Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Controlled Medications Not Properly Accounted For: The facility failed to account for and properly dispense controlled meds. Two residents had oxycodone and alprazolam doses documented as removed from the cart without matching administration records, and an LPN and unit manager confirmed liquid lorazepam in a locked refrigerator drawer was not included in the narcotic count book or verified during shift counts. The medication storage policy did not include specific instructions for tracking narcotic use.
Medication storage was not maintained in a safe and sanitary manner. An LPN observed severe frost buildup in the med refrigerator, with ice and moisture affecting a house stock meropenem IV bag, and an unrefrigerated med cart contained multiple Lantus insulin pens for two residents, including opened pens with no open dates, one pen without a cap, and one unopened pen that should have remained refrigerated until opening. Manufacturer instructions and the facility policy required proper refrigeration and secure storage of medications.
Kitchen sanitation and food storage deficiencies were identified when surveyors found food debris, grease buildup, sticky floors, and splatters on kitchen equipment and surfaces. Multiple food items in coolers, refrigerators, and dry storage were unlabeled, undated, or expired, and staff lunches were stored in resident refrigerators. The DS confirmed several findings, and the facility could not provide policies for kitchen sanitation and food storage.
The facility failed to accommodate a resident’s preference for beautician services and failed to keep another resident’s call light within reach. Staff and family confirmed the beautician request had not been honored, and the resident was not on the salon appointment list despite repeated requests. In a separate finding, a resident with cognitive impairment and fall risk was observed in bed with the call light on the floor and out of reach, contrary to the care plan and facility policy.
Inaccurate advance directive information was found in the records for two residents. Both residents had care plans listing them as full code, while current MD orders showed DNR-CCA status; one resident was severely cognitively impaired and the other was cognitively intact. A UM verified the discrepancies, and a nursing note also documented one resident as full code after hospital readmission.
A resident's room had a deteriorated ceiling directly above her bed, with peeling, flaking, and detached material exposing the underlying substrate. The resident, who was cognitively intact and needed hands-on assist with ADLs, stated the ceiling had been worsening with each rainstorm for over six months and that the facility had long been aware of the issue. The Administrator verified the condition.
Failure to Timely Report and Investigate Alleged Abuse: A resident with intact cognition and significant ADL dependence reported feeling sexually assaulted when an aide placed a pillow between her legs during care. OT and CNA witnesses reported the concern to the unit manager/DON, but the allegation was not documented in the MR, no skin assessment was found, and the LNHA said the event was dismissed as a fabrication because of the resident’s prior accusatory behaviors. The facility did not file the required SRI until after surveyor inquiry, despite policy requiring all possible abuse allegations to be identified, investigated, and reported within required timeframes.
A resident with intact cognition and extensive ADL assistance reported that an aide shoved a pillow between her legs during care and that she felt sexually assaulted. An OT found the resident crying, observed a pillow between her thighs, and reported the allegation to the rehab director and unit manager, while a CNA also confirmed the pillow placement. The LNHA and DON believed the allegation was fabricated because of the resident’s prior accusatory behaviors, and the facility did not file the required SRI until after surveyors questioned the event.
A facility failed to thoroughly investigate a resident’s allegation of sexual abuse after she reported that an aide shoved a pillow between her legs during care and also used profanities toward her. The resident had intact cognition and needed substantial assistance with toileting and dressing. An OT and CNA both reported the resident’s complaint and observed a pillow between her thighs, but the medical record lacked a documented abuse allegation or skin assessment, and the LNHA said the allegation was considered fabricated because of the resident’s accusatory behavior. No SRI was filed at the time, and the facility’s abuse policy required all possible abuse incidents to be identified, investigated, and reported.
The facility failed to timely complete required PASRR screening for three residents before admission or when a 30-day hospital exemption ended. The residents had diagnoses including schizophrenia, bipolar disorder, personality disorder, anxiety disorder, type 2 DM, spinal stenosis, and constipation, and a LSW verified the PASRRs were not completed as required.
A resident with COPD, malnutrition, and severe cognitive impairment was identified as an elopement risk on the baseline care plan, and staff documented wandering into other residents’ rooms while sleeping. However, the comprehensive care plan did not include any focus or interventions for elopement risk or wandering, and an LPN confirmed the omission.
A resident with a recent fracture, cognitive impairment, and ADL needs missed an orthopedic follow-up because the facility did not coordinate transportation and escort arrangements. Records showed the appointment was scheduled and an escort was needed, but the family reported the resident was not taken, an LPN said the follow-up was missed because transport was not scheduled, and the DON stated the appointment was not rescheduled.
Delayed Incontinence Care: Two residents with documented bowel and bladder incontinence did not receive timely peri-care/incontinence care. One resident with dementia and severe functional impairment was found on the floor with stool on her skin and floor and without proper clothing or non-skid footwear, while another resident who required 2-person assist stated she had been saturated with urine for hours and had waited 15 to 20 minutes after activating her call light before staff responded.
A resident receiving dialysis had no documented monitoring order or completed nursing assessment for dialysis catheter infection signs. The resident later developed a significant change in mental status, unstable BP, and severe hypoxia, was sent to the hospital, and was found to have MSSA bacteremia secondary to the dialysis line, along with fever, leukocytosis, fluid overload, and altered mental status. Facility staff stated they could not find evidence of catheter infection monitoring in the record.
Failure to provide behavioral health care and services was cited for three residents. One resident had cognitive impairment and a care plan for frustration and familiar belongings, another resident with schizoaffective disorder and kleptomania repeatedly entered rooms and took items despite repeated redirection and therapy notes that did not address the kleptomania until later, and a third resident with severe cognitive impairment and a PHQ-9 score indicating high depressive symptoms had no evidence of psychiatric or related services offered, with the SSD citing a language barrier.
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.
Controlled Medications Not Properly Accounted For
Penalty
Summary
The facility failed to ensure controlled medications were accounted for and dispensed appropriately. During observation of the East Hall medication cart and review of the narcotic count sheet and resident records, three oxycodone doses for one resident were documented as removed on the same day, but only two doses were documented as administered to that resident. For another resident, two alprazolam doses were documented as removed on the same day, but only one dose was documented as given. The report also noted that the first oxycodone removal time was illegibly written and that one alprazolam removal time appeared to be 8:00 P.M. Observation of the East Hall medication refrigerator revealed a locked drawer containing two sealed bottles of lorazepam. In interview, the East Hall floor nurse and unit manager stated the liquid lorazepam was not accounted for in the narcotic count book, was not verified during change-of-shift narcotic counts, and they knew of no way to verify whether any bottles were missing. They also confirmed that oxycodone and alprazolam had been withdrawn without an account of administration to the prescribed residents. Review of the facility medication storage policy dated 11/2020 revealed no specific instructions for tracking narcotic use.
Medication Storage and Refrigeration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in a safe and sanitary manner. During observation of the East Hall medication refrigerator, the freezer section was completely filled with white and brown frost buildup that pressed against the shelf in the freezer door and appeared to have damaged it. Standing frost ran down the back of the interior refrigerator and trapped the tubing for a house stock one gram in 100 milliliters meropenem IV bag in ice, with loose ice flakes and moisture present on the IV bag. An LPN confirmed these findings during interview. The unrefrigerated North Hall medication cart contained one opened Lantus insulin pen for one resident with no labeled open date, and four Lantus insulin pens for another resident, including two with no labeled open date, one with no open date and no cap, and one unopened insulin pen labeled to keep refrigerated until opening. The LPN confirmed these findings. Manufacturer instructions for Lantus SoloStar stated pens should be refrigerated until opened and discarded 28 days after opening, and the facility's medication storage policy required drugs to be stored in locked compartments under proper temperature and humidity controls and refrigerated medications to be stored in a secure refrigerator.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen area and failed to ensure appropriate labeling and dating of food items. During observation of the main kitchen, surveyors found containers of sherbet ice cream on the freezer floor, food splatters inside and on the door of the microwave, floating food debris and grease buildup on the deep fryer, grease and food debris on the tilt skillet, drips of food debris on the flat top and stove, and a sticky kitchen floor with dried spills and food debris. The kitchen staff member interviewed stated the deep cleaning was done on Thursdays and as needed, and that night shift was supposed to sweep and mop daily, but it did not appear to have been done the prior night. Surveyors also observed multiple food storage and labeling problems in the reach-in cooler, walk-in refrigerator, dry storage area, and unit refrigerators. Items included uncovered trays of mixed fruit and peaches with no label or date, English muffins wrapped in foil with no label or date, applesauce with no label or date, lettuce and cut tomatoes with no label or date, hot dogs dated 06/18/26, an onion with a black spot appearing to be mold, an onion half in a baggie with no label or date, three half gallons of milk past the use-by date, cereal dispensers with no opening dates, opened dry goods without open or use-by dates, and staff lunches stored in resident refrigerators. The dietary supervisor confirmed several of these findings and stated staff were not supposed to store their food in the resident refrigerator. The facility was unable to provide policies for kitchen sanitation and food storage, although policies reviewed required food to be dated after opening and brought-in food to be labeled and dated.
Failure to Honor Beautician Requests and Keep Call Light Within Reach
Penalty
Summary
The facility failed to accommodate resident needs and preferences by not providing access to beautician services for a resident who, according to the care plan, had a trauma history and was to be empowered to choose services and supports of her choice. The resident’s record showed cognitive impairment with memory problems and disorganized thinking, and her family representative stated that requests for beautician services had been made for weeks and months without being honored. Facility staff confirmed that the resident had requested to be added to the beautician list, but her name was not on the appointment lists reviewed, and the facility had gone without a beautician for approximately eight months between the prior beautician’s last day and the new beautician’s start date. The business office manager acknowledged the resident was not on the list for prior or upcoming visits and was observed adding the resident’s name after the issue was raised. The facility also failed to ensure a resident’s call light was within reach. The resident’s record identified him as severely impaired in decision making and at risk for falls, with a care plan intervention to ensure the call light was within reach. During observation, the resident was lying in bed and the call light was found on the floor beneath the bed, out of reach. A CNA confirmed that call lights were to be within reach when residents were in bed and verified that the resident’s call light was not in reach at the time of the interview. The facility policy also stated that when a resident is in bed, the call light should be within reach.
Inaccurate Advance Directive Information in Resident Records
Penalty
Summary
The facility failed to ensure accurate advance directive information was present throughout the medical record for two residents reviewed. Resident #3 was admitted with diagnoses including malnutrition, type 2 diabetes, and neurocognitive disorder, and the most recent MDS showed severe cognitive impairment and need for hands-on assistance with activities of daily living. The care plan for advance directives listed the resident as full code, but the current physician order was for DNR-CCA status. Resident #60 was admitted with diagnoses including malnutrition, type 2 diabetes, and difficulty walking, and the most recent MDS showed the resident was cognitively intact and needed hands-on assistance with activities of daily living. The care plan for advance directives listed the resident as full code, but the current physician order was for DNR-CCA status. A nursing progress note also documented the resident as full code upon readmission from the hospital. The Unit Manager verified the discrepancies in the records for both residents and confirmed each had DNR-CCA status. The facility policy stated the Care Plan Team would be informed of changes or revocations so appropriate changes could be made in the MDS and care plan.
Deteriorated Ceiling Above Resident Bed
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for Resident #46 by allowing the ceiling above her bed to remain in a deteriorated condition. Resident #46 was admitted with diagnoses including epilepsy, type 2 diabetes, and major depressive disorder, and her most recent MDS showed she was cognitively intact and required hands-on assistance from one staff person for activities of daily living. During observation, multiple areas of the ceiling directly above her bed were peeling, flaking, and detached, with exposed underlying substrate, and the surrounding ceiling was cracked, bubbled, and visibly deteriorated. The resident stated the ceiling had been slowly deteriorating with each rainstorm for over six months and that the facility had long been aware of the issue. The Administrator verified the condition of the ceiling above the resident's bed.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not timely reporting and investigating an allegation of abuse involving one resident. Resident #45 had an admission date of 06/09/26, diagnoses including diabetes mellitus, anxiety disorder, fibromyalgia, chronic pain syndrome, bilateral primary osteoarthritis of the hip, difficulty walking, and COPD, and an admission MDS showing intact cognition. The resident required substantial to maximal assistance with toileting hygiene, was dependent for lower body dressing, and was frequently incontinent of bowel and bladder. On 06/18/26, the resident told OT staff that she felt she had been sexually assaulted when nursing placed a pillow between her legs. The OT documented that the resident was crying, stated an aide shoved a pillow between her thighs and near her vagina, and reported the concern to the director of rehabilitation and the nursing unit manager. A CNA also observed a pillow between the resident’s thighs and the allegation was reported to the Unit Manager. The record contained no documented abuse allegation, no documented skin observation or assessment after the report, and the paper Head-to-Toe assessment noting the resident was poorly groomed, alert and oriented, argumentative, and offered hospital transfer was not located in the medical record. The resident later told the provider she was irritated with the care provided and had already made her complaint to have it addressed. During interviews, the resident stated an aide had shoved a pillow between her legs by her vagina and had whispered an expletive in her ear, and she said she had complained to the Administrator and DON but the aide still worked with her. The LNHA acknowledged awareness of the allegation but stated the facility determined it was a fabrication because the resident had accusatory behaviors, and confirmed no self-reported incident was filed with the state agency at the time of the allegation. The OT and CNA both stated the allegation was reported, and the OT stated she had not heard anything further about the findings. The facility policy required identification, investigation, and reporting of all possible abuse incidents within required timeframes, but the facility did not file the SRI until after surveyor questions.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse to the state agency after a resident stated that a staff member had shoved a pillow between her legs during care and that she felt sexually assaulted. The resident had diagnoses including diabetes mellitus, anxiety disorder, fibromyalgia, chronic pain syndrome, bilateral primary osteoarthritis of the hip, difficulty walking, and COPD. Her MDS showed intact cognition, substantial to maximal assistance needed for toileting hygiene, dependence for lower body dressing, and frequent bowel and bladder incontinence. An occupational therapist found the resident crying and documented that the resident said she felt sexually assaulted or raped by a nighttime staff member placing a pillow between her legs and grazing her vaginal area. The therapist observed a pillow folded in half between the resident’s thighs and reported the allegation to the director of rehabilitation and the nursing unit manager. A CNA also confirmed seeing a pillow between the resident’s thighs and that the allegation was reported up the chain. The resident later told surveyors that she felt mistreated by an aide, that the aide had shoved a pillow between her legs by her vagina, and that she had complained to the Administrator and DON. The LNHA stated the facility believed the allegation was fabricated because the resident had a history of accusatory behaviors, and the DON questioned the resident about whether the event could be rape and whether she had been touched. The facility did not file a self-reported incident at the time of the allegation, and survey review found no evidence of an SRI investigation related to the resident’s allegation of sexual abuse and verbal abuse. After surveyors asked questions about the allegation, the facility then filed an SRI for sexual abuse. The record also showed no documented abuse allegation in the medical record and no documented skin observation or assessment after the report.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of sexual abuse involving a resident who had intact cognition on the admission MDS and required substantial to maximal assistance with toileting hygiene and lower body dressing, with frequent bowel and bladder incontinence. The resident reported to occupational therapy that she felt sexually assaulted when staff placed a pillow between her legs during care. The allegation was relayed to facility leadership, but the medical record did not contain a documented abuse allegation, and there was no documented observation or assessment of the resident’s skin after the report. The resident later told surveyors that an aide was upset because she could not open her legs for brief care and shoved a pillow between her legs by her vagina. She stated she also reported being spoken to in a profane and demeaning manner and that the aide continued to work with her after she complained. The resident said she had spoken with the Administrator and DON about feeling mistreated. The LNHA acknowledged awareness of the allegation but stated the facility determined the allegation was fabricated because the resident had a history of accusatory behaviors, and no self-reported incident was filed with the state at that time. Interviews and witness statements showed that the occupational therapist found the resident crying, heard her say she had been sexually assaulted or raped by a nighttime staff member placing a pillow between her legs, and observed a folded pillow between the resident’s thighs. A CNA also stated she saw a pillow between the resident’s thighs and that the allegation was reported to the Unit Manager. The DON and LNHA later interviewed the resident and focused on whether the pillow placement could be considered rape, while the DON noted the resident later changed her report. Review of facility records showed no SRI investigation for the sexual abuse and verbal abuse allegation until after surveyors questioned the matter, and the facility policy required all possible incidents of abuse to be identified, investigated, and reported within required timeframes.
