Avon Health Center

In the surveyor’s words

From the most serious findings on record at Avon Health Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 17, 2026

  Based on interviews, observations, clinical record review, and review of facility policy for the only sampled resident reviewed for respiratory care (Resident #29), the facility failed to maintain a safe environment for a resident (Resident #29) on continuous oxygen by allowing long-term unsupervised use of petroleum-based jelly on the face and lips without a physician order, staff oversight, or self-administration assessment. Staff were aware of the resident's repeated use of petroleum jelly but did not intervene, despite flammability warning on the oxygen equipment and established contraindications. […]

• Actual harm, isolatedF689Jul 22, 2025

  Based on review of clinical records, facility documentation, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was provided care in accordance with physician orders and the plan of care to prevent a fall resulting in a femur fracture that required a closed non-surgical reduction of fractured bone. Resident #1 was admitted to the facility with diagnoses that included Alzheimer's disease, anxiety, and osteoarthritis. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severe cognitive impairment, required extensive assistance with two (2) staff for bed mobility, and was incontinent. […]

• No harm, potential for more than minimal, patternF695Jul 22, 2024

  Based on clinical record reviews, observations, review of policy for 2 of 2 residents ( Resident # 32 and Resident # 52) reviewed for respiratory treatment, the facility failed to ensure the residents nebulizer tubing was changed and stored according to facility policy. The findings included: 1. Resident #32's diagnoses included centrilobular emphysema and presence of a cardiac pacemaker. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 was moderately cognitively intact and required one person assist with bed mobility, supervision with transfers, eating and toileting. […]

• No harm, potential for more than minimal, patternF812Aug 31, 2022

  Based on observations of the kitchen, facility policy and interviews, the facility failed to ensure foods were stored and prepared under sanitary conditions, hair net was covering hair, food temperature were taken before serving food, food was labeled and dated and the nourishment refrigerator was free from dirty, food in refrigerator and freezer were labeled or dated in a sanitary manner within professional standards. The findings included: Tour of the Kitchen with the Director of Dietary on 8/24/22 at 10:00 AM identified the following: 1 10:10 AM the cook was observed in front of the stove with a large tray in her hands. Cook #1 had her hair net on only covering the back half of her hair without the benefit of it covering the front half and her bangs. […]

• No harm, potential for more than minimal, isolatedF610Mar 17, 2026

  Based on review of the clinical record, interviews, facility documentation and facility policy for 1 of 2 residents (Resident #76) reviewed for mistreatment, the facility failed to complete a thorough investigation related to an allegation of untimely incontinent care. The findings include: Resident #76 was admitted to the facility in March 2021 with diagnoses that included cerebral infarction (CVA), hypertension, and behavior disturbances.Physician orders dated 7/16/25 directed to provide 2 caregivers for care. […]