Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Avalon Springs Care Center during CMS and state inspections, most recent first.
Care plans were not reviewed and revised to reflect current code status for three residents. One resident with heart failure, A-fib, and depression had DNR orders and a POLST for DNR with limited interventions, another resident with GERD, hypothyroidism, and osteoporosis had DNR orders and a POLST for DNR with comfort measures only, and a third resident with GERD, diabetes, and HTN had DNR/Allow Natural Death orders and a POLST for DNR with limited interventions; however, each care plan still listed Advance Directive: Full Code. The DON confirmed the mismatch during interview.
MDS coding was inaccurate for two residents. One resident’s MDS did not correctly show that two pressure ulcers were present on admission, even though wound care notes documented bilateral heel ulcers and the LPNAC confirmed the error. Another resident’s MDS incorrectly coded anticoagulant use as current, despite the MAR showing no anticoagulant administration during the look-back period; the LPNAC confirmed the coding error.
A resident with A-Fib, diabetes, and MDD had orders for Apixaban, insulin glargine, quetiapine, and sertraline, but the clinical record lacked a comprehensive care plan addressing anticoagulant use, diabetes/insulin, and antipsychotic and antidepressant monitoring. The DON confirmed the missing care plan during interview, despite facility policy requiring a person-centered plan with measurable objectives and timetables.
The facility failed to obtain necessary approvals from the Department of Health State Plan Review and the Life Safety Division for flood remediation projects affecting two building levels. Observations revealed ongoing remediation work and use of rooms for storage due to flood damage, without the required approvals. The maintenance supervisor confirmed the deficiency during a revisit survey.
An LPN failed to clean a blood glucometer between uses on two residents, contrary to facility policy requiring disinfection between uses. The LPN acknowledged the oversight and identified the available cleansing wipes in the medication cart.
Care plans not updated to match current code status
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect current care and services for three residents. Review of facility policy showed that comprehensive, person-centered care plans are to be developed and revised as resident assessments and conditions change, and that advance directives are to be consistent with the resident’s documented treatment preferences and/or advance directive. Clinical record review showed that one resident had diagnoses including heart failure, atrial fibrillation, and depression, with a physician order for DNR and a POLST indicating DNR and limited additional interventions, yet the comprehensive care plan still listed Advance Directive: Full Code. Another resident had diagnoses including GERD, hypothyroidism, and osteoporosis, with a physician order for DNR and a POLST indicating DNR and comfort measures only, but the care plan still listed Advance Directive: Full Code. A third resident had diagnoses including GERD, diabetes, and high blood pressure, with a POLST and physician order indicating DNR/Allow Natural Death and limited additional interventions, but the care plan still listed Advance Directive: Full Code. During interview, the DON confirmed that the care plans for these residents were not reviewed and revised to reflect current resident care and services regarding code status.
MDS Coding Errors for Pressure Ulcers and Anticoagulant Use
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected resident status for two residents reviewed. For one resident admitted with diagnoses including GERD, diabetes, and high blood pressure, the significant change MDS with an ARD of 9/26/25 coded section M0300 G1 as two unstageable deep tissue injury pressure ulcers, but coded M0300 G2 as zero present on admission. Clinical records and wound care consultant progress notes dated 9/4/25, 9/11/25, 9/18/25, and 9/25/25 documented that the resident was admitted with pressure ulcers to the right and left heel, and the LPNAC later confirmed that M0300 G2 should have been coded as two. For another resident admitted with CHF, GERD, and a fractured left femur, the quarterly MDS with an ARD of 10/8/25 coded section N0415E Anticoagulant as currently taking. The physician order showed Lovenox 30 mg SQ daily for 21 days, but review of the October 2025 MAR showed no evidence that the resident received any anticoagulant during the 7-day look-back period for the MDS. During interview, the LPNAC confirmed that the MDS was coded incorrectly and that section N0415E should not have been coded as receiving during the last seven days.
Incomplete Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident with multiple clinical needs. The resident was admitted with diagnoses including A-Fib, diabetes, and major depressive disorder, and had physician orders for Apixaban 5 mg twice daily, Insulin Glargine 20 units subcutaneously at bedtime, Quetiapine Fumarate 25 mg at bedtime, and Sertraline 50 mg in the morning. The resident's clinical record lacked evidence of a care plan addressing anticoagulant use, diabetes and insulin use, and the use and monitoring of antipsychotic and antidepressant medications. Facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables, and the DON confirmed during interview that no care plan had been developed for these areas.
Failure to Obtain Required Approvals for Flood Remediation Projects
Penalty
Summary
The facility failed to maintain compliance with general requirements as outlined in NFPA 101, affecting two of three building levels. On November 14, 2024, observations revealed that the facility had not obtained the necessary approvals from the Department of Health State Plan Review and the Life Safety Division for several projects. Specifically, the first floor, north hall, had undergone remediation work due to recent flood damage, which required the evacuation and relocation of residents. Additionally, the ground floor, north hall, dementia unit, experienced total remediation of partitioning studs due to flood damage. Various rooms throughout the facility were also being used for item storage as a result of the flood event. During an onsite revisit survey on January 9, 2025, it was confirmed that the facility still had not obtained the required approvals for the aforementioned projects. The maintenance supervisor confirmed that the facility was in the process of preparing the necessary drawings and applications for submission. This ongoing deficiency highlights the facility's failure to secure the necessary approvals and occupancy grants from relevant authorities, as required by the Life Safety Code.
Plan Of Correction
The facility will not occupy the flooded areas. Cleanup and sanitation completed. Plans for rebuild on hold due to the pending change of facility ownership scheduled for 3/1/2025. A narrative and plans will be submitted for plan review prior to any work being conducted in the flooded areas. The facility is using designated storage areas for facility storage. Facility maintenance staff or designee will round daily to ensure the space remains safe and secure until rebuild is completed.
Failure to Clean Blood Glucometer Between Uses
Penalty
Summary
The facility failed to properly clean and prevent potential cross-contamination during the use of a blood glucometer (BGM) for two residents during medication administration. The facility's policy, dated 3/21/24, requires that BGMs be cleaned and disinfected between uses. However, during an observation on 11/04/24, an LPN was seen using a BGM on two residents without cleaning it between uses. The LPN confirmed during an interview that the BGM should be cleaned between each resident and identified the approved cleansing wipes available in the medication cart, acknowledging that the BGM was not cleaned as required during the observed process.
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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 Mercer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quality Life Services - Mercer | 1.3 mi | ★★★★★ | 8 | 0 |
| Shenango Presbyterian Seniorcare | 10 mi | ★★★★★ | 0 | 0 |
| Saint John Xxiii Home | 10.1 mi | ★★★★★ | 1 | 0 |
| Quality Life Services - Grove City | 10.2 mi | ★★★★★ | 6 | 0 |
| Kadima Rehabilitation & Nursing At New Wilmington | 10.3 mi | ★★★★★ | 13 | 0 |
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