Pennsylvania Department of Health
AVALON SPRINGS CARE CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

AVALON SPRINGS CARE CENTER
Inspection Results For:

There are 107 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


AVALON SPRINGS CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on December 31, 2025, it was determined that Avalon Springs Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for three of 17 residents reviewed (Residents R5, R49, and R2).

Findings include:

Review of facility policy entitled, "Care Plans, Comprehensive Person-Centered" dated 3/1/25, indicated that "a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change."

Review of facility policy entitled, "Advance Directives" dated 3/1/25, indicated that, " the resident has a right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment; the plan of care for each resident is consistent with his or her documented treatment preference and/or advance directive; changes are documented in the care plan and medical record."

Resident R5's clinical record revealed an admission date of 2/18/25, with diagnoses that included Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed).

Resident R5's physician's orders dated 9/27/25, revealed an order for DNR / Do Not Attempt Resuscitation (allow natural death).

Resident R5's clinical record revealed a Pennsylvania Orders for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) dated 6/5/25, that revealed Resident R5 requested Do Not Resuscitate (DNR), Limited Additional Interventions.

Resident R5's comprehensive care plan dated 6/4/25 with revision date of 11/5/25, revealed "Advance Directive: Full Code" (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest), indicating that the care plan was not reviewed and revised to reflect the current care and services regarding the code status.

Resident R49's clinical record revealed an admission date of 7/1/24, with diagnoses that included gastro-esophageal reflux disease (GERD - a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and osteoporosis (a condition where bone strength weakens and is susceptible to breaking).

Resident R49's physician's order dated 10/1/25, revealed an order for DNR / Do Not Attempt Resuscitation (allow natural death).

Resident R49's clinical record revealed a POLST dated 10/6/25, that revealed Do Not Resuscitate (DNR), Comfort Measures Only.

Resident R49's comprehensive care plan dated 8/13/25 with revision date of 10/21/25, revealed "Advance Directive: Full Code", indicating that the care plan was not reviewed and revised to reflect the current care and services regarding the code status.

During an interview on 12/30/25, at 11:10 a.m. the Director of Nursing (DON) confirmed that the care plans for Residents R5 and Resident R49 were not reviewed and revised to reflect current resident care and services regarding code status.

Resident R2's clinical record revealed an admission date of 9/3/25, with diagnoses that included GERD, Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure.

Resident R2's clinical record revealed a POLST dated 7/22/25, that revealed DNR / Do Not Attempt Resuscitation (Allow Natural Death), Limited Additional Interventions.

Resident R2's physician's order dated 9/16/25, revealed an order for DNR / Do Not Attempt Resuscitation (allow natural death).

Resident R2's comprehensive care plan dated 9/5/25, with revision date of 10/1/25, revealed "Advance Directive: Full Code."

During an interview on 12/30/25, at 2:21 p.m. the DON confirmed that the care plan for Resident R2 was not reviewed and revised to reflect current resident care and services regarding code status.

28 Pa. Code 211.5(f)(i) Medical records

28 Pa. Code 211.10(c)(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 02/25/2026

- Resident R5, R49 and R2 care plans have been updated to reflect current care and services. Director of Nursing reviewed all current residents Advanced Directives to ensure all care plans are accurate.

- Regional Registered Nurse Assessment coordinator will re-educate nursing team on the facilities Policy "Care Plans, Comprehensive Person-Centered." With special attention on updating Care plans as needed.

- Facility Director of Nursing or designee will audit 5 care plans per week for one month and monthly for 2 months to ensure policy compliance and care plan accuracy.

- Audit findings will be reviewed as part of the facility Quality Assurance and Performance Improvement Committee and monitored for tracking and trending.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of two of 17 residents reviewed (Residents R2 and R4).

Findings include:

MDS instructions for section M "Skin Conditions", Subsection M0300 "Current number of unhealed pressure ulcers/injuries at each stage" indicated "For each pressure ulcer, determine the deepest anatomical stage" and "For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission / entry or reentry and not acquired while the resident was in the care of the nursing home."

MDS instructions for section N "Medications", Subsection N0415 "High-Risk Drug Classes: Use and Indication" indicated under the column "Is Taking" to "check if the resident is taking any medication by pharmacological classification, not how it is used, during the last 7 days or since admission / entry or reentry if less than 7 days."

Resident R2's clinical record revealed an admission date of 9/3/25, with diagnoses that included Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure.

