185, admitted with streptococcal arthritis, stated in the presence of family members that he did not receive a written summary of his baseline care plan, despite the care plan indicating that a copy would be given to the resident. Resident 188, admitted for surgical aftercare following nervous system surgery, also did not receive a copy of the baseline care plan, as confirmed by the DON. The facility's policy and procedures (P&P) titled 'Care Plan - Baseline,' revised in March 2022, indicated that a baseline plan of care should be developed within 48 hours of admission to meet the resident's immediate health and safety needs. The P&P also stated that a written summary of the baseline care plan should be provided to the resident or their representative in a language they can understand, and this provision should be documented in the medical records. The DON acknowledged that the interdisciplinary team members did not complete the baseline care plans within the required timeframe and that summaries were not provided to the residents or their representatives.
Failure to Implement Care Plan for Resident at Risk of Aspiration
Penalty
Summary
The facility failed to implement its Care Plans, Comprehensive Person-Centered policy and procedure for Resident 6, who was at risk of aspiration due to dysphagia. Despite a physician's order for the use of a provale cup to prevent choking and aspiration pneumonia, the staff stopped using the specialized cup because Resident 6 found it frustrating. Instead, Resident 6 was given a regular plastic cup, which led to frequent coughing during meals. This change was not communicated to the speech therapist, nor was a speech evaluation conducted. Additionally, there were no active care plans addressing Resident 6's risk of aspiration and dysphagia diagnosis. Observations and interviews revealed that Resident 6, who had poor cognition and a history of swallowing disorders, was repeatedly coughing when fed certain foods and liquids. The Director of Nursing acknowledged that Resident 6 was at high risk for aspiration but did not take appropriate steps to mitigate this risk. The facility's policy required a comprehensive, person-centered care plan to be developed within seven days of the MDS assessment and no more than 21 days after admission, but this was not done for Resident 6.
Failure to Assess Severe Weight Loss in Resident
Penalty
Summary
The facility failed to assess a resident (Resident 16) who experienced severe weight loss. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, dementia, dysphagia, depressive disorder, and an acquired absence of the digestive tract, showed a significant weight loss of 21 pounds (11%) over six months and 8 pounds in one month. Despite these changes, the last nutrition-related documentation by a Registered Dietitian (RD) was a Quarterly Nutrition assessment and a Progress Note dated several months prior. The care plan related to weight loss was last revised over a month before the most recent weight loss was recorded. The Minimum Data Set (MDS) indicated that the resident had severe cognitive impairment and had experienced significant weight loss without being on a physician-prescribed weight-loss regimen. Interviews with facility staff, including the Licensed Vocational Nurse (LVN) MDS Coordinator and the Director of Nursing (DON), revealed that the RD was responsible for filling out the MDS section related to weight loss. The DON stated that when unplanned weight loss was identified, the RD was supposed to conduct an assessment and present it to the Interdisciplinary Team (IDT) for discussion and intervention planning. However, this process was not followed in the case of Resident 16, leading to a failure in timely assessment and intervention for the resident's severe weight loss.
Failure to Monitor and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs when psychotropic medications were administered without adequate clinical indication and monitoring. Resident 2 was administered Ziprasidone HCL for dementia and depression without adequate monitoring of target behaviors. Despite being calm and cooperative, Resident 2 continued to receive the medication without documented behavioral symptoms or side effect monitoring. The Consultant Pharmacist had recommended a gradual dose reduction, but this was not implemented, and there was no documentation of target behavior monitoring in the Medication Administration Record (MAR) for January and February 2024. Resident 16 was administered Zyprexa for altered sensorium and aggressive behaviors, and Trazodone for sleep without adequate monitoring of hours of sleep. Additionally, Resident 16 received PRN Lorazepam for anxiety and aggressive behavior without the implementation of non-pharmacological interventions first. The PRN Lorazepam was extended beyond 14 days without physician documentation of the clinical rationale for continued use. Despite the Consultant Pharmacist's recommendation to update the Zyprexa order to include indication and to review PRN psychotropic medications every 14 days, these actions were not taken. Interviews with staff revealed that both residents were calm and cooperative, contradicting the need for continued use of these medications. The Director of Nursing (DON) acknowledged that non-pharmacological interventions should be offered before administering PRN psychotropic medications and that the hours of sleep for Resident 16 were not monitored. The facility's policy indicated that psychotropic medications should not be prescribed or given on a PRN basis unless necessary to treat a diagnosed specific condition, and PRN orders should be limited to 14 days unless otherwise documented by the physician.
Failure to Use Assistive Device and Consult Speech Therapist
Penalty
Summary
The facility failed to consider alternative recommendations for the use of the provale cup assistive device for a resident identified at risk for aspiration. Despite the resident's refusal to use the provale cup, which was prescribed to help prevent choking by delivering a measured amount of liquid, the staff did not consult with the Speech Therapist for alternative recommendations. This resulted in the resident being given water from a plain plastic cup, leading to frequent coughing during meals. The resident had a history of dysphagia and was diagnosed with Non-Alzheimer's Dementia, which further increased the risk of aspiration. During observations, the resident was seen coughing repeatedly when fed corn bread and salad, and the Restorative Nursing Assistant provided water from a regular plastic cup. Interviews with the Director of Nursing and the Speech Therapist revealed that the Speech Therapist was not informed of the resident's refusal to use the provale cup, and no re-evaluation was conducted. The resident's Minimum Data Set indicated poor cognition and a swallowing disorder, highlighting the need for appropriate assistive devices and consultation with specialists to prevent aspiration and potential pneumonia.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility had two resident rooms with multiple beds that provided less than the required 80 square feet per resident. Room [ROOM NUMBER] measured 280 square feet, equating to 70 square feet per resident, and room [ROOM NUMBER] measured 286.6 square feet, equating to 71.65 square feet per resident. During observations and interviews, staff members, including CNAs, stated that there was enough space to provide care and no issues with maneuvering necessary care equipment. Residents also reported having adequate space for their belongings and no concerns about room space. Despite these statements, the rooms did not meet the regulatory space requirements, which could potentially result in inadequate space for care delivery and storage of residents' belongings. No negative consequences were observed due to the decreased space in the two rooms, and a room size waiver was recommended.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 548 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Livermore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stratford Villa Post-acute | 0 mi | ★★★★★ | 3 | 0 |
| The Vineyards Healthcare Center | 0.2 mi | ★★★★★ | 2 | 0 |
| Creekview Skilled Nursing | 4.1 mi | ★★★★★ | 0 | 0 |
| Pleasanton Nursing And Rehabilitation Center | 5 mi | ★★★★★ | 11 | 0 |
| The Reutlinger Community | 10.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avondale Villa Post-acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.