Below 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 Majestic Care Of Avon during CMS and state inspections, most recent first.
The facility failed to provide sufficient staffing, with PBJ data showing weekend staffing below required nursing coverage levels. A resident on the secured memory care unit with dementia, psychotic disorder, and repeated falls sustained an unwitnessed fall during the evening meal period and was later found to have a head laceration, subarachnoid hemorrhage, and rib fractures while the unit had only one QMA and two CNAs. Surveyors also observed inconsistent beverage availability in memory care, and residents reported ongoing unresolved grievances about laundry, evening snacks, rude nursing staff, and delayed call light response.
Kitchen freezer equipment was not kept in proper working order when surveyors observed frozen drips on the walls, fans, and ceiling, along with water-damaged boxes, ice on stored items, and boxes frozen together. The Maintenance Director said a missing piece of weather stripping may have been causing the freezer to thaw, and the DON provided the facility policy stating all food service equipment must be clean, sanitary, and in proper working order.
Failure to Resolve Repeated Resident Grievances: Residents repeatedly raised concerns about missing or stained laundry, snacks not being available or offered, and rude or mean nursing staff. Resident council minutes over many months showed the same issues continuing, and residents stated prior grievances were not followed up effectively, with replacement items still not provided months later. Interviews with the SSD and DON showed the grievance process relied on department follow-up, but the documented concerns remained unresolved.
A facility failed to ensure residents with dementia received needed ADL assistance, with multiple residents observed unshaven, unwashed, in unchanged or soiled clothing, or with unmet toileting needs. Records and interviews showed limited showering, incomplete refusal documentation, and care plans that did not fully reflect grooming preferences, while staff also appeared to rely on family members for routine hygiene care for one resident.
Drugs and biologicals were not properly labeled and stored on three medication carts. A vial of fluphenazine, eye drops, and multiple inhalers were found without open dates, one bottle of latanoprost eye drops was opened and expired, and anti-itch topical cream was stored beside eye drops and oral meds. The DON provided a medication storage policy stating that external products are to be stored separately from internal and injectable medications.
A facility failed to ensure residents on the Memory Care unit had sufficient, accessible fluids throughout the day. During observations, residents repeatedly had no water at bedside or in common areas, some asked staff for water or ice, and one resident drank from a pitcher used for medication administration. Room checks found multiple residents without fresh water, and one room had uncovered cups with old liquids and gnats. The DON said the unit relied on a Hydration Station system, but it had not been provided that week due to staffing shortages, lack of pitchers, and confusion over responsibility.
A resident did not receive timely NOMNC when Medicare-covered services were ending. The notice was signed by the resident’s wife and legal representative on the same day services ended, even though the SSD stated it should be issued at least two days before termination to allow time for appeal.
A resident who used oxygen was found in bed with oxygen tubing draped nearby while a CNA’s cell phone, backpack, and notebook were left in her room. The resident reported a strong odor of marijuana from the backpack, and the Administrator later found a vaporized smoking device with unknown substances on the resident’s chest. The DON stated staff personal items should not be stored in a resident’s room.
A CNA was observed passing lunch trays alone, and food temperatures on the 600 hall were found to be below required standards, with items such as chicken and vegetables measured well under the facility's policy for hot food holding. Fourteen residents receiving room tray service were potentially affected.
A resident with multiple medical conditions, including weight loss, was not served her physician-ordered diet, which required double portions and a magic cup at lunch. The omission was observed and confirmed by a CNA, who subsequently provided the missing items.
The facility failed to address ongoing Resident Council Grievance concerns about call light wait and response times, affecting 5 of 82 residents. Despite repeated complaints documented in meeting minutes, the issue persisted, with residents experiencing long wait times and accidents. Interviews revealed that grievance responses were inconsistent, and the facility's policy on prompt grievance resolution was not effectively implemented.
The facility failed to enforce its non-smoking policy, allowing residents with various health conditions to smoke on the premises and keep smoking materials in their rooms. Despite being a non-smoking facility, residents were observed smoking on the grounds, and some admitted to storing cigarettes and lighters in their rooms. The facility lacked smoking assessments for these residents, contributing to the deficiency.
The facility failed to label and date medications when opened and did not remove expired medications from use, as observed in three medication carts and one refrigerator. Medications for several residents, including inhalers, insulin pens, and nasal sprays, were found without opening dates or were expired. Additionally, a vial of tuberculin and a bottle of aplisol in the medication room refrigerators were improperly dated or expired.
