Avon Oaks Nursing Home

In the surveyor’s words

From the most serious findings on record at Avon Oaks Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 16, 2025

  Based on observation, staff interview, and review of policy, the facility failed to ensure food items were labeled and dated and further failed to ensure refrigerators did not contain expired items. This had the potential to affect all 87 residents who received food from the kitchen. The facility identified one Resident (#32) as receiving nothing by mouth (NPO). The facility census was 88. Findings include: 1. Observation on [DATE] from approximately 8:10 A.M. to 8:45 A.M. with Dietary Aide #223 revealed the following concerns: In the refrigerator located in the kitchen, there were two undated and unlabeled cups containing a yellow substance, one undated and unlabeled zip-lock bag containing crackers, one undated and unlabeled plate containing an unknown food substance, one undated and… […]

• No harm, potential for more than minimal, patternF558Mar 19, 2026

  Based on observations, resident record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure call lights were within reach. This affected four residents (#6, #13, #73, and #95) of four residents reviewed for call lights. The facility census was 92.Findings include:1. Review of the medical record for Resident #6 revealed he was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of the right hand, and contracture, left and right knee.Review of the physician orders dated 10/04/22 revealed an order for fall prevention per protocol.Review of the physician orders dated 08/16/24 revealed an order for Hoyer (mechanical lift) for… […]

• No harm, potential for more than minimal, patternF880Jan 16, 2025

  Based on observation, staff interview, review of facility Transmission Based Precautions (TBP) postings, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policies and documents, the facility failed to ensure proper infection control practices were implemented related to residents on TBP. This affected seven residents (#10, #46, #58, #63, #98, and #349), and had the potential to affect 55 ( Resident #2, #3, #4, #6, #7, #11, #12, #14, #15, #16, #17, #19, #22, #23, #24, #25, #28, #30, #31, #32, #34, #35, #36, #38, #39, #40, #42, #43, #48, #52, #54, #59, #60, #64, #67, #68, #70, #71, #72, #74, #76, #77, #79, #83, #86, #87, #97, #99, #100, #101, #198, #347, #348, #350, and #351) additional residents residing on the 100-hall, 300-hall, and… […]

• No harm, potential for more than minimal, isolatedF600Aug 28, 2026

  Based on medical record review, review of video footage, staff interview, resident representative interview, and policy review the facility failed to ensure residents were free from abuse by staff. This affected one (#1) of three residents reviewed for abuse. The facility census was 94.Findings include:Review of the medical record for Resident #1 revealed an admission date of 01/23/25 with diagnoses that included Parkinson's disease, dementia, and cognitive communication deficit. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required hands on assistance of two staff persons for completing her activities of daily living (ADLs) including dressing, bathing, and toileting. […]

• No harm, potential for more than minimal, isolatedF609Aug 28, 2026

  Based on medical record review, review of self-reported incidents, review of video footage, resident representative interview, staff interview, and policy review, the facility failed to report an allegation of abuse to the State Survey Agency as required. This affected one (#1) of three residents revealed for abuse. The facility census was 94.Findings include:Review of the medical record for Resident #1 revealed an admission date of 01/23/25 with diagnoses that included Parkinson's disease, dementia, and cognitive communication deficit. […]