Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Village during CMS and state inspections, most recent first.
A resident with end-stage kidney disease, a stage 4 sacral pressure ulcer, and a history of cancer had multiple skin issues and wounds that were not completely or accurately documented in the medical record. After a Dermablade biopsy on the left lower extremity, there was no documentation that the biopsy site remained open, was monitored, or treated, and later notes described a new wound on the left inner ankle attributed to a prior biopsy without clear assessment or investigation. A NP documented an additional open wound on the left outer lower leg and bruising on several body areas, but the facility record did not reflect a separate lateral leg wound or the bruising. New Skin Event forms and wound management reports lacked full wound assessments, cause or type of wound, peri-wound details, and specific interventions, and documentation of skin tears, bruises, and cancelled wound clinic visits was incomplete, contrary to facility policy and expectations for thorough, timely wound and skin documentation.
The facility failed to provide proper nephrostomy care for two residents with chronic kidney disease, leading to multiple hospital transfers due to nephrostomy tube complications. Physician orders for site care were incomplete, and staff were unaware of necessary procedures, despite facility policy requiring such care.
A facility failed to follow medication disposition guidelines when a nurse dropped a duloxetine capsule and administered it to a resident after picking it up with ungloved fingers. The facility lacked a drug buster for proper disposal of contaminated medications, as confirmed by staff interviews and observations. The resident involved had major depressive disorder, COPD, and dementia.
A facility failed to accurately document a wound assessment for a resident with a venous stasis ulcer. An LPN changed the resident's dressing, but an RN recorded the assessment before the LPN's evaluation, leading to discrepancies in documentation. The resident had a history of peripheral vascular disease and diabetes, and the facility lacked a policy for accurate documentation.
A facility failed to ensure proper infection control practices during wound care for a resident. An LPN's unrestrained hair touched the resident's bedding and a plastic bag with a soiled dressing multiple times during the procedure. The resident had a venous stasis ulcer and was at risk for colonization with multi-drug-resistant organisms. The facility's policy required hair to be kept neat and not touch objects or residents.
A resident with severe cognitive impairment and a high risk of falls was injured during a transfer when a CNA attempted to move her alone using a hoyer lift, contrary to the facility's policy requiring two staff members. The resident became restless and slid out of the lift, resulting in a head injury.
Incomplete and Inaccurate Wound and Skin Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records that reflected a resident’s clinical status, particularly related to skin integrity and wound care. The resident had multiple serious diagnoses, including end-stage kidney disease on dialysis, a stage 4 sacral pressure ulcer, and a history of multiple cancers, and was alert and able to make his own decisions. A care plan noted a suspicious lesion on the left lower extremity that was later diagnosed as benign and treated with chemotherapy cream, with interventions to assess and document the skin condition weekly and as needed. A dermatology visit documented a Dermablade biopsy of a non-healing lesion on the left lower extremity with instructions for local wound care, and reference material indicated such biopsy sites typically heal in 7–10 days. However, there was no documentation in the facility record that the biopsy site remained open, was monitored, or was treated after the procedure, nor any indication that a new biopsy had been performed. Subsequent documentation showed multiple inconsistencies and omissions regarding new and existing wounds and bruising. A nurse note and New Skin Event form documented a new open wound on the left inner ankle with drainage, but the form lacked depth and full wound assessment details. An IDT note linked this wound to a prior biopsy and described its appearance and drainage, but there was no further assessment or investigation recorded. Wound management reports later provided by the wound nurse contained measurements but did not specify the cause or type of wound, peri-wound assessment, or wound-specific interventions. A NP note described a new open wound on the left outer lateral lower leg, which the resident believed was being managed by a wound clinic, yet the facility record did not reflect a separate lateral wound or clarify that there were two distinct wounds on the left lower leg. Additionally, a NP note documented bruising to the left back, left lateral abdomen, and right forearm, but these findings were not recorded on the facility’s skin, wound sheets, or progress notes. Further gaps in documentation included a cancelled wound clinic appointment with no record of rescheduling or weekly wound measurements, and incomplete information regarding skin tears and bruising. A nurse note reported two skin tears on the right hip without documenting their size, physician notification, or treatment. An IDT note the next day described a diffuse purple bruise on the right hip and stated there were no skin tears or swelling, but did not document assessment, measurement, monitoring, or cause of the bruising. Another nurse note referenced ongoing skin tears without specifying their location. Interviews with nursing staff and leadership confirmed that facility policy required new skin impairments to be fully documented on New Skin Event forms, with measurements, assessments, treatments, and notifications, and that the wound nurse was responsible for weekly wound monitoring and complete documentation. Despite this, the resident’s record lacked thorough, timely, and complete entries consistent with the facility’s Skin Management Program policy.