A facility failed to complete necessary assessments for a resident self-administering medications. The resident had fluticasone nasal spray, carboxymethylcellulose eye drops, and metronidazole lotion in her room, but the facility's documentation was incomplete. The Medication Self-Administration Safety Screen and care plan lacked proper assessments and specific listings for these medications, contrary to the facility's policy requiring interdisciplinary team assessments.
A resident with Alzheimer's in the Memory Care unit fell and fractured her hip after being found in another resident's bed. The fall was not accurately coded in the MDS assessments, initially marked as no falls and later not indicating the fracture. The facility's policy on accurate assessment was not followed.
The facility failed to provide sufficient licensed nurse coverage on weekends, affecting all 82 residents. The CASPER report highlighted staffing concerns in the second quarter of 2024. A review of the May 2024 schedule showed a downward trend in licensed staff per-patient-per-day (PPD), with several days not meeting the minimum required PPD. The Executive Director acknowledged the issue and noted that leadership staff were mainly scheduled for weekdays, suggesting a potential rearrangement to cover weekends. The Facility Assessment Tool indicated the required minimum PPD, which was not met.
The facility failed to provide appropriate assessments and person-centered care for two residents with dementia who wished to have a relationship. Despite family approval, the care plans and assessments did not reflect the residents' preferences and behaviors, leading to a deficiency in care.
The facility failed to provide person-centered care, supervision, and engaging activities in the secured memory care unit, leading to multiple resident-to-resident altercations and injuries. Residents frequently wandered into each other's rooms, causing distress and physical altercations. The facility lacked adequate supervision and activities to redirect residents, especially during the night shift.
A facility failed to protect a non-verbal, cognitively impaired resident from abuse. A video showed a CNA hitting the resident during care while a QMA did not intervene. Family members, watching live through a web camera, reported the incident. Interviews and records revealed the resident's cognitive impairments and the facility's ongoing abuse investigation.
The facility failed to ensure staff immediately reported witnessed abuse by another staff member to a resident. During care, a CNA hit a resident, and the QMA did not intervene or report the incident immediately. The Administrator received reports later in the morning, but the QMA did not follow the facility's policy for immediate reporting.
Insufficient staffing affected resident care, falls, hydration, and grievance follow-up
Penalty
Summary
The facility failed to ensure sufficient staffing during the second quarter of 2025, including on weekends, and the Payroll Based Journal staffing data showed weekend staffing was significantly lower than weekday averages and below required nursing coverage thresholds. The report states this staffing pattern had the potential to affect all 80 residents in the facility and was associated with delays in assistance with ADLs, reduced supervision, and delayed responses to call lights and resident needs. The report also states the reduced weekend staffing had the potential to affect clinical assessments, medication administration, and monitoring of residents' health needs. Resident 80, a long-term care resident on the secured memory care unit, had diagnoses including unspecified dementia with moderate mood disturbance, psychotic disorder with delusion related to her known physiological condition, and pseudobulbar affect. Her record showed multiple behaviors including excessive wandering, tearfulness, agitation, altercations with other residents, and repeated falls. In April 2025 she had five falls. On 5/25/25, after receiving a PRN medication for agitation earlier in the day, she later had an unwitnessed fall during the evening meal period and sustained a laceration to the back of her head. A nurse from another unit was called to the secured memory care unit, found bleeding from the back of her head, could not obtain vital signs because the resident was restless, and 911 was called. The resident was sent to the emergency department and later admitted to a local trauma hospital with a subarachnoid hemorrhage and rib fractures. The evening shift schedule at the time showed only one QMA and two CNAs on the unit. Continued staffing concerns were also identified in relation to ADLs and resident grievances. During multiple observations, residents in memory care did not consistently have beverages available at bedside, in rooms, or in common areas. The DON stated the unit did not typically do an ice-water pass and instead used a Hydration Station system, but a staff member reported that the Hydration Station had not been provided that week because of staffing shortages, lack of pitchers, and confusion over responsibility. Resident council members also reported ongoing concerns that grievances about laundry issues, snacks not being provided in the evening, and nursing staff having poor attitudes were not followed up on or resolved, and they described delays in staff response to call lights and rude interactions with nursing staff.
Kitchen Freezer Not Kept in Proper Working Order
Penalty
Summary
The facility failed to ensure kitchen equipment was in proper working order when the freezer was observed with drips of water frozen on the walls, fans, and ceiling, and boxes stored inside had water damage on the cardboard, ice on top of the boxes, and some boxes were frozen together. During interview, the Maintenance Director stated the company had come out on 8/4/25 to fix the freezer, but he believed the current problem was a small missing piece of weather stripping that could be causing the freezer to thaw. The DON later provided the facility policy titled, Equipment, dated 9/2017, which stated that all food service equipment will be clean, sanitary, and in proper working order.
Failure to Resolve Repeated Resident Grievances
Penalty
Summary
The facility failed to appropriately follow up on resident grievances and resident council concerns related to laundry, snacks, and staff behavior over a 12-month period. Resident council minutes repeatedly documented ongoing complaints that snacks were not available on weekends or at the nurses’ station, that residents were not being offered snacks in the evenings, and that clothing was missing, stained, or returned from laundry with items belonging to other residents. The minutes also reflected repeated concerns about rude or mean nursing staff, poor attitudes, delayed response to call lights, and staff not providing proper care. The record review showed multiple grievances filed for these same issues, including complaints about stained laundry, missing clothing, rude or mean staff, and concerns about care and staffing. Several grievance forms documented that residents or family members raised the same concerns more than once, and resident council minutes showed that the issues continued month after month. During the 8/20/25 resident council meeting, residents stated the facility still had major laundry problems, still did not consistently provide snacks at the nurses’ station, and still had nursing staff with poor attitudes who were rude, mean, or slow to respond. Residents also stated that when grievances had been filed in the past, the facility did not follow up effectively and that replacement items had still not been provided months later. Interviews with the SSD and Administrator showed the grievance process depended on department heads completing follow-up, but the SSD stated the follow-ups were not great and were not really solutions. The Administrator stated he reviewed grievance forms to ensure resolution, but the resident council minutes and grievance records showed repeated unresolved concerns across the year. The facility policy titled Grievances stated the facility would make prompt efforts to resolve grievances, yet the documented concerns continued without effective resolution in the records reviewed.
Failure to Provide Needed ADL Assistance on Memory Care Unit
Penalty
Summary
The facility failed to ensure residents with dementia in the secured memory care unit received necessary assistance with ADLs for 11 of 20 residents reviewed. Multiple residents were observed with unshaven faces, long or untrimmed fingernails, unbrushed or greasy hair, and clothing that appeared unchanged or soiled over repeated observations. The report identified residents who remained in the same attire across several days, residents whose grooming needs were not met, and residents whose clothing was visibly inappropriate or labeled with another resident’s name. Resident 27 was repeatedly observed with facial stubble, greasy unbrushed hair, and long fingernails until staff took him to his room and he later returned shaved, with trimmed nails and brushed hair. Resident 14 was also repeatedly observed with long fingernails and facial stubble; after staff took him to his room, his face was shaved and hair brushed, but his nails remained untrimmed. Resident 13 was observed with long fingernails, unbrushed hair, and facial stubble, and later in stained clothing that remained unchanged over multiple observations. His records showed severe cognitive impairment, a need for staff reminders, cues, and assistance with personal hygiene and ADLs, and shower documentation showed a gap after 8/6/25 until 8/18/25. His care plan did not include or specify shaving and haircut preferences. Resident 20’s family member stated staff appeared to rely on the family to provide ADL care, including showers, shaving, and oral care, and said the resident appeared not to have been shaved or had clothes changed since the family’s prior visit. Shower sheets showed the family provided showers except for one refusal entry that did not identify who refused or whether redirection or follow-up attempts occurred. Resident 63 was repeatedly observed unkempt with a long beard, unwashed-looking hair, crumbs on his shirt, and a strong urine odor in the room; his record showed dementia, COPD, poor hygiene, incontinence, and a need for assistance with incontinent care and personal hygiene. Shower sheets from April through August showed very limited showers, numerous refusals, and no documented second attempts, nurse follow-up, or family/POA notification on the refusal forms. Other residents were also observed with unmet ADL needs. Resident 9 wore oversized clothing with another resident’s name visible on the garments. Resident 76 was observed with long fingernails, day-old facial stubble, unbrushed hair, and later in the same shirt and jeans for three days. Resident 51 had pants pulled down to the middle of her thighs in the main activity room and staff adjusted her clothing in front of peers rather than privately. Resident 64 repeatedly asked to use the bathroom and waited over 20 minutes before being assisted. The Memory Care Unit Manager stated CNAs should complete shaving as part of routine hygiene care and document refusals, and the facility policy stated residents on the dementia unit should receive appropriate ADL care daily to meet their needs.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles on three medication carts observed. On the 600 hall medication cart, a vial of fluphenazine for Resident 77, a bottle of Refresh Tears eye drops for Resident 47, and albuterol inhalers for Residents 75 and 55 were found without dates indicating when they were opened. RN 37 confirmed the items were not dated and removed them from the cart. On the 800 hall medication cart, anti-itch topical cream was stored beside eye drops and oral medications. On another medication cart, two albuterol inhalers for Resident 42, Incruse Ellipta inhaler for Resident 25, and atropine sulfate solution 1% for Resident 23 were found without open dates, and latanoprost eye drops for Resident 64 were found opened on [DATE] and expired. The facility policy titled Medication Storage stated that external products are to be stored separately from internal and injectable medications.
Insufficient Hydration Access on Memory Care Unit
Penalty
Summary
The facility failed to ensure residents in the Memory Care unit had sufficient and accessible fluids available throughout the day for 5 of 5 days observed. During multiple observations from 8/17/25 through 8/21/25, residents in the Memory Care unit did not consistently have beverages available at bedside, in their rooms, or in common areas. Resident 32 was observed at the nurses' station pouring herself water from a pitcher designated for medication administration, and Resident 27 repeatedly asked for water before a nurse poured him a small cup from the same pitcher. Resident 10 repeatedly asked for ice, and a family friend of Resident 19 asked whether residents were not allowed to have ice water in their rooms and requested ice and a pen to get water for Resident 19's room. Random room checks on multiple occasions showed residents including 59, 70, 28, 64, 74, 20, 27, 32, and 39 had no fresh water in their rooms, and there were no communal hydration options available at those times. One room contained multiple uncovered cups with old liquids and gnats on the rims. The DON stated the unit did not typically do an Ice-Water pass and instead used a Hydration Station system, but staff were supposed to bring out beverages such as lemonade or ice water with fresh fruit and keep pitchers at the nurses' station for residents to access. On 8/21/25, [NAME] 5 stated Hydration Station had not been provided that week due to staffing shortages, lack of pitchers, and confusion over whose responsibility it was to prepare and deliver the beverages.
Late Medicare Noncoverage Notice
Penalty
Summary
The facility failed to ensure that Resident 89 received timely notification that Medicare coverage was ending. Record review showed the resident’s Notice of Medicare Noncoverage (NOMNC) was dated 5/1/25 and signed by the resident’s wife and legal representative the same day services ended. The resident’s representative had requested discharge on 5/2/25, but the resident’s services were ending on 5/1/25 and the notice should have been issued by 4/29/25 to allow time for appeal. During interview, the SSD stated NOMNCs should be issued at least two days before services end, and the Administrator later provided the facility policy stating the NOMNC must be issued at least two calendar days before termination of services.
Resident Room Contained Staff Personal Items and Unknown Smoking Device Near Oxygen
Penalty
Summary
The facility failed to keep a resident room free from accident hazards and to provide adequate supervision when staff personal belongings were left in Resident 35’s room while she was using oxygen. On 8/17/25, Resident 35 was observed resting in bed with an oxygen concentrator running beside her and oxygen tubing draped on the bed. During the observation, a cell phone plugged into a charging cable was found on the empty bed next to the resident, and she stated it belonged to CNA 7. A backpack was also on a guest chair in the room, and when the resident looked inside, she reported a strong odor of marijuana coming from the bag. The resident removed a notebook from the bag that had CNA 7’s name in it. During interview, the DON stated it would not be appropriate for staff to store personal items in a resident’s room and said CNA 7 had been suspended pending a drug test. Later, the Administrator stated that he and another staff member went into Resident 35’s room to ask her about the incident and found a vaporized smoking device with unknown substances inside on the resident’s chest. The facility policy titled, Incidents, Accidents & Supervision, stated the resident environment will remain as free of accident hazards as possible.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
During a lunch service observation, a CNA was found to be passing trays alone on the 600 hall. Temperatures of the food items on the lunch trays were checked and found to be below the facility's required holding temperature of greater than 135 degrees Fahrenheit, with chicken measured at 122 degrees, mashed potatoes at 122.7 degrees, and mixed vegetables at 117 degrees. The facility's policy, provided by the Executive Director, specifies that hot foods must be held at appropriate temperatures, with poultry and stuffed foods requiring a minimum of 165 degrees Fahrenheit and all foods held above 135 degrees Fahrenheit. Fourteen residents who had their trays delivered to their rooms on the 600 hall were potentially affected by this deficiency.
