Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Avalon View Health And Wellness during CMS and state inspections, most recent first.
A resident’s personal bank funds were transferred through the BOM’s personal [NAME] account to pay facility charges without the resident’s permission. The resident, who had no cognitive impairment and could speak with the bank, denied giving verbal or written authorization, while a floor tech said the BOM asked him or her to impersonate the resident during bank calls. Bank records showed multiple transfers, and the BOM acknowledged the personal account should not have been used.
Three residents with cognitive impairments and rashes consistent with scabies were not placed on contact precautions as required by facility policy and physician orders. Staff did not use PPE or isolate affected individuals, and care plans did not address scabies treatment. Despite clinical diagnoses and recommendations from dermatology for isolation and contact precautions, the facility did not implement these measures, and staff were largely unaware of the outbreak or the need for infection control.
Failure to Invoke DPOA and Establish Decision-Making Authority: Staff allowed family members to make medical decisions for residents without confirming that DPOA authority had been activated, and two residents who had been declared incapacitated by physicians had no guardian or DPOA in place. Affected residents had diagnoses including dementia, Alzheimer’s disease, vascular dementia, CKD, COPD, and mood disorders, with MDS BIMS scores showing moderate to severe cognitive impairment. Despite capacity statements and DPOA documents with specific invocation requirements, family members gave verbal consent or declined vaccines without documented activation of authority.
A resident with significant mobility limitations was transported in a facility van without being properly restrained with a seat belt, contrary to facility policy. The driver, new to the transportation role, failed to secure the seat belt, resulting in the resident sliding out of the wheelchair and falling during a sudden stop. The incident was confirmed by interviews with the resident, the driver, and facility staff, all indicating that required safety procedures were not followed.
A resident with severe cognitive impairment and behavioral issues was struck on the back by another cognitively impaired resident with a history of aggression while in the dining area. Staff were present and intervened after the incident, but the altercation resulted in visible redness to the affected resident's back.
The facility failed to maintain a sanitary and comfortable environment, with observations of urine odors, disrepair, and uncleanliness. Staff interviews revealed communication issues and inadequate systems for equipment maintenance and cleanliness. The Physical Therapy Assistant and Director of Physical Therapy were aware of wheelchairs in disrepair, but there was a discrepancy in ordering new equipment. Housekeeping staff reported insufficient staffing and lack of a task checklist, while the Maintenance Director relied on inconsistently used logbooks for repair requests.
The facility failed to provide adequate assistance with ADLs, including grooming, showering, and incontinence care, for several residents. Observations and interviews revealed that residents often went extended periods without showers, and incontinence care was not provided timely. Staffing shortages contributed to these deficiencies, impacting residents' hygiene and dignity.
The facility failed to provide an ongoing activities program for three residents, resulting in a deficiency. One resident with severe cognitive deficits had minimal engagement, often found in bed with the TV on mute. Another resident with significant cognitive impairment had no activity care plan, with limited engagement noted. A third resident with undetermined cognitive status also lacked a care plan, with sporadic engagement and an outdated activity calendar. Staff interviews revealed inconsistencies in activity planning and execution.
The facility failed to employ a qualified Activity Director, as the current director had not completed an approved training program and lacked necessary certifications. Despite having worked in housekeeping for twenty-five years, the director only trained for one day with an activity staff member and was not enrolled in any certification course. The Administrator acknowledged the deficiency and mentioned plans for the director to complete a course.
The facility failed to secure hazardous areas, including a clean utility room and biohazard room, in the memory care unit. Residents with cognitive impairments were observed near these unlocked areas, which contained open electrical boxes, oxygen tanks, and hazardous chemicals. Staff interviews revealed a lack of awareness and adherence to safety protocols.
The facility failed to ensure residents had accessible water at their bedside, affecting four residents. Despite policies requiring sufficient fluid provision, observations showed water was not consistently available. A resident with cognitive impairment and a UTI was observed without water, while another resident at risk for dehydration due to diuretic use reported infrequent water passing. Two other residents also experienced inadequate water availability, with one reporting water was passed only once a day.
The facility failed to provide trauma-informed care to two residents with a history of trauma, leading to re-traumatization and distress. One resident with PTSD was triggered by loud noises, while another exhibited paranoia and delusions without proper interventions. Staff were unaware of the residents' triggers, and no trauma-informed care training was provided in the past year.
The facility failed to provide sufficient nursing staff to meet residents' basic care needs, including repositioning, incontinent care, and bathing. Observations showed residents left unattended for hours without necessary care, and call lights were not answered promptly due to staff shortages. Interviews with staff confirmed that inadequate staffing affected the quality of care, leading to missed showers and delayed assistance with feeding and transfers.
The facility failed to properly store and label medications, affecting several residents. Medications were left unlocked and unattended, expired drugs were not removed, and some residents had medications at bedside without proper authorization. Staff interviews revealed confusion about responsibilities for medication security and cleanliness.
