Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 & Rehabilitation Center during CMS and state inspections, most recent first.
Medication carts and the med storage refrigerator contained multiple labeling and storage issues. An LPN and RN found inhalers without open dates, topical gels stored next to oral meds, OTC bottles with missing or unreadable labels, a prescription bottle without a pharmacy label, OTC meds marked only AM/PM, and an open vial of Tubersol with no open date. Facility policy required external products to be stored separately from internal meds and for outdated or unlabeled meds to be identified during routine inspection.
Failure to Reconcile Medications at Discharge: A resident with stroke, aphasia, depression, osteoporosis, and muscle weakness was discharged with family in a rush, and the DON stated her medications were gathered and sent with her. The record lacked documentation of medication reconciliation at discharge, despite multiple ordered meds including Eliquis, Keppra, Protonix, and lactulose.
Failure to provide baseline care plans and physician orders within 48 hours affected three residents. One resident with MI, weakness, falls, arthritis, and HTN had a blank care plan section and no signed proof his daughter received the documents. A second resident with stroke, aphasia, depression, and osteoporosis had only fall potential addressed, and her daughter’s section was left blank. A third resident admitted for rehab after a fall-related fracture had a blank baseline care plan section, was identified as a fall risk, and did not have a fall care plan implemented by the following Monday.
A facility failed to follow physician orders for BP meds and daily weights for multiple residents. One resident with HTN and CHF had several BP readings outside ordered hold parameters, yet hydralazine, isosorbide ER, losartan, and spironolactone were still given without documentation they were held or the MD notified. Another resident received metoprolol despite BP below the hold threshold. Two residents with CHF also had missed or undocumented daily weights, including weight gains that met notification criteria without evidence the MD was notified.
A resident with a below-the-knee amputation fell during a Hoyer lift transfer when the lift malfunctioned and a bolt came out of the hydraulic arm. The CNA completed the transfer alone instead of using two staff members as required by the resident’s care plan and facility policy. The resident was found on the floor and later complained of pain, and the investigation noted that a missing lock nut on the sling attachment had not been identified during routine inspections.
A facility failed to update a resident's PASARR after a new diagnosis of delusional disorders was added to her medical history. The resident had a Level 1 PASARR that did not include this diagnosis. An MDS LPN noted the diagnosis, but a new level of care was not completed until later, which indicated the need for a Level 2 PASARR referral. The facility's policy required notification and referral for residents with new serious mental disorders, which was not initially followed.
A facility failed to update a resident's care plan to accurately reflect her advanced directives. The resident had conflicting documentation regarding her code status, with a care plan indicating a DNR status and an active order indicating a full code status. The DON acknowledged the error, noting that the care plan should have been updated to reflect the full code status as per the facility's policy.
A resident with a suprapubic catheter in a memory care unit did not receive adequate care, leading to potential risks for UTIs. The facility failed to conduct regular catheter assessments and did not follow physician orders for catheter changes. The resident's urine output was frequently unrecorded, and there was no documentation of physician notification for hematuria and catheter bag leaks. The care plan lacked revisions to address the resident's behavior of emptying his catheter bag and did not include specific catheter specifications or urologist instructions.
A facility failed to provide adequate dementia care and activities for a resident in isolation for influenza A. Despite care plan directives for one-on-one engagement and diversional activities, the resident received limited activities during isolation. The facility's policies on individualized care and meaningful activities were not effectively implemented, resulting in a deficiency.