Failure to Provide Prescribed Therapeutic Diet to Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including weakness, hypertension, and weight loss did not receive her prescribed diet as ordered by the physician. The resident's orders specified a regular diet with ground meat, double portions, and a magic cup at lunch. During observation, the resident was served lunch without the double portions or the magic cup. This was confirmed by a CNA, who then retrieved the missing items. No facility policy was provided at the time of the survey exit.
Failure to Address Call Light Response Concerns
Penalty
Summary
The facility failed to address Resident Council Grievance concerns regarding call light wait and response times in a timely and effective manner. This issue affected 5 of 82 residents who attended the Resident Council Meeting and complained on behalf of all 82 residents residing in the facility. The Executive Director (ED) was unable to locate Resident Council Minutes from October 2023 through February 2024, but provided minutes from March 2024 to July 2024. These minutes consistently documented complaints about overnight staff not responding to call lights for 1-2 hours and staff using phones during resident care. Despite these ongoing complaints, the facility did not effectively resolve the issue, as evidenced by repeated grievances and lack of improvement in call light response times. Interviews with residents and staff revealed that the problem persisted, with residents experiencing long wait times for assistance, leading to accidents in their briefs. The Activity Director (AD) confirmed that call light response times and inappropriate phone use by staff were major concerns. Although grievance forms were submitted, responses were inconsistent, and some grievances related to call light issues were not addressed. The Assistant Director of Nursing (ADON) reported conducting night shift observations without finding concerns, and staff had been educated multiple times. However, the facility's policy on grievances, which mandates prompt resolution efforts, was not effectively implemented, resulting in ongoing resident dissatisfaction.
Non-Smoking Policy Violation in LTC Facility
Penalty
Summary
The facility failed to adhere to its non-smoking policy, allowing residents who had not been assessed for smoking to smoke on the premises and keep smoking materials in their rooms. This deficiency was observed in six residents, all of whom had various medical conditions that could be exacerbated by smoking. Despite the facility's policy stating it was a non-smoking environment, residents were found smoking on the grounds, and some admitted to keeping cigarettes and lighters in their rooms. Resident 6, who had chronic obstructive pulmonary disease (COPD) and other health issues, was observed smoking in the parking lot. His care plan indicated he was a smoker and should comply with the facility's smoking policy, but there was no documentation of a smoking assessment in his records. Similarly, Resident 22, with schizoaffective disorder and COPD, kept cigarettes in her room, contrary to the policy. Resident 7, who also had COPD, admitted to smoking on the facility grounds and keeping smoking materials in his car. Other residents, such as Resident 67 with schizophrenia and dementia, and Resident 77 with dementia and PTSD, were also found to be non-compliant with the smoking policy. They kept smoking materials in their rooms and smoked on the premises. Resident 26, with dementia and anxiety, was observed smoking with the help of another resident, despite having a behavioral contract prohibiting smoking on facility grounds. The facility's Executive Director and staff acknowledged the lack of smoking assessments and the failure to enforce the non-smoking policy, contributing to the deficiency.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to properly label and date medications when opened and did not remove expired medications from use, as observed in three of five medication carts and one of two refrigerators. On the 600 hall medication cart, an albuterol inhaler and a trelegy ellipta inhaler for a resident, as well as a fluticasone nasal spray for another resident, were found without dates indicating when they were opened. On the 700 hall medication cart, expired Humalog insulin pens for two residents and a glargine insulin pen for another resident were found, along with a carboxymethyl solution without an opening date. On the 800 hall medication cart, insulin pens and a nasal spray for two residents were also found without opening dates. Additionally, the medication room refrigerators on the 600, 700, and 800 halls contained a vial of tuberculin that had expired and a bottle of aplisol with an unclear date. These observations indicate a failure to adhere to the facility's policy of ensuring medications are stored according to manufacturer's recommendations, which includes proper labeling, dating, and removal of expired medications.
