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 Oaks Nursing Home during CMS and state inspections, most recent first.
Call Lights Not Within Reach for Multiple Residents Four residents with fall prevention interventions and varying levels of cognitive and physical impairment were observed without their call lights within reach. In each case, the call light was not visible or accessible, and staff later located it in places such as a nightstand drawer, wrapped around the bed frame, behind a nightstand, or in a recliner. Residents stated they could not find the call light or would have to yell for help, and staff confirmed the call lights should have been within reach.
Failure to Honor Resident Preference for Body Pillow: A resident with cognitive impairment, ADL dependence, and high fall risk had a spouse-requested body pillow used as part of bed positioning and fall prevention. Staff and records showed the pillow was tied to the spouse's preference, but it was not consistently honored, and an LPN confirmed the preference was not followed. The spouse and the Administrator/DON acknowledged the issue.
Failure to assist a dependent resident with ADL and meals. A resident with severe cognitive impairment, an amputated leg, dysphagia, and malnutrition was found in bed yelling for help, slouched under the overbed table with an untouched breakfast tray and no call light within reach. A RT repositioned the resident and gave water, while a CNA walked away despite hearing the resident call out for help; the RD confirmed the resident needed set-up assistance, prompting, and reminders during meals.
Failure to complete ordered weight monitoring for two residents at nutrition risk. One resident with malnutrition, paraplegia, and dysphagia had significant unplanned weight loss, was ordered supplements and weekly weights, but missed multiple scheduled weigh-ins. A second resident with DM2, dementia, and dysphagia also had weekly weight orders but was not weighed on several scheduled dates. The RD confirmed both residents were high-risk and should have been weighed per MD orders.
A resident with respiratory failure and oxygen dependence did not receive respiratory care as ordered. Her nasal cannula and tubing were not dated, her portable O2 tank was near empty, and her pulse oximetry was found at 77% and then 74% despite an order to keep saturation above 92%. The spouse reported the facility was not keeping the tank full or monitoring her breathing, and the DON and an LPN confirmed the equipment and O2 status issues.
The facility failed to ensure proper labeling and dating of food items in various refrigerators, potentially affecting all residents receiving food from the kitchen. Observations revealed undated and unlabeled items in the kitchen and unit refrigerators, confirmed by staff to belong to them, despite policies requiring labeling with names, content, and dates.
The facility failed to implement proper infection control practices for residents on Transmission Based Precautions. A CNA entered a resident's room multiple times without wearing necessary PPE, and an LPN reused contaminated masks across different resident rooms. Another CNA did not adhere to PPE protocols for a resident on enhanced droplet precautions. These actions were inconsistent with facility policies and CDC guidelines.
A facility failed to notify a resident's representative of new physician orders for antibiotics and labs due to a urinary tract infection. The resident, who was cognitively impaired, had an indwelling catheter. Despite policy requirements, nursing staff did not document the notification, leading to a communication breakdown.
The facility failed to provide written Notice of Medicare Non-Coverage (NOMNC) to two residents or their families before services ended. Both residents received Medicare Part A skilled services, but only telephonic notifications were documented, with no evidence of written notices. The Administrator noted the previous social worker was terminated, and the signed NOMNCs were missing.
A resident with limited English proficiency, primarily speaking Serbian, faced significant communication barriers in the facility. Despite documented needs for an interpreter, staff were not consistently equipped with communication devices or interpreters, leading to misunderstandings and limited interaction. Observations showed a lack of effective communication support, with staff mistaking the resident's language and failing to address communication attempts adequately.
A facility failed to provide adequate pressure ulcer care for a resident with a stage three ulcer on the right heel. Despite a care plan that included frequent repositioning and heel protector boots, these measures were not consistently implemented. Observations showed the resident's feet were not elevated, and heel boots were not worn. The facility's documentation and assessment of the ulcer were inadequate, with improper wound staging and incomplete documentation. The facility's failure to adhere to its own policy and physician orders led to this deficiency.
The facility failed to implement fall prevention interventions for two residents at high risk for falls. One resident attempted to transfer from bed to wheelchair without assistance due to the call light being out of reach, and required safety measures like a fall mat were not in place. Another resident's care plan included a body pillow for fall prevention, but it was not used as intended. Staff confirmed these lapses, contributing to the deficiency.
A resident with significant weight loss and a stage three pressure ulcer did not receive recommended nutritional interventions due to a failure to enter physician orders for supplements. Despite the dietician's recommendations and the resident's willingness to take the supplements, there was no documentation of the interventions being implemented, leading to continued weight loss.
A facility failed to monitor a resident's dialysis care as per policy, lacking documentation of required assessments from November to January. Despite orders for daily fistula monitoring and post-dialysis assessments, these were not performed, as confirmed by the DON.
A resident with cognitive impairment and a physician's order for a pureed diet was served a regular texture meal upon returning from the hospital. The error was identified by the resident's daughter, and the dietary manager confirmed the oversight. The facility's policy on ensuring meal accuracy was not followed.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for four residents who were reviewed for call light access. The deficiency was identified through observations, record review, resident interviews, staff interviews, and policy review, and it involved residents who had care plans and physician orders that included keeping the call light within reach as part of their fall prevention interventions. Resident #6 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, contractures of the right hand and both knees, and severe cognitive impairment with dependence on staff for ADL. During observation, he was lying in bed with his bed against the wall, and his call light was observed about three feet away and tucked inside the drawer of the bedside nightstand. He stated he could not locate the call light and did not know where it was. A CNA stated she had removed the call light during breakfast and then placed it on the bed after it was found in the drawer. Resident #13 had stiff-man syndrome, spinal stenosis, muscle weakness, and impairment of both upper and lower extremities, with dependence on staff for ADL. During observation, his call light was not visible and not within reach while he was lying in bed. He stated he did not know where it was and was observed trying to locate it with his arm. An RT then found the call light wrapped around the head of the bed frame directly behind his head and placed it next to him. Resident #73, who had lupus, rheumatoid arthritis, a history of falls, moderate cognitive impairment, and dependence on staff for ADL, was observed sitting in her wheelchair with her call light not visible and not within reach. She stated she did not know where it was and would have to yell for help. An LPN found the call light approximately five feet away behind her nightstand. Resident #95, who had peripheral vascular disease, an above-the-knee amputation, diabetes, severe cognitive impairment, and dependence on staff for ADL, was observed lying in bed screaming for help. He needed help repositioning and with breakfast, but his call light was not visible or within reach. An RT found the call light in a recliner approximately five feet away and placed it next to him.
Failure to Honor Resident Preference for Body Pillow
Penalty
Summary
The facility failed to honor Resident #51's spouse's preferences regarding the resident's body pillow. Resident #51 was admitted with diagnoses including COPD, cerebral infarction, muscle weakness, and difficulty walking. The record showed he had a BIMS score of 7, was dependent on staff for ADLs, and was assessed as high risk for falls and at risk for wandering. Physician orders included fall prevention measures, including a perimeter mattress and floor mat, and the care plan identified decreased ability to perform ADLs with interventions for bed positioning, mobility, transfers, and the need for a bolstered mattress with a mat on the floor. Documentation and observations showed the body pillow was part of the spouse's preference and was intended to help keep Resident #51 from rolling out of bed. A progress note and concern log reflected that the Administrator was replacing the missing body pillow and that the spouse had raised concern about it. During observation, the resident's recliner had a sign stating no pillows, blankets, or sheets on the chair, while three regular pillows and one body pillow were piled on the recliner. An LPN stated the body pillow should be placed in the bed and tucked under the sheet around the perimeter to stop the resident from falling out of bed, and confirmed the spouse's preferences were not honored. The spouse stated the facility rarely honored her preferences regarding the resident's care, and the Administrator and DON confirmed they were aware of the spouse's preference for the body pillow and had replaced it in the past.
Failure to Assist Dependent Resident With ADL and Meals
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for care was assisted with activities of daily living. Resident #95 was admitted with peripheral vascular disease, an acquired absence of the right leg above the knee, type 2 diabetes, dysphagia, and a need for assistance with personal care. The record also showed a fall prevention order, a diet order for no added sugar/no concentrated sweets with mechanical soft texture and thin liquids, and a nutritional risk assessment indicating the resident remained malnourished. The care plan identified decreased ability to perform ADL, a history of dehydration, and nutrition/hydration risk related to severe protein calorie malnutrition, with interventions including keeping the call light within reach and providing feeding assistance as needed. The MDS showed a BIMS score of six, severe cognitive impairment, impairment of one lower extremity, and dependence on staff for ADL. During observation, the resident was lying in bed screaming for help, stated he needed help to be repositioned and help with eating breakfast and drinking water, and was observed slouched down beneath the overbed table with an untouched breakfast tray. The call light was not visible or within reach. A rehabilitation therapist then repositioned the resident and gave him a drink of water, confirming the resident's need for assistance. A CNA, who was aware of the resident's care needs and heard him yelling for help, walked away from the room without entering and stated, "He doesn't need any help. He just having a bad day." The RD later confirmed the resident was at high risk for malnutrition, had wounds, required some assistance, had a poor appetite, and needed set-up assistance with prompting and reminders during meals.