The facility failed to provide adequate dietary staffing, resulting in significant delays in meal service for residents. Observations showed that meals were served much later than scheduled, with residents left waiting without drinks or utensils. Staff from other departments had to assist with meal service, indicating a shortage of dietary staff. Meal times were not posted, and there was no policy regarding dietary staffing.
The facility failed to ensure food was palatable, attractive, and at a safe temperature. Observations showed staff did not check food temperatures or follow recipes, leading to complaints from residents about cold, poorly prepared meals. Interviews with staff revealed unmet expectations for temperature checks and recipe adherence.
The facility failed to maintain professional standards in kitchen sanitation and food handling, with staff neglecting to properly clean and sanitize equipment, maintain a clean kitchen, and adhere to handwashing protocols. Observations showed unsanitary conditions, improper food storage, and lack of hair and beard coverings, posing potential risks to residents.
The facility failed to maintain a safe and sanitary environment, with issues such as cobwebs, rusted doors, and debris-filled light fixtures. Observations also noted broken window blinds, loose air conditioning units, and mold-like substances on shower curtains. Interviews revealed understaffing in housekeeping and reliance on a logbook for maintenance requests, with the administrator acknowledging the need for further improvements.
The facility failed to maintain resident dignity and provide adequate care, as evidenced by incidents where a resident was left walking in a hallway in a pull-up brief, another was unable to return to bed due to a lack of clean sheets, and a third was left waiting to be dressed in personal clothes. These incidents highlight issues with staff responsiveness and linen supply, impacting the residents' dignity and quality of life.
Three residents were denied access to their personal funds after business hours and on weekends due to the facility's failure to maintain sufficient cash on hand. The Business Office Manager and Administrator acknowledged delays in cash availability, particularly when the Administrator was off work, leading to instances where residents could not access their money.
A facility failed to ensure consistent documentation of a resident's code status across clinical records. The resident had multiple health conditions and was listed as full code in physician's orders and care plan, but a DNR status was noted in an external form. Staff interviews revealed awareness of the discrepancy, which was corrected by an RN during the survey.
The facility failed to maintain confidentiality for two residents. One resident's DPOA document was given to an unauthorized person due to lack of identity verification by the administrator. Another resident's medication packaging with personal information was found outside the facility due to a tipped-over shred box. These incidents indicate a failure to protect residents' confidential information.
The facility failed to develop comprehensive care plans for two residents, neglecting to address specific medical and activity needs. One resident with severe cognitive deficits and a tracheostomy lacked a care plan for tracheostomy care and activity preferences. Another resident with cognitive impairments and mobility issues had no activity preferences included in their care plan, despite having conditions like anxiety and depression.
A resident with severe contractures and limited cognitive abilities was not consistently provided with a cervical collar as ordered by their physician. The collar, meant to be worn during the day, was repeatedly found on the bedside table, dirty and unused. Staff interviews indicated the collar was sometimes taken for cleaning, but there was no documentation of refusal or unavailability. The facility's DON and Administrator expected adherence to physician's orders, highlighting a deficiency in care provision.
The facility failed to maintain an effective pest control program, resulting in a fly infestation in a resident's room. The resident, who had significant cognitive and physical impairments, was unable to swat the flies away. Despite the facility's use of an outside pest control company, the issue persisted, and the facility did not provide pest control invoices to verify services.
A deficiency was found where a resident's right to retain and use personal possessions was not honored, as documented under Event ID 45RI12.
Resident Funds Transferred Without Permission
Penalty
Summary
The facility failed to allow a resident to exercise his or her rights when funds were transferred from the resident’s personal checking account to the Business Office Manager’s personal [NAME] account without the resident’s permission. The resident’s care plan stated that the resident’s rights, autonomy, dignity, and self-determination would be honored, and that the resident had the right to manage his or her own financial and personal affairs. The resident’s admission agreement also stated that the resident had the right to manage personal funds and that the facility needed written permission to handle those funds. The resident’s bank records showed multiple withdrawals from the resident’s personal account that were deposited into the BOM’s [NAME] account, and the facility transaction report showed corresponding payments made to the facility for room and board. The resident’s annual MDS indicated no cognitive impairment, though the resident was dependent on staff for ADLs, incontinent of bowel and bladder, and had diagnoses including multiple sclerosis, depression, and hemiplegia. The resident stated that he or she did not give verbal or written permission for the BOM or facility staff to access the personal bank account or transfer funds, and stated that the resident was capable of speaking with the bank and should be the one to decide how money was spent. The BOM stated in interviews that the resident gave verbal permission to use the BOM’s [NAME] account to transfer money, but also acknowledged that the resident did not sign anything giving permission for the BOM to take funds from the personal bank account and that the BOM should not have used the [NAME] account to withdraw money from the resident’s account. A floor technician stated that the BOM asked him or her to impersonate the resident over the phone to the bank and authorize access to the resident’s account. A bank fraud investigator reported that two individuals called the resident’s bank and impersonated the resident, one identified as the BOM and another male caller who did not sound like the resident. The administrator stated that the BOM should not have used a personal account to transfer money out of the resident’s account without permission, and that the facility had not refunded the money as of the interview.
Failure to Implement Contact Precautions and Infection Control for Scabies
Penalty
Summary
The facility failed to follow its own policy and physician orders regarding the implementation of contact precautions and infection control measures to prevent the spread of scabies among residents in the special care unit. Three residents with cognitive impairments and rashes consistent with scabies were not placed on contact precautions as required by facility policy and physician recommendations. Observations revealed that these residents were not isolated, and staff did not use personal protective equipment (PPE) such as gloves or gowns when providing care or engaging in activities with them. There were no signs posted to indicate the need for contact precautions, and PPE was not made available near the affected residents' rooms. Medical records and interviews confirmed that the residents had been diagnosed or treated for scabies, with orders for Ivermectin and, in some cases, topical Permethrin. Despite these diagnoses and orders, the residents' care plans did not address scabies or its treatment, and staff were largely unaware of the scabies outbreak or the need for infection control measures. The dermatologist's office provided written recommendations for isolation and contact precautions, but these were not implemented by the facility. Staff interviews indicated a lack of awareness about the contagious nature of the rashes and the need for PPE, with several staff members stating they would have used precautions if they had known about the scabies diagnosis. The facility's infection control nurse and DON stated that no contact precautions were implemented because there was no definitive diagnosis of scabies via skin scraping, despite clinical diagnoses and treatment orders from dermatology. All residents in the memory care unit were treated prophylactically after a staff member reported a rash and was prescribed Permethrin, but the facility did not enforce isolation or contact precautions at any point. The lack of communication and failure to follow established protocols led to the deficiency in infection control practices.
Failure to Invoke DPOA and Establish Decision-Making Authority
Penalty
Summary
The facility failed to ensure staff invoked Durable Power of Attorney (DPOA) documents before allowing designated agents to make medical decisions for residents, and it also failed to ensure two residents had designated individuals to make medical decisions after being declared incapacitated by two physicians. The deficiency involved seven of eleven sampled residents, including residents with cognitive impairment, dementia, and other chronic conditions, and the facility census was 111. Resident #33 had diagnoses including traumatic brain injury, bipolar disorder, impulse disorder, psychosis, dementia with agitation, and major depressive disorder. The quarterly MDS showed a BIMS score of 10, indicating moderately impaired cognition. The care plan addressed memory care placement, elopement risk, aggression, delusions, and impaired cognition. A Certificate of Capacity stated the resident was incapacitated due to dementia and that the DPOA/health care directive should be invoked, but no guardianship, DPOA, or health care directive was in place. Despite this, the resident signed vaccination consent forms on multiple occasions. Resident #48 had Alzheimer’s disease, mood disorder, COPD, generalized anxiety disorder, dysphagia, and major depressive disorder, with an annual MDS BIMS score of 3 indicating severely impaired cognition. A Certificate of Capacity stated the resident was incapacitated due to cognitive impairment/dementia, but no guardianship, DPOA, or health care directive was in place. The resident gave verbal consent for vaccines, and the resident’s son later gave verbal consent to decline vaccinations. Resident #53 had COPD, type 2 diabetes mellitus with circulatory complications, vascular dementia, CKD, and major depressive disorder, with a BIMS score of 9. The resident had a Living Will naming the daughter as Personal Representative, but no letters or certificates of capacity were on file, while the daughter gave verbal consent for vaccines. Resident #63 had CKD, dysphagia, vascular dementia, anxiety disorder, and major depressive disorder, with a BIMS score of 12. The resident had a DPOA naming the son as POA and stating it was invoked when the resident was certified incapacitated by one physician, but no letters or certificates of capacity were on file; the son gave verbal consent for vaccines. Resident #73 had CKD, bipolar disorder, mild neurocognitive disorder, and dementia, with a BIMS score of 11. The resident had a DPOA naming the brother as POA, but the document did not specify when it was invoked and required two physician statements of incapacity under Missouri statute; no letters or certificates of capacity were on file, and the brother verbally declined vaccines. Resident #95 had dementia with agitation and a BIMS score of 5. The resident had a DPOA for health care naming the mother as POA and stating it became effective when two physicians certified incapacity, but no letters or certificates of capacity were on file, and the mother signed vaccination declination forms for the resident.
Failure to Properly Restrain Resident During Transportation
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all care and had significant mobility limitations due to central cord syndrome and bilateral lower extremity contractures, was not properly restrained during transportation in the facility van. The facility's transportation policy required that all residents be properly secured with seat belts and wheelchair restraints during transport, and that drivers be trained and competent in these procedures. On the day of the incident, the designated transportation driver, who was new to the role, failed to apply the seat belt to the resident's wheelchair, although the wheelchair was locked in place with hooks. During the transport, the driver had to stop suddenly at a red light, causing the resident to slide out of the wheelchair and fall forward onto the floor of the van, hitting the left side of the face/forehead on the back of the driver's seat. The resident reported not having a seat belt on and stated that this was the first time with this particular driver. The driver admitted to forgetting to apply the seat belt and was not fully aware of the seat belt procedure, as prior training had not included this step. The resident was assessed after the incident and did not report new pain or visible injury at the time, but later mentioned some pain around the eye without bruising or cuts. Interviews with facility staff confirmed that the transportation driver had not completed the required competency demonstration for securing residents prior to the incident. The driver had only been shown how to use the wheelchair hooks and was not instructed on the use of seat belts. The facility's policy and staff statements indicated that all residents should be properly restrained during transport, but this was not followed in this case, resulting in the resident's fall and injury during transportation.
Resident-to-Resident Physical Abuse in Dining Area
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of wandering and rummaging entered the dining area and walked by another resident's table. The second resident, who also had severe cognitive impairment and a history of physical aggression, yelled at the first resident to go away and then struck the resident on the back. This resulted in visible redness to the back of the resident who was struck. At the time of the incident, the first resident had diagnoses including dementia with agitation, depression, low back pain, mood disorder, and dysphagia, and was known to require supervision during meals due to behavioral issues. The second resident had diagnoses of aphasia, diabetes mellitus type 2, seizures, mild cognitive impairment, and dementia, and was identified as having the potential for physical aggression related to anger. Both residents were in the dining area when the altercation occurred, and staff were present in the room assisting with breakfast preparations and medication administration. The facility's policies defined abuse to include resident-to-resident altercations resulting in physical harm, and the care plans for both residents identified behavioral risks and the need for staff intervention to prevent escalation. Despite these identified risks and interventions, the altercation occurred, resulting in physical harm to one resident.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment, as evidenced by multiple observations of disrepair and uncleanliness. Observations included a strong odor of urine in the special care unit and hallways, peeling baseboards, scuffed doors, and resident wheelchairs with torn armrests and caked-on dirt. Privacy curtains in several rooms were stained, torn, or missing hooks, and dirty dishes were left in common areas. Additionally, dead bugs were found in hand sanitizer dispensers, and floors were observed to be sticky and dirty. Interviews with staff revealed a lack of effective communication and systems for maintaining equipment and cleanliness. The Physical Therapy Assistant and Director of Physical Therapy acknowledged awareness of wheelchairs in disrepair, but there was a discrepancy in ordering new equipment, as the Central Supply Manager had not received recent orders. The Corporate Nurse admitted to a system breakdown in replacing wheelchairs. Housekeeping staff reported being unable to complete all necessary tasks due to insufficient staffing and lack of a task checklist. The Maintenance Director and Housekeeping Supervisor described their expectations for cleanliness and repair, but there was a lack of coordination and follow-through. The Maintenance Director relied on logbooks for repair requests, which were not consistently utilized. The Administrator expected daily cleaning and collaborative efforts between housekeeping and maintenance, but acknowledged that while progress had been made, more improvements were needed. Overall, the facility's failure to ensure a clean and well-maintained environment was due to inadequate systems and communication among staff and departments.
Inadequate Assistance with ADLs and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, including grooming, showering, and incontinence care. Nine residents did not receive showers at least twice a week as required, and one resident did not receive necessary shaving and nail care. Observations revealed that residents often went extended periods without showers, with some residents receiving only a few showers over several months. Interviews with residents confirmed their dissatisfaction with the infrequency of showers, and staff interviews indicated that staffing shortages contributed to the inability to meet residents' hygiene needs. In addition to inadequate showering, the facility failed to provide timely incontinence care for two residents. Observations showed that these residents were left in soiled conditions for extended periods without being offered toileting assistance. Staff interviews revealed that while there was an expectation for residents to receive incontinence care every two hours, this was not consistently achieved due to busy schedules and insufficient staffing. The facility's failure to meet residents' ADL needs was further compounded by inadequate staffing, as reported by multiple staff members. The shower aide was frequently reassigned to other duties, leaving residents without necessary hygiene care. The administrator acknowledged that the facility's goal of offering showers twice weekly was not consistently met due to staffing challenges, impacting residents' overall care and dignity.
Deficiency in Resident Activity Engagement
Penalty
Summary
The facility failed to provide an ongoing activities program to support the needs of three residents, leading to a deficiency in meeting their individual activity preferences and needs. Resident #153, who had severe cognitive deficits and multiple medical conditions, was observed to have minimal engagement in activities. Despite having preferences for activities such as television, music, and family visits, the resident's activity records showed limited interaction, primarily involving passive activities like music playing and television being on without sound. Observations confirmed the lack of meaningful engagement, with the resident often found in bed with the television on mute. Resident #93, also with significant cognitive impairment and medical complexities, had no care plan for activities. The resident's activity records indicated frequent instances of being asleep or minimally engaged, with occasional interactions such as staff reading or talking to the resident. Observations showed the resident often in bed with the television on mute, despite a noted preference for specific TV shows. The lack of a structured activity plan contributed to the resident's limited engagement. Resident #52, with undetermined cognitive status and multiple diagnoses, had no care plan for activity preferences. The resident's activity records showed sporadic engagement, primarily involving passive activities like listening to music or being read to. Observations revealed a lack of activity engagement during certain periods, and the activity calendar in the resident's room was outdated. Interviews with staff highlighted inconsistencies in activity planning and execution, contributing to the deficiency in providing a comprehensive activities program for the residents.
Facility Lacks Qualified Activity Director
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program, as required by regulations. The designated Activity Director had been in the position for one year but had not completed an approved activity professional training program. The facility's policy outlined that an Activity Director should be licensed or registered by the state and meet specific qualifications, such as being eligible for certification as a therapeutic recreation specialist or having completed a state-approved training course. However, the current Activity Director did not meet these qualifications, having worked in housekeeping for twenty-five years and only trained for one day with an activity staff member at a sister facility. During interviews, the Activity Director admitted to not having been trained in activities and not being enrolled in any certification course. The Administrator acknowledged the need for the Activity Director to have certifications and mentioned that the facility had purchased a course for the Activity Director to participate in, with the coursework anticipated to be completed in the following month. Despite these intentions, the deficiency remained as the Activity Director was not qualified at the time of the survey.
Unsafe Access to Hazardous Areas in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe environment for residents, as evidenced by multiple observations of unlocked rooms containing hazardous materials and equipment. Specifically, the memory care unit had an unlocked clean utility room with open electrical boxes, oxygen tanks, and cleaning supplies, as well as an unlocked biohazard room containing sharps and hazardous chemicals. Additionally, the area behind the nurses' desk was found to be unlocked, with a bottle of drug destroyer and a multipurpose cleaner accessible. These conditions were observed over several days, with no staff present to supervise or secure these areas. Resident #3, who has severe cognitive impairment and uses a wheelchair, was observed propelling themselves near the unlocked clean utility and biohazard rooms. Despite their cognitive and physical limitations, no staff were present to prevent the resident from accessing these hazardous areas. Similarly, Resident #89, also with severe cognitive impairment and mobility issues, was seen near the unlocked biohazard room and nurses' station without staff supervision. Resident #67, with moderate cognitive impairment, was observed walking near the unlocked rooms, again with no staff nearby to ensure their safety. Interviews with staff members, including CNAs, LPNs, the Maintenance Director, and the Administrator, revealed a lack of awareness and adherence to safety protocols. Staff were unsure if the doors should be locked, and some indicated that the doors had been unlocked for an extended period. The Maintenance Director and Administrator acknowledged that these areas should be secured to prevent resident access to hazardous materials, but the necessary actions to ensure this were not taken.
Failure to Provide Accessible Water to Residents
Penalty
Summary
The facility failed to ensure that residents had water at their bedside that was easily accessible, affecting four out of 23 residents sampled. The facility's policy for hydration requires that residents be offered sufficient fluids consistent with their needs and preferences to maintain proper hydration and health. However, observations and interviews revealed that water was not consistently available at the bedside for the affected residents, and staff did not pass water as frequently as required by the facility's policy. Resident #90, who has minor cognitive impairment and is dependent on staff for eating, was observed multiple times without water at the bedside. Despite being on antibiotics for a urinary tract infection and having a care plan indicating a risk for dehydration, the resident's water needs were not adequately met. The resident's daughter reported that when water was requested, flavored water was provided instead of the preferred unflavored water. Resident #12, who is cognitively impaired and at risk for dehydration due to diuretic use, also did not have water readily available. The resident reported that water was not passed often, and observations confirmed the absence of water in the room. Similarly, Resident #49, who is cognitively intact but requires assistance with eating, reported that water was passed only once a day, and observations showed insufficient water in the resident's cup. Resident #87, who is cognitively intact and has diabetes mellitus, reported that it took over a week for the facility to change out water, and observations confirmed the lack of water and ice being passed regularly.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to two residents with a history of trauma, leading to re-traumatization and distress. Resident #49, diagnosed with PTSD, was exposed to loud noises from other residents yelling, which triggered memories of past abuse. Despite the resident's care plan identifying loud noises as a trigger, no interventions were implemented to mitigate this. Interviews with staff revealed a lack of awareness about the resident's triggers, indicating a communication breakdown within the facility. Resident #87, who had experienced multiple traumatic events, exhibited behaviors such as paranoia and delusions, believing staff were casting spells on him/her. The care plan did not identify any specific triggers for this resident, and staff interviews showed a lack of understanding of the resident's needs and triggers. The resident was known to be triggered by certain staff members and would become agitated, yet no interventions were in place to address these issues. The facility's failure to provide trauma-informed care was compounded by the lack of staff training on the subject. Training logs showed no trauma-informed care training had been provided in the past year, and staff interviews confirmed this gap. The Social Services Director attempted to communicate trauma triggers to staff, but the process was ineffective, leading to inadequate care for residents with trauma histories.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the basic care needs of several residents, including assistance with repositioning, incontinent care, basic hygiene, and bathing. Observations revealed that residents were left unattended for extended periods without being offered toileting or repositioning, despite being dependent on staff for these activities. For instance, one resident with severe cognitive impairment and incontinence was observed sitting in a wheelchair for several hours without receiving necessary care, such as toileting or repositioning, which was not in accordance with their care plan. Additionally, the facility did not provide timely responses to call lights, as reported by multiple residents during a Resident Council meeting. Residents expressed that call times could take an hour or longer, particularly at night and on weekends when staffing levels were low. This delay in response was attributed to the staff being overworked and short-handed, impacting the residents' ability to receive timely assistance with their needs. Interviews with staff members, including CNAs, LPNs, and the Director of Nursing, confirmed that staffing shortages were a significant issue affecting the quality of care provided. Staff reported being unable to meet the care needs of residents due to insufficient numbers, leading to missed showers, inadequate pericare, and delayed assistance with feeding and transfers. The facility's inability to maintain adequate staffing levels resulted in compromised resident care and unmet basic needs.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs and biologicals in accordance with accepted professional principles, affecting five residents. Medications were not stored in locked compartments, and unauthorized staff and residents had access to them. The medication cart was observed to be left unlocked and unattended multiple times, and expired medications were not removed or destroyed as required. Additionally, some medication labels were illegible, and there was a lack of clarity among staff regarding responsibilities for maintaining the cleanliness and security of medication carts. Resident #12, who was cognitively impaired, had an albuterol inhaler at their bedside without a physician's order or a self-administration assessment. The resident's care plan did not include provisions for self-administration of medication, and staff interviews revealed confusion about whether the resident was allowed to keep the inhaler at bedside. Observations showed multiple inhalers at the resident's bedside, some of which were empty or lacked visible numbers, indicating improper monitoring and storage. Resident #154, with moderate cognitive loss and multiple diagnoses, had medications at their bedside without a physician's order or self-administration assessment. Observations showed gabapentin and nystatin powder in the resident's room, despite the resident not being present. Interviews with staff confirmed that the resident should not have had medications at bedside, highlighting a failure to adhere to the facility's medication storage policy.
Inadequate Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to adequately staff the kitchen with enough dietary staff to ensure meals were served to residents in a timely manner, potentially affecting all 104 residents. Observations over several days revealed significant delays in meal service, with lunch service starting and completing much later than the scheduled times. On multiple occasions, residents were left waiting in the dining room without drinks or meals, and there was a lack of utensils and condiments available for residents to use with their meals. The facility's meal serving policy was not adhered to, as residents were not checked on at regular intervals, and additional fluids were not consistently offered. The report highlights specific instances where meal service was delayed, such as on one day when the first meal was served 69 minutes late on average. Staff from other departments, including corporate staff and environmental services, were observed assisting with meal service, indicating a shortage of dietary staff. Additionally, there were inconsistencies in the type of utensils provided, with some residents receiving metal silverware and others receiving plastic utensils. The facility did not have a policy regarding dietary staffing, and meal times were not posted anywhere in the facility, contributing to the disorganization and delays in meal service.