Failure to Complete Resident Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that resident assessments were completed for a resident who self-administers medications. Resident 15 was observed to have medications in her room, including fluticasone nasal spray, carboxymethylcellulose eye drops, and metronidazole lotion. The physician's orders allowed Resident 15 to self-administer these medications, but the facility's documentation was incomplete. The Medication Self-Administration Safety Screen dated 1/3/24 only assessed the fluticasone nasal spray, while the eye drops and topical creams were not considered applicable. Furthermore, the resident's electronic medical record lacked documentation of quarterly self-administration assessments for all three medications. A new Medication Self-Administration Safety Screen dated 8/5/24 assessed only the carboxymethylcellulose eye drops, omitting the fluticasone and metronidazole. The medication care plan dated 4/4/24 indicated that Resident 15 could self-administer eye medication and face cream, but did not specifically list the metronidazole lotion. During an interview, Resident 15 mentioned that the facility staff had taken away her rosacea medication, which she had previously been allowed to keep in her room. The facility's policy on self-administration of medications requires an interdisciplinary team assessment, which was not adequately documented in this case.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately code falls on the Minimum Data Set (MDS) for a resident in the Memory Care unit. The resident, who had Alzheimer's disease, experienced a fall on her right hip after being found in another resident's bed and was escorted back to her room. This incident resulted in an acute, impacted, nondisplaced right subcapital femoral neck fracture, which required surgical repair. However, the significant change MDS assessment initially indicated no falls since admission or prior assessment, and a subsequent assessment failed to note the fracture resulting from the fall. The facility's policy on accurate assessment, effective at the time, was not adhered to, as the resident's status was not accurately reflected in the MDS assessments.
Insufficient Weekend Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure sufficient licensed nurse coverage on weekends during one of the four quarters reviewed, potentially affecting all 82 residents. The CASPER report indicated staffing concerns were triggered in the second quarter of 2024 due to low weekend staffing. Upon reviewing the licensed nursing schedule for May 2024, it was found that the licensed staff per-patient-per-day (PPD) trended down throughout the month, with several days not meeting the minimum required PPD. Specific days, including Thursdays and weekends, showed PPDs below the minimum threshold, with the lowest being 0.19 on a Sunday. During an interview, the Executive Director (ED) acknowledged the staffing issues and noted that leadership staff, such as the Medical Records Coordinator and the Assistant Director of Nursing, were primarily scheduled for weekday office hours. The ED suggested that some of these hours could be rearranged to cover weekends. The Facility Assessment Tool, dated May 20, 2024, indicated the required minimum PPD for RNs and LPNs, which was not met according to the schedule review. The ED confirmed that the Facility Assessment Tool served as the policy for staffing requirements.
Deficiency in Person-Centered Care for Residents with Dementia
Penalty
Summary
The facility failed to ensure that two cognitively impaired residents, who wished to have a relationship and resided on the secured memory care unit, had appropriate assessments, ongoing supervision, and person-centered goals and interventions. The report highlights that the facility did not adequately document or revise care plans to reflect the residents' preferences and behaviors, particularly regarding their relationship. This lack of documentation and revision in care plans contributed to the deficiency. Resident 53, who was severely cognitively impaired with a BIMS score of 3 out of 15, had a history of wandering and seeking affection from male residents. Despite her family's approval of her relationship with Resident 55, the facility did not update her care plan to include her preference for companionship with him. Additionally, her behavioral assessments lacked documentation of her seeking affection, and her activity assessments did not reflect her meaningful relationship with Resident 55. Resident 55, who was moderately cognitively impaired with a BIMS score of 10 out of 15, also had a care plan that did not address his relationship with Resident 53. His behavioral assessments did not document his feelings towards her, and his activity assessments lacked information about his preference for companionship. The facility's failure to incorporate these aspects into their care plans and assessments resulted in a deficiency in providing person-centered care for these residents.
