Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avon Place Healthcare Center during CMS and state inspections, most recent first.
A former resident who had been hospitalized after a hip fracture and later died had her medical records requested by her family’s attorney, who supplied all required authorizations and identifying documents. The facility initially sent only partial records and, despite repeated written, faxed, and telephone follow-up requests for specific missing items such as MDS, assessments, nursing notes, MD progress notes, therapy notes, MARs, TARs, and ADL logs, did not provide evidence that a complete record was released within the timeframe outlined in its own policy. The medical records staff stated that all requests are routed through the Administrator to corporate and are not released without corporate approval, and the Administrator acknowledged receiving multiple requests and forwarding them to corporate but could not provide a corporate contact, resulting in delayed and incomplete access to the former resident’s records.
A resident with paraplegia, ventilator dependence, and a stage 4 pressure ulcer had ordered oral medications, including a blood thinner, iron, and fludrocortisone for blood pressure, left unattended in a medication cup on the bedside table while the resident was asleep and the nurse was at the nurse’s station. The unit manager confirmed the medications and that they were left in the room while the resident slept. Facility policy required medications to be administered as prescribed and to remain in the sight of the nurse until administration, but this was not followed.
A resident with multiple chronic conditions was hospitalized after a fall, yet an LPN documented over several days that the resident remained in the facility, had no change in condition, was receiving skilled PT/OT/speech therapy, and had comprehensive assessments completed. The notes also stated the resident reported generalized pain and was given PRN Percocet. Review of the MAR and narcotic count sheets showed no Percocet was administered during that time, and interviews confirmed the resident was in the hospital when these entries were made. Facility policy required objective, complete, and accurate documentation, which was not met.
A resident with dementia, COPD, and atrial fibrillation experienced multiple changes in condition, including bruising, diarrhea, emesis, and decreased oxygen saturation requiring supplemental oxygen. Staff failed to promptly report or document these changes to the physician or family, and there was no evidence of timely communication or follow-up as required by facility policy.
A resident with severe cognitive impairment and multiple health conditions was found with unexplained bruising on the right hand. Staff did not perform a comprehensive assessment for additional injuries or range of motion, and failed to respond to the resident's verbalized leg pain. Only the bruised hand was documented, and further injuries were identified later at the hospital. Facility policy lacked specific guidance for such assessments in cognitively impaired residents.
A resident with COPD and severe cognitive impairment was not properly assessed or monitored during oxygen therapy after a change in condition. Despite care plan and physician orders requiring respiratory monitoring and documentation, staff failed to document ongoing assessments, oxygen administration, or notify the physician when oxygen was started. The facility's policy for oxygen administration was not followed, and the DON confirmed the lack of required documentation.
The facility did not provide wound care as ordered by physicians and failed to ensure wound dressings were initialed and dated according to policy. Several residents with pressure ulcers or wounds were observed without proper dressings or documentation, and staff interviews confirmed lapses in wound care and awareness of dressing status.
Two residents with suprapubic catheters did not have securement devices in place as required by their care plans and physician orders. Despite documentation and policy requiring securement to prevent dislodgement, observations and staff interviews confirmed the absence of securement devices, and the residents were either unaware of or had never received the devices.
A resident with multiple chronic conditions was care planned and ordered to have a urinary catheter securement device, with staff required to monitor it each shift. Despite this, the device was not in place, and staff, including an LPN, admitted to documenting its presence and monitoring in the medical record when it was not actually present, resulting in falsified documentation.
The facility did not post required Enhanced Barrier Precautions (EBP) signage outside the rooms of two residents with pressure ulcers and failed to ensure staff wore appropriate PPE, such as gowns and gloves, during wound and personal care. Staff were observed using only gloves and not following proper infection control procedures, despite facility policy and physician orders requiring EBP.
A resident with significant physical limitations and high risk for pressure ulcers was found with their call light out of reach, resulting in an inability to request assistance for turning, repositioning, or toileting. The resident reported no staff entered the room overnight, leading to an episode of incontinence without the ability to call for help. Facility policy required call lights to be within reach, but this was not followed.
A resident was found with a medication cup containing unidentified pills left on a table in their room, which were their morning medications. The LPN had left the medications while the resident was in the restroom, without an order for self-administration. The facility's policy requires medications to be administered by authorized personnel and that they remain with the resident until the medication is swallowed, which was not followed.