Resident R2's significant change MDS with an Assessment Reference Date (ARD) of 9/26/25, revealed section M0300 G1 "Number of Stage Unstageable Deep Tissue Injury Pressure Ulcers (purple or marron area of discolored intact skin due to damage of underlying soft tissue)" was coded as "2."Section M0300 G2 "Number of these unstageable pressure ulcers that were present upon admission / entry or reentry" was coded as "0."

Resident R2's clinical record revealed progress notes completed by wound care consultants on 9/4/25, 9/11/25, 9/18/25, and 9/25/25 indicating that Resident R2 was admitted with pressure ulcers to his/her right and left heel.

During an interview on 12/30/25, at 1:47 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) confirmed that Resident R2's 9/26/25, MDS was coded incorrectly and Resident R2's Section M0300 G2 should have been coded as a two.

Resident R4's clinical record revealed an admission date of 7/21/25, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), GERD, and fractured left femur (a break in the thigh bone).

Resident R4's quarterly MDS with an ARD of 10/8/25, revealed section N "Medications", Subsection N0415 "High Rick Drug Classes" E "Anticoagulant" (medication used to thin the blood) was coded as currently taking.

Resident R4's clinical record revealed a physician's order dated 7/21/25, for Lovenox (anticoagulant medication) 30 milligrams (mg) subcutaneous (sq injection into the fatty tissue just beneath the skin) daily for 21-days. Review of the October 2025 Medication Administration Record (MAR) revealed no evidence of Resident R4 receiving any anticoagulant during the seven-day look-back period for the 10/8/25 MDS.

During an interview on 12/30/25, at 1:39 p.m. the LPNAC confirmed that Resident R4's 10/8/25, MDS was coded incorrectly and Resident R4's Section N0415E should not have been coded as receiving during the last seven days.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(f)(ix) Medical records

Plan of Correction - To be completed: 02/25/2026

"The facility submits this plan of correction under the procedures established by the Department of Health in order to comply with the department's directive to change conditions which the department alleges are deficient under state and/or federal long term care regulations. This plan of correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of state or federal regulatory requirements."

- Resident R2 and R4's MDS have been corrected, they are accurately coded. The facilities MDS team will audit our current residents most recent MDS to ensure accuracy. The facilities wound nurse will provide the MDS team with the weekly skin report, the team will cross-reference the residents MDS to ensure accuracy. The clinical team will provide oversight on accurate MDS coding prior to submission with a focus on skin integrity and medications.

- Regional MDS coordinator will educate the facility LPNAC on proper MDS coding.

- Facility RNAC will audit 5 resident MDS weekly for one month and monthly for 2 months to ensure accuracy

- Audit findings will be reviewed as part of our facilities Quality Assurance and Performance Improvement committee and monitored for tracking and trending.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 17 residents reviewed (Resident R3).

Findings include:

Review of facility policy entitled, "Care Plans, Comprehensive Person-Centered" dated 3/1/25, indicated that "a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change."

Resident R3's clinical record revealed an admission date of 10/21/25, with diagnoses thatincluded Atrial Fibrillation (A-Fib irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), Diabetes (a health condition caused by the body's inability to produce enough insulin), and Major Depressive Disorder (MDD-characterized by persistent feeling of sadness, loss of interest in activities once enjoyed).

Resident R3's clinical record revealed a physician's order dated 10/21/25, for Apixaban (anticoagulant medication used to prevent blood clots) 5 milligrams (mg - metric unit of measure) two times a day; a physician's order dated 10/22/25, for Insulin Glargine (medication used to treat diabetes - a health condition caused by the body's inability to produce enough insulin) 20 units subcutaneously (sq - a short needle is used to inject a drug into the tissue layer between the skin and the muscle) at bedtime for diabetes; a physician's order dated 10/22/25, for Quetiapine Fumarate (an antipsychotic medication used as an adjunctive therapy of major depressive disorder) 25 mg at bedtime for major depressive disorder; a physician's order dated 11/6/25, for Sertraline (medication used to treat depression) 50 mg in the morning for depression.

Resident R3's clinical record lacked evidence that a care plan had been developed to address his/her usage of an anticoagulant; diabetes and usage of insulin; and usage and monitoring of an antipsychotic and antidepressant medication.