Failure to Complete Ordered Weight Monitoring for Residents at Nutrition Risk
Penalty
Summary
The facility failed to ensure weight loss prevention interventions were completed as ordered for two residents, both of whom were identified as having nutrition and/or hydration risk. One resident was admitted with diagnoses including moderate protein-calorie malnutrition, paraplegia, and dysphagia oropharyngeal phase. Her record showed physician orders for a regular diet with Greek yogurt daily, weekly weights, and later Ensure Plus twice daily and Pro-Stat 30 mL twice daily. The resident was assessed as high risk with a 7% weight loss in less than 30 days, had a BIMS score of 12, required some ADL assistance, and had difficulty or pain when swallowing. She also stated she had not intended to lose weight and was trying to eat her meals, but had trouble finishing them. The weight summary showed ongoing weight loss, with the resident decreasing from 153.4 lbs. to 142.4 lbs. and then 140 lbs., and she was not weighed on multiple scheduled Sundays as ordered. The second resident had diagnoses including type II diabetes, dysphagia oropharyngeal phase, and dementia, with a BIMS score of 6 and supervision and/or touch assistance needed for eating. Her care plan identified nutrition and/or hydration risk due to suboptimal intakes, and physician orders required a no added salt, no added concentrated sweets, mechanical soft diet with thin consistency and weekly weights. The weight summary showed she was also not weighed on multiple ordered Sundays. The RD confirmed both residents were high-risk for nutrition and were to be weighed according to physician orders, and the facility policy stated weights were to be monitored to prevent unplanned significant weight changes.
Failure to Provide Ordered Oxygen Therapy and Monitoring
Penalty
Summary
The facility failed to ensure respiratory care was implemented as ordered for a resident with acute respiratory failure with hypercapnia, shortness of breath, dependence on supplemental oxygen, and chronic respiratory failure with hypercapnia. The resident’s physician orders included oxygen at 2 LPM as needed for shortness of breath and to maintain pulse oximetry over 92%, as well as continuous oxygen via nasal cannula. The resident’s care plan identified altered respiratory status and oxygen dependence, with interventions including supplemental oxygen use and monitoring for respiratory distress. The resident also had severe cognitive impairment, required staff assistance with ADLs, and had orders to change and date oxygen tubing weekly. During observation, the resident was found outside her room with her nasal cannula wrapped around her shoulders and attached to a portable oxygen tank that was near empty, with the regulator gauge in the red zone. Her nasal cannula and tubing were not dated. The resident’s spouse reported the facility did not ensure the oxygen tank was always full, did not monitor pulse oximetry, and did not keep the nasal cannula, tubing, and nebulizer cleaned and sanitized. The DON verified the tank was near empty and the equipment was not dated. The resident’s spouse then used a portable pulse oximeter and obtained readings of 77% and later 74%, while an LPN stated the resident had an order to keep pulse oximetry above 92% and confirmed the oxygen equipment was not dated and the portable tank was in the red zone.
Failure to Label and Date Food Items in Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in various refrigerators, which could potentially affect all 87 residents receiving food from the kitchen. During an observation, it was noted that the kitchen refrigerator contained undated and unlabeled items, including cups with a yellow substance, a zip-lock bag with crackers, and other unknown food substances. Dietary Aide #223 confirmed these items belonged to staff, who were not supposed to store personal items in the kitchen refrigerator. Additionally, the unit refrigerator on the secured unit contained undated and unlabeled items such as a lunch tote, cups with diced peaches, and other food items, which Registered Nurse #219 confirmed should have been labeled and dated. Further observations revealed similar issues in other refrigerators within the facility. The refrigerator near the dining area of the 300-hall and 400-hall contained expired and unlabeled items, including chips and salsa, pop bottles, and flavored water, which Dietary Aide #223 confirmed likely belonged to staff. Another refrigerator near the dining area of the 100-hall and 200-hall contained a sandwich labeled with a name but not a discard date, which Dietary Manager #235 confirmed and disposed of. The facility's policies on outside food and food storage required labeling with the resident's name, content, preparation date, and discard date, which were not adhered to in these instances.