Failure to Timely Provide Complete Medical Records to Former Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to timely release a complete medical record for a former resident to the resident’s family and their legal representative, despite multiple written and faxed requests. The former resident was admitted on 01/11/24 and later discharged to the hospital after a fall with hip fracture, and subsequently died. On 10/30/25, the family’s attorney submitted an initial request for a certified copy of the resident’s medical record for a specified date range, providing the resident’s identifying information, a notarized affidavit of next of kin, a signed authorization for release of medical records, the death certificate, and contact information. The facility’s policy stated that residents or their representatives may obtain photocopies of records by providing at least 48 hours’ notice (excluding weekends and holidays). The facility’s medical records staff member reported that record requests are forwarded to the Administrator, who then sends them to corporate, and that records are not released until corporate approves what can be released. The attorney reported receiving only partial records on 12/11/25, including a consent to treat form for psychiatric therapy, the facility discharge form, a hospital history and physical, diagnosis and allergy audit reports, immunization audit report, order summary report, weight and vital summary, and the care plan report. On 12/15/25, the attorney notified the facility via fax and mail that the record was incomplete and specifically requested additional documents such as the MDS, all assessments, nursing notes, physician progress notes, therapy notes, MARs, TARs, caregiver notes, consultations, and ADL logs. Additional requests were sent on multiple later dates, with fax confirmations and documented phone calls and voicemails to the Administrator, but there was no response indicating that the missing portions were provided. The Administrator confirmed receiving all of the dated requests and stated that they were forwarded to corporate and that, to her knowledge, the complete record had been sent, but she did not provide a corporate contact number when asked. This sequence of events shows that the facility did not provide timely and complete access to the former resident’s medical record as required by its own policy and regulatory expectations.
Unattended Oral Medications Left at Bedside Contrary to Facility Policy
Penalty
Summary
Facility staff failed to ensure medications were administered as ordered and properly stored until administration for one resident. The resident had paraplegia, was ventilator dependent, and had a stage four pressure ulcer, with an admission date of 05/14/25. A quarterly MDS indicated the resident had intact cognitive function and required set up for eating, and the care plan documented a need for assistance with activities of daily living due to weakness, with an intervention to administer medications as ordered. Physician orders included Xarelto 10 mg by mouth in the morning, Ferrous Sulfate 325 mg by mouth once daily, and Fludrocortisone Acetate 0.1 mg, two tablets by mouth daily for blood pressure. On 03/17/26 at 8:13 A.M., surveyors observed a small medication cup containing four medications left on the resident’s bedside table while the resident was in bed sleeping with a sheet over his head, and the nurse was down the hall at the nurse’s station. The unit manager confirmed that the medications in the cup were Xarelto, Ferrous Sulfate, and Fludrocortisone Acetate and verified that the medications had been left unattended in the room while the resident was sleeping. Review of the facility’s “Administering Medications” policy, revised April 2019, showed that medications were to be administered in a safe and timely manner as prescribed, with medication administration times determined by resident need and benefit, and that during administration medications were to be kept in the sight of the nurse until given to the resident. The observed practice of leaving medications unattended in the resident’s room was inconsistent with this policy.
Inaccurate Documentation on Hospitalized Resident’s Condition and PRN Narcotic Use
Penalty
Summary
Facility staff failed to maintain accurate and complete medical record documentation for one resident during a hospitalization period. The resident, admitted with diagnoses including Parkinson's disease, Lewy Body dementia, diabetes mellitus, and congestive heart failure, had an MDS indicating intact cognition. Nursing progress notes showed the resident was transferred to a local hospital following an overnight fall and returned to the facility via stretcher several days later. Despite this, Skilled Progress Notes completed by an LPN on three consecutive days during the hospitalization documented that the resident had no change in condition, no cognitive impairment, and was receiving skilled PT, OT, and speech therapy services. These notes also described assessments of neurological/musculoskeletal, skin, cardiac/respiratory, gastrointestinal/genitourinary status, and monitoring for medication side effects, all indicating no new or negative findings. The same Skilled Progress Notes further documented that the resident complained of generalized pain and that PRN Percocet was administered as ordered. However, review of the narcotic count sheets and the MAR for the month showed no Percocet was administered during the period in question. Interviews with the LPN who authored the notes and another LPN confirmed that the resident was hospitalized and not in the facility on the dates when these assessments and medication administrations were charted, and they could not explain why documentation was completed on an absent resident. The Administrator verified there were no discrepancies in the narcotic count sheets. Facility policy on charting and documentation required that medical record entries be objective, complete, and accurate, and made only by licensed personnel in accordance with state law and facility policy, which was not followed in this instance.
Failure to Report and Document Changes in Resident Condition
Penalty
Summary
The facility failed to ensure that changes in a resident's condition were promptly reported to the physician, resident, and family as required by policy. A resident with multiple diagnoses, including dementia, COPD, and atrial fibrillation, was observed to have several changes in condition, such as visible bruising on the right hand, episodes of diarrhea, emesis, and a decline in oxygen saturation requiring supplemental oxygen. Despite these changes, there was no documentation in the medical record of timely notification to the physician or family regarding the bruising, diarrhea, or the need for oxygen administration. Surveillance video and staff interviews revealed that CNAs observed and provided care for the resident during episodes of incontinence and noted the resident voicing pain in her leg, but these concerns were not reported to nursing staff or documented. Nursing staff, including LPNs and RNs, either were not made aware of these changes or did not recall the events, and there was no evidence that the physician was notified about the resident's decline in oxygen saturation or the administration of oxygen. The physician later confirmed that he was not aware of the resident's emesis or oxygen use, and stated that protocol would have required further evaluation if he had been notified. Review of facility policies and job descriptions confirmed that staff were required to report changes in resident condition, including injuries, significant changes in physical status, and the need to alter medical treatment. However, the facility did not follow these protocols, as evidenced by the lack of timely communication and documentation regarding the resident's condition changes. This deficiency was identified through review of medical records, surveillance footage, and staff interviews.
Failure to Accurately Assess Resident for Additional Injuries After Unexplained Bruising
Penalty
Summary
A deficiency occurred when staff failed to accurately assess a resident for additional injuries after the discovery of unexplained bruising. The resident, who had severe cognitive impairment due to dementia and multiple comorbidities including osteoporosis and atrial fibrillation, was observed on surveillance video with visible bruising on the right hand during incontinence care. Later, while being assisted out of bed, the resident verbalized leg pain, but this concern was not acknowledged or reported by the CNAs present. Documentation showed that only the bruised hand was noted, and no comprehensive assessment for other injuries or range of motion was performed at that time. Subsequent hospital records revealed that the resident had sustained fractures to the right hand and possibly the left hip, with imaging recommended to further assess the hip. Interviews with staff confirmed that a full head-to-toe assessment and range of motion evaluation were not completed after the initial discovery of the injury. The nurse and CNA involved did not remove the resident's gown to check for additional injuries, nor did they respond to the resident's complaint of leg pain. The facility's policy on focused nursing assessment did not provide specific guidance for assessing range of motion or additional injuries in cognitively impaired residents with unexplained bruising. Staff interviews indicated a lack of consistent practice in assessing residents with injuries of unknown origin, particularly in residents with cognitive impairment who may not be able to clearly communicate their symptoms. The deficiency was further evidenced by the absence of documentation regarding a thorough assessment and the failure to identify additional injuries until after hospital evaluation.
Failure to Assess and Monitor Resident During Oxygen Therapy After Change in Condition
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and monitored while receiving oxygen therapy following a change in condition. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and severe cognitive impairment, experienced vomiting and a decline in oxygen saturation. Although the care plan and physician orders required monitoring of respiratory status and oxygen administration as needed, there was no documentation of ongoing respiratory assessments, monitoring of oxygen saturation, or notification to the physician when oxygen was initiated. The medical record lacked evidence of continued monitoring or documentation of oxygen administration on the medication administration record (MAR) after the resident's condition changed. Staff interviews confirmed that the physician was not notified of the resident's need for oxygen, and nursing staff could not recall details of the resident's respiratory assessments or monitoring. The DON verified the absence of documentation regarding oxygen monitoring and administration. The facility's policy required assessment and documentation during oxygen administration, including lung sounds, oxygen saturation, and the resident's response, but these procedures were not followed. This deficiency affected one resident out of three reviewed for change in condition, with a total of nine residents in the facility receiving oxygen therapy.
Failure to Provide Wound Care per Physician Orders and Document Dressing Changes
Penalty
Summary
The facility failed to provide wound care according to physician's orders and did not ensure wound dressings were initialed and dated as required by facility policy. Multiple residents were affected, with one resident not having any of the prescribed wound dressings in place for three pressure ulcers, and several other residents observed with wound dressings that were not initialed or dated. Staff interviews confirmed that wound care was not consistently performed as ordered, and that there was a lack of awareness among nursing staff regarding the status of wound dressings. Resident records revealed that one resident with multiple sclerosis, severe protein calorie malnutrition, and a history of pressure ulcers was at very high risk for skin breakdown. This resident was dependent on staff for hygiene and positioning and had multiple stage three and four pressure ulcers. Despite clear physician orders for specific wound care regimens and dressing changes, observations showed that dressings were missing or not applied as ordered, and staff were unaware of the lapses in care. Additional observations of other residents found wound dressings that were not initialed or dated, with some dressings falling off or not changed as needed. Resident interviews indicated uncertainty about when dressings were last changed, and staff interviews confirmed that required documentation and dressing changes were not consistently performed. Review of facility policy confirmed the expectation to follow physician orders and to mark dressings with initials and dates, which was not adhered to in these cases.