Deficient Nephrostomy Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate nephrostomy care for two residents, Resident 5 and Resident 41, as observed during a survey. Resident 5, diagnosed with chronic kidney disease and neuromuscular dysfunction of the bladder, had physician orders for nephrostomy care that were not fully implemented. The orders included changing urine collection bags monthly, irrigating nephrostomy tubes with saline every shift, and recording output every shift. However, there were no orders for cleansing the nephrostomy tube sites or applying dressings. Resident 5's care plan also lacked instructions for site care, leading to multiple hospital transfers due to issues with the nephrostomy tubes, including dislodgement and infections. Resident 41, also diagnosed with chronic kidney disease and urinary tract obstruction, had similar deficiencies in care. The resident had a nephrostomy tube and a urinary bladder catheter, with physician orders to change the drainage bag monthly and record output every shift. Like Resident 5, there were no orders for cleansing or dressing the nephrostomy tube sites. Resident 41 experienced several hospital transfers due to nephrostomy tube complications, such as damage and dislodgement. Interviews with facility staff, including a registered nurse and the Director of Nursing, revealed a lack of awareness and familiarity with the necessary nephrostomy tube care. The facility's policy required verification of physician orders and specified cleansing and dressing of nephrostomy tube sites, but these were not followed. The Administrator acknowledged the concern regarding nephrostomy tube care and infection prevention, highlighting a systemic issue in the facility's adherence to care protocols.
Failure to Follow Medication Disposition Guidelines
Penalty
Summary
The facility failed to adhere to medication disposition guidelines during a medication pass for one resident. During the observation, a registered nurse dropped a duloxetine 60 mg capsule on the medication cart and subsequently picked it up with ungloved fingers, placing it back into the medication cup with other medications, which were then administered to the resident. This action was contrary to the facility's policy, which mandates that medications should not come into contact with any surface other than the medication cup and should be discarded immediately if contaminated. Further investigation revealed that the facility lacked the necessary drug disposal resources, such as a drug buster, which should have been available in the medication room for proper disposal of contaminated medications. Interviews with nursing staff and the Director of Nursing confirmed the absence of drug buster in the medication room and on medication carts. The resident involved had a history of major depressive disorder, chronic obstructive pulmonary disease, and dementia, and was cognitively intact according to their recent assessment.
Inaccurate Wound Assessment Documentation
Penalty
Summary
The facility failed to ensure accurate wound assessment documentation for a resident with a venous stasis ulcer. During a wound care observation, the resident was found with a gauze dressing on the right foot, which was dated the previous day. The dressing was removed, and a new one was applied by an LPN. However, the progress notes documented by an RN indicated that the wound assessment was recorded before the LPN's assessment, raising concerns about the accuracy of the documentation. The resident involved had a history of peripheral vascular disease, type 2 diabetes mellitus with diabetic nephropathy, and essential hypertension. The care plan required daily observation for signs of infection and documentation of the wound's condition. Despite this, the RN admitted to not performing any assessments and instead recorded the LPN's findings without verifying the information. Additionally, the facility lacked a policy for accurate documentation, as confirmed by the Regional Nurse Consultant.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to implement proper infection control practices during wound care for one of the residents. During an observation, an LPN was seen performing wound care on a resident with shoulder-length hair that was not restrained. The LPN's hair came into contact with the resident's bedding and a plastic bag containing a soiled dressing multiple times throughout the procedure, including during the removal of the dressing, cleansing of the wound, and application of wound treatment. No attempt was made to restrain the hair, which is against the facility's infection control practices. The resident involved had a history of peripheral vascular disease, type 2 diabetes mellitus with diabetic nephropathy, and essential hypertension, and was cognitively intact with a BIMS score of 15. The resident had a venous stasis ulcer and was at risk for colonization with multi-drug-resistant organisms. The care plan required standard precautions, including hand hygiene and evidence-based practices. The facility's dress code policy, as provided by the Administrator, indicated that hair should be kept neat and should not touch objects or residents.
Failure to Follow Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure that fall interventions were followed for Resident J, who was at risk for falls due to severe cognitive impairment and required maximal assistance with activities of daily living. The care plan for Resident J, revised on 7/1/24, specified that two staff members were needed to assist with transfers using a hoyer mechanical lift. However, on 6/27/24, Resident J experienced a fall resulting in a laceration to the back of her head when a CNA attempted to transfer her alone using the hoyer lift. During the transfer, Resident J became restless and slid out of the hoyer pad, hitting her head on the bedside table. Interviews with staff members, including CNAs and a nurse, confirmed that the facility's policy required two staff members to be present during transfers with mechanical lifts to ensure resident safety. Despite this policy, the incident occurred due to non-compliance with the established procedure. The facility's investigation revealed that the CNA involved in the incident did not adhere to the requirement of having two staff members present during the transfer, leading to the resident's fall and injury.
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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.
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Nursing homes near Ligonier
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Syracuse Skilled Nursing Facility, The | 7.6 mi | ★★★★★ | 22 | 0 |
| Waterford Crossing | 11.9 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Goshen | 12 mi | ★★★★★ | 6 | 0 |
| Greencroft Healthcare | 12.6 mi | ★★★★★ | 4 | 0 |
| Restoracy Of Goshen, The | 14.7 mi | ★★★★★ | 1 | 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.