Inadequate Infection Control Practices for Residents on Precautions
Penalty
Summary
The facility failed to implement proper infection control practices for residents on Transmission Based Precautions (TBP). This deficiency was observed in several instances involving multiple residents and staff members. For Resident #25, who was diagnosed with Zoster and later exhibited symptoms of gastrointestinal illness, the facility did not ensure that staff adhered to the required precautions. Certified Nursing Assistant (CNA) #267 entered Resident #25's room multiple times without wearing the necessary personal protective equipment (PPE), such as a gown, gloves, or an N-95 respirator, and failed to sanitize hands between tasks, despite the resident being on contact and airborne precautions. In another instance, Licensed Practical Nurse (LPN) #205 did not follow proper PPE protocols while administering medications to residents on droplet precautions for COVID-19. LPN #205 reused contaminated masks, including an N-95 respirator and a surgical mask, across different resident rooms, including those of residents who were not on droplet precautions. This practice was contrary to the facility's policy, which required the removal and disposal of PPE, including respirators, after leaving a resident's room. Additionally, CNA #317 failed to adhere to the required PPE protocols when entering the room of a resident on enhanced droplet precautions for COVID-19. The CNA entered the room wearing only a surgical mask instead of the required N-95 respirator and did not remove the contaminated PPE before exiting the room. These actions were inconsistent with the facility's infection control policies and the CDC guidelines, which emphasize the importance of using appropriate PPE to prevent the transmission of infectious agents.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically the initiation of new physician orders for antibiotics and laboratory tests. The resident, who was cognitively impaired and had an indwelling catheter, was diagnosed with a urinary tract infection and prescribed gentamicin. Despite the facility's policy requiring notification of significant changes, the resident's guardian reported inconsistent updates regarding the resident's care. Interviews with nursing staff revealed a breakdown in communication. RN #218 did not notify the resident's representative due to the late hour and passed the responsibility to the day shift nurse, RN #215. However, RN #215 failed to document any notification in the progress notes, indicating that the representative was not informed as required by the facility's policy. This oversight affected the resident's care and was identified during a review of the medical record and staff interviews.
Failure to Provide Written NOMNC to Residents
Penalty
Summary
The facility failed to provide written Notice of Medicare Non-Coverage (NOMNC) to residents or their families before the termination of services. This deficiency affected two former residents who were receiving Medicare Part A skilled services. For Former Resident #198, the episode started on 07/24/24, with the last date of coverage on 09/23/24. The medical record showed that only a telephonic notification was given to the family, with no evidence of a written NOMNC being sent. Similarly, Former Resident #199 began receiving services on 09/13/24, with coverage ending on 10/29/24. Again, only a telephonic notification was documented, with no written NOMNC provided. An interview with the Administrator revealed that the previous social worker was terminated, and the signed NOMNCs could not be located.
Failure to Provide Adequate Communication Support for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide adequate alternative methods of communication for a resident who spoke limited English, specifically Serbian. The resident, who had been admitted with diagnoses including type II diabetes mellitus, chronic kidney disease, hypertension, muscle weakness, and difficulty in walking, was noted to have significant communication barriers. Despite the resident's need for an interpreter being documented in their care plan, staff interviews and observations revealed that no effective communication devices or interpreters were consistently available. The resident's ability to communicate was limited to non-verbal cues and occasional assistance from visiting family members, who were also unaware of any available communication aids. Observations and interviews highlighted that staff were not equipped to communicate effectively with the resident, as evidenced by a CNA mistaking the resident's language for Spanish and failing to follow up on the resident's attempts to communicate. Nursing progress notes indicated ongoing communication challenges, with the resident being described as difficult to understand and engaging in limited conversation due to the language barrier. The lack of signage or communication devices in the resident's room further underscored the deficiency in providing necessary communication support, leaving the resident unable to fully express needs or concerns.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident identified as being at risk for pressure ulcers. The resident, who had multiple diagnoses including cerebral edema and type two diabetes mellitus, was dependent on staff for bed mobility and had a stage three pressure ulcer on the right heel. Despite having a care plan that included interventions such as frequent repositioning and the use of heel protector boots, these measures were not consistently implemented. Observations revealed that the resident's feet were not elevated, and heel boots were not worn as required. The facility's documentation and assessment of the pressure ulcer were inadequate. The initial skin assessments did not classify or stage the wound, and subsequent assessments lacked detailed descriptions of the wound bed. The wound nurse practitioner's progress notes later identified the ulcer as a stage three pressure ulcer, but the facility's Director of Nursing admitted that nurses were instructed not to stage pressure ulcers, indicating a lack of adherence to proper wound assessment protocols. Additionally, there was a failure to document any refusal by the resident to wear heel boots, and nursing assistants did not notify nurses when the wound dressing was found off the resident's heel. The facility's policy on the prevention and treatment of pressure ulcers required comprehensive wound assessments and interventions to reduce tissue load, such as floating heels off surfaces. However, these protocols were not followed, as evidenced by the lack of proper wound staging, incomplete documentation, and failure to ensure the resident's heels were offloaded. The facility's failure to adhere to its own policy and physician orders contributed to the deficiency in providing adequate pressure ulcer care for the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents at high risk for falls. Resident #28, with a complex medical history including heart failure and chronic kidney disease, was found attempting to transfer from bed to wheelchair without assistance, as the call light was not within reach. Despite a care plan requiring a fall mat and specific placement of the wheelchair, these interventions were not consistently in place, as observed on multiple occasions. Staff interviews confirmed the absence of these safety measures, which were intended to prevent falls. Similarly, Resident #38, diagnosed with Parkinson's disease and other conditions, was also at high risk for falls. The care plan included the use of a body pillow as a fall intervention, but observations revealed the pillow was not in use while the resident was in bed. A CNA confirmed the pillow was supposed to be in place but was instead found folded in a chair. These lapses in implementing prescribed fall interventions contributed to the deficiency noted in the facility's care practices.
