Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
The facility did not adhere to its policy of posting daily nurse staffing information, as required. The policy specifies that the facility must display the total number and actual hours worked by RNs, LPNs, and CNAs per shift. However, from early December to early January, the facility's Daily Nurse Staffing forms lacked this information. The Staffing Coordinator confirmed the omission during an interview.
The facility failed to employ a full-time or part-time RD or qualified DM, affecting 55 residents receiving meals. The RD's responsibilities included ensuring dietary compliance and monitoring residents' nutritional status. Since the week of Christmas, the facility lacked an RD, and the Dietary Supervisor was still obtaining certification. Interviews revealed confusion about the RD's role, with an Interim RD contracted but not yet engaged with staff.
The facility failed to provide sufficient staff with the necessary competencies to effectively carry out food and nutrition services, impacting meal preparation and delivery for 55 residents. Despite awareness of staffing concerns, the facility could not provide competency documentation for kitchen staff, leading to delays in meal service.
The facility failed to maintain sanitary conditions in food storage, handling, preparation, and service. Dietary staff did not adhere to hand hygiene protocols, with instances of serving food without gloves and failing to wash hands after potential contamination. The kitchen contained improperly labeled, undated, and expired food items, and the 3 compartment sink was not properly sanitized before use. The Dietary Supervisor confirmed these deficiencies, indicating a failure to follow facility policies.
The facility failed to follow infection control practices during medication administration and resident care. An LPN dropped medication on an unprotected surface and intended to administer it, while another LPN did not use a gown during PEG tube medication administration. A resident on contact isolation received meals on regular trays, and an LPN used unsanitized equipment between residents. The DON confirmed these lapses in infection control practices.
A resident with multiple diagnoses, including heart failure, experienced significant weight gain over six months, but the facility failed to revise the care plan to address this change. Despite the resident's weight increasing from 156 to 180 pounds, the care plan was not updated to reflect the resident's heart failure diagnosis or the need for dietary adjustments. Interviews with facility staff confirmed that the care plan should have been revised.
The facility failed to follow physician orders for two residents. One resident with severe cognitive impairment and a history of bradycardia did not have their heart rate monitored as ordered, leading to an emergency room visit. Another resident, who refused antibiotics due to diarrhea, did not have a stool sample collected for C. diff testing as ordered. These deficiencies highlight lapses in documenting and executing physician orders.
A facility failed to maintain the dignity of a resident with an indwelling urinary catheter. Despite a physician order for a privacy bag to be used every shift, observations showed the catheter bag was visible from the hallway without a cover. The resident, who was cognitively intact and dependent on staff, had diagnoses including MS and UTI. The DON confirmed the catheter bag should always be covered to promote dignity.
A resident with heart failure and other conditions experienced significant weight gain, which was not properly assessed or communicated to the physician by the facility. Despite policies in place, the facility failed to have a Registered Dietitian reassess the weight gain or notify the physician, leading to a deficiency in care.
A facility failed to reassess the effectiveness of pain medication for a resident with multiple diagnoses, including chronic pain conditions. Despite the facility's policy requiring pain level assessments before and after medication administration, the resident's pain levels were not documented post-medication. Interviews with staff confirmed the expectation for such assessments, yet the deficiency persisted, indicating a lapse in the facility's pain management practices.
The facility failed to properly store medications in the Medication Room, as oral glucose gel was stored with external medications like hydrocortisone cream and antibiotic ointment, and nasal spray was stored with ear and eye drops without dividers. Interviews with staff confirmed these practices were against facility policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with its policy on posting daily nurse staffing information, as evidenced by a review of the facility's Daily Nurse Staffing forms and an interview with the Staffing Coordinator. The policy, dated December 1, 2024, mandates that the facility must make nurse staffing information readily available in a readable format to residents and visitors at any given time. This information should include the facility name, total number, and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) per shift. However, for the period from December 2, 2024, through January 2, 2025, the facility's Daily Nurse Staffing forms did not include the total number of RNs, LPNs, and CNAs, nor the total hours worked by these staff members. The Staffing Coordinator confirmed during an interview on January 9, 2025, that the facility had not provided the required staffing information on the Daily Nurse Staffing form.
Lack of Registered Dietitian Oversight in Facility
Penalty
Summary
The facility failed to employ a full-time or part-time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to oversee the kitchen operations, staff competencies, and residents' dietary needs. This deficiency potentially affected all 55 residents receiving meals from the kitchen. The job descriptions for both the RD and DM outlined responsibilities such as ensuring compliance with dietary standards, monitoring residents' nutritional status, and overseeing meal preparation and service. However, the facility did not have an RD since the week of Christmas, and the Dietary Supervisor, who was in the process of obtaining certification, confirmed this gap in staffing. Interviews with facility staff revealed a lack of clarity and communication regarding the RD's role and responsibilities. The Administrator was unsure about the current RD's identity and whether they had been onsite, while the Director of Nursing confirmed the former RD's last day was 12/27/2024. An Interim RD was contracted during the week of 1/5/2025 but had not yet communicated with the Administrator or nursing staff about resident concerns. This lack of oversight and communication could impact the nutritional care and meal service provided to the residents.
Inadequate Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skill sets to effectively carry out the functions of the food and nutrition services. This deficiency was observed in four staff members, including three dietary cooks and a dietary supervisor, who were responsible for preparing and serving meals to all 55 residents. The facility's policies on food safety, handwashing, and manual warewashing were reviewed, revealing requirements for safe food handling and hygiene practices. However, during an observation, it was noted that only two kitchen staff members were present to cook and prepare the dinner meal, resulting in a delay in meal delivery. The facility's administrator acknowledged awareness of staffing concerns in the kitchen and mentioned that CNAs were cross-trained to assist. Despite this, the facility was unable to provide documentation of the kitchen staff's competencies. The dietary supervisor admitted to being behind schedule, indicating a struggle to meet the demands of meal preparation and service with the available staff. This situation highlights the facility's failure to adhere to its own policies and ensure adequate staffing levels to maintain timely and safe food service for its residents.
Sanitation and Food Handling Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, handling, preparation, and service, as evidenced by multiple observations and interviews. Dietary staff members did not adhere to hand hygiene protocols, with instances of staff failing to wash hands before handling clean dishes and after engaging in activities that could contaminate their hands. Additionally, staff were observed serving food without gloves and not performing hand hygiene after leaving and returning to the steam table. The facility's kitchen was found to have several instances of improperly labeled, undated, and expired food items. Observations revealed unlabeled and undated packages of hotdog buns, cinnamon rolls, roasted potatoes, fries, and other food items stored in the freezer and refrigerator. Expired containers of tuna salad and cucumber and onion salad were also found in the walk-in refrigerator, along with an unlabeled and undated cooked hamburger patty. Furthermore, the facility did not ensure proper sanitation of the 3 compartment sink, as one dietary staff member failed to test the sanitation solution before use, resulting in a knife being washed without proper sanitation. The Dietary Supervisor confirmed the necessity of labeling and dating food items, performing hand hygiene, and testing the sanitation of the sink prior to use, highlighting the facility's failure to adhere to its own policies and procedures.
Infection Control Lapses During Medication Administration and Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration and resident care. An LPN was observed dropping a Phenytoin capsule on an unprotected medication cart surface and then placing it into a medication cup with another medication, intending to administer both to a resident. The LPN acknowledged the error, confirming that the medications were contaminated and should have been discarded and replaced. Additionally, another LPN did not follow Enhanced Barrier Precautions while administering medications via a PEG tube, as they failed to wear a gown during the procedure. The facility also did not follow proper transmission-based precautions for a resident on contact isolation due to MRSA. Meals were delivered on regular trays instead of Styrofoam containers, as the dietary department was not informed of the resident's isolation status. Furthermore, an LPN was observed entering the resident's room without a gown, using a multi-use blood pressure machine without sanitizing it between residents, and failing to perform hand hygiene after glove removal. Interviews with the Director of Nursing and other staff confirmed the lapses in infection control practices. The DON acknowledged that medications dropped on unprotected surfaces should be discarded, and Enhanced Barrier Precautions, including gown and glove use, should be followed during PEG tube medication administration. The DON also confirmed that reusable equipment should be cleaned between residents and that staff should wear appropriate PPE when entering rooms of residents on contact precautions.
Failure to Revise Care Plan for Resident with Significant Weight Gain
Penalty
Summary
The facility failed to revise a person-centered care plan for a resident who experienced significant weight gain. The resident, who was admitted with diagnoses including Heart Failure, Coronary Artery Disease, Failure to Thrive, Diabetes, Aphasia, and Dementia, showed a steady increase in weight over several months. Despite the resident's weight increasing from 156.0 pounds to 180 pounds over a period of six months, the care plan was not updated to address this weight gain or the resident's heart failure diagnosis. The care plan initially included dietary measures such as a pureed diet and the administration of Megestrol Acetate as an appetite stimulant, but it did not reflect the resident's changing condition. Interviews with facility staff, including the Director of Nursing and the MDS Coordinator, confirmed that the care plan should have been revised in response to the significant weight gain. The Director of Nursing acknowledged the need to review the resident's weights with the provider to determine if medication adjustments were necessary. The MDS Coordinator also confirmed that a care plan revision was warranted given the resident's significant weight gain. However, these actions were not taken, resulting in a deficiency in the facility's care planning process.
