Avon, IN

Majestic Care Of Avon

2-star overall rating with 1-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

445 S County Road 525 E, Avon, IN

(317) 745-2522

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

117

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Majestic Care

Operator or chain grouping

Approved since

1989-08-07

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

34 facilities

Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.54

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.73

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.53

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.80

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.27

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.31

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.35

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.46

CMS adjusted RN staffing hours

Adjusted total hours

3.26

CMS adjusted total nurse staffing hours

Case-mix index

1.59

Higher values indicate more complex resident acuity

RN turnover

69%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,371

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

Composite VBP score used to determine payment impact.

Payment multiplier

0.9817

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

2.38

Baseline 62.67% · Performance 53.95% · Measure score 2.38 · Achievement 2.38 · Improvement 1.81

Adjusted total nurse staffing

1.02

Baseline 2.14 hours · Performance 2.69 hours · Measure score 1.02 · Achievement 0 · Improvement 1.02

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.32%	10.72% 1.4 pts better	No Different than the National Rate · Eligible stays 31 · Observed rate 0% · Lower 95% interval 5.56%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.27	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 20 · Denominator 20
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 20
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 20 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 79
Staff flu vaccination coverage	44.53%	42% 2.5 pts better	Numerator 57 · Denominator 128
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.2%	93.6% 0.6 pts better	93.4% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 93.3% · Q3 97.5% · Q4 89.7% · 4Q avg 94.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.1%	95.4% 0.3 pts worse	95.5% 0.4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1%
Percentage of long-stay residents experiencing one or more falls with major injury	4.8%	3.8% 1 pts worse	3.3% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.0% · Q3 5.0% · Q4 6.4% · 4Q avg 4.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	65.5%	24.6% 40.9 pts worse	11.4% 54.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 67.1% · Q2 63.4% · Q3 65.8% · Q4 65.8% · 4Q avg 65.5%
Percentage of long-stay residents who lose too much weight	8.8%	5.6% 3.2 pts worse	5.4% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 11.1% · Q3 6.7% · Q4 11.6% · 4Q avg 8.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	37.3%	23.5% 13.8 pts worse	19.6% 17.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 37.5% · Q3 38.7% · Q4 39.1% · 4Q avg 37.3%
Percentage of long-stay residents who received an antipsychotic medication	14.2%	14.8% 0.6 pts better	16.7% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 13.0% · Q3 10.0% · Q4 15.4% · 4Q avg 14.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	4.9%	13.3% 8.4 pts better	16.3% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.5% · Q3 2.2% · Q4 10.2% · 4Q avg 4.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.6%	11.7% 8.1 pts better	14.9% 11.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 1.4% · Q4 7.7% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.4% 0.4 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.9%	1.2% 0.7 pts worse	1.7% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 1.2% · Q4 1.3% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.4%	24.2% 0.8 pts better	19.8% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 25.9% · Q3 35.0% · Q4 18.5% · 4Q avg 23.4%
Percentage of long-stay residents with pressure ulcers	2.5%	4.1% 1.6 pts better	5.1% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.9% · Q3 1.9% · Q4 2.7% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	70.7%	81.6% 10.9 pts worse	81.7% 11 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 65.5% · Q2 81.8% · Q3 79.2% · Q4 58.3% · 4Q avg 70.7%
Percentage of short-stay residents who newly received an antipsychotic medication	2.5%	1.3% 1.2 pts worse	1.6% 0.9 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	65.2%	79.0% 13.8 pts worse	79.7% 14.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 65.2%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-22 · Fire 2025-08-22

10 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2024-08-08 · Fire 2024-08-08

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

5 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 3 Health 2023-06-30 · Fire 2023-06-30

15 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-08-22

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-10-17

E · Potential for more than minimal harm 2025-08-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-17

E · Potential for more than minimal harm 2025-08-22

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-10-17

E · Potential for more than minimal harm 2025-08-22

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-08-22

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-10-17

F · Potential for more than minimal harm 2024-08-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-10

F · Potential for more than minimal harm 2024-08-08

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-09-10

F · Potential for more than minimal harm 2024-08-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-09-10

E · Potential for more than minimal harm 2024-08-08

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-09-10

E · Potential for more than minimal harm 2024-08-08

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-10-10

F · Potential for more than minimal harm 2023-06-30

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-08-04

E · Potential for more than minimal harm 2023-06-30

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-17

E · Potential for more than minimal harm 2023-06-30

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-08-04

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-08-22

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-10-01

F · Potential for more than minimal harm 2025-08-22

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-10-01

E · Potential for more than minimal harm 2025-08-22

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-10-01

E · Potential for more than minimal harm 2025-08-22

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-10-01

E · Potential for more than minimal harm 2025-08-22

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-10-01

E · Potential for more than minimal harm 2025-08-22

F807 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-22

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-22

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-10-01

E · Potential for more than minimal harm 2025-06-25

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-07-17

D · Potential for more than minimal harm 2025-06-25

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2025-07-17

E · Potential for more than minimal harm 2024-08-08

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-08-08

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-08-08

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-08

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-08

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-08

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-08-08

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-03-13

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2024-04-12

D · Potential for more than minimal harm 2024-02-06

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-02-06

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-03-01

F · Potential for more than minimal harm 2023-06-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-08-04

E · Potential for more than minimal harm 2023-06-30

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2023-08-04

E · Potential for more than minimal harm 2023-06-30

F574 · Resident Rights Deficiencies

Health

The resident has the right to receive notices in a format and a language he or she understands.

Corrected 2023-08-04

E · Potential for more than minimal harm 2023-06-30

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-08-04

E · Potential for more than minimal harm 2023-06-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-08-04

E · Potential for more than minimal harm 2023-06-30

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2023-08-04

E · Potential for more than minimal harm 2023-06-30

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2023-08-04

D · Potential for more than minimal harm 2023-06-30

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-08-04

D · Potential for more than minimal harm 2023-06-30

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-08-04

D · Potential for more than minimal harm 2023-06-30

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-08-04

B · Minimal harm 2023-06-30