Failure to Secure Suprapubic Catheters as Ordered
Penalty
Summary
The facility failed to ensure that suprapubic catheters were properly secured for two residents who required securement devices as part of their care. For one resident with multiple sclerosis, muscle weakness, and other significant diagnoses, the care plan and physician orders specified the use of a catheter securement device to prevent accidental dislodgement, with orders to replace the device every seven days and as needed. Despite documentation indicating a securement device was in place, direct observation and staff interviews confirmed that the resident did not have a securement device at the time of inspection, and the resident was unaware of how long it had been missing. A second resident with paraplegia, diabetes, morbid obesity, and other chronic conditions also had a care plan and physician orders requiring a catheter securement device, with instructions for daily and shift monitoring. Observation revealed that this resident's suprapubic catheter was not secured, and both the resident and her husband reported never having seen a securement device in use during her stay. Staff interviews further confirmed the absence of the securement device. Facility policy required the use of a securement device or leg band for catheter care, but this was not followed for either resident.
Falsification of Medical Record Regarding Catheter Securement Device
Penalty
Summary
The facility failed to ensure the accuracy and integrity of a resident's medical record, resulting in falsified documentation. A review of the medical record for a resident with multiple diagnoses, including paraplegia and chronic kidney disease, showed that the care plan required a urinary catheter securement device to be in place, and physician orders directed staff to monitor the device daily and every shift. The Treatment Administration Record (TAR) for the month indicated that nurses documented the securement device as being in place every shift. However, direct observation revealed that the resident did not have a catheter securement device, and both the resident and her husband reported that she had never had one while at the facility. Staff interviews confirmed the absence of the device, and an LPN admitted to documenting in the electronic medical record that the securement device was present and monitored, despite knowing it was not. This action was in direct violation of the facility's policy requiring objective, complete, and accurate documentation in the medical record.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to implement proper Enhanced Barrier Precautions (EBP) for residents requiring such measures, as evidenced by observations and record reviews. For one resident with multiple diagnoses including cerebral infarction, malnutrition, diabetes, hypertension, and two stage four pressure wounds, staff did not follow correct infection control procedures during a dressing change. The LPN performing the dressing change wore only gloves, did not change gloves between tasks, and used a bottle of normal saline with both dirty and clean gloves, contrary to infection control protocols. The LPN confirmed that only gloves were worn during the procedure, despite the care plan and physician orders specifying EBP. Additionally, another resident with multiple sclerosis, severe malnutrition, and several stage three and four pressure ulcers did not have the required EBP signage posted outside the room. Observations showed that staff providing incontinence, wound, and catheter care to this resident wore only gloves and did not use gowns as required by facility policy. Staff interviews confirmed that the appropriate PPE was not used and that the necessary signage was missing. The facility's policy mandates both gown and gloves for EBP and requires signage to be posted outside the resident's room.
Call Light Inaccessible for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, muscle weakness, severe protein calorie malnutrition, hyperlipidemia, and hypertension was found to have their call light out of reach while lying in bed. The resident's care plan indicated a need for assistance with activities of daily living and positioning due to high risk for pressure ulcers, with documented stage three and stage four pressure ulcers present. Observation revealed the call light was hanging on the tube feeding pole, not accessible to the resident. During the observation, the resident was found crying and reported that no staff had entered the room throughout the night, resulting in no assistance with turning, repositioning, or toileting. The resident stated they experienced an episode of bowel incontinence and could not call for help. A CNA confirmed the call light was out of reach and that the resident was incontinent and unable to call for assistance. Facility policy required that call lights be within reach for residents in bed or confined to a chair, but this was not followed in this instance.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered properly and were not left at the resident's bedside, affecting one resident. Resident #20, who was cognitively intact with a BIMS score of 15, was observed with a medication cup containing five unidentified pills on a table in their room. The resident reported that the medications were their morning doses, which had been left by an LPN while the resident was in the restroom. The LPN confirmed that they had placed the medication cup on the table and left the room. A review of the electronic medical record revealed no order for self-administration of medication for Resident #20. Interviews with the DON and ADON confirmed the absence of such an order. The facility's policy on medication administration requires that medications be administered by authorized personnel and that they remain with the resident until the medication is swallowed, which 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) |
|---|---|---|---|---|
| St Mary Of The Woods | 1.7 mi | ★★★★★ | 11 | 0 |
| Rae Ann Suburban | 1.9 mi | ★★★★★ | 0 | 0 |
| O'neill Healthcare Bay Village | 2.1 mi | ★★★★★ | 23 | 0 |
| Crocker Pointe Health And Rehabilitation | 2.2 mi | — | 1 | 0 |
| Brookdale Westlake Village | 2.3 mi | ★★★★★ | 4 | 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.