Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Avon Health Center during CMS and state inspections, most recent first.
A resident with COPD and continuous O2 was allowed to keep and self-apply petroleum-based jelly to the lips and face without an order or staff intervention, despite staff awareness and oxygen flammability warnings. Surveyors also found multiple resident bathroom and shower temperatures above 120°F, while the DM was only checking boiler-room temperatures and not resident-use fixtures.
Incomplete Investigation of Untimely Incontinent Care Allegation: A resident with CVA, HTN, behavior disturbances, cognitive impairment, and total dependence for incontinent care had a grievance after a visitor found the resident saturated in urine and reported an unanswered call bell that had been turned off at the nurse station. The RN spoke with an agency NA who said care had not yet been provided, but no written staff statements or flow sheet review were completed for the allegation. Nursing leadership later confirmed the investigation was not thorough and did not include the required staff interviews and documentation review.
A resident with COPD, chronic respiratory failure with hypoxia, and OSA was ordered oxygen at 3 L/min via NC continuously, but was repeatedly observed without oxygen in place, including while in a wheelchair and at the hairdresser. The resident stated oxygen was used only at night, and the ADNS confirmed the resident was not wearing oxygen as ordered and that the physician order should be followed.
Expired heparin lock flushes and expired 0.45% NS IV hydration bags were found stored in medication storage areas. An RN stated there should be no expired IV supplies in the rooms and that she did not check for IV meds and supplies, while the DNS stated nursing was responsible for ensuring expired medications were removed. The facility policy required all expired medications to be removed from active supply and destroyed.
A resident with severe dysphagia and G-tube dependence was on EBP for device care involving the feeding tube. During initiation of the tube feeding, an LPN performed hand hygiene and donned gloves but did not wear a gown as required by the EBP signage and facility policy. The LPN stated she forgot to put on the gown, and the DNS confirmed that tube feeding required both gown and gloves.
Dining rooms were not opened for routine meals, and residents were instead eating in their rooms or at the bedside. Two residents stated they would choose to eat in a dining room if it were available, and 7 residents at a Resident Council meeting said they had not been offered that choice for daily meals. The DON and Administrator stated the dining rooms had not been in use since the COVID-19 pandemic, with only special recreation-sponsored meals held in the dining room.
A resident with HTN, anxiety, and encephalopathy had conflicting code status documentation: a signed paper CPR/DNR form showed full code, while the physician order and EMR listed DNR/DNI/RNP. Staff interviews confirmed the discrepancy, and the ADNS could not locate a signed CPR/DNR Discussion Form for the code status change documented in the physician note. The resident later stated a preference to be full code, and facility policy required a new form whenever advance directive status changed.
A resident with severe cognitive impairment and mobility issues, who required two staff for all ADLs per physician orders and care plan, was provided incontinent care by a single NA. During care, the resident became resistive and fell from the bed, resulting in a femur fracture. The NA did not check the care card or follow the two-staff assist directive, leading to the incident.
A resident with multiple chronic conditions reported missing cash and a credit card from their bedside wallet, later discovering unauthorized charges. Investigation found that an agency nurse aide accessed the wallet while delivering a meal tray, removed the items, and returned the wallet, violating the facility's policy against misappropriation of resident property.
The facility failed to follow its policy for changing and storing nebulizer tubing for residents requiring respiratory treatment. A resident with emphysema had tubing that was not changed weekly, and two other residents with respiratory conditions had nebulizer masks improperly stored without bags. An LPN and the DNS confirmed the expectation for weekly changes and proper storage according to the facility's policy.
The facility failed to ensure advanced directive forms were completed and signed for two residents. One resident's DNR status was not properly documented with a signed form, despite verbal consent and a physician's order. Another resident's form lacked a facility representative's signature, despite the family's signature being present. The facility's policy did not specify when the directive needed to be signed, leading to documentation lapses.
A resident with moderate cognitive impairment reported being slapped by a nursing aide during care. The facility's internal investigation was incomplete, lacking interviews with other staff or witnesses. The incident was not documented in the medical record or reported to the state agency, violating the facility's abuse policy.
A resident with moderate cognitive impairment reported that a nursing aide slapped their hand during care. The incident was not documented in the medical record or reported to the state agency, as required by the facility's abuse policy. The Director of Nursing Services conducted an internal investigation but did not interview other staff or witnesses, concluding that the incident did not constitute abuse.