Deficiencies in Food Service and Temperature Control
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations revealed that staff did not check the temperature of cooked foods, and recipes were not followed for several residents. Specifically, during the preparation of beef tacos and Spanish rice, the cook did not measure ingredients accurately, failed to perform temperature checks at critical points, and did not follow the recipe instructions. The taco meat was observed to be watery and bland, and the Spanish rice was initially in a soupy state before being placed on the steam line without a final taste test or temperature check. Interviews with residents and the resident council highlighted significant dissatisfaction with the food service. Residents reported that meals were often cold, poorly prepared, and not served on time. Some residents mentioned receiving moldy hamburger buns and unidentifiable menu items, while others noted that the food was difficult to chew or too salty. The resident council expressed that food service was their number one complaint, with issues such as meals being burnt, meal tickets not being followed, and utensils not being provided promptly. Interviews with facility staff, including the Dietary Manager and Registered Dietician, revealed expectations for temperature checks and recipe adherence that were not met. The Administrator also expressed expectations for proper food service, including the availability of cream, sugar, and utensils for coffee, as well as clean napkins for each meal. However, these expectations were not consistently met, contributing to the deficiencies observed in the facility's food service.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by multiple deficiencies in the kitchen's sanitation and food handling practices. Observations revealed that staff did not manually clean and sanitize kitchen equipment properly, as they failed to check temperatures or test sanitizing solution concentrations in the three-compartment sink. Additionally, sanitizing buckets were not changed out after four hours of use, and the kitchen lacked visible sanitizing buckets during meal service times. These lapses in procedure were confirmed by interviews with the Dietary Manager and Registered Dietician, who expressed expectations for regular temperature checks and visible sanitizing buckets. The facility's kitchen was found to be in an unsanitary state, with excessive dust and dirt on ventilation ducts, sticky floors, and accumulation of debris on various surfaces. Observations noted old food debris in ovens, food splatter on equipment, and missing paint with dirt buildup near the sink area. The dry storage room and cleaning closet were also cluttered and dusty, posing potential contamination risks. The Dietary Manager acknowledged these issues but considered the kitchen clean and up to their standards, despite the visible dirt and grime. Handwashing practices were inadequate, with staff failing to wash hands after handling raw meat or before donning gloves. The handwashing sink only provided hot water, and staff were observed using the same gloves for multiple tasks, increasing the risk of cross-contamination. Additionally, there was no policy on hair and beard coverings, and staff were observed without proper coverings. Food storage practices were also deficient, with unlabeled and undated items found in the freezer and storage areas, contrary to the facility's policy.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. Observations revealed numerous issues, including large cobwebs with dead bugs, rusted exit doors, gouged and nicked wallpaper, and light fixtures filled with dead bugs and debris. Additionally, there were brown water stains on ceiling tiles, dirt and debris on mechanical hand sanitizer drip trays, and broken window blinds held together with zip ties. The facility's air conditioning units were loose from the wall, and the ceiling vents were covered with dirt and dust. The shower room curtain was found with dirt, debris, and a black mold-like substance, and baseboards were warped, curved away from the wall, and missing in some areas. Interviews with staff revealed that the housekeeping department was understaffed, with one person unable to complete all necessary tasks. There was no checklist for completed tasks, and the maintenance director relied on a logbook for repair requests. The maintenance director had been employed for four months and conducted weekly walk-through inspections with administration. The administrator expected the facility to be clean and odor-free, with vents, floors, and ceilings cleaned collaboratively by housekeeping and maintenance. Despite some progress in cleanliness, the facility acknowledged that more work was needed to address these deficiencies.
Failure to Maintain Resident Dignity and Adequate Care
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving inadequate care and attention to personal needs. One resident was observed walking down a hallway wearing only a white pull-up brief without pants, passing by staff and other residents without being assisted or covered. This resident, who was cognitively intact and required assistance with personal hygiene and dressing, was eventually taken to the therapy room without any intervention to address their state of undress. Another resident expressed feelings of being degraded by staff, who treated them as if they could not think for themselves. This resident, who was frequently incontinent and required assistance with personal care, reported being woken up at 4:00 A.M. to use the bathroom, only to find that there were no clean sheets available for their bed afterward. This situation forced the resident to remain awake and unable to return to sleep, highlighting issues with the facility's linen supply, as confirmed by staff interviews. A third resident, who was cognitively intact and had specific preferences for their daily routine, was left waiting to be dressed in their personal clothes. Despite expressing a desire to be dressed by 8:30 A.M., the resident remained in a hospital gown due to a lack of clean pants, as staff were observed discussing the issue outside the resident's room. These incidents collectively demonstrate a failure to provide adequate and respectful care, impacting the residents' dignity and quality of life.
Residents Denied Access to Personal Funds After Hours
Penalty
Summary
The facility failed to ensure residents had access to their personal funds after business hours and on weekends, impacting three residents. Resident #83, with moderately impaired cognition and diagnoses including depression and diabetes, reported not always having access to money because the facility had not gone to the bank. Resident #28, also with moderately impaired cognition and conditions such as COPD and dementia, stated they did not have full access to their money. Resident #5, who was cognitively intact, mentioned being denied money when the facility had not gone to the bank. The Business Office Manager (BOM) explained that residents typically request money from the receptionist, with a turnaround time of one day. However, cash was not disbursed on holidays, and there was uncertainty about weekend access. The BOM noted that the facility had increased the cash on hand due to previous shortages. The Administrator confirmed that funds were available during banking hours, but delays occurred when they were off work, as no other staff were designated to obtain cash. This led to instances where residents were denied access to personal funds due to insufficient cash on hand.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistent documentation of a resident's code status across all parts of the clinical record. This deficiency was identified for one resident out of a sample of 23, in a facility with a census of 104. The resident in question had multiple diagnoses, including mild cognitive impairment, diabetes, kidney failure, high blood pressure, GERD, and obstructive uropathy. The resident's physician's orders indicated a full code status, while an Outside the Hospital Do Not Resuscitate Order form signed later showed a DNR status. Additionally, the resident's care plan, which was undated, also listed the resident as full code. During interviews, a CNA and an RN both referred to the resident's code status as full code, but the RN noticed the discrepancy during the interview and changed the status to DNR. The Director of Nursing and Administrator stated that the protocol for handling an unresponsive resident involves checking the code book and chart to determine the code status.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records for two residents. For Resident #80, the deficiency occurred when a staff member provided a copy of the resident's Durable Power of Attorney (DPOA) document to an unauthorized individual who falsely claimed to be the designated family member. The administrator admitted to not verifying the identity of the individual by asking for photo identification, which led to the unauthorized disclosure of the resident's protected information. This incident was confirmed through interviews with the actual family member and the administrator, who acknowledged the breach of confidentiality. For Resident #153, the breach of confidentiality was observed when empty medication packaging with the resident's personal information was found outside the facility. The packaging was visible due to a tipped-over locked shred box located behind the D hall unit. The administrator confirmed that resident information should not be exposed and visible outside the facility. These incidents highlight the facility's failure to implement adequate security measures to protect residents' confidential information, as outlined in their HIPAA policy.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their needs. Resident #153, who has severe cognitive deficits and multiple medical conditions including respiratory failure and a tracheostomy, did not have a care plan addressing their activity preferences or the care of their tracheostomy. Despite having specific medical orders for tube site care and tracheostomy maintenance, these were not reflected in the resident's care plan, indicating a lack of comprehensive planning to address the resident's complex needs. Similarly, Resident #52, who has cognitive impairments and is dependent on a wheelchair, did not have their activity preferences included in their care plan. The resident's diagnoses include anxiety disorder, aphasia, depression, and respiratory failure, yet the care plan only included general encouragement for social interaction and emotional support without specific activity preferences. The facility's failure to incorporate these elements into the care plans demonstrates a deficiency in providing person-centered care tailored to the residents' individual needs.
Failure to Apply Cervical Collar as Ordered
Penalty
Summary
The facility staff failed to adhere to physician's orders regarding the application of a cervical collar for a resident who was dependent on staff for mobility and care. The resident, who had severe contractures and was non-verbal with limited cognitive abilities, was observed multiple times without the cervical collar that was ordered to be worn during the day. The collar was found on the bedside table, dirty and discolored, indicating it had not been applied as required. The resident's care plan and physician's orders specified the need for the cervical collar to be worn during the day and removed at night for skin checks, but these instructions were not consistently followed. Interviews with facility staff, including an occupational therapist and a registered nurse, revealed that the cervical collar was not applied on several occasions, allegedly due to it being taken for cleaning. However, there was no documentation of the resident refusing the collar or any indication that the collar was unavailable for extended periods. The Director of Nursing and the Administrator both expressed expectations that staff should follow physician's orders unless a resident refused care, which should be documented. The failure to apply the cervical collar as ordered represents a deficiency in the provision of care according to professional standards.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and roaches. Observations on [NAME] Hall revealed large cobwebs with dead bugs at the corner of the exit door and multiple flies in room B1. A resident in room B1, who had significant cognitive and physical impairments, was observed with flies flying around their room. The resident was unable to swat the flies away due to their condition, which included aphasia, muscle weakness, lack of coordination, epilepsy, and Rett syndrome. The resident's representative reported that flies had been a persistent issue since the resident's admission, and they had resorted to purchasing fly strips to address the problem. Interviews with facility staff, including the Maintenance Director and the Administrator, confirmed that pest control was managed by an outside company that visited monthly to check and spray for pests. However, the facility did not provide pest control invoices to verify these services. The Administrator acknowledged the presence of flies in the facility and expressed an expectation for the facility to be as free of pests as possible. Despite these measures, the facility's pest control program was ineffective in preventing the infestation of flies, particularly in the resident's room.
Failure to Respect Resident's Personal Possessions
Penalty
Summary
The deficiency involves the failure to honor a resident's right to be treated with respect and dignity and to retain and use personal possessions. The report indicates that surveyors found an incident where a resident's personal possessions were not respected or properly managed. Specific details about the resident's medical history or condition at the time of the deficiency are not provided in the report. The event was documented under Event ID 45RI12.
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 709 citations issued within 25 miles in the last 12 months — including the 18 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 Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norterre | 2.3 mi | ★★★★★ | 1 | 0 |
| Liberty Health And Wellness | 2.3 mi | — | 0 | 0 |
| Pleasant Valley Manor Care Center | 2.9 mi | ★★★★★ | 16 | 2 |
| Linden Woods Village | 5.8 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Kansas City, Llc | 6 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avalon View Health And Wellness.
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.