Above 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 Oaks At Avon during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a functional call light system in multiple rooms across three halls, where call lights did not illuminate in the hallway or enunciate at the nurses’ station, and in one room the call light would not reset after activation. A CNA, the DON, the Director of Maintenance, and LPN staff confirmed that some call lights were not working, that issues were reported through an electronic work order system, and that residents were given handheld bells when call lights were inoperable. The facility did not have a specific written call light maintenance policy available for review.
The facility did not ensure that previous survey results were readily available for residents and families. Survey information was not visible in the lobby, and the binder containing survey reports was found in the NHA's office with only two reports from 2021 and 2022, despite more recent surveys. The NHA confirmed the limited contents and mentioned that the previous NHA kept them in his office due to removal concerns, violating the facility's policy for accessible survey results.
The facility failed to accurately complete and update PASRR forms for several residents, leading to omissions of critical diagnoses such as depression, anxiety, and traumatic brain injury. The DON confirmed these oversights during interviews, highlighting a lapse in following the facility's policy for preadmission screenings.
The facility failed to maintain a sanitary kitchen environment, with the dishwashing machine not reaching the required temperature, unsanitary storage of personal items near clean dishes, and improper cleaning of beverage carts. Expired food and stained cookware were also observed, potentially affecting 87 residents.
A facility failed to implement PASRR recommendations for a resident with multiple psychiatric diagnoses, including schizoaffective disorder and major depressive disorder. The resident's care plan did not include the recommended psychiatric medication management and supportive counseling. Interviews confirmed the absence of follow-up with psychology or psychiatry services, and the facility's policy requiring PASRR recommendations to be implemented was not followed.
The facility failed to provide respiratory care according to professional standards for two residents receiving oxygen therapy. One resident received oxygen at 2.5 LPM instead of the prescribed 3 LPM, while another was observed at 2.5 LPM despite orders for 2 LPM as needed. Staff interviews confirmed discrepancies in monitoring and documentation of oxygen settings.
An unsecured toilet in a shared bathroom was observed in a LTC facility, affecting two independent residents. Despite one resident's report of the issue to staff, no work orders were logged to address the problem. Interviews confirmed staff awareness, but the facility's electronic work order system showed no requests to secure the toilet, violating the policy for maintaining a safe environment.
Failure to Maintain Functional Call Light System in Multiple Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that resident room call light systems were maintained in working order on one of two units and across three halls (100, 200, and 300). On a specified survey date and time, multiple resident rooms (including rooms 101, 102, 200, 202, 204, 209, 304, and 300) were observed to have nonfunctioning call lights. In several rooms, when the call lights were activated and tested multiple times, the corridor light above the room door did not illuminate and the system did not enunciate at the nurses’ station. In another room, the call light would not reset after initial activation. These findings were based on direct testing of the call light devices by surveyors. During interviews, a CNA assigned to the 100 unit confirmed that at least one room’s call light did not illuminate above the door or enunciate at the nurses’ station and explained that staff submit electronic work orders to maintenance and provide residents with handheld bells when call lights are not working. The DON acknowledged prior call light problems on a different wing and stated there was no awareness of current issues on the observed hall until the survey findings were presented, while confirming that all call lights should be functional and within residents’ reach. The Director of Maintenance confirmed previous call light concerns on the North unit, stated he was unaware of issues on the South unit, and verified that the identified room call lights were not working. Additional LPN staff reported that nonfunctioning call lights are reported via the electronic work order system and that residents are given handheld bells until repairs are made. The facility did not have a specific written call light maintenance policy and procedure available for review.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that previous survey and inspection results were readily available for residents and families to review. During an observation of the facility's lobby area, it was noted that there was no immediate indication of the location or presence of past survey information. The Regional Nurse Consultant (RNC) indicated that the survey results were kept in the Nursing Home Administrator's (NHA) office and retrieved a binder titled 'Annual Surveys' from there. Upon review, the binder contained only two survey reports from 2021 and 2022, despite the facility having undergone additional compliance surveys in 2022, 2023, and 2024. The NHA confirmed that the binder only contained the two reports and initially stated that no surveys had been conducted since 2022. However, she was reminded of the more recent surveys. The NHA explained that the previous NHA had kept the survey results in his office due to concerns about them being removed. The facility's policy requires that survey results be placed in a readily accessible location for residents and families, which was not adhered to, leading to the deficiency.
Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) forms were completed accurately and updated for five residents. Resident #83 was admitted with diagnoses of major depressive disorder and anxiety, but these were not reflected in the PASRR Level I form. The Director of Nursing (DON) confirmed the oversight during an interview. Similarly, Resident #74's PASRR Level I form did not include a diagnosis of traumatic brain injury, despite it being part of the resident's medical history. The DON acknowledged this omission as well. Resident #86 was admitted with a diagnosis of insomnia, and later prescribed Lexapro for depression. However, the PASRR Level I form was not updated to include the new diagnosis of depression. The DON confirmed that a review of PASRRs was conducted, but Resident #86's form remained incorrect. Resident #200's PASRR Level I form also failed to include diagnoses of dementia and depression, which were part of the resident's medical record. The DON confirmed these diagnoses should have been included. Lastly, Resident #201 had a diagnosis of major depressive disorder that was not reflected in the PASRR Level I form. The DON confirmed this diagnosis was omitted from the form. The facility's policy requires PASRR screenings to be completed prior to admission and reviewed for accuracy, but these procedures were not followed, leading to the deficiencies identified in the report.