A resident with cognitive impairment reported being slapped by a nursing aide during care. The facility failed to document and thoroughly investigate the allegation, as required by their abuse policy. The DNS conducted a limited investigation without interviewing other staff or witnesses, and the incident was not recorded in the resident's medical file.
The facility failed to provide adequate supervision during meals for a resident with dysphagia, resulting in unsupervised eating despite care plan requirements. Another resident with chronic pain lacked nonpharmaceutical interventions in their care plan, relying solely on opioids. Additionally, a resident receiving antianxiety medication did not have a behavioral care plan, hindering the evaluation of intervention effectiveness.
A resident with cognitive impairment and dysphagia was involved in an incident where an LPN improperly disposed of a narcotic medication by leaving it in a cup on an uncovered trash receptacle. The LPN was unaware of the facility's policy for proper disposal, and an RN later identified the correct procedure, which was not followed due to the unavailability of a Drug Buster.
A facility failed to provide therapeutic recreation activities for a non-verbal resident with Alzheimer's, leaving them without stimulation for hours. Despite a care plan that included escorting the resident to activities and offering music, observations and interviews revealed a lack of engagement and coordination between nursing and recreation staff.
The facility failed to conduct timely nutritional assessments and reposition two residents with pressure ulcers. One resident with Multiple Sclerosis developed a stage II pressure ulcer without a subsequent nutritional assessment. Another resident with diabetes and Alzheimer's disease developed two new pressure injuries and was not repositioned as per the care plan, remaining in a wheelchair for extended periods. Facility policies for wound management and nutrition therapy were not followed.
A resident with cognitive impairment and dysphagia was improperly administered extended-release and delayed-release medications by an LPN who opened and crushed the capsules, contrary to facility policy and physician orders. The resident spit out the capsules, and a pharmacist later confirmed that the medications should not have been opened.
The facility did not label Morphine Sulfate 100 MG with an open date sticker after it was opened for a resident. An LPN documented the open date elsewhere, contrary to the facility's policy requiring a date open sticker on the medication container. An RN later prompted the LPN to correct this.
The facility failed to ensure proper infection control practices, as observed with a dietary aide not performing hand hygiene between glove changes and a nurse aide handling soiled linens and assisting residents without washing hands. The facility's hand hygiene policy was not followed, and no additional staff education was provided during a recent COVID-19 outbreak.
Unsafe Oxygen Use and Excessive Water Temperatures
Penalty
Summary
The facility failed to maintain a safe environment for a resident with COPD, chronic respiratory failure with hypoxia, and obstructive sleep apnea who was ordered to receive oxygen at 3 liters per minute continuously via nasal cannula. The resident had intact cognition and was independent with toileting, transfers, and bed mobility. During the survey, the resident was observed in a wheelchair at the bedside without oxygen in use at one point, with an uncovered 1.75-ounce tub of petroleum-based jelly on the nightstand. The resident later stated that a family member had brought in the jelly and that the resident had been applying it to the lips several times a day, especially at night, for years while the oxygen was running. Staff were aware that the resident had petroleum-based jelly in the room and that the resident was self-administering it to the face while on continuous oxygen, but no intervention occurred before surveyor inquiry. A nurse aide acknowledged awareness of the jelly on the nightstand and of the resident’s use of it while on oxygen. An LPN stated there was no physician order for petroleum-based jelly and that family items were sometimes brought in without checking with staff. The oxygen vendor stated that residents on oxygen should not use petroleum-based or oil-based products on the face or lip area because of the potential to burn or cause injury. The oxygen equipment also had flammability warnings and labels stating that oil and combustibles should be kept away. The facility also failed to monitor water temperatures at resident points of use. Surveyors found multiple resident bathroom and shower room temperatures above 120 degrees Fahrenheit across several units, including readings as high as 135.8 degrees Fahrenheit. The Director of Maintenance stated he monitored water temperatures in the boiler room and mixing valves, but not in resident rooms or shower areas, and he was not aware of a regulation requiring monitoring in resident bathrooms. The facility’s logs showed that water temperatures in resident care areas were not being monitored as expected, and the facility’s own policy directed that resident-use fixtures be checked and documented on a routine schedule and kept within a safe range.
