Oaks at Avon

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF577Jun 11, 2024

  Based on observation and interview, the facility failed to ensure previous survey/inspection results were readily available for residents and families to review for a census of 95 residents. Findings included: On 06/11/24 at 10:06 a.m. an observation of the facility lobby area did not immediately reveal the location or presence of past survey information/availability for review. During an interview with the Regional Nurse Consultant (RNC) on 06/11/24 at 10:11 a.m., she stated The book must be in the Nursing Home Administrator's [NHA] office. The RNC went into the NHA's office and produced a binder titled Annual Surveys. Additionally, the RNC stated the book is normally kept on the lower shelf of a table by the facility's main entrance. On 06/11/24 at 10:15 a.m. […]

• No harm, potential for more than minimal, patternF919Jan 20, 2026

  Based on observations, interviews and record review, the facility failed to ensure all resident rooms had maintained and working call light/call light devices in one of two units and on three of three halls (100, 200, and 300) to include resident rooms 101, 102, 200, 202, 204, 209, 304, and 300.Findings include: On 1/20/2026 at 9:10 a.m. the following resident rooms were observed with the following concerns: *Resident room [ROOM NUMBER] call light was tested twice at 9:27 a.m. the light in the hallway above the room door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]a call light was tested twice at 9:13 a.m. the light in the hallway above the door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]a call light was tested three times at 9:28 a.m. […]

• No harm, potential for more than minimal, patternF645Jun 11, 2024

  Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review form (PASRR) was completed to include accurate admission diagnoses, and updated when new diagnoses were added for five residents (#83, #86, #200, #201 and #74) of 15 residents sampled. Findings included: 1. Review of the Admission Record showed Resident #83 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder and anxiety. Review of the care plan for Resident #83 showed: -[Resident #83] uses psychotropic medications r/t [related to] anxiety, date initiated: 02/05/2024. […]

• No harm, potential for more than minimal, patternF812Jun 11, 2024

  Based on observation, interview and record review the facility failed to ensure the kitchen was maintained in a clean and sanitary manner related to not ensuring the dishwashing machine reached the required wash temperature, not sanitizing beverage carts prior to beverage service, not ensuring cookware was in good condition, and not ensuring expired food was removed from the walk in refrigerator that could potentially affect 87 residents of a census of 95. Findings included: An observation on [DATE] of the two dietary aides (Staff A and Staff E) at 9:58 a.m. revealed they were washing the dishes from the breakfast service. […]

• No harm, potential for more than minimal, isolatedF644Jun 11, 2024

  Based on interviews and record review the facility did not ensure the recommendations from a Level II Preadmission Screening and Resident Review (PASRR) were initiated for one resident (#7) out of 15 residents sampled. Findings included: Review of the Admission Record revealed Resident #7 had an initial admitted [DATE] with a readmitted [DATE]. Resident #7 had a primary diagnosis of hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting the left non-dominant side. […]