Sanitation and Temperature Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which could potentially affect 87 residents out of a census of 95. Observations revealed that the dishwashing machine did not reach the required wash temperature of 150 degrees Fahrenheit, with temperatures varying between 130 and 140 degrees. Despite this, the dietary aides did not rewash the dishes. The dietary manager confirmed that the wash temperature should be at least 150 degrees and stated that staff should notify her if the machine does not reach the correct temperature. Further observations showed unsanitary conditions in the kitchen, including a personal cell phone and a bottle of disinfectant cleaner stored near clean dishes, and a beverage cart with containers of creamers that had drips of a light brown substance. Expired food was found in the walk-in refrigerator, and a muffin pan was noted to have blackened and brown staining. Additionally, the toaster was observed to have a heavy coat of crumbs, which the dietary manager attempted to remove unsuccessfully. The facility's cleaning and sanitizing procedures were not followed correctly, as evidenced by the improper cleaning of beverage carts. Staff used soapy water instead of a sanitizer solution to clean the carts, and only two of the six carts were recleaned with the correct solution. The dietary manager stated that she provides training to her staff monthly and annually, but the observations indicate that the training may not be effectively implemented or followed by the staff.
Failure to Implement PASRR Recommendations for Resident
Penalty
Summary
The facility failed to ensure that the recommendations from a Level II Preadmission Screening and Resident Review (PASRR) were implemented for a resident. The resident, who was admitted with a primary diagnosis of hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, also had multiple secondary diagnoses including unspecified psychosis, schizoaffective disorder, and major depressive disorder. The resident's care plan included goals and interventions for managing mood and psychotropic medication use, but did not incorporate the PASRR recommendations for psychiatric medication management and supportive counseling. Upon review, it was found that the resident's medical records lacked documentation of psychological or psychiatric entries regarding supportive counseling, which was recommended in the PASRR determination. Interviews with the Social Services Director and the Director of Nursing confirmed the absence of follow-up with psychology or psychiatry services based on the PASRR recommendations. The facility's policy required that PASRR recommendations be implemented into the resident's plan of care, but this was not done for the resident in question. The deficiency was identified during a review of the facility's adherence to PASRR requirements, which are intended to ensure appropriate placement and identification of specialized services for residents with serious mental illness or intellectual disability. The failure to implement the PASRR recommendations resulted in a lack of necessary psychiatric support for the resident, as evidenced by the absence of psychiatric notes and follow-up in the resident's records.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards for two residents receiving oxygen therapy. Resident #44 was readmitted with diagnoses including acute respiratory failure, COVID-19, and pneumonia. Observations revealed that the resident was receiving oxygen at 2.5 liters per minute (LPM) via nasal cannula, despite physician orders specifying 3 LPM continuously. The Treatment Administration Record (TAR) indicated inconsistent documentation of oxygen administration, and during an interview, the resident expressed that the oxygen felt low. A registered nurse confirmed the discrepancy in the oxygen setting, acknowledging the responsibility to monitor oxygen levels during medication passes. Resident #206, admitted with pneumonia, was observed receiving oxygen at 2.5 LPM, although physician orders specified 2 LPM as needed for shortness of breath. The Director of Nursing confirmed that nurses should check oxygen settings every shift and that a check mark in the TAR indicates this was done. However, the observations and interviews suggest a failure to adhere to the prescribed oxygen settings. The facility's policy on oxygen therapy, effective November 2023, states that oxygen should be provided based on physician's orders, highlighting a deviation from this standard in the care of these residents.
Unsecured Toilet in Resident Bathroom
Penalty
Summary
The facility failed to maintain a safe and homelike environment due to an unsecured toilet in a bathroom shared by two independent residents. Observations revealed that the toilet in room 405 was crooked and could be moved when pushed. One resident, who uses a wheelchair and has uncontrolled bodily movements, reported that the toilet moves and expressed concerns about safety. Despite informing the facility staff, the issue was not addressed. The Maintenance Work Orders Log Book did not contain any requests to fix the toilet in room 405, and the electronic work order system showed no work orders for securing the toilet during the months of April, May, or June 2024. Interviews with staff and residents confirmed awareness of the issue. A CNA acknowledged the toilet's instability and mentioned adjusting it back into place. Both residents in room 405 confirmed using the toilet independently and noted its movement. The Nursing Home Administrator and the Director of Risk Management confirmed that the electronic work order system did not include any requests to secure the toilet, despite a policy requiring a safe and comfortable environment. The facility's policy emphasizes maintaining essential equipment in safe operating condition, which was not adhered to in this case.
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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 Avon Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Care Of Avon Park | 1.7 mi | ★★★★★ | 1 | 0 |
| Palms At Sebring Nursing And Rehabilitation The | 8.8 mi | ★★★★★ | 2 | 0 |
| Vivo Healthcare Sebring | 9.3 mi | ★★★★★ | 1 | 0 |
| Vivo Healthcare Wauchula | 18.7 mi | ★★★★★ | 0 | 0 |
| Groves Center | 20.3 mi | — | 19 | 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.