Incomplete Investigation of Untimely Incontinent Care Allegation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation that a resident’s incontinent care was not provided in a timely manner. Resident #76 had diagnoses including CVA, hypertension, and behavior disturbances, and the care plan directed incontinent care every 2 hours and as needed, with preventive skin care for each incontinent episode. The quarterly MDS identified the resident as cognitively impaired, always incontinent of urine, and totally dependent on staff for incontinent care. A grievance was completed after a visitor reported that the resident’s incontinent brief and draw sheet were saturated with urine and that the resident’s call bell had been turned off at the nursing station without being answered. The RN who completed the grievance spoke with an agency NA, who stated she had not yet provided incontinent care and had not gotten to the resident because it was very busy. The grievance response documented that the NA was spoken to and staff education was initiated regarding call bells, but no written statements were located for the concern about untimely incontinent care or the call bell issue. Interviews with nursing leadership and staff showed that the investigation was incomplete. The DNS stated she was not aware of statements from the RN regarding the timeliness of incontinent care or the call bell being turned off, and the RN who handled the grievance stated she did not obtain written statements from staff working the overnight and day shifts or review the NA flowsheets for the times incontinent care was provided. The RN later acknowledged she should have investigated further and obtained statements, and the DNS confirmed the investigation was not complete based on facility policy.
Failure to Administer Ordered Continuous Oxygen
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident with chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and obstructive sleep apnea. Physician orders dated 1/20/26 directed oxygen at 3 liters per minute via nasal cannula continuously every shift for hypoxia related to COPD. The resident’s care plan identified altered respiratory status and difficulty breathing related to oxygen dependence and COPD, with interventions to monitor oxygen saturation and provide oxygen at 3 liters per minute via nasal cannula. During observations, the resident was repeatedly found without oxygen in place despite the active order. On the initial tour, the resident was in a wheelchair at the bedside not using oxygen. On later observations, the resident was at the hairdresser and then seated in a wheelchair with a portable oxygen tank hanging from the wheelchair, but not wearing oxygen. The resident stated he/she used oxygen only at night while sleeping. The ADNS confirmed the resident had a current order for oxygen 3 liters via nasal cannula continuously, stated the resident was not wearing oxygen as ordered, and said the physician orders should be followed. A nurse aide also stated the resident used oxygen at night.
Expired IV Medications Stored in Medication Rooms
Penalty
Summary
Expired heparin lock flushes and expired 0.45% normal saline IV hydration bags were found stored in two medication storage areas. In the North unit medication storage room, observation with RN #5 identified 52 expired heparin lock flushes dated 7/2022 in a drawer. In the OTC storage room where IV stock supplies were kept, there were 2 expired 1000 mL 0.45% NS IV hydration bags, one expired in April 2025 and one expired in November 2025. RN #5 stated there should be no expired IV supplies in the medication storage rooms and said she was not sure who was responsible for removing them. She also stated she did not check for IV medications and supplies. The DNS stated there should be no expired IV medications or solutions stored in the medication storage rooms and that nursing was responsible for ensuring expired medications were removed. The facility policy stated that all expired medications are to be removed from active supply and destroyed regardless of amount remaining.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
Enhanced Barrier Precautions were not followed during the initiation of a tube feeding for a resident with severe dysphagia and G-tube dependence. The resident was admitted with diagnoses including traumatic brain injury and schizophrenia, and the quarterly MDS identified severe cognitive impairment, dependence in activities of daily living, and a swallowing disorder requiring tube feeding. The resident care plan and physician orders identified that Enhanced Barrier Precautions were required because of the resident’s G-tube, and the facility’s signage outside the room directed staff to wear gloves and a gown for high-contact care activities involving feeding tubes. During observation, a LPN initiated the tube feeding after performing hand hygiene, donning gloves, preparing the feeding, verifying the order, checking residuals, and confirming the head of bed was elevated above 30 degrees. However, the LPN did not don a gown as required by the Enhanced Barrier Precautions signage and facility policy for device care involving feeding tubes. The LPN stated she should have worn a gown but forgot. The DNS confirmed that tube feeding was a high-contact resident care activity requiring both a gown and gloves, and the facility policy identified feeding tubes as indwelling medical devices requiring Enhanced Barrier Precautions.
Dining Rooms Not Opened for Resident Meals
Penalty
Summary
The facility failed to ensure dining rooms were opened for meals, despite residents expressing a preference to eat in a dining room and the facility’s own policy addressing dining preferences. Resident #83, who was admitted with diagnoses including Type 2 diabetes, chronic kidney disease, and hypertension, had intact cognition and was independent with eating. The resident stated during interview that he/she would eat in a dining room daily unless not feeling well, but did not think a dining room was available for daily meals. Observation showed the resident eating lunch in the room on one occasion and in the dining room only during a weekly recreation-sponsored pub lunch. Resident #102, admitted with CHF, hypertension, and muscle weakness, had mild cognitive impairment and was independent with eating. The resident was observed eating lunch at the bedside in the room and stated that meals were eaten there because there was no dining room for meals. The resident said that if a dining room were opened, he/she would eat most meals there unless not feeling up to it, and stated that no one had ever offered a choice to eat meals in a dining room. At the Resident Council meeting, all 7 residents who attended stated they would eat in a dining room if one were available and that a dining room was not available for all meals except special breakfast and lunches held by Recreation. They also stated they did not believe they had ever been offered a choice to eat in the dining room daily. The Administrator and DNS stated that dining rooms had not been opened since the COVID-19 pandemic, that the facility had special dining programs once a week, and that the dining room had not been in use for about 3 years. The facility’s Dining and Food Preferences policy stated that dining preferences, including location and mealtimes, were to be determined within 72 hours of admission, and the Resident Rights statement noted residents had the right to reasonable accommodations of individual needs and preferences.
Unsigned CPR/DNR Form After Code Status Change
Penalty
Summary
The facility failed to ensure the advance directives CPR/DNR Discussion Form was signed by the resident when the physician changed the code status. Resident #37 had diagnoses including hypertension, anxiety, and encephalopathy. The clinical record contained a CPR/DNR Discussion Form signed by the resident and a staff member that identified the resident as full code, while physician orders directed the resident was DNR. The care plan identified advance directive code status as DNR, DNI, and RNP, with interventions stating the resident/family wishes were to be honored and the DNR/CPR sheet reviewed with the resident/family and consent signed. The quarterly MDS identified the resident as moderately cognitively impaired and independent with eating, transfers, bathing, toileting, and dressing. The EMR identified the resident as DNR, DNI, and RNP, which conflicted with the signed paper CPR/DNR Discussion Form. During interview, the resident stated he/she would want CPR and be full code if unresponsive. An LPN stated the resident was full code per the signed paper form and would receive CPR if needed, while the ADNS acknowledged the discrepancy between the paper chart and EMR and stated both should match. The ADNS also identified a physician progress note documented a discussion with the resident and a change to DNR, but a signed CPR/DNR Discussion Form for that change could not be located. The DNS stated a CPR/DNR Discussion Form was to be completed and signed whenever code status changed, and the facility policy required a new form if a resident decided to change advance directive status.
Failure to Follow Two-Staff Assist Orders Results in Resident Fall and Fracture
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, anxiety, and osteoarthritis was admitted with orders for comfort care, do not hospitalize, and required extensive assistance from two staff for bed mobility and activities of daily living (ADLs). The resident's care plan and physician orders specifically directed that two staff members assist with all ADLs and that a Hoyer lift be used for transfers, as the resident was non-ambulatory and at high risk for falls due to impaired mobility, incontinence, and cognitive impairment. On the day of the incident, a nurse aide (NA) provided incontinent care to the resident alone, despite the care plan and physician orders requiring two staff for such care. During the process of turning the resident onto their side, the resident became resistive and rolled away from the NA, ultimately falling from the bed to the floor. The NA was unable to prevent the fall, which resulted in the resident sustaining an acute distal femur fracture. The NA later stated she believed only one staff member was needed for ADL care and was unaware of the requirement to check the resident care cards prior to providing care. Interviews with facility staff confirmed that the resident required two staff for all care, including turning and positioning, and that this information was available on the electronic care card accessible to all staff. The NA involved did not consult the care card before providing care and proceeded alone, contrary to established orders and care plans. The incident led to the resident requiring a hospital transfer for a closed reduction of the fracture, after initial management in the facility.
Failure to Protect Resident from Theft of Personal Property by Staff
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including acute-on-chronic diastolic heart failure, essential hypertension, and Type 2 diabetes, reported that their credit card and cash were missing from their wallet, which was kept at the bedside. The resident was alert, oriented, and required staff assistance with activities of daily living. The incident was discovered after the resident noticed unauthorized charges on their credit card and missing cash, with the last known presence of the items being the day before the charges began. Facility documentation and interviews revealed that a nurse aide, who was an agency staff member and had limited prior shifts at the facility, had access to the resident's wallet while delivering a meal tray. The aide took the wallet from the nightstand, removed the credit card and cash, and then returned the wallet. The facility's abuse policy prohibits misappropriation of resident property, defined as the wrongful use of a resident's belongings or money without consent. The aide was not available for a facility interview but later admitted to the theft during a police investigation.
Failure to Change and Store Nebulizer Tubing as per Policy
Penalty
Summary
The facility failed to adhere to its policy for changing and storing nebulizer tubing for residents requiring respiratory treatment. Resident #32, diagnosed with centrilobular emphysema and a cardiac pacemaker, had a nebulizer mask with tubing dated 7/2/24, which was not changed weekly as required. The Licensed Practical Nurse (LPN) confirmed the tubing should have been changed weekly, and the Director of Nursing Services (DNS) expected compliance with this policy. The facility's policy directed that nebulizer masks be changed weekly and stored in a clear bag when not in use. Similarly, Resident #51, with diagnoses including congestive heart failure and a history of acute respiratory failure, had a nebulizer mask left on the bedside table without a storage bag. The LPN acknowledged the mask should have been stored in a plastic bag, and the DNS confirmed this expectation. Additionally, Resident #52, diagnosed with chronic obstructive pulmonary disease, had a nebulizer mask on the bedside table without a bag, with tubing dated 12/13/23, indicating it was not changed weekly. The LPN and DNS both confirmed the expectation for weekly changes and proper storage according to the facility's policy.
Failure to Complete and Sign Advanced Directive Forms
Penalty
Summary
The facility failed to ensure that the advanced directive election forms were completed and signed by the resident or responsible party after verbal consent was obtained to change the election, and a physician order was written. For Resident #8, despite a physician's progress note and order indicating a Do Not Resuscitate (DNR) status, the advanced directive election form reflecting this change was not signed by the resident. The resident's care plan and Minimum Data Set (MDS) assessment indicated a DNR status, but the facility could not locate a signed form confirming this. Interviews with the Director of Nursing Services (DNS) and a Registered Nurse (RN #3) revealed that the form was missing, and a new form was awaiting signature, indicating a lapse in ensuring proper documentation. For Resident #405, the facility also failed to have the advanced directive form signed by a facility representative, despite the family's signature being present. The resident was identified as cognitively impaired and required extensive assistance, with a care plan indicating DNR and Do Not Intubate (DNI) status. However, the facility's policy did not specify when the advanced directive needed to be signed, leading to a lack of clarity and proper documentation. The DNS was unable to explain why the form was not signed by the facility representative, highlighting a deficiency in the facility's adherence to its own policies regarding advanced directives.
Failure to Implement Abuse Policy and Document Incident
Penalty
Summary
The facility failed to implement its abuse policy for an allegation of abuse involving a resident with moderate cognitive impairment and requiring substantial assistance with personal care. The resident, who was receiving palliative care, reported to a social worker that a nursing aide had slapped their hand during care. The internal investigation conducted by the Director of Nursing Services (DNS) concluded that the aide had not slapped the resident, but the investigation lacked thoroughness as it did not include interviews with other staff or potential witnesses. The incident was not documented in the resident's medical record, and no Accident/Incident report was filed. Additionally, the incident was not reported to the state agency's online Reportable Event portal. The facility's abuse policy requires thorough investigation and documentation of all allegations, but these procedures were not followed in this case. Interviews with staff revealed inconsistencies in the reporting and documentation of the incident. The social worker and DNS provided conflicting dates regarding when the incident was reported and investigated. The social worker did not document the date of the allegation, and the DNS admitted to writing the wrong date on the internal investigation. The facility's failure to adhere to its abuse policy and properly document and report the incident resulted in a deficiency.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a resident to the state agency. The resident, who had moderate cognitive impairment and required assistance with personal hygiene, reported that a nursing aide slapped their hand during care. The incident was reported to the social worker by a third party, but there was no documentation in the medical record or any report made to the state agency. The Director of Nursing Services conducted an internal investigation but did not interview other staff or witnesses, concluding that the incident did not constitute abuse. The facility's abuse policy requires that all allegations of abuse be investigated, documented, and reported according to federal and state guidelines. However, the facility did not follow these procedures, as evidenced by the lack of documentation and failure to report the incident to the state agency. The Director of Nursing Services did not consider the incident an allegation of abuse, which led to the deficiency in reporting and documentation as required by the facility's policy.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to initiate and complete a thorough investigation for an allegation of abuse involving a resident with moderate cognitive impairment and multiple health conditions, including heart disease and diabetes. The incident involved a nursing aide allegedly slapping the resident's hand during personal care. The resident reported the incident to a third party, who then informed the social worker. However, the facility did not maintain proper documentation of the investigation, and there was no record of the incident in the resident's medical file. The Director of Nursing Services (DNS) conducted an internal investigation but did not interview other staff or potential witnesses, relying solely on interviews with the resident and the nursing aide involved. The facility's abuse policy requires thorough investigation and documentation of all allegations, but this was not adhered to in this case. The DNS acknowledged a mistake in recording the date of the incident and did not document the incident in the electronic medical record, citing no change to the care plan. The nursing aide involved, who was a floating aide, denied slapping the resident and stated they were assisting the resident with handwashing. The lack of documentation and comprehensive investigation led to the deficiency noted by the surveyors.
Deficiencies in Supervision, Pain Management, and Behavioral Care Plans
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident diagnosed with Alzheimer's disease, dysphagia, and dyskinesia of the esophagus. Despite orders for aspiration precautions and supervision during meals, the resident was observed eating independently without staff supervision. The Speech Therapist later adjusted the care plan to require assistance as needed, but documentation of meal assistance was inconsistent, with many instances of missing records and incorrect levels of assistance noted. Another deficiency involved a resident with chronic pain who was prescribed opioid medications. The care plan did not include nonpharmaceutical interventions for pain relief, and there was no evidence of alternative pain management strategies being explored. The facility's policy emphasized the importance of using interventions to prevent pain from interfering with quality of life, yet the care plan lacked documentation of any non-medication interventions. Additionally, the facility failed to address specific behaviors and interventions in the care plan for a resident receiving antianxiety and antidepressant medications. Although there were orders for behavioral monitoring, the care plan did not include strategies for managing the resident's anxiety. This oversight was acknowledged by staff, who noted that without a behavioral care plan, the effectiveness of interventions could not be evaluated.
Improper Disposal of Narcotic Medication
Penalty
Summary
The facility failed to ensure the proper disposal of a narcotic medication during medication administration for a resident diagnosed with essential hypertension, mood disorder, and gastric esophageal reflux. The resident, who was severely cognitively impaired and had dysphagia, was prescribed Propranolol and Duloxetine. During a medication administration observation, an LPN indicated the need to dispose of medications, including a narcotic, before repouring them for the resident. However, the discarded medications were left in a cup on top of an uncovered trash receptacle, indicating improper disposal. The LPN involved admitted to not knowing the facility's policy for proper disposal of medications, including narcotics. An RN later identified that the medication should have been disposed of using a Drug Buster, which was not available at the time. The facility's policy required that controlled medications be destroyed in the presence of two licensed nurses if not administered. Despite a request, the facility did not provide the specific policy for narcotic disposal, highlighting a deficiency in adherence to professional standards of quality in medication management.
Failure to Provide Therapeutic Recreation Activities
Penalty
Summary
The facility failed to provide therapeutic recreation activities to meet the psycho-social needs of a resident diagnosed with diabetes mellitus, pain, and Alzheimer's disease. The resident was identified as severely cognitively impaired, non-verbal, and dependent for all aspects of care. The Resident Care Plan included interventions such as informing, inviting, and escorting the resident to appropriate recreation programs, offering music in the room, and providing one-on-one recreation visits to promote socialization. However, observations on a specific date revealed that the resident was left in a wheelchair at the bedside without any form of stimulation for several hours. Interviews with the Recreation Director and Recreation Therapists indicated that the resident was brought to activities and provided with sensory stimulation like stuffed animals and music. However, documentation showed that the resident was only engaged in activities on one day during the week in question, with no further activities or one-on-one visits documented. The Recreation Therapists acknowledged challenges in getting residents to activities, particularly non-verbal residents, due to a lack of coordination between the nursing and recreation departments. The Recreation Director also noted that the nursing department did not consistently follow through with bringing residents to activities.