Failure to Provide Person-Centered Care and Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure the secured memory care unit provided person-centered care, supervision, and engaging activities to prevent resident-to-resident altercations and/or accidents. This deficiency affected all 30 residents in the secured memory care unit. Observations, interviews, and record reviews revealed that residents frequently wandered into each other's rooms, leading to altercations and injuries. For instance, Resident L, who had a history of verbal and physical aggression, pushed Resident B, causing him to fall and sustain severe head injuries. Resident B had been agitated and wandering the halls, and staff attempts to put him to bed only increased his agitation. The facility lacked adequate supervision and activities to redirect residents, especially during the night shift when the activity room was closed and no materials for redirection were available. Resident L's family member reported that she had experienced a decline in cognitive abilities and an increase in aggression, leading to her transfer to the facility. Despite being placed in a room near the activity room, Resident L was frequently disturbed by other residents wandering into her room, which agitated her further. The facility's attempts to use a Velcro stop-sign to prevent other residents from entering her room were ineffective. Resident L's care plan lacked person-centered interventions to address her history of aggression and need for personal space. The facility also failed to provide adequate supervision and engaging activities for other residents, leading to multiple resident-to-resident altercations. For example, Resident EE wandered into Resident GG's room, resulting in an altercation where Resident EE sustained an abrasion. Similarly, Resident X wandered into Resident M's room, leading to an altercation where Resident X sustained a skin tear and bruising. Observations during the survey period showed continuous unsafe and unsupervised wandering by several residents, with no staff intervention or redirection. The care plans for these residents lacked person-centered, specialized interventions for dementia care and intrusive wandering.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a non-verbal, cognitively impaired resident was free from abuse. During the survey, a video provided by the family showed Qualified Medication Aide (QMA) 11 and Certified Nurse Aide (CNA) 12 providing incontinence care to Resident B. The video captured CNA 12 hitting Resident B on the left arm and upper abdomen with both open hands and yelling at the resident. QMA 11 did not intervene to stop the abuse and did not reposition Resident B's legs or reassure her during the incident. Family members, who were watching the care live through a web camera, voiced their concerns to the staff during the incident. The facility's grievance log indicated that a grievance was filed by the family on the same day, and an abuse investigation was ongoing. Interviews with staff and family members revealed that Resident B had a history of cognitive impairment and required assistance with activities of daily living. QMA 11 and CNA 12 were providing care when the incident occurred. QMA 11 admitted to witnessing CNA 12 hit Resident B and reported the incident to the oncoming nurse. Family members had previously installed a web camera in Resident B's room due to concerns about her care. The family provided the video evidence to the facility and filed a grievance. The facility's Director of Nursing (DON) confirmed that the abuse prevention policy was in place, which included training staff to manage residents' verbal or physical aggression and monitoring staff behavior. Resident B's medical records indicated diagnoses of Pick's disease, general anxiety disorder, depression, and psychotic disorder with delusions. The care plans for Resident B included interventions for cognitive impairment, impulsivity, and communication difficulties. The records lacked documentation of the incident, and focused charting on the day of the incident did not indicate any signs of emotional distress or changes in Resident B's condition. The facility's policy emphasized the residents' right to be free from abuse and the importance of staff training and monitoring to prevent such incidents.
Failure to Immediately Report and Intervene in Resident Abuse
Penalty
Summary
The facility failed to ensure staff immediately reported to the Administrator witnessed abuse by another staff member to a resident. The incident involved Resident B, who was being cared for by a Qualified Medication Aide (QMA) and a Certified Nurse Aide (CNA). During the care, the CNA hit Resident B on the left arm and upper abdomen, and yelled at the resident. The QMA did not intervene or stop the abuse and did not reposition Resident B's legs or reassure her. The incident was witnessed by Resident B's family members through a web camera, who voiced their concerns during the event. The QMA attempted to call the Administrator but did not receive a response and did not make further attempts to report the incident immediately. The Administrator received multiple calls reporting the abuse allegation later in the morning from other staff members and Resident B's family. The QMA provided a handwritten statement the following day, indicating she had called the Administrator but did not receive a response. The Administrator's call log showed no missed calls from the QMA. The facility's policy required immediate reporting of abuse to the Administrator or the Director of Nursing (DON) if the Administrator was unavailable. The QMA did not follow up with additional calls or notify the DON as required by the policy. Resident B's medical records indicated she had diagnoses including Pick's disease, general anxiety disorder, depression, and psychotic disorder with delusions. The resident had adequate hearing and vision, was not comatose, and sometimes understood others. The facility's policy on abuse prevention emphasized the importance of immediate reporting of any suspected abuse to facility management. The failure to report the abuse immediately and the lack of intervention during the incident led to the deficiency cited in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 835 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Avon Health & Rehabilitation Center | 1.2 mi | ★★★★★ | 5 | 0 |
| Countryside Meadows | 2.8 mi | ★★★★★ | 15 | 0 |
| Danville Regional Rehabilitation | 3.6 mi | ★★★★★ | 0 | 0 |
| Plainfield Health Care Center | 4.6 mi | ★★★★★ | 32 | 1 |
| Brooke Knoll Village | 4.8 mi | ★★★★★ | 10 | 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.