A facility failed to manage a resident's medication regimen, leading to the administration of unnecessary medications. The resident, diagnosed with dementia and insomnia, was prescribed quetiapine without documented behaviors justifying its use. The diagnosis was updated to psychosis without a psychiatric evaluation, and there was no consent for antipsychotic usage. Observations showed the resident appeared sleepy, and interviews revealed a lack of awareness about the medication's purpose.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Medications and topical products were not consistently labeled or stored in accordance with accepted medication storage practices on the 100-, 300-, and 400-hall medication carts. On the 100-hall cart, a resident’s Incruse Ellipta inhaler had no open date, and another resident’s Arnicare topical gel was stored in the same drawer and next to oral medications. On the 300-hall cart, one resident had a Trelegy inhaler and two residents had albuterol inhalers dated 1/10, a resident’s Diclofenac topical gel was stored in the same drawer and next to oral medications, and an OTC vitamin D3 bottle had a rubbed-off, unreadable label. On the 400-hall cart, a resident’s Memantine Hydrochloride bottle had no pharmacy label, and several OTC medications for another resident had only AM or PM written on them with no resident name or label. Expired or improperly stored medications were also found in the medication storage refrigerator. A loose vial of Tubersol was open and had no open date. During the review, staff stated that one inhaler had been opened without the date being placed on it, that the Memantine bottle should have had a pharmacy label, and that the AM and PM markings on the OTC bottles were written by the resident’s family to indicate when the medications were to be given. The facility policy provided stated that external products are to be stored separately from internal medications and that medication rooms are to be inspected for outdated or deteriorated medications with worn, illegible, or missing labels. The facility guideline also stated that albuterol inhalers expire one week after opening if stored outside the foil package and that Ellipta inhalers, including Trelegy and Incrusa, expire 42 days after opening.
Failure to Reconcile Medications at Discharge
Penalty
Summary
The facility failed to reconcile a resident's medications upon discharge for 1 of 3 residents reviewed, Resident 125. Resident 125 had diagnoses including muscle weakness, cerebral infarction (stroke), aphasia, major depressive disorder, and osteoporosis, and she was discharged with family on 1/27/26 at 4:08 p.m. During interview, the DON stated the resident was discharged in a rush and her medications were gathered and sent with her. The resident's record lacked documentation of medication reconciliation at discharge, despite physician orders listing multiple medications that should have been reconciled, including alendronate, atorvastatin, cholecalciferol, famotidine, MiraLAX, mirtazapine, potassium chloride, prenatal vitamin, thiamine, Eliquis, Keppra, Protonix, and lactulose. A facility policy titled Drug Disposition stated that discontinued, outdated, or deteriorated medication shall not be maintained or used in the facility and shall be disposed of in compliance with federal, state, and local laws.
Failure to Provide Baseline Care Plans and Physician Orders Within 48 Hours
Penalty
Summary
The facility failed to develop and provide the resident and/or family representative with a copy of the resident's baseline care plan and physician orders within 48 hours of admission for Residents 123, 125, and 52. Resident 123 had diagnoses including muscle weakness, MI, history of falling, arthritis, and essential hypertension. His admission assessment on 1/15/25 had the care plan section left blank, and a Living Well Meeting on 1/20/26 indicated his daughter was present, but the document lacked a signature showing she received a copy of the care plan and physician orders. Resident 125 had diagnoses including muscle weakness, cerebral infarction, aphasia, major depressive disorder, and osteoporosis. Her admission assessment on 12/29/25 addressed only fall potential in the care plan section, and a Living Well Meeting on 1/17/26 documented a phone call with her daughter, but the section was left blank, indicating the daughter did not receive a copy of the care plan and physician orders. Resident 52 was admitted for assistance with personal care and rehabilitation after a fall at home that resulted in a fracture requiring surgery, and she also had a history of falling and stroke. Her 2/6/26 nursing admission assessment left the baseline care plan section blank, her fall risk assessment showed she was at risk for falls, and a fall care plan was not implemented with interventions the following Monday, 2/9/26. The DON stated the facility used the Living Well assessment for the baseline care plans, and the facility policy stated the baseline care plan would be developed within 48 hours of admission and verified by a supervising nurse within 48 hours.
Failure to Follow Medication Parameters and Daily Weight Orders
Penalty
Summary
The facility failed to follow physician orders for blood pressure medications for Resident 7 and Resident 9. Resident 7 had diagnoses including essential primary hypertension and chronic diastolic congestive heart failure. Orders required hydralazine, isosorbide ER, losartan, and spironolactone to be held when blood pressure parameters were not met and the physician notified if medications were held. The MARs for December 2025 through February 2026 showed multiple instances when the resident’s systolic or diastolic blood pressure was outside ordered parameters at the time medications were due, but the record lacked documentation that the medications were held or that the physician was notified. Progress notes also lacked documentation of holding the medications or notifying the physician when blood pressures were outside the ordered limits. Resident 9 had diagnoses including hypertension and heart disease and an order for metoprolol succinate ER 50 mg daily with instructions to hold for systolic blood pressure less than 95 or pulse less than 60. On 2/9/26, the resident’s blood pressure was 92/56 with a pulse of 72, but the February MAR showed the metoprolol was administered rather than held as ordered. The resident’s care plan indicated his blood pressure would be managed and that he would take blood pressure medications as ordered. The facility also failed to follow daily weight orders for Resident 126 and Resident 70. Resident 126 had CHF and an order for daily weights with notification to the physician for weight gain greater than 2 pounds in one day or 5 pounds in a week; the record showed weight gains of 2.6 pounds and 3.4 pounds on separate occasions without documentation that the physician was notified. Resident 70 had CHF and an order for daily weights, but multiple daily weights were missing in January and February 2026. The facility policy required staff to consult and follow physician orders and parameters, and the DON stated blood pressure medications should have been held as ordered and that the facility was working on compliance with parameters.
Unsafe Hoyer Lift Transfer Resulted in Resident Fall
Penalty
Summary
The facility failed to ensure a Hoyer lift transfer was completed safely for one resident who had an acquired absence of the left leg below the knee and required assistance with ADLs. The resident reported that he was dropped from the Hoyer lift when a bolt came off, and he fell. A progress note documented that staff found the resident on the floor, and another note later indicated the resident was observed on the floor between the mechanical lift wheelbase and complained of pain after the event. Record review showed the resident had been transferred with the mechanical lift when the equipment malfunctioned. The investigation file included a statement from the CNA who performed the transfer alone, stating that no other employee was available and that he chose to complete the Hoyer transfer by himself. He described lifting the resident, moving the lift toward the chair, and then the Hoyer breaking and the resident falling straight down. The DON stated that a bolt came out of the hydraulic arm during the transfer and that the resident fell when the lift failed. The resident’s care plan indicated he required two staff members and a Hoyer lift for transfers. The facility’s Safe Resident Handling/Transfers policy stated that two staff members must be utilized when transferring residents with a mechanical lift and that staff should inspect equipment prior to use. The manufacturer’s guidance also called for periodic functional checks of mechanical parts such as hooks, pins, and screws. The report further noted that the lift had monthly checks documented, but the incident investigation identified that a missing lock nut on the sling attachment had not been identified during regular inspections.
Failure to Update PASARR for Resident with New Diagnosis
Penalty
Summary
The facility failed to complete a new level of care Pre-admission Screening and Resident Review (PASARR) for a resident when a diagnosis of psychosis was added to her medical history. The resident, who had diagnoses including hypertension, type 2 diabetes mellitus, generalized anxiety, and delusional disorders, had a Level 1 PASARR in her medical record that did not include the diagnosis of delusional disorders. During an interview, the MDS LPN indicated that delusional disorders were on the resident's list of diagnoses, which led to the coding of delusional disorders. The Director of Nursing later indicated that a new level of care was being completed for the resident, and a subsequent review indicated the need for a Level 2 PASARR referral on site. The facility's policy required the Social Service Director to notify and refer residents with newly evident or possible serious mental disorders to the state mental health authority, which was not initially done in this case.
Failure to Update Resident's Advanced Directives in Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive resident-centered care plan was accurately revised to reflect the advanced directives of a resident. Specifically, Resident 32 had conflicting documentation regarding her code status. An active care plan dated May 17, 2023, indicated a Do Not Resuscitate (DNR) status, while an active order dated December 13, 2024, indicated a full code status. This discrepancy was identified during a review of Resident 32's medical records. The Director of Nursing (DON) acknowledged the error, indicating that the DNR care plan was incorrect and should have been updated to reflect a full code status. The facility's policy on comprehensive care plans, dated September 18, 2024, requires that care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. The failure to update the care plan according to the resident's preferences and the active order led to the deficiency.
Inadequate Catheter Care for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to provide adequate care for a resident with a suprapubic catheter, leading to potential risks for urinary tract infections. Resident 70, who resided in the secured memory care unit, had a history of dementia, anxiety, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident's medical record showed an initial catheter assessment and a quarterly assessment, but subsequent quarterly assessments were missing. Additionally, a urology physician's order for catheter changes every 4 to 6 weeks was not reflected in the facility's physician order list. The facility's records revealed multiple instances where Resident 70's urine output was not recorded across several shifts in March, April, and May 2024. Nursing progress notes indicated occurrences of hematuria and catheter bag leaks, yet there was no documentation of physician notification. The resident frequently emptied his catheter bag without staff knowledge, and the facility's records lacked documentation of interdisciplinary team follow-up or interventions to address this behavior. Resident 70's comprehensive care plan, initiated in March 2024, included interventions for catheter care but lacked revisions to address the resident's behavior of emptying his bag and the specific catheter specifications. The care plan also did not include the urologist's instructions or contact information. The facility's policies on suprapubic catheterization and comprehensive care plans emphasized the need for adherence to physician orders and resident-specific interventions, which were not adequately followed in this case.
Deficiency in Dementia Care and Activities for Isolated Resident
Penalty
Summary
The facility failed to adequately implement care planned interventions and provide appropriate activities for a resident diagnosed with dementia who was in isolation for influenza A. The resident, who resided in the memory care unit, was observed attempting to leave her room multiple times, but was redirected back by a CNA without any special engagement or activities being provided. The CNA indicated that staff did not typically engage residents in isolation with activities, although the resident's care plan specified the need for one-on-one conversation and diversional activities. The resident's comprehensive care plan included interventions such as offering snacks, drinks, conversation, and activities of choice when the resident wandered or expressed a desire to leave. Despite these care plan directives, the resident's activity logs showed limited engagement during the isolation period, with only four activities provided and five instances where the resident was marked as unavailable. The Activity Director acknowledged that residents in isolation should still receive one-on-one activities, but this was not consistently implemented. The facility's policies on resident self-determination, dementia care, and activities emphasized the importance of individualized, non-pharmacological approaches and meaningful activities for residents, including those in isolation. However, these policies were not effectively executed for the resident in question, leading to a deficiency in providing appropriate dementia care and activities during the isolation period.
Failure to Manage Resident's Medication Regimen Appropriately
Penalty
Summary
The facility failed to manage a resident's medication regimen appropriately, leading to a deficiency in the administration of unnecessary medications. Resident 265, who had diagnoses including dementia with behavioral disturbances, palliative care, and insomnia, was prescribed multiple medications, including quetiapine, without documented behaviors justifying its use. The pharmacist recommended adding a diagnosis for quetiapine, which was updated to psychosis without a psychiatric evaluation. The resident's medical record lacked documentation of behaviors associated with the use of quetiapine, and there was no consent for antipsychotic usage in the medical record. Observations and interviews revealed that Resident 265 appeared sleepy and unresponsive, and her son was unaware of the purpose of quetiapine. The Director of Nursing indicated that the resident entered the facility on these medications and that it was not time for a gradual dose reduction. The hospice nurse confirmed that the resident had been on quetiapine long before hospice care began and was unsure of its purpose. The facility's policy on gradual dose reduction of psychotropic drugs was provided, but it did not appear to have been followed 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
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Avon | 1.2 mi | ★★★★★ | 18 | 0 |
| Danville Regional Rehabilitation | 2.5 mi | ★★★★★ | 0 | 0 |
| Countryside Meadows | 3.9 mi | ★★★★★ | 15 | 0 |
| Plainfield Health Care Center | 5.7 mi | ★★★★★ | 32 | 1 |
| Brooke Knoll Village | 5.7 mi | ★★★★★ | 10 | 0 |
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