Majestic Care of Avon

In the surveyor’s words

From the most serious findings on record at Majestic Care of Avon, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 2, 2021

  A. Based on observation, interview, and record review, the facility failed to ensure a resident with a history of suicidal ideation (thinking about or planning suicide) and verbal threats of harming himself was supervised and free from items that could be used to harm himself for 1 of 3 residents reviewed for behavioral symptoms which resulted in an immediate jeopardy when Resident D while on 15-minute checks injured himself by breaking a glass plate and cutting his neck and verbalized he would commit suicide if he did not leave the facility; and after verbalizing threats of suicide again and while on 15 minute checks Resident D stabbed himself in the abdomen multiple times with a fork and was observed with a corded telephone in his room during multiple observations. B. […]

• No harm, potential for more than minimal, widespreadF725Aug 22, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure sufficient staffing for the second quarter of 2025, sufficient staffing to prevent falls and to provide routine activities of daily living (ADLs), and sufficient staffing to address ongoing resident grievance concerns. This deficient practice had the potential to affect 80 of 80 residents who resided in the facility. Findings include:1. Based on the review of the Payroll Based Journal (PBJ) staffing data for the second quarter of 2025, the facility was identified by the Centers of Medicare and Medicaid Services (CMS) as triggering for excessively low weekend staffing. […]

• No harm, potential for more than minimal, widespreadF908Aug 22, 2025

  Based on observations and interviews, the facility failed to ensure all kitchen equipment was in proper working order. This deficient practice had the potential to affect 80 of 80 residents who ate meals in the facility.Findings include:On 8/17/25 at 1:36 p.m. an initial tour of the kitchen was conducted. The freezer was observed; the walls, fans and ceiling of the freezer had drips of water that had been frozen over, and boxes that had been pushed up against the wall had water damage on the cardboard, ice on top of the boxes and some boxes were frozen together.During an interview on 8/17/25 at 2:20 p.m. […]

• No harm, potential for more than minimal, widespreadF812Jun 30, 2023

  Based on observation, interview, and record review, the facility failed to ensure the kitchen foods were dated, all refrigeration units had working thermometers, the kitchen was clean, and staff facial hair was covered for 3 of 3 kitchen observations, and the facility failed to ensure staff used appropriate hand hygiene with making, delivering, and assisting to fed residents for 4 of 4 random observations (Residents 4, 59, 71, and 95). Findings include: 1. On 6/25/23 at 9:46 a.m., a trash can was observed uncovered. On 6/25/23 at 9:48 a.m., Dietary Aide (DA) 34 was observed wearing a surgical mask in the kitchen, the sides of his beard were exposed. On 6/25/23 at 9:49 a.m., the Kitchen Manager in Training (KMIT) provided a tour of the kitchen. […]

• No harm, potential for more than minimal, patternF565Aug 22, 2025

  Based on observation, interview, and record review, the facility failed to appropriately follow up to grievances made by individual residents and as a group during resident council for 12 of 12 months of resident council minutes reviewed and for 2 of 2 meetings with residents observed. Findings include:On 8/19/25 at 2:00 p.m. the Activities Director provided copies of Resident Council meeting minutes going back to August 2024.A Resident Council Minutes form, dated 8/8/24, indicated under old business there were no snacks on the weekends. […]