Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avon Health & Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to update a resident's PASARR after a new diagnosis of delusional disorders was added to her medical history. The resident had a Level 1 PASARR that did not include this diagnosis. An MDS LPN noted the diagnosis, but a new level of care was not completed until later, which indicated the need for a Level 2 PASARR referral. The facility's policy required notification and referral for residents with new serious mental disorders, which was not initially followed.
A facility failed to update a resident's care plan to accurately reflect her advanced directives. The resident had conflicting documentation regarding her code status, with a care plan indicating a DNR status and an active order indicating a full code status. The DON acknowledged the error, noting that the care plan should have been updated to reflect the full code status as per the facility's policy.
A resident with a suprapubic catheter in a memory care unit did not receive adequate care, leading to potential risks for UTIs. The facility failed to conduct regular catheter assessments and did not follow physician orders for catheter changes. The resident's urine output was frequently unrecorded, and there was no documentation of physician notification for hematuria and catheter bag leaks. The care plan lacked revisions to address the resident's behavior of emptying his catheter bag and did not include specific catheter specifications or urologist instructions.
A facility failed to provide adequate dementia care and activities for a resident in isolation for influenza A. Despite care plan directives for one-on-one engagement and diversional activities, the resident received limited activities during isolation. The facility's policies on individualized care and meaningful activities were not effectively implemented, resulting in a deficiency.
A facility failed to manage a resident's medication regimen, leading to the administration of unnecessary medications. The resident, diagnosed with dementia and insomnia, was prescribed quetiapine without documented behaviors justifying its use. The diagnosis was updated to psychosis without a psychiatric evaluation, and there was no consent for antipsychotic usage. Observations showed the resident appeared sleepy, and interviews revealed a lack of awareness about the medication's purpose.
Failure to Update PASARR for Resident with New Diagnosis
Penalty
Summary
The facility failed to complete a new level of care Pre-admission Screening and Resident Review (PASARR) for a resident when a diagnosis of psychosis was added to her medical history. The resident, who had diagnoses including hypertension, type 2 diabetes mellitus, generalized anxiety, and delusional disorders, had a Level 1 PASARR in her medical record that did not include the diagnosis of delusional disorders. During an interview, the MDS LPN indicated that delusional disorders were on the resident's list of diagnoses, which led to the coding of delusional disorders. The Director of Nursing later indicated that a new level of care was being completed for the resident, and a subsequent review indicated the need for a Level 2 PASARR referral on site. The facility's policy required the Social Service Director to notify and refer residents with newly evident or possible serious mental disorders to the state mental health authority, which was not initially done in this case.
Failure to Update Resident's Advanced Directives in Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive resident-centered care plan was accurately revised to reflect the advanced directives of a resident. Specifically, Resident 32 had conflicting documentation regarding her code status. An active care plan dated May 17, 2023, indicated a Do Not Resuscitate (DNR) status, while an active order dated December 13, 2024, indicated a full code status. This discrepancy was identified during a review of Resident 32's medical records. The Director of Nursing (DON) acknowledged the error, indicating that the DNR care plan was incorrect and should have been updated to reflect a full code status. The facility's policy on comprehensive care plans, dated September 18, 2024, requires that care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. The failure to update the care plan according to the resident's preferences and the active order led to the deficiency.
Inadequate Catheter Care for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to provide adequate care for a resident with a suprapubic catheter, leading to potential risks for urinary tract infections. Resident 70, who resided in the secured memory care unit, had a history of dementia, anxiety, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident's medical record showed an initial catheter assessment and a quarterly assessment, but subsequent quarterly assessments were missing. Additionally, a urology physician's order for catheter changes every 4 to 6 weeks was not reflected in the facility's physician order list. The facility's records revealed multiple instances where Resident 70's urine output was not recorded across several shifts in March, April, and May 2024. Nursing progress notes indicated occurrences of hematuria and catheter bag leaks, yet there was no documentation of physician notification. The resident frequently emptied his catheter bag without staff knowledge, and the facility's records lacked documentation of interdisciplinary team follow-up or interventions to address this behavior. Resident 70's comprehensive care plan, initiated in March 2024, included interventions for catheter care but lacked revisions to address the resident's behavior of emptying his bag and the specific catheter specifications. The care plan also did not include the urologist's instructions or contact information. The facility's policies on suprapubic catheterization and comprehensive care plans emphasized the need for adherence to physician orders and resident-specific interventions, which were not adequately followed in this case.
Deficiency in Dementia Care and Activities for Isolated Resident
Penalty
Summary
The facility failed to adequately implement care planned interventions and provide appropriate activities for a resident diagnosed with dementia who was in isolation for influenza A. The resident, who resided in the memory care unit, was observed attempting to leave her room multiple times, but was redirected back by a CNA without any special engagement or activities being provided. The CNA indicated that staff did not typically engage residents in isolation with activities, although the resident's care plan specified the need for one-on-one conversation and diversional activities. The resident's comprehensive care plan included interventions such as offering snacks, drinks, conversation, and activities of choice when the resident wandered or expressed a desire to leave. Despite these care plan directives, the resident's activity logs showed limited engagement during the isolation period, with only four activities provided and five instances where the resident was marked as unavailable. The Activity Director acknowledged that residents in isolation should still receive one-on-one activities, but this was not consistently implemented. The facility's policies on resident self-determination, dementia care, and activities emphasized the importance of individualized, non-pharmacological approaches and meaningful activities for residents, including those in isolation. However, these policies were not effectively executed for the resident in question, leading to a deficiency in providing appropriate dementia care and activities during the isolation period.
Failure to Manage Resident's Medication Regimen Appropriately
Penalty
Summary
The facility failed to manage a resident's medication regimen appropriately, leading to a deficiency in the administration of unnecessary medications. Resident 265, who had diagnoses including dementia with behavioral disturbances, palliative care, and insomnia, was prescribed multiple medications, including quetiapine, without documented behaviors justifying its use. The pharmacist recommended adding a diagnosis for quetiapine, which was updated to psychosis without a psychiatric evaluation. The resident's medical record lacked documentation of behaviors associated with the use of quetiapine, and there was no consent for antipsychotic usage in the medical record. Observations and interviews revealed that Resident 265 appeared sleepy and unresponsive, and her son was unaware of the purpose of quetiapine. The Director of Nursing indicated that the resident entered the facility on these medications and that it was not time for a gradual dose reduction. The hospice nurse confirmed that the resident had been on quetiapine long before hospice care began and was unsure of its purpose. The facility's policy on gradual dose reduction of psychotropic drugs was provided, but it did not appear to have been followed in this case.
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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) |
|---|---|---|---|---|
| Majestic Care Of Avon | 1.2 mi | — | 5 | 0 |
| Danville Regional Rehabilitation | 2.5 mi | — | 0 | 0 |
| Countryside Meadows | 3.9 mi | — | 15 | 0 |
| Plainfield Health Care Center | 5.7 mi | — | 11 | 1 |
| Brooke Knoll Village | 5.7 mi | — | 9 | 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 August 2026) and official state health department websites.