Delayed PASRR Screening for Three Residents
Penalty
Summary
The facility failed to timely complete required PASRR screening for three residents prior to admission or at the end of a 30-day hospital exemption. Resident #20 was admitted with diagnoses including schizophrenia, bipolar disorder, and heart failure, remained in the facility without breaks in stay, and had a PASRR completed only on 01/09/26. Resident #37 was admitted with diagnoses including personality disorder, anxiety disorder, and a bone disorder, remained in the facility without breaks in stay, and had a PASRR completed only on 01/27/25. Resident #75 was admitted with diagnoses including type 2 diabetes, spinal stenosis, and constipation, remained in the facility without breaks in stay, and had a PASRR completed only on 06/12/26. A Licensed Social Worker verified that the PASRR screens for these residents were not completed prior to admission or at the conclusion of the 30-day hospital exemption as required.
Failure to Address Elopement Risk in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan to address Resident #72’s elopement risk. Resident #72 was admitted with diagnoses including a right rib fracture, COPD, and moderate protein-calorie malnutrition. Admission paperwork dated 04/15/26 stated that prior to admission she was confused when ambulating and required assistance from a therapist to return to her room. A progress note dated 04/17/26 at 9:45 P.M. documented that she was resting in bed with no attempts to exit seek, and the baseline care plan dated 04/19/26 identified her as at risk for elopement. The MDS assessment dated [DATE] showed a BIMS score of five, indicating severe cognitive impairment, and noted that she required some assistance from staff for activities of daily living. A progress note dated 04/20/26 at 1:13 A.M. documented that she continued to wander in and out of other residents’ rooms while they were sleeping but was easily redirected. Review of the comprehensive care plan dated 04/28/26 revealed no focus or interventions for her elopement risk and wandering. During interview on 06/30/26 at 2:38 P.M., an LPN confirmed that Resident #72 was admitted as an elopement risk and that the baseline care plan identified this risk, but it was not addressed in the comprehensive care plan, including no interventions.
Missed Orthopedic Follow-Up Due to Failed Transport Coordination
Penalty
Summary
The facility failed to coordinate a resident’s orthopedic care after the resident fell in her room and sustained a fracture. Resident #10 was admitted with diagnoses including a stress fracture of the right femur, COPD, hypertension, and bipolar disorder, and the MDS showed memory problems, moderate impairment for daily decision-making tasks, disorganized thinking, and some need for staff assistance with ADLs. The care plan identified her as at risk for falls and noted an ADL deficit with treatments as ordered. A physician order documented a follow-up orthopedic appointment for a recent fracture, and a progress note stated that an escort was needed and the front desk was made aware. The resident’s family member stated the resident was supposed to have another x-ray to confirm healing, but the facility did not arrange transportation on the day of the appointment and no new appointment had been made. An LPN stated the resident missed the follow-up because transportation was not scheduled and that management was supposed to schedule the appointment. The receptionist stated nurses completed a form for transportation and recalled setting up transport and the need for a facility escort, while the transporter stated he was unaware why the resident did not make it to the appointment. The DON stated floor nurses were responsible for scheduling appointments and the receptionist set up transportation, but she did not schedule or reschedule the follow-up orthopedic appointment and was unaware of what happened.
Delayed Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for ADLs and had documented bowel and bladder incontinence. One resident had dementia, muscle weakness, unsteadiness on feet, and severe impairment in daily tasks; the care plan directed staff to assist with toileting and provide peri-care with each incontinence episode. During a fall investigation, the resident was found in her room in front of an open bathroom door without pants or a brief, with stool on her skin and on the floor, and without non-skid shoes or socks. At the time of observation, she was on the floor scooting across the room with stool on her legs, and staff acknowledged they could not watch everyone while assisting other residents. A second resident was cognitively intact but required hands-on assistance from two staff members and was frequently incontinent of bowel and bladder. Her care plan directed staff to check her per policy/program for incontinence. During an overnight observation, the resident stated she needed incontinence care, was saturated with urine, and had not received care all night, estimating she had been wet for about four hours. Her call light had been on for 15 to 20 minutes before the interview. An LPN entered the room and turned off the call light, and CNAs later provided incontinence care; afterward, a CNA stated the resident was really wet and appeared not to have received incontinence care in a long time. The resident stated that waiting extended periods for incontinence care happens practically every night.
Failure to Monitor Dialysis Catheter for Infection
Penalty
Summary
The facility failed to ensure ongoing monitoring for signs and symptoms of infection for a resident’s dialysis catheter. Resident #69 had chronic kidney disease, dependence on renal dialysis, congestive heart failure, and acute respiratory failure, and received dialysis treatments in the facility’s dialysis den. The medical record showed no physician order for monitoring the dialysis catheter for signs and symptoms of infection, and the dialysis transition of care form was not completed by the facility nurse in the section for signs of infection. During the resident’s dialysis care, the pre-treatment assessment documented no nausea, vomiting, diarrhea, shortness of breath, edema, chest pain, or other symptoms, and catheter care was completed by dialysis staff. Later, the resident had a significant change in mental status, unstable blood pressure, and severe oxygen desaturation, requiring emergency transfer to the hospital. Facility staff interviewed after the event stated the resident had not been responding normally and that they did not find evidence in the record of monitoring the dialysis site for signs of infection. The hospital after-visit summary showed the resident was admitted with MSSA bacteremia secondary to the right chest dialysis line, along with fluid overload due to missed dialysis treatment, altered mental status, fever, leukocytosis, hypoxia, and hypercapnia. The dialysis line was replaced, and IV cefazolin was ordered. The facility’s coordination agreement stated it would provide supportive care including inspection of the dialysis access site for bleeding and monitoring for signs of infection, and the facility policy stated residents with ESRD would be cared for according to recognized standards of care and staff would be educated to recognize and intervene in hemorrhage and septic infection.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that residents received and that the facility provided necessary behavioral health care and services. The deficiency involved three residents and was based on record review, observation, and interview. The cited concerns included behaviors related to taking personal property, behaviors addressed during therapy, and the absence of psychiatric or related services for depressive symptoms. One resident was admitted with diagnoses including cerebral infarction, tachycardia, and hallucinations. The record showed cognitive impairment, including short- and long-term memory problems, inattention, and severe impairment in decision-making for daily tasks. The care plan identified the resident as cognitively compromised and included interventions such as keeping familiar belongings nearby, providing a calm and relaxing environment, and removing signs and symptoms related to frustration. Another resident was admitted with diagnoses including schizoaffective disorder, kleptomania, and hypertension. The record showed no cognitive impairment on BIMS, but the care plan documented wandering, entering other residents’ rooms, rummaging through belongings, and taking items from other residents’ rooms. Progress notes documented repeated incidents of entering rooms, taking food and drinks from behind the nurse’s station, taking items from other residents, and being redirected and educated multiple times. Staff and family reported that the behavior continued, including entering a resident’s room and taking personal items, and staff stated that therapy sessions were occurring but kleptomania was not addressed in those sessions until after the issue was identified during survey. A third resident was admitted with diagnoses including recurrent depressive disorder, dementia, and type 2 diabetes. The most recent MDS showed severe cognitive impairment and a PHQ-9 score of 15, indicating high depressive symptoms. Review of the electronic and paper charts found no evidence that psychiatric services or similar services had been offered to the resident or family to address the depressive symptoms. The SSD confirmed that no psychiatric or related services had been offered and stated that the reason was the resident’s language barrier.
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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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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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) |
|---|---|---|---|---|
| St Mary Of The Woods | 1.7 mi | ★★★★★ | 1 | 0 |
| Rae Ann Suburban | 1.9 mi | ★★★★★ | 5 | 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 October 2026) and official state health department websites.