Failure to Conduct Nutritional Assessments and Reposition Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper nutritional assessment and care for two residents with pressure ulcers. Resident #25, diagnosed with Multiple Sclerosis, was identified as being at risk for pressure ulcers. Despite the development of a stage II pressure ulcer on the left heel, no subsequent nutritional assessment was conducted to determine if dietary modifications were needed. The dietitian, who was responsible for monitoring residents with wounds, did not assess Resident #25's nutritional status after the pressure ulcer was reported, as confirmed by the Director of Nursing Services. Resident #42, with diagnoses including diabetes mellitus and Alzheimer's disease, developed two new pressure injuries on the left heel. Despite being at high risk for skin impairment, no nutritional assessment was conducted following the development of these injuries. The resident's care plan directed repositioning every two hours and a maximum of two hours in a wheelchair, but observations revealed the resident remained in the wheelchair for extended periods without repositioning. Interviews with nursing staff confirmed the care plan was not followed, and the resident was not repositioned as required. The facility's policies for wound management and medical nutrition therapy were not adhered to, as evidenced by the lack of timely nutritional assessments and failure to reposition residents according to their care plans. The Director of Nursing Services acknowledged the expectation for repositioning residents with pressure injuries every 2-3 hours, which was not met in these cases.
Improper Administration of Extended-Release Medications
Penalty
Summary
The facility failed to ensure the proper administration of extended-release and delayed-release medications for a resident with essential hypertension, mood disorder, and gastric esophageal reflux. The resident, who was severely cognitively impaired and had dysphagia, required medications to be crushed. During a medication administration observation, an LPN was seen opening and crushing the capsules of Propranolol 120 MG extended-release and Duloxetine 60 MG delayed-release, mixing them with applesauce, and attempting to administer them to the resident. Upon intervention by the surveyor, the LPN acknowledged the error and repoured the medications, but the resident spit out the capsules. The facility's policy on medication crushing guidelines, dated June 2024, indicated that time-released capsules should not be opened without consulting a reference or pharmacist. A subsequent review with a pharmacist confirmed that the Propranolol and Duloxetine capsules should not be opened, as they are designed to release medication over a sustained period. The incident highlighted a significant medication error due to the improper preparation of medications, which was not in accordance with the facility's policy or the physician's orders.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to appropriately label medications once opened in one of its medication rooms. During an observation of the A/B Wing medication room, it was identified that Morphine Sulfate 100 MG prescribed to a resident was opened but did not have a date open sticker on the medication container. An interview with an LPN revealed that the date was documented elsewhere, specifically in the Medication Book, which indicated the Morphine was opened on 7/7/24. Following an inquiry, an RN prompted the LPN to place the open date on the container. The facility's Storage of Medications Policy requires that when the original seal of a manufacturer's container or vial is initially broken, the container or vial must be dated. The policy specifies that the nurse should place a date open sticker on the medication, which was not adhered to in this instance.
Infection Control Deficiencies in Dietary and Nursing Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff, as observed during a survey. Dietary Aide #1 was noted to have a facial hair covering that did not adequately cover the facial hair of the upper lip while plating food. After being advised by the Dietary District Manager, the aide adjusted the facial hair net but failed to perform hand hygiene between glove changes. The facility's hand hygiene policy requires hand washing after glove removal, which was not adhered to in this instance. Additionally, Nurse Aid (NA) #4 was observed handling soiled linens and interacting with residents without performing necessary hand hygiene. NA #4 exited a resident's bathroom with dirty linens and gloves, used the gloved hand to open doors, and accessed the dirty linen cart without removing the gloves. Furthermore, NA #4 was seen eating chips and licking fingers before assisting a resident with a tissue, again without washing hands. The facility's hand hygiene policy mandates hand washing before and after resident care and glove use, which was not followed. The Director of Nursing Services (DNS) acknowledged the lack of additional staff education on infection control during a recent COVID-19 outbreak.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Avon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Rehab Avon | 0.2 mi | ★★★★★ | 17 | 0 |
| Countryside Manor Of Bristol | 4.6 mi | — | 0 | 0 |
| Autumn Lake Healthcare At West Hartford | 4.9 mi | ★★★★★ | 21 | 0 |
| Cherry Brook Health Care Center | 4.9 mi | ★★★★★ | 5 | 0 |
| Amberwoods Of Farmington | 5.2 mi | ★★★★★ | 10 | 0 |
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