Avalon Rehab and Care Center

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to date, label, and/or cover food products stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 154 of 159 residents who consume food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of 42 sampled residents (Resident (R) 2) were treated with dignity and respect in a manner and environment that maintained their quality of life. This failure had the potential to negatively impact the quality of life and self-esteem for the affected residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to inform and provide written information for 13 out of 19 residents (Residents (R ) 9 R10, R11, R15, R17, R19, R36, R92, R99, R117, R121, R140 and R142 concerning the right to accept or refuse medical or surgical treatment and, at the resident's or family's or legal representative's option, to formulate and advance directive. This failure had the potential to affect the residents' and their legal representatives' right to participate in and be informed of his or her treatment.

Inspectors wroteBased on record review and interviews the facility failed to ensure Pre-admission Screen and Resident Review (PASARR), an evaluation for serious mental illness and/or intellectual disability, Level I (preliminary assessment) was accurately completed to identify the resident's psychiatric diagnoses for two out of seven residents, (Resident (R) 5 and R19). The failure to accurately complete the assessment created the potential for R5 and R19 not to be assessed to receive specialized services as needed. Findings Include:1. Review of R5's admission Record, found in the electronic medical record (EMR) under the Profile tab, revealed R5 was initially admitted to the facility on [DATE] with diagnoses that included bipolar disorder. [...]

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to provide assistance with activities of daily living (ADLs) for five residents (Resident (R) 6, 16, 9, 140, and R36) reviewed for activities of daily living (ADLs) out of a total sample of 33. This failure increased the potential for residents to have unmet hygiene needs.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure proper personal protective equipment (PPE), was donned (put on) by Licensed Practical Nurse (LPN) 1 prior to entering into one of six sample residents (Resident (R) 92's) room who was under enhanced barrier precaution. This increased the likelihood that infectious organisms could be transmitted from residents to staff, other residents, or the environment.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide reasonable access to a telephone without being overheard. This deficient practice was identified for 1 of 3 residents reviewed, Resident#1, and as evidenced by the following:The surveyor reviewed the electronic medical record (EMR) for Resident #1. A review of the resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to, schizophrenia (a long-lasting brain disorder that affect how people think logically) and mild intellectual disabilities (below average cognitive functioning). [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents were provided with written transfer/discharge notice that contained the option to appeal the transfer/discharge for four of four residents (Resident (R) 50, R110, R123, and R57) reviewed for facility initiated emergent hospital transfer of 33 sample residents. This failure had the potential to affect the residents and their Resident Representative by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents and/or resident representatives were provided with a written bed hold notice for facility initiated emergent hospital transfer for four of four residents (Resident (R) 50, R110, R123, R57) reviewed for facility initiated emergent hospital transfers of 33 sample residents. This