Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of a facility policy, the facility failed to notify the Certified
Nurse Practitioner (CNP) or Physician of a residents elevated blood pressure in accordance with a
physician order. This affected one (#63) out of five residents reviewed for unnecessary medications. The
facility census was 97.
Findings include:
Medical record review revealed Resident #63 admitted to the facility on [DATE]. Diagnosis included
Alzheimer's disease, hypertension, hypertensive encephalopathy, non-traumatic subdural hemorrhage,
hypertensive heart disease and anemia.
Review of Resident #63's physician orders revealed an order dated 02/12/19 instructing staff to notify the
CNP if the resident's systolic blood pressure was greater than 160 millimeters of mercury (mmHg).
Review of the residents vital signs record revealed Resident #63's systolic blood pressure was greater than
160 mmHg on the following instances: on 06/17/19 at 7:35 A.M. blood pressure reading 160/62; on
06/18/19 at 4:18 P.M. blood pressure reading 167/71; on 06/23/19 at 8:00 A.M. blood pressure reading
178/60; on 06/23/19 at 4:33 PM. blood pressure reading 178/73; on 06/26/19 at 8:12 A.M. blood pressure
reading 183/62; on 06/27/19 at 8:04 A.M. blood pressure reading 181/75; on 07/01/19 at 6:13 P.M. blood
pressure reading 166/62; on 07/02/19 at 7:36 A.M. blood pressure reading 162/63; on 07/03/19 at 7:51
A.M. blood pressure reading 176/74; on 07/11/19 at 9:46 A.M. blood pressure reading 186/69; on 07/12/19
at 7:46 A.M. blood pressure reading 164/69 and on 07/15/19 at 4:27 P.M. blood pressure reading 162/73
Review of Resident #63's progress notes revealed no evidence the facility notified the CNP or Physician of
the residents systolic blood pressure readings greater than 160 mmHg on the dates listed.
Interview on 07/17/19 at 3:26 P.M. the Director of Nursing (DON) confirmed the resident's systolic blood
pressure was greater than 160 mmHg on 06/17/19, 06/18/19, 06/23/19, 06/26/19, 06/27/19, 07/01/19,
07/02/19, 07/03/19, 07/11/19, 07/12/19 and 07/15/19. The DON further confirmed the facility was unable to
provide evidence the facility notified the CNP or Physician of the blood pressure readings.
Review of a facility policy titled, Monitoring of Vital Signs for Residents, most recent revision date 12/18/19,
revealed if a resident's vital signs were out of normal range, or specific perimeter
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
365762
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365762
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avon Oaks Nursing Home
37800 French Creek Rd
Avon, OH 44011
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
as ordered by physician, the nurse was to call and inform the physician or hold medications as ordered.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365762
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365762
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avon Oaks Nursing Home
37800 French Creek Rd
Avon, OH 44011
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of a facility policy, the facility failed to develop a
comprehensive plan of care for a resident who was receiving anticoagulation therapy. This affected one
resident (#25) out of five residents reviewed for comprehensive care plans. The facility census was 97.
Findings included:
Review of the medical record revealed Resident #25 admitted to the facility on [DATE]. Diagnoses included
paroxysmal atrial fibrillation and Diabetes mellitus.
Review of the quarterly Minimum Data Sets (MDS) assessment, dated 06/30/19, revealed the resident's
cognition was intact. Further review revealed the resident received an anticoagulant medication seven of
the seven review days.
Review of the resident's physician orders, dated 05/24/19, revealed the resident was ordered Eliquis (blood
thinning medication) five milligram twice a day. Review of the administration record for 07/2019 revealed the
medication was administered as ordered.
Review of the most recent plan of care, dated 05/21/19, revealed no plan of care developed for the
resident's anticoagulation therapy.
Interview on 07/18/19 at 9:37 A.M., Registered Nurse (RN) #300 revealed all resident's who were on
anticoagulant medication were supposed to have a plan of care initiated to monitor the anticoagulation
therapy. RN #300 confirmed a plan of care for Resident #25's anticoagulation therapy was not developed.
Review of a facility policy titled, MDS 3.0 Comprehensive Assessment and Care Planning, most recent
revision date 06/18/19, revealed the facility was supposed to develop a comprehensive assessment and
plan of care for each resident. The plan of care was to include measurable objectives and timetables to
meet residents' medical, functional, mental and psychosocial needs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365762
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365762
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avon Oaks Nursing Home
37800 French Creek Rd
Avon, OH 44011
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of a facility policy, the facility further failed to initiate their
bowel protocol when a resident did not have a bowel movement for three days. This affected one (#63) out
of five residents reviewed. The facility census was 97.
Residents Affected - Few
Findings include:
Medical record review revealed Resident #63 admitted to the facility on [DATE]. Diagnosis included
Alzheimer's disease, hypertension, hypertensive encephalopathy, non-traumatic subdural hemorrhage,
hypertensive heart disease and anemia.
Review of the resident's bowel tracking revealed the resident did not have a bowel movement for three
consecutive days on 05/15/19 through 05/17/19, 05/20/19 through 05/22/19, 06/03/19 through 06/05/19
and 07/02/19 through 07/04/19.
Review of the residents physician orders revealed an order to administer Milk of Magnesia every 24 hours
as needed for constipation. If ineffective, the resident was to be administered a Biscolax suppository every
24 hours. If the suppository was ineffective, the resident was supposed to be administered a Phosphate
Enema.
Review of the resident's 05/2019, 06/2019 and 07/2019 Medication Administration Record, revealed no
documented evidence the resident was administered Milk of Magnesia, Biscolax suppository or Phosphate
Enema on 05/15/19 through 05/17/19, 05/20/19 through 05/22/19, 06/03/19 through 06/05/19 or 07/02/19
through 07/04/19.
Interview on 07/17/19 at 1:57 P.M., the Director of Nursing (DON) confirmed the resident had no
documented bowel movements on 05/15/19 through 05/17/19, 05/20/19 through 05/22/19, 06/03/19
through 06/05/19 or 07/02/19 through 07/04/19. The DON further confirmed there was no evidence staff
followed the facility bowel protocol for Resident #63.
Review of a facility policy titled, Bowel Program, most recent revision date 04/2019, revealed if a resident
had not had a bowel movement in three days the resident would be administered Milk of Magnesium, on
day three, with the bedtime medication administration. If ineffective by breakfast ends the following morning,
the resident was to be administered a Bisacodyl suppository. If that was not effective staff were to
administer an enema. If no results, the physician was to be notified.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365762
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365762
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avon Oaks Nursing Home
37800 French Creek Rd
Avon, OH 44011
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of controlled drug records, staff interview and policy review, the facility failed
to ensure accurate documentation of administered Ativan (anti-anxiety medication) on the medication
administration record. This affected one (#46) of five residents reviewed for medications. The facility
identified 12 residents receiving as needed antianxiety medications. The facility census was 97.
Findings include:
Medical record review revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included
Alzheimer's disease, depressive disorder, diabetes mellitus type two, depression, psychotic disorder with
delusions and dementia with behavioral disturbances.
Review of a physician orders dated 03/26/19 and 07/10/19 revealed Resident #46 was ordered Ativan 0.5
milligrams by mouth every eight hours as needed (PRN) for agitation.
Review of the controlled drug records (CDR) and medication administration record (MAR) from 05/09/19
through 07/15/19 revealed 12 doses of Ativan were signed out on the CDR and not documented on the
MAR. These included doses of Ativan administered on 05/09/19, 06/12/19, 06/17/19, 06/27/19, 06/29/19,
07/03/19, 07/09/19, 07/10/19 and 07/15/19.
Interview on 07/18/19 at 10:48 A.M. with the Unit Manager Registered Nurse (RN) #308 verified 12 tablets
of Ativan were not documented as administered on the MAR on 05/09/19, 06/12/19, 06/17/19, 06/27/19,
06/29/19, 07/03/19, 07/09/19, 07/10/19 and 07/15/19.
Review of the policy for the Standards for Medication Administration, dated 03/2015 revealed after
administering medication it was the responsibility of the nurse to document the administration of the
medication on the medication administration record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365762
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365762
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avon Oaks Nursing Home
37800 French Creek Rd
Avon, OH 44011
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents did
not receive unnecessary medication when they administered mediation outside of administration
parameters set forth by the physician. This affected one (#63) out of five residents reviewed for
unnecessary medications. The facility census was 97.
Residents Affected - Few
Findings include:
Medical record review for Resident #63 admitted to the facility on [DATE]. Diagnosis included Alzheimer's
disease, hypertension, hypertensive encephalopathy, non-traumatic subdural hemorrhage, hypertensive
heart disease and anemia.
Review of Resident #63's physician orders revealed the resident was ordered Carvedilol (a medication to
treat high blood pressure and heart failure) 3.125 milligrams to be administered twice a day. Further review
revealed the medication was supposed to be withheld if the resident systolic blood pressure was less than
100 millimeters of mercury (mmHg) or if her heart rate was less than 55 beats per minute (BPM).
Review of Resident #63's Medication Administration Record (MAR) revealed the resident was administered
Carvedilol seven separate times despite the resident's heart rate being below 55 BPM. The resident
received Carvedilol on the following instances and with the following pulse readings: on 05/07/19 at 8:00
A.M. pulse was 52 BPM; on 05/27/19 at 8:00 A.M. pulse was 49 BPM; on 05/30/19 at 8:00 A.M. pulse was
51 BPM; on 05/31/19 at 5:00 P.M. pulse was 54 BPM; on 06/13/19 pulse was 53 BPM and on 07/02/19 at
8:00 A.M. pulse was 52 BPM.
Interview on 07/17/19 at 1:57 P.M , the Director of Nursing (DON) confirmed the resident's Carvedilol was
ordered to be withheld if her systolic blood pressure was less than 100 and/or her heart rate was less than
55 BPM. The DON verified the resident was administered the medication on 05/07/19, 05/27/19, 05/30/19,
05/31/19, 06/13/19 and 07/02/19, and the resident's heart rate was less than 55 BPM when administered.
Review of a facility policy titled, Standards for Medication Administration, dated 03/2015, revealed when a
resident's medication administration was dependent upon laboratory values or vital sign measures,
monitoring and appropriate documentation would occur according to the facility policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365762
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365762
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/18/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avon Oaks Nursing Home
37800 French Creek Rd
Avon, OH 44011
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff interview, and review of a facility policy, the facility failed to ensure laboratory
testing was completed per physician orders. This affected one (#25) out of four residents sampled. The
facility census was 97.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #25 admitted to the facility on [DATE]. Diagnoses included
paroxysmal atrial fibrillation and Diabetes mellitus.
Review of the quarterly Minimum Data Sets (MDS) assessment, dated 06/30/19, revealed the resident's
cognition was intact. Further review revealed the resident received an anticoagulant medication seven of
the seven review days.
Review of a laboratory test result, dated 06/17/19, revealed the resident's red blood cell count, hemoglobin
and hematocrit were low. Written on the lab was stool for occult (a fecal test to check for blood). The
laboratory test was signed by the physician on 06/17/19.
Review of the resident's 06/2019 and 07/2019 physician orders revealed no order to test the resident's stool
for occult blood. Further review of the resident's Medication Administration and Treatment Record for
06/2019 and 07/2019 revealed no evidence the testing was completed.
Interview on 07/18/19 at 9:32 A.M., the Director of Nursing (DON) confirmed an order to obtain stool for
testing was written on a laboratory test result dated 06/17/19. The DON revealed staff failed to transcribe
the information and the order was never initiated nor was the testing completed.
Review of a facility policy titled, Laboratory results-verification system, most recent revision date 12/2018,
revealed the facility was to ensure laboratory services were accurate and timely and results were reviewed
and acted upon, so the utility of laboratory testing for diagnosis, treatment, prevention or assessment was
maximized to meet the needs of residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365762
If continuation sheet
Page 7 of 7
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
FAQ · About this visit
Common questions about this visit
What happened during the July 18, 2019 survey of AVON OAKS NURSING HOME?
This was a inspection survey of AVON OAKS NURSING HOME on July 18, 2019. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVON OAKS NURSING HOME on July 18, 2019?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.