Failure to Follow Physician Orders for Monitoring and Testing
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For Resident #31, who was admitted with conditions including hypertension and severe cognitive impairment, a nurse practitioner issued a verbal order to monitor the resident's heart rate every hour for six hours due to a history of bradycardia. However, the Licensed Practical Nurse (LPN) did not document this order, and the resident's heart rate was only checked once during the shift. The Medical Director was informed of the low heart rate later in the day, and the resident was subsequently sent to the emergency room for further evaluation. For Resident #159, who was admitted with diagnoses including a Methicillin Resistant Staphylococcus Aureus Infection and a pressure ulcer, the resident refused intravenous antibiotics due to diarrhea. The Assistant Director of Nursing (ADON) noted the need to hold the antibiotics and collect a stool sample to test for Clostridium Difficile (C. diff). However, the order for the stool sample was not documented, and the sample was not collected, resulting in a failure to perform the necessary test as ordered by the provider.
Failure to Maintain Resident Dignity with Indwelling Catheter
Penalty
Summary
The facility failed to ensure the dignity of a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including Multiple Sclerosis, Depression, Anxiety, Urinary Tract Infection, and Disorder of Bladder, was cognitively intact and dependent on staff for activities of daily living. The care plan indicated the use of an indwelling catheter, and a physician order specified that a privacy bag should be used every shift to maintain the resident's dignity. However, observations on multiple occasions revealed that the urinary catheter bag was attached to the resident's bed frame without a privacy cover, making it visible from the hallway. This was confirmed by the Director of Nursing, who acknowledged that the catheter bag should always be covered to promote dignity.
Failure to Monitor and Address Significant Weight Gain in Resident with Heart Failure
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident diagnosed with heart failure, coronary artery disease, failure to thrive, diabetes, aphasia, and dementia. The resident experienced a significant weight gain over several months, which was not adequately assessed or addressed by the facility. Despite the resident's weight increasing from 156 pounds to 180 pounds over a period of months, the facility did not have a Registered Dietitian or Qualified Nutritional Professional reassess the resident's weight gain to determine if it was due to actual weight gain or fluid retention related to heart failure. Additionally, the facility failed to notify the resident's physician or practitioner about the significant weight gain. The facility's policies on nutritional management and weight monitoring were not effectively implemented, as evidenced by the lack of timely reassessment and communication with the resident's healthcare provider. The Director of Nursing was unaware of the resident's ideal body weight and confirmed that the resident's weights were being gathered for review with the provider to determine if medication adjustments were necessary. This oversight in monitoring and addressing the resident's nutritional status and weight changes led to a deficiency in the care provided to the resident.
Failure to Reassess Pain Medication Effectiveness
Penalty
Summary
The facility failed to reassess the effectiveness of pain medication for a resident, leading to a deficiency in pain management. The facility's policy on pain management, dated December 1, 2024, mandates that pain management services must be provided to residents who require them, including monitoring the effectiveness of medication. However, a review of the medical records for a resident with multiple diagnoses, including Hidradenitis Suppurativa, Diabetes, End Stage Renal Failure, Pain, and Cellulitis, revealed that the resident did not have a documented pain level after the administration of pain medications. The resident, who was cognitively intact with a BIMS score of 15, confirmed that staff did not reassess her pain level after administering pain medication. Interviews with the facility's Nurse Practitioner and the Director of Nursing confirmed that the procedure for pain medication administration includes assessing the resident's pain level before and after administering pain medication, with documentation of the results. Despite receiving pain medication on a routine and as-needed basis, the facility failed to ensure the resident's pain was reassessed for the effectiveness of the pain medication, as required by their policy. This oversight was identified during a survey, highlighting a deficiency in the facility's pain management practices.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in one of its medication storage areas, specifically the Medication Room. The facility's policy, dated December 1, 2024, mandates that medications be stored in a manner that ensures proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. It specifies that drugs for external use should be stored separately from internal and injectable medications, and medications to be administered by mouth should be stored separately from other formulations. However, during an observation on January 7, 2025, it was found that four tubes of glucose gel, an oral medication, were stored together with hydrocortisone cream and triple antibiotic ointment, both external medications, in a plastic container without a divider. Additionally, the observation revealed that nasal decongestant spray was stored with ear wax removal solution and eye drops in a plastic container without a divider. Interviews with the Licensed Practical Nurse, Assistant Director of Nursing, and Director of Nursing confirmed that these storage practices were not in compliance with the facility's policy. The glucose gel should have been stored separately from the external medications, and the nasal spray should have been stored separately from the ear and eye drops, each with appropriate dividers to ensure proper segregation.
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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 Humboldt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| W D Bill Manning Tennessee State Veterans Home | 1.6 mi | ★★★★★ | 0 | 0 |
| Christian Care Center Of Medina | 8.9 mi | ★★★★★ | 2 | 0 |
| Trenton Health And Rehabilitation Center, Llc | 9.2 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Milan | 9.7 mi | ★★★★★ | 11 | 0 |
| Northbrooke Post Acute | 11 mi | ★★★★★ | 0 | 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.