Failure to Implement Nutritional Interventions for Resident with Weight Loss
Penalty
Summary
The facility failed to implement recommended nutritional interventions for a resident who experienced significant weight loss. The resident, who had intact cognition and was dependent on staff for bed mobility, was identified with a stage three pressure ulcer and unplanned significant weight loss. The nutritional care plan, revised in December, indicated the resident was at risk for clinically significant weight loss, and interventions included providing supplements and protein modules as recommended by the dietician. Despite these recommendations, there were no physician orders for the nutritional supplements Glucerna and liqucel, and the medication administration records showed no documentation of the resident receiving these interventions. Interviews with staff, including a registered nurse and the registered dietician, confirmed that the orders for the supplements were never entered into the electronic health record, and the dietician was responsible for entering these orders. The resident expressed willingness to take the supplements to aid in wound healing, but there was no documentation of refusal. The resident's weight continued to decline, with a 23 percent weight loss observed. The Director of Nursing confirmed the dietician's responsibility for entering physician orders for nutritional recommendations, and the facility's policy on weight management emphasized monitoring resident weights and initiating interventions to prevent unplanned significant weight changes.
Failure to Monitor Dialysis Care
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident undergoing dialysis, as required by their policy. The resident, who had been admitted with conditions including end-stage renal disease, diabetes mellitus, and dementia, was scheduled for dialysis three times a week. Despite physician orders and care plan updates mandating daily monitoring of the fistula site and assessments upon return from dialysis, there was no documented evidence of such monitoring from early November to mid-January. The Director of Nursing confirmed the absence of documentation for the required assessments and monitoring of the resident's dialysis site. The facility's policy required daily monitoring of fistula sites for infection and changes in functioning, as well as assessments after dialysis treatments. However, these procedures were not followed, leading to a deficiency in the care provided to the resident.
Failure to Provide Appropriate Meal Consistency
Penalty
Summary
The facility failed to provide a resident with the appropriate meal consistency as per physician orders. Resident #3, who was cognitively impaired and required assistance for most activities of daily living, was admitted to the facility and later returned from a hospital stay with a revised diet order for a pureed diet. Despite this, the resident was served a meal with regular texture foods, contrary to the physician's order for a pureed diet. This incident was observed when an activities staff member delivered a meal tray containing regular texture foods to the resident's room. The error was identified when the resident's daughter informed the staff member of the diet change. The staff member then sought guidance on how to communicate the diet change to the kitchen. The dietary manager confirmed that the resident had a current order for a pureed diet but had received a regular texture meal due to a recent return from the hospital. The facility's policy on Resident Centered Dining, which includes using diet spreads and allergy reports to ensure meal accuracy and resident safety, was not adhered to in this instance.
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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) |
|---|---|---|---|---|
| Woods On French Creek Nursing & Rehab Center The | 0.6 mi | ★★★★★ | 2 | 0 |
| St Mary Of The Woods | 1.6 mi | ★★★★★ | 11 | 0 |
| Main Street Care Center | 3.3 mi | ★★★★★ | 12 | 0 |
| Avon Place Healthcare Center | 3.3 mi | ★★★★★ | 11 | 0 |
| Northridge Health Center, The | 4.2 mi | ★★★★★ | 7 | 0 |
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