Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
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 Majestic Care Of Avon during CMS and state inspections, most recent first.
A CNA was observed passing lunch trays alone, and food temperatures on the 600 hall were found to be below required standards, with items such as chicken and vegetables measured well under the facility's policy for hot food holding. Fourteen residents receiving room tray service were potentially affected.
A resident with multiple medical conditions, including weight loss, was not served her physician-ordered diet, which required double portions and a magic cup at lunch. The omission was observed and confirmed by a CNA, who subsequently provided the missing items.
The facility failed to address ongoing Resident Council Grievance concerns about call light wait and response times, affecting 5 of 82 residents. Despite repeated complaints documented in meeting minutes, the issue persisted, with residents experiencing long wait times and accidents. Interviews revealed that grievance responses were inconsistent, and the facility's policy on prompt grievance resolution was not effectively implemented.
The facility failed to enforce its non-smoking policy, allowing residents with various health conditions to smoke on the premises and keep smoking materials in their rooms. Despite being a non-smoking facility, residents were observed smoking on the grounds, and some admitted to storing cigarettes and lighters in their rooms. The facility lacked smoking assessments for these residents, contributing to the deficiency.
The facility failed to label and date medications when opened and did not remove expired medications from use, as observed in three medication carts and one refrigerator. Medications for several residents, including inhalers, insulin pens, and nasal sprays, were found without opening dates or were expired. Additionally, a vial of tuberculin and a bottle of aplisol in the medication room refrigerators were improperly dated or expired.
A facility failed to complete necessary assessments for a resident self-administering medications. The resident had fluticasone nasal spray, carboxymethylcellulose eye drops, and metronidazole lotion in her room, but the facility's documentation was incomplete. The Medication Self-Administration Safety Screen and care plan lacked proper assessments and specific listings for these medications, contrary to the facility's policy requiring interdisciplinary team assessments.
A resident with Alzheimer's in the Memory Care unit fell and fractured her hip after being found in another resident's bed. The fall was not accurately coded in the MDS assessments, initially marked as no falls and later not indicating the fracture. The facility's policy on accurate assessment was not followed.
The facility failed to provide sufficient licensed nurse coverage on weekends, affecting all 82 residents. The CASPER report highlighted staffing concerns in the second quarter of 2024. A review of the May 2024 schedule showed a downward trend in licensed staff per-patient-per-day (PPD), with several days not meeting the minimum required PPD. The Executive Director acknowledged the issue and noted that leadership staff were mainly scheduled for weekdays, suggesting a potential rearrangement to cover weekends. The Facility Assessment Tool indicated the required minimum PPD, which was not met.
The facility failed to provide appropriate assessments and person-centered care for two residents with dementia who wished to have a relationship. Despite family approval, the care plans and assessments did not reflect the residents' preferences and behaviors, leading to a deficiency in care.
The facility failed to provide person-centered care, supervision, and engaging activities in the secured memory care unit, leading to multiple resident-to-resident altercations and injuries. Residents frequently wandered into each other's rooms, causing distress and physical altercations. The facility lacked adequate supervision and activities to redirect residents, especially during the night shift.
A facility failed to protect a non-verbal, cognitively impaired resident from abuse. A video showed a CNA hitting the resident during care while a QMA did not intervene. Family members, watching live through a web camera, reported the incident. Interviews and records revealed the resident's cognitive impairments and the facility's ongoing abuse investigation.
The facility failed to ensure staff immediately reported witnessed abuse by another staff member to a resident. During care, a CNA hit a resident, and the QMA did not intervene or report the incident immediately. The Administrator received reports later in the morning, but the QMA did not follow the facility's policy for immediate reporting.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
During a lunch service observation, a CNA was found to be passing trays alone on the 600 hall. Temperatures of the food items on the lunch trays were checked and found to be below the facility's required holding temperature of greater than 135 degrees Fahrenheit, with chicken measured at 122 degrees, mashed potatoes at 122.7 degrees, and mixed vegetables at 117 degrees. The facility's policy, provided by the Executive Director, specifies that hot foods must be held at appropriate temperatures, with poultry and stuffed foods requiring a minimum of 165 degrees Fahrenheit and all foods held above 135 degrees Fahrenheit. Fourteen residents who had their trays delivered to their rooms on the 600 hall were potentially affected by this deficiency.
Failure to Provide Prescribed Therapeutic Diet to Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including weakness, hypertension, and weight loss did not receive her prescribed diet as ordered by the physician. The resident's orders specified a regular diet with ground meat, double portions, and a magic cup at lunch. During observation, the resident was served lunch without the double portions or the magic cup. This was confirmed by a CNA, who then retrieved the missing items. No facility policy was provided at the time of the survey exit.
Failure to Address Call Light Response Concerns
Penalty
Summary
The facility failed to address Resident Council Grievance concerns regarding call light wait and response times in a timely and effective manner. This issue affected 5 of 82 residents who attended the Resident Council Meeting and complained on behalf of all 82 residents residing in the facility. The Executive Director (ED) was unable to locate Resident Council Minutes from October 2023 through February 2024, but provided minutes from March 2024 to July 2024. These minutes consistently documented complaints about overnight staff not responding to call lights for 1-2 hours and staff using phones during resident care. Despite these ongoing complaints, the facility did not effectively resolve the issue, as evidenced by repeated grievances and lack of improvement in call light response times. Interviews with residents and staff revealed that the problem persisted, with residents experiencing long wait times for assistance, leading to accidents in their briefs. The Activity Director (AD) confirmed that call light response times and inappropriate phone use by staff were major concerns. Although grievance forms were submitted, responses were inconsistent, and some grievances related to call light issues were not addressed. The Assistant Director of Nursing (ADON) reported conducting night shift observations without finding concerns, and staff had been educated multiple times. However, the facility's policy on grievances, which mandates prompt resolution efforts, was not effectively implemented, resulting in ongoing resident dissatisfaction.
Non-Smoking Policy Violation in LTC Facility
Penalty
Summary
The facility failed to adhere to its non-smoking policy, allowing residents who had not been assessed for smoking to smoke on the premises and keep smoking materials in their rooms. This deficiency was observed in six residents, all of whom had various medical conditions that could be exacerbated by smoking. Despite the facility's policy stating it was a non-smoking environment, residents were found smoking on the grounds, and some admitted to keeping cigarettes and lighters in their rooms. Resident 6, who had chronic obstructive pulmonary disease (COPD) and other health issues, was observed smoking in the parking lot. His care plan indicated he was a smoker and should comply with the facility's smoking policy, but there was no documentation of a smoking assessment in his records. Similarly, Resident 22, with schizoaffective disorder and COPD, kept cigarettes in her room, contrary to the policy. Resident 7, who also had COPD, admitted to smoking on the facility grounds and keeping smoking materials in his car. Other residents, such as Resident 67 with schizophrenia and dementia, and Resident 77 with dementia and PTSD, were also found to be non-compliant with the smoking policy. They kept smoking materials in their rooms and smoked on the premises. Resident 26, with dementia and anxiety, was observed smoking with the help of another resident, despite having a behavioral contract prohibiting smoking on facility grounds. The facility's Executive Director and staff acknowledged the lack of smoking assessments and the failure to enforce the non-smoking policy, contributing to the deficiency.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to properly label and date medications when opened and did not remove expired medications from use, as observed in three of five medication carts and one of two refrigerators. On the 600 hall medication cart, an albuterol inhaler and a trelegy ellipta inhaler for a resident, as well as a fluticasone nasal spray for another resident, were found without dates indicating when they were opened. On the 700 hall medication cart, expired Humalog insulin pens for two residents and a glargine insulin pen for another resident were found, along with a carboxymethyl solution without an opening date. On the 800 hall medication cart, insulin pens and a nasal spray for two residents were also found without opening dates. Additionally, the medication room refrigerators on the 600, 700, and 800 halls contained a vial of tuberculin that had expired and a bottle of aplisol with an unclear date. These observations indicate a failure to adhere to the facility's policy of ensuring medications are stored according to manufacturer's recommendations, which includes proper labeling, dating, and removal of expired medications.
Failure to Complete Resident Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that resident assessments were completed for a resident who self-administers medications. Resident 15 was observed to have medications in her room, including fluticasone nasal spray, carboxymethylcellulose eye drops, and metronidazole lotion. The physician's orders allowed Resident 15 to self-administer these medications, but the facility's documentation was incomplete. The Medication Self-Administration Safety Screen dated 1/3/24 only assessed the fluticasone nasal spray, while the eye drops and topical creams were not considered applicable. Furthermore, the resident's electronic medical record lacked documentation of quarterly self-administration assessments for all three medications. A new Medication Self-Administration Safety Screen dated 8/5/24 assessed only the carboxymethylcellulose eye drops, omitting the fluticasone and metronidazole. The medication care plan dated 4/4/24 indicated that Resident 15 could self-administer eye medication and face cream, but did not specifically list the metronidazole lotion. During an interview, Resident 15 mentioned that the facility staff had taken away her rosacea medication, which she had previously been allowed to keep in her room. The facility's policy on self-administration of medications requires an interdisciplinary team assessment, which was not adequately documented in this case.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately code falls on the Minimum Data Set (MDS) for a resident in the Memory Care unit. The resident, who had Alzheimer's disease, experienced a fall on her right hip after being found in another resident's bed and was escorted back to her room. This incident resulted in an acute, impacted, nondisplaced right subcapital femoral neck fracture, which required surgical repair. However, the significant change MDS assessment initially indicated no falls since admission or prior assessment, and a subsequent assessment failed to note the fracture resulting from the fall. The facility's policy on accurate assessment, effective at the time, was not adhered to, as the resident's status was not accurately reflected in the MDS assessments.
Insufficient Weekend Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure sufficient licensed nurse coverage on weekends during one of the four quarters reviewed, potentially affecting all 82 residents. The CASPER report indicated staffing concerns were triggered in the second quarter of 2024 due to low weekend staffing. Upon reviewing the licensed nursing schedule for May 2024, it was found that the licensed staff per-patient-per-day (PPD) trended down throughout the month, with several days not meeting the minimum required PPD. Specific days, including Thursdays and weekends, showed PPDs below the minimum threshold, with the lowest being 0.19 on a Sunday. During an interview, the Executive Director (ED) acknowledged the staffing issues and noted that leadership staff, such as the Medical Records Coordinator and the Assistant Director of Nursing, were primarily scheduled for weekday office hours. The ED suggested that some of these hours could be rearranged to cover weekends. The Facility Assessment Tool, dated May 20, 2024, indicated the required minimum PPD for RNs and LPNs, which was not met according to the schedule review. The ED confirmed that the Facility Assessment Tool served as the policy for staffing requirements.
Deficiency in Person-Centered Care for Residents with Dementia
Penalty
Summary
The facility failed to ensure that two cognitively impaired residents, who wished to have a relationship and resided on the secured memory care unit, had appropriate assessments, ongoing supervision, and person-centered goals and interventions. The report highlights that the facility did not adequately document or revise care plans to reflect the residents' preferences and behaviors, particularly regarding their relationship. This lack of documentation and revision in care plans contributed to the deficiency. Resident 53, who was severely cognitively impaired with a BIMS score of 3 out of 15, had a history of wandering and seeking affection from male residents. Despite her family's approval of her relationship with Resident 55, the facility did not update her care plan to include her preference for companionship with him. Additionally, her behavioral assessments lacked documentation of her seeking affection, and her activity assessments did not reflect her meaningful relationship with Resident 55. Resident 55, who was moderately cognitively impaired with a BIMS score of 10 out of 15, also had a care plan that did not address his relationship with Resident 53. His behavioral assessments did not document his feelings towards her, and his activity assessments lacked information about his preference for companionship. The facility's failure to incorporate these aspects into their care plans and assessments resulted in a deficiency in providing person-centered care for these residents.
Failure to Provide Person-Centered Care and Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure the secured memory care unit provided person-centered care, supervision, and engaging activities to prevent resident-to-resident altercations and/or accidents. This deficiency affected all 30 residents in the secured memory care unit. Observations, interviews, and record reviews revealed that residents frequently wandered into each other's rooms, leading to altercations and injuries. For instance, Resident L, who had a history of verbal and physical aggression, pushed Resident B, causing him to fall and sustain severe head injuries. Resident B had been agitated and wandering the halls, and staff attempts to put him to bed only increased his agitation. The facility lacked adequate supervision and activities to redirect residents, especially during the night shift when the activity room was closed and no materials for redirection were available. Resident L's family member reported that she had experienced a decline in cognitive abilities and an increase in aggression, leading to her transfer to the facility. Despite being placed in a room near the activity room, Resident L was frequently disturbed by other residents wandering into her room, which agitated her further. The facility's attempts to use a Velcro stop-sign to prevent other residents from entering her room were ineffective. Resident L's care plan lacked person-centered interventions to address her history of aggression and need for personal space. The facility also failed to provide adequate supervision and engaging activities for other residents, leading to multiple resident-to-resident altercations. For example, Resident EE wandered into Resident GG's room, resulting in an altercation where Resident EE sustained an abrasion. Similarly, Resident X wandered into Resident M's room, leading to an altercation where Resident X sustained a skin tear and bruising. Observations during the survey period showed continuous unsafe and unsupervised wandering by several residents, with no staff intervention or redirection. The care plans for these residents lacked person-centered, specialized interventions for dementia care and intrusive wandering.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a non-verbal, cognitively impaired resident was free from abuse. During the survey, a video provided by the family showed Qualified Medication Aide (QMA) 11 and Certified Nurse Aide (CNA) 12 providing incontinence care to Resident B. The video captured CNA 12 hitting Resident B on the left arm and upper abdomen with both open hands and yelling at the resident. QMA 11 did not intervene to stop the abuse and did not reposition Resident B's legs or reassure her during the incident. Family members, who were watching the care live through a web camera, voiced their concerns to the staff during the incident. The facility's grievance log indicated that a grievance was filed by the family on the same day, and an abuse investigation was ongoing. Interviews with staff and family members revealed that Resident B had a history of cognitive impairment and required assistance with activities of daily living. QMA 11 and CNA 12 were providing care when the incident occurred. QMA 11 admitted to witnessing CNA 12 hit Resident B and reported the incident to the oncoming nurse. Family members had previously installed a web camera in Resident B's room due to concerns about her care. The family provided the video evidence to the facility and filed a grievance. The facility's Director of Nursing (DON) confirmed that the abuse prevention policy was in place, which included training staff to manage residents' verbal or physical aggression and monitoring staff behavior. Resident B's medical records indicated diagnoses of Pick's disease, general anxiety disorder, depression, and psychotic disorder with delusions. The care plans for Resident B included interventions for cognitive impairment, impulsivity, and communication difficulties. The records lacked documentation of the incident, and focused charting on the day of the incident did not indicate any signs of emotional distress or changes in Resident B's condition. The facility's policy emphasized the residents' right to be free from abuse and the importance of staff training and monitoring to prevent such incidents.
Failure to Immediately Report and Intervene in Resident Abuse
Penalty
Summary
The facility failed to ensure staff immediately reported to the Administrator witnessed abuse by another staff member to a resident. The incident involved Resident B, who was being cared for by a Qualified Medication Aide (QMA) and a Certified Nurse Aide (CNA). During the care, the CNA hit Resident B on the left arm and upper abdomen, and yelled at the resident. The QMA did not intervene or stop the abuse and did not reposition Resident B's legs or reassure her. The incident was witnessed by Resident B's family members through a web camera, who voiced their concerns during the event. The QMA attempted to call the Administrator but did not receive a response and did not make further attempts to report the incident immediately. The Administrator received multiple calls reporting the abuse allegation later in the morning from other staff members and Resident B's family. The QMA provided a handwritten statement the following day, indicating she had called the Administrator but did not receive a response. The Administrator's call log showed no missed calls from the QMA. The facility's policy required immediate reporting of abuse to the Administrator or the Director of Nursing (DON) if the Administrator was unavailable. The QMA did not follow up with additional calls or notify the DON as required by the policy. Resident B's medical records indicated she had diagnoses including Pick's disease, general anxiety disorder, depression, and psychotic disorder with delusions. The resident had adequate hearing and vision, was not comatose, and sometimes understood others. The facility's policy on abuse prevention emphasized the importance of immediate reporting of any suspected abuse to facility management. The failure to report the abuse immediately and the lack of intervention during the incident led to the deficiency cited in the report.
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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) |
|---|---|---|---|---|
| Avon Health & Rehabilitation Center | 1.2 mi | — | 5 | 0 |
| Countryside Meadows | 2.8 mi | — | 15 | 0 |
| Danville Regional Rehabilitation | 3.6 mi | — | 0 | 0 |
| Plainfield Health Care Center | 4.6 mi | — | 11 | 1 |
| Brooke Knoll Village | 4.8 mi | — | 9 | 0 |
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