During an interview on 12/30/25, at 11:10 a.m. the Director of Nursing confirmed that a care plan had not been developed to address Resident R3's usage of an anticoagulant; diabetes and usage of insulin; and usage and monitoring of an antipsychotic and antidepressant medication.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12(d)(3)(5) Nursing services

Plan of Correction - To be completed: 02/25/2026

- Resident R3's care plan was updated to address usage of an anticoagulant, insulin and monitoring of an antipsychotic and antidepressant medication. A review of all resident's plan of care by the interdisciplinary team will be completed to ensure that a comprehensive plan of care is in place. With focus on psychotropic medications, anticoagulants and diabetes.

- Regional Registered Nurse Assessment Coordinator will educate the facility interdisciplinary team on properly developing a comprehensive care plan and updating care plans as needed.

- Facility Director of Nursing or designee will audit 5 care plans weekly for one month and monthly for to 2 months to ensure care plan accuracy.

- Findings will be reviewed as part of the facilities Quality Assurance and Performance Improvement Committee and monitored for tracking and trending.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 02/25/2026

1)The facility will meet minimum nurse aide to resident ratio each day by calculating out projected ratios needed at current census levels.

2) The Nursing Home Administrator will educate the Director of Nursing, Assistant Director of Nursing, Nursing Supervisors and Scheduler on required ratios to ensure facility is meeting ratios.

3) System changes to help ensure proper staffing ratios are met include, continue to offer extra shift bonus to current staff for picking up shifts, ensure all vacant positions are in recruitment.

4) The Director of Nursing or designee will audit to ensure that the facility meets the required minimum number of nurse aide to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Audits will be completed weekly for one month. Audits will be reviewed as part of the facilities Quality Assurance and Performance Improvement committee and monitored for tracking and trending.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 02/25/2026

1)The facility will meet minimum LPN to resident ratio each day by calculating out projected ratios needed at current census levels.

2) The Nursing Home Administrator will educate the Director of Nursing, Assistant Director of Nursing, Nursing Supervisors and Scheduler on required ratios to ensure facility is meeting ratios.

3) System changes to help ensure proper staffing ratios are met include, continue to offer extra shift bonus to current staff for picking up shifts, ensure all vacant positions are in recruitment.

4) The Director of Nursing or designee will audit to ensure that the facility meets the required minimum number of LPN to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Audits will be completed weekly for one month. Audits will be reviewed as part of the facilities Quality Assurance and Performance Improvement committee and monitored for tracking trending.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the 3.20 minimum number of general nursing care hours for each 24-hour period for 18 of 21 days reviewed (7/1/25, 7/2/25, 7/3/25, 7/4/25, 7/5/25, 7/6/25, 7/7/25,10/7/25, 10/8/25, 10/9/25, 10/10/25, 10/11/25, 10/12/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, and 12/27/25).

Findings include:

Review of facility nursing staffing documents for the time periods from 7/1/25, through 7/7/25; 10/7/25, through 10/13/25; 12/23/25, through 12/29/25, revealed the following general nursing care hours was below the minimum 3.20 per patient day (PPD) on the following days:

7/1/25 2.93 PPD
7/2/25 2.95 PPD
7/3/25 3.08 PPD
7/4/25 2.93 PPD
7/5/25 2.61 PPD
7/6/25 2.76 PPD
7/7/25 2.79 PPD
10/7/25 3.18 PPD
10/8/25 3.12 PPD
10/9/25 3.05 PPD
10/10/25 3.04 PPD
10/11/25 3.00 PPD
10/12/25 3.14 PPD
12/23/25 3.05 PPD
12/24/25 3.11 PPD
12/25/25 3.04 PPD
12/26/25 3.11 PPD
12/27/25 2.84 PPD

During an interview on 12/30/25, at 1:45 p.m. the Nursing Home Administrator confirmed that the facility did not meet the 3.20 PPD minimum nursing care hours on the above dates.

Plan of Correction - To be completed: 02/25/2026

1)The facility will meet minimum number of general nursing care hours for each 24-hour period.

2) The Nursing Home Administrator will educate the Director of Nursing, Assistant Director of Nursing, Nursing Supervisors and Scheduler on the minimum number of general nursing care hours required in a 24-hour period.

3) System changes to help ensure the required PPD is met include, continue to offer extra shift bonus to current staff for picking up shifts, ensure all vacant positions are in recruitment.

4) The Director of Nursing or designee will audit to ensure that the facility meets the required minimum nursing PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Audits will be completed weekly for one month. Audits will be reviewed as part of the facilities Quality Assurance and Performance Improvement committee and monitored for tracking and trending.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement