Inspection Reports for Avon Health & Rehabilitation Center
4171 FOREST POINTE CIRCLE, AVON, IN, 46123
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 12, 2025, found Avon Health & Rehabilitation Center in compliance with life safety and licensure requirements, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to life safety code issues, such as electrical hazards and fire drill procedures, as well as resident care concerns including medication management, care planning, and infection prevention. Complaint investigations were mostly unsubstantiated or found no related deficiencies, except for a substantiated medication error involving transdermal patches in August 2023 and an elopement risk due to unsecured doors in January 2023. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent clean inspection suggests improvement in addressing prior deficiencies, particularly in life safety compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
110% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
75% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 103
Capacity: 137
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/11/25 was performed to verify compliance with life safety and licensure requirements.
Findings
At this PSR survey, Avon Health & Rehabilitation Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for one detached wooden shed used for storage.
Report Facts
Facility capacity: 137
Resident census: 103
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on January 28, 2025.
Findings
Avon Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 103
Capacity: 137
Deficiencies: 2
Date: Feb 11, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101, Life Safety Code, Chapter 19.
Findings
The facility was found not in compliance with Life Safety from Fire requirements. Deficiencies included an unsafe electrical junction box in a riser room and failure to verify fire alarm signal transmission during fire drills for 10 of 12 drills in the past year.
Deficiencies (2)
Failed to ensure 1 of 3 riser rooms were maintained in a safe operating condition due to exposed wires and improperly secured electrical conduit.
Failed to ensure 10 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station.
Report Facts
Certified beds: 137
Census: 103
Fire drills lacking verification: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian P McKamie | Administrator | Facility Administrator present at exit conference and verified repairs |
| Director of Maintenance | Named in deficiency related to electrical conduit and fire drill verification; involved in corrective actions and interviews | |
| Regional Maintenance Director | Present at exit conference and involved in discussion of deficiencies | |
| Maintenance Assistant | Educated on fire drill verification requirements | |
| Executive Director | Verified repairs and reviewed fire drill documentation |
Inspection Report
Annual Inspection
Census: 27
Capacity: 108
Deficiencies: 5
Date: Jan 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00448672, IN00446400, and IN00447062, and a State Residential Licensure Survey.
Complaint Details
Complaints IN00448672, IN00446400, and IN00447062 were investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have several deficiencies including failure to complete a new level of care PASARR for a resident, failure to revise a care plan related to advanced directives, failure to prevent urinary tract infections in a resident with a suprapubic catheter, inadequate dementia care activities for a resident in isolation, and failure to manage a resident's medication regimen for unnecessary psychotropic medications. No deficiencies were cited related to the investigated complaints.
Deficiencies (5)
Failed to complete a new level of care Pre-admission screening and resident review (PASARR) for a resident with psychosis diagnosis.
Failed to revise a comprehensive resident centered care plan related to advanced directives to reflect resident's current wishes.
Failed to ensure treatment and services to prevent urinary tract infections for a resident with a suprapubic catheter.
Failed to adequately implement care planned interventions and provide activities for a resident in isolation on the dementia care unit.
Failed to manage a resident's medication regimen for unnecessary psychotropic medications in the absence of documented behaviors or specific conditions.
Report Facts
Survey dates: January 21, 22, 23, 24, 27, and 28, 2025
Census Bed Type: 108
Residential Census: 27
Medication dosages: 100
Medication dosages: 12
Medication dosages: 100
Medication dosages: 7.5
Medication dosages: 325
Medication dosages: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian P McKamie | Administrator | Signed the report |
| Director of Nursing | Director of Nursing | Provided information and policies related to deficiencies and corrective actions |
| CNA 125 | Certified Nursing Assistant | Observed interacting with Resident 72 and provided information about resident care |
| Son of Resident 265 | Interviewed regarding Resident 265's medication and condition | |
| Hospice nurse | Interviewed regarding Resident 265's medication | |
| Activity Director | Activity Director | Provided information about activities for residents in isolation and dementia care |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00428030.
Complaint Details
Complaint IN00428030 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 141
Census Bed Type - SNF/NF: 114
Census Bed Type - SNF: 1
Census Bed Type - Residential: 26
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 28
Census Payor Type - Total: 115
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 3, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on November 20, 2023.
Findings
Avon Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 110
Capacity: 137
Deficiencies: 2
Date: Jan 2, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included a missing escutcheon on a sprinkler head in a corridor and a set of smoke barrier doors that did not fully close, potentially affecting residents and staff.
Deficiencies (2)
Missing escutcheon on the sprinkler head outside resident room #101 in the corridor.
Set of smoke barrier doors in the corridor leading to the Assisted Living area did not fully close, leaving a one-inch gap.
Report Facts
Certified beds: 137
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged missing escutcheon and smoke barrier door issues during observations and interviews | |
| Facility Administrator | Discussed deficiencies during exit conference |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 01/02/24 was completed on 02/20/24.
Findings
Avon Health & Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 113
Capacity: 140
Deficiencies: 6
Date: Nov 20, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of three complaints (IN00419946, IN00417946, and IN00416459).
Complaint Details
Complaints IN00419946, IN00417946, and IN00416459 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including accuracy of assessments, unnecessary drug use, food temperature and safety, hand hygiene during feeding assistance, service plan documentation, and medication labeling. No deficiencies were related to the investigated complaints.
Deficiencies (6)
Failed to accurately code the MDS with appropriate PASRR Level 2 information for 2 of 3 residents reviewed.
Failed to ensure a resident was observed for adverse effects related to opiate medication and failed to set parameters for medication administration.
Failed to ensure Memory Care residents received warm food during lunch services for 25 of 25 residents observed.
Failed to ensure staff washed their hands appropriately while assisting Memory Care residents with eating for 2 of 3 lunch observations.
Failed to ensure residents and/or their representatives were provided a copy of their most recent Service Plan with a signature of acknowledgement for 8 of 8 residents reviewed.
Failed to ensure over-the-counter medications were properly labeled for 11 of 27 residents.
Report Facts
Survey dates: 6
Census Bed Type: 140
Census Payor Type: 113
Residents reviewed for service plan: 8
Residents with unlabeled OTC medications: 11
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414436 and IN00414657 concerning medication errors related to transdermal medication patches.
Complaint Details
The investigation was triggered by complaints IN00414436 and IN00414657. The complaints were substantiated with federal deficiencies cited at F760 related to medication errors involving transdermal patches.
Findings
The facility failed to ensure that transdermal medication patches were removed per physician's orders for 1 of 11 residents reviewed, resulting in a resident being found with two scopolamine patches simultaneously, which contributed to altered mental status and hospitalization. The facility conducted an investigation, educated staff, and implemented corrective actions prior to the survey.
Deficiencies (1)
Failed to ensure transdermal medication patches were removed per physician's order for 1 of 11 residents reviewed.
Report Facts
Census: 118
Medicare residents: 15
Medicaid residents: 83
Other residents: 20
SNF/NF beds: 116
SNF beds: 2
Medication patches in box: 10
Patches remaining in box: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
Paper compliance review related to an unrelated deficiency cited during the Investigation of Complaints IN00401425 and IN00402596 completed on June 20, 2023.
Findings
Avon Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the unrelated deficiency cited during the complaint investigations.
Inspection Report
Complaint Investigation
Census: 117
Capacity: 143
Deficiencies: 1
Date: Jun 19, 2023
Visit Reason
This visit was for the investigation of complaints IN00401425 and IN00402596. No deficiencies related to the allegations were cited, but an unrelated deficiency was identified regarding call light placement.
Complaint Details
Complaint IN00401425 and Complaint IN00402596 were investigated with no deficiencies related to the allegations cited.
Findings
The facility failed to ensure call lights were within reach for 7 of 13 residents observed, posing a risk to resident safety. The residents affected had various diagnoses and care plans indicating fall risk and need for assistance. Staff acknowledged the issue and corrective actions were planned.
Deficiencies (1)
Failed to ensure call lights were within reach for 7 of 13 residents observed.
Report Facts
Residents observed with call light placement issues: 7
Census SNF/NF beds: 117
Census Residential beds: 26
Total licensed capacity: 143
Medicare census: 12
Medicaid census: 82
Other payor census: 23
Complaint investigation survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Brummitt | RN, DON | Signed as Laboratory Director's or Provider/Supplier Representative |
| RN 7 | Indicated resident F was primarily dependent and did not always use the call light | |
| RN 10 | Observed entering Resident H's room during survey | |
| LPN 6 | Indicated Resident L required assistance and did not routinely use call light | |
| LPN 12 | Indicated Resident P was declining and required assistance; also commented on Resident Q's call light use | |
| QMA 14 | Qualified Medication Aide | Observed walking by Resident P's room without responding to call |
| Assistant Director of Nursing | ADON | Interviewed regarding call light policy and staff responsibilities |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00391937 completed on January 19, 2023.
Complaint Details
Investigation of Complaint IN00391937 completed on January 19, 2023; facility found in compliance.
Findings
Avon Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 120
Capacity: 146
Deficiencies: 1
Date: Jan 17, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00391937, IN00392507, IN00393626, IN00394231, and IN00399010) regarding the facility's compliance and resident safety.
Complaint Details
Complaint IN00391937 was substantiated with federal/state deficiencies cited at F689. Other complaints IN00392507, IN00394231, and IN00399010 were substantiated but no deficiencies were cited. Complaint IN00393626 was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure proper management and oversight of a confused resident (Resident B) resulting in elopement due to a service hallway door that did not close or latch properly and an exit door that was not alarmed. The resident was found outside in the employee parking lot, leading to mental anguish risks. The facility has since repaired the doors, installed alarms, and reviewed elopement risk policies.
Deficiencies (1)
Failed to ensure management and oversight of a confused resident resulting in elopement due to unsecured service hallway doors and exit doors.
Report Facts
Census Bed Type - SNF/NF: 118
Census Bed Type - SNF: 2
Census Bed Type - Residential: 26
Total Capacity: 146
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 73
Census Payor Type - Other: 32
Total Census: 120
Elopement Risk Assessment Score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Brummitt | RN, DCS | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Nurse Practitioner 20 | Provided late entry notes regarding Resident B's condition and elopement incident | |
| Housekeeper 13 | Reported on keypad lock installation and door issues | |
| Certified Nursing Assistants 7 and 9 | CNA | Observed door issues and assisted Resident B after elopement |
| Licensed Practical Nurse 8 | LPN | Witnessed Resident B being escorted back into the building after elopement |
| Contracted Construction Workers 17 and 18 | Demonstrated door alarm system and keypad lock functionality | |
| Assistant Director of Clinical Services | ADCS | Provided notes and interviews regarding Resident B and door issues |
| Maintenance Supervisor | Reported on door maintenance and keypad installation | |
| Regional Nurse | Reported on alarm system functionality and incident | |
| Licensed Practical Nurse 19 | LPN | Described alarm system and staff response procedures |
| Director of Clinical Services | DCS | Provided facility elopement/missing resident policy |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 139
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00396199.
Complaint Details
Complaint IN00396199 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint IN00396199 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 139
Census Payor Type Total: 110
SNF/NF Beds: 106
SNF Beds: 4
Residential Beds: 29
Medicare Residents: 7
Medicaid Residents: 75
Other Payor Residents: 28
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 30, 2022
Visit Reason
Paper compliance to the Recertification and State Licensure review completed on August 22, 2022.
Findings
Avon Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regards to the paper compliance review to the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 124
Capacity: 137
Deficiencies: 6
Date: Sep 19, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain emergency power system inspection and testing documentation, failure to maintain battery powered emergency lights, improper exit signage, lack of annual testing of battery backup lights, failure to test electrical receptacles annually, and incomplete generator load testing records.
Deficiencies (6)
Failed to implement emergency power system inspection, testing, and maintenance requirements; missing monthly load test documentation for September 2021.
Battery-operated emergency light in 100 Hall mechanical closet failed to function during test.
Failed to ensure annual 90-minute testing of two battery backup lights and maintain written records of visual inspections and tests.
One door to the outside was improperly identified as both an exit and not an exit, causing contradictory signage.
Failed to ensure approximately 450 nonhospital-grade electrical receptacles at resident room locations were tested at least annually per NFPA 99 requirements.
Failed to maintain a complete written record of monthly generator load testing for one of the last 12 months (September 2021).
Report Facts
Certified beds: 137
Census: 124
Battery backup lights: 2
Nonhospital-grade electrical receptacles: 450
Generator load test months missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Interviewed regarding generator testing, emergency lighting, and electrical receptacle testing deficiencies. | |
| Facility Administrator | Participated in exit conference and acknowledged deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
The document reports on paper compliance for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey conducted on 09/19/22 and completed on 10/27/22.
Findings
Avon Health & Rehabilitation Center was found in compliance with the Emergency Preparedness Requirements and Life Safety Code requirements for Medicare/Medicaid participation.
Inspection Report
Recertification
Census: 120
Capacity: 146
Deficiencies: 11
Date: Aug 22, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00381444, IN00384815, and IN00386296.
Complaint Details
Complaint IN00381444 - Substantiated with no deficiencies cited. Complaint IN00384815 - Unsubstantiated due to lack of evidence. Complaint IN00386296 - Substantiated with no deficiencies cited.
Findings
The facility had substantiated complaints with no deficiencies cited related to the allegations. Deficiencies were cited related to failure to notify physicians of changes, medication management, privacy breaches, criminal background checks, assessment accuracy, hospice care, accident prevention, dialysis care, dementia care, and emergency preparedness.
Deficiencies (11)
Failed to notify resident's physician of change in condition related to increased pain and medication refusal.
Failed to maintain resident privacy by improperly disposing medication containers with identifiable information.
Failed to complete criminal background checks for all newly hired employees prior to starting work.
Failed to accurately code Minimum Data Set (MDS) for resident with PASRR Level II condition.
Failed to ensure hospice orders were transcribed and plan of care revised accordingly for resident receiving hospice services.
Failed to ensure timely repair or replacement of broken bed to prevent resident falls and failed to ensure medications were not left at bedside.
Failed to ensure appropriate care and labeling of enteral feeding for resident receiving tube feeding.
Failed to ensure post-dialysis assessments were completed after resident's dialysis appointments.
Failed to ensure resident was informed of reason for move to secured memory care unit, failed to assess accurately, and failed to implement less restrictive interventions prior to move.
Failed to maintain updated fire and disaster preparedness plan, failed to ensure all staff had annual fire and disaster education, and failed to complete required fire drills on all shifts.
Failed to ensure resident service plans included information for care of diagnosed mental illnesses.
Report Facts
Survey dates: 2022-08-15 to 2022-08-22
Total beds: 146
Current census: 120
Fire drills required: 12
Fire drills completed in AL: 2
Shifts QMA 17 worked: 7
Shifts CNA 16 worked: 4
Pre-Dialysis assessments: 58
Post-Dialysis assessments: 14
Shifts Resident 25 worked: 27
Hours Resident 25 worked: 170.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident 21 | Named in deficiency related to failure to notify physician of pain and medication refusal | |
| RN 21 | Registered Nurse | Named in deficiency related to failure to notify physician of Resident 21's condition |
| CNA 19 | Certified Nursing Assistant | Named in deficiency related to medication refusal by Resident 21 |
| Housekeeper 25 | Named in deficiency related to missing criminal background check | |
| DON | Director of Nursing | Named in multiple deficiencies including pain management, hospice care, dialysis care, emergency preparedness |
| ADON | Assistant Director of Nursing | Named in deficiency related to medication refusal notification |
| RN 23 | Registered Nurse | Named in deficiency related to Resident 32 behavior assessment |
| CNA 18 | Certified Nursing Assistant | Named in deficiency related to Resident 32 aggressive behavior |
| CNA 20 | Certified Nursing Assistant | Named in deficiency related to Resident 32 aggressive behavior |
| Resident 32 | Named in deficiency related to move to secured memory care unit without proper assessment and consent | |
| Resident 35 | Named in deficiency related to dialysis post-assessment | |
| Resident 41 | Named in deficiency related to broken bed and fall | |
| Resident 44 | Named in deficiency related to enteral feeding care | |
| Resident 104 | Named in deficiency related to medication administration and vision impairment | |
| Resident 26 | Named in deficiency related to mental health care plan | |
| Resident 11 | Named in deficiency related to mental health care plan |
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