Avon Oaks Nursing Home

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 114 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 60.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 78 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 99 beds and averages 91.3 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.82 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.17 hrs/resident/day on weekends vs 4.68 on weekdays — 11% thinner on weekends. RN hours go from 0.87 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

• Potential for harm · E2026-03-19 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 transfers.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. Review of the MDS assessment revealed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-19 · tag F0551 — isolated
  Give the resident's representative the ability to exercise the resident's rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident record review, resident interviews, staff interviews, and facility document review, the facility failed to honor Resident #51's preferences. This affected one resident (#51) of one reviewed for preferences. The facility census was 92.Findings include:Review of the medical record for Resident #51 revealed he was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cerebral infarction, muscle weakness and difficulty in walking.Review of the physician orders dated 10/24/24 revealed an order for fall prevention per protocol.Review of the physician orders dated 01/22/25 revealed an order for perimeter mattress and floor mat for fall prevention.Review of the progress note dated 01/21/26 at 4:16 P.M. revealed Resident #51 had a care plan meeting that indicated he was at risk of wandering and was at high risk for falls.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a Brief Interview for Mental Status…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident record review, resident and staff interviews, the facility failed to ensure Resident #95, who was dependent on staff for care, was assisted with activities of daily living (ADL). This affected one resident (#95) of one reviewed for ADL. The facility census was 92.Findings include:Review of the medical record for Resident #95 revealed he was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, acquired absence of the right leg above the knee, type 2 diabetes, dysphagia oral phase and oropharyngeal phase and need for assistance with personal care.Review of the physician orders dated 08/05/25 revealed an order for fall prevention per protocol.Review of the physician orders dated 09/22/25 revealed an order for a no added sugar and no concentrated sweets diet, mechanical soft texture and regular and/or thin consistency.Review of the nutritional risk assessment dated [DATE] revealed Resident #95 remained malnourished.Review of the care plan dated 02/08/26…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, resident and staff interviews, and facility policy review, the facility failed to ensure weight loss prevention interventions were completed as ordered. This affected two residents (#11 and #65) of two residents reviewed for nutrition. The facility census was 92.Findings include:1. Review of the medical record for Resident #11 revealed she was admitted to the facility on [DATE] with diagnoses that included moderate protein-calorie malnutrition, paraplegia, and dysphagia oropharyngeal phase.Review of the physician orders dated 09/26/25 revealed an order for a regular diet, regular texture and regular consistency with a Greek yogurt daily at breakfast.Review of the physician orders dated 01/25/26 revealed an order to weigh Resident #11 every Sunday.Review of the care plan dated 02/14/26 revealed Resident #11 had potential fluid deficit related to sepsis and had a nutrition and/or hydration risk due to moderate protein calorie malnutrition with interventions that included monitoring…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident record review, resident and staff interviews, and facility policy review, the facility failed to ensure respiratory care was implemented as ordered for Resident #65. This affected one resident (#65) of one reviewed for respiratory care. The facility census was 92.Findings include:Review of the medical record for Resident #65 revealed she was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypercapnia, shortness of breath, dependence on supplemental oxygen, and chronic respiratory failure with hypercapnia.Review of the physician orders dated 01/15/26 revealed an order for 2 liters per minute (LPM) of oxygen as needed for shortness of breath and to maintain pulse oximetry over 92 percent (%) as needed and oxygen continuously via nasal cannula.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. Review of the MDS…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 01/13/25 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 unlabeled cup containing an unknown liquid, and two undated and unlabeled cups with straws. Interview at the time of observation, with Dietary Aide #223, confirmed the areas of concern and stated all items in the refrigerator belonged to staff, and stated although staff were not supposed to store…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-01-16 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 400-hall. The facility census was 88. Findings include: 1. Review of the medical record revealed Resident #25 revealed an admission date of 02/20/24. Diagnoses included encounter for palliative care, asthma, hyperlipidemia, peripheral…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-16 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, resident representative interview, staff interview, and policy review, the facility failed to ensure a resident's representative was provided notification of the resident's change in condition. This affected one (#23) of one resident reviewed for notification of change in condition. The facility census was 88. Finding include: Review of the medical record revealed Resident #23 had an admission date of 12/09/16. Diagnoses included hemiplegia and hemiparesis, aphasia, obstructive and reflux uropathy, benign prostatic hyperplasia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. The resident had an indwelling catheter. Review of a nurses progress note dated 01/04/25 at 12:33 A.M., revealed the resident had new physician orders for the antibiotic gentamicin 160 milligrams intramuscular three times a day for seven days for a urinary tract infection. The resident was also ordered laboratory…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-16 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interview, the facility failed to ensure Notice of Medicare Non Coverage (NOMNC) notification was provided in writing to the resident or family member prior to services ending. This affected two (#198 and #199) of three reviewed for notices. The facility census was 88. Findings include: Review of the medical record revealed Former Resident #198 received Medicare Part A skilled services with an episode start date of 07/24/24 and a last date of coverage of Part A Service being 09/23/24. Review of the undated and untimed NOMNC revealed a telephonic notification was communicated to the family. There was no evidence of the written NOMNC being sent to the resident or family regarding the discharge date of 09/23/24. Review of the medical record revealed Former Resident #199 received Medicare Part A skilled services with an episode start date of 09/13/24 and a last date of coverage of Part A Service being 10/29/24. Review of the NOMNC revealed a telephonic notification was communicated on 10/26/24 to family. There was no evidence of the written NOMNC being…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-16 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, family interview, resident interview, and medical record review, the facility failed to ensure alternative methods of communication were provided to facilitate adequate communication for a resident who spoke limited English. This affected one (#349) of one resident reviewed for alternate methods of communication. The facility census was 88. Findings include: Review of the medical record revealed Resident #349 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic kidney disease, hypertension, muscle weakness, and difficulty in walking. Review of the admission Minimum Data Set assessment dated [DATE] revealed a brief interview for mental status was not completed due to Resident #349 being rarely or never understood. Resident #349's primary language was Serbian and the resident needed/wanted an interpreter to communicate with a doctor or health care staff. Review of the current plan of care dated 10/31/24 revealed Resident #349 had an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to COLEV GESTETNER — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH