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 Catalina Island Health during CMS and state inspections, most recent first.
The facility failed to ensure the storage, preparation, and distribution of food were done under sanitary conditions. Observations revealed that several food items in the kitchen and residents' refrigerator were not labeled with an open date, contrary to facility policy. This failure placed residents at risk for foodborne illness.
The facility failed to implement baseline care plans for two residents taking Melatonin for sleep difficulty. Despite physician's orders and documented administration of the medication, no care plans or interventions were created. Interviews with staff confirmed that care plans should have been initiated and updated to monitor the effectiveness of the medication and ensure appropriate care.
The facility failed to monitor a resident's behavior and adverse reactions to antipsychotic medication, leading to potential overuse without proper documentation. Staff interviews revealed a lack of monitoring and documentation, contrary to the facility's policies on behavioral assessment and dementia clinical protocol.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to ensure the storage, preparation, and distribution of food were done under sanitary conditions. During an observation of the kitchen, it was found that baking powder and garlic salt were not labeled with an open date. Additionally, the refrigerator contained a half-gallon of milk, Salted Caramel Creamer, and Planet Oat Milk that were also not labeled with an open date. In the residents' refrigerator, a half-gallon of milk and a container of cottage cheese were found without a name or open date. The Dietary Service Supervisor admitted to forgetting to label the milk and creamer and confirmed that the facility's policy requires all opened food items to be dated to ensure they are discarded when they become unsafe to consume. Further observations and interviews revealed that the Food Service Worker verified the undated items in the residents' refrigerator and stated that food brought in from outside the facility should be labeled with the resident's name, room number, and the date it was opened. The facility's policies and procedures, including those from the FDA and the facility's own guidelines, mandate that all refrigerated, ready-to-eat, time/temperature control for safety foods must be clearly marked with the date they were opened if they are held for more than 24 hours. The failure to follow these procedures placed the residents at risk for foodborne illness.
Failure to Implement Baseline Care Plans for Sleep Difficulty
Penalty
Summary
The facility failed to implement a baseline care plan for two residents who were taking Melatonin for sleep difficulty. Resident 2 was admitted with diagnoses including dementia with agitation, insomnia, unsteady gait, and hypertension. Despite a physician's order for Melatonin, there were no care plans or interventions related to sleep difficulty documented. The Medication Administration Record indicated that Resident 2 received Melatonin daily for a period, but the care plan was not updated to reflect this. Interviews with nursing staff confirmed that care plans are supposed to be initiated on admission and updated regularly, but this was not done for Resident 2's sleep issues. Similarly, Resident 1, who had diagnoses including PTSD, chronic psychotic disturbance, dementia, mood disturbance, and generalized anxiety disorder, also did not have a care plan for sleep difficulty despite having a physician's order for Melatonin. The Medication Administration Record showed that Resident 1 received Melatonin, but there were no care plans or interventions documented. Interviews with nursing staff and the Director of Nursing confirmed that sleep issues should be care planned to monitor the effectiveness of the medication and ensure appropriate care. The facility's policy indicated that comprehensive, person-centered care plans should be developed and implemented for each resident, but this was not followed in these cases.
Failure to Monitor Antipsychotic Medication Effectiveness and Adverse Reactions
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary drugs by not monitoring the specific behavior manifestation according to the prescribed antipsychotic medication dose ordered. Resident 2, who was admitted with diagnoses including dementia with agitation, insomnia, unsteady gait, and hypertension, was on antipsychotic medications. The Minimum Data Set (MDS) indicated that Resident 2 had potential indicators of psychosis and was on antipsychotic medications, but the facility did not monitor for adverse reactions or the effectiveness of the medication on Resident 2's psychotic behaviors. This led to the potential overuse of antipsychotic medication without proper monitoring, which could result in adverse drug reactions. The facility's policy required monitoring for efficacy and adverse consequences when medications are prescribed for behavioral symptoms, but this was not followed in Resident 2's case. Interviews with staff, including the RN, Pharmacist, LVN, and DON, revealed that there was no place to document Resident 2's behaviors on the Medication Administration Record (MAR), and the staff acknowledged the importance of monitoring and documenting behaviors to ensure the medication's effectiveness and appropriateness. The facility's policies on behavioral assessment and dementia clinical protocol emphasized the need for non-pharmacological interventions and monitoring for side effects and complications related to psychoactive medications, but these were not adequately implemented for Resident 2.
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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.
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Nursing homes near Avalon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seacrest Post-acute Care Center | 27.6 mi | ★★★★★ | 36 | 1 |
| White Point Care Center | 27.6 mi | ★★★★★ | 4 | 0 |
| Providence Little Comp Of Mary Subacute Care Ctr | 27.6 mi | ★★★★★ | 11 | 0 |
| Crystal Cove Care Center | 30.4 mi | ★★★★★ | 6 | 0 |
| Pelican Ridge Post Acute | 30.5 mi | ★★★★★ | 62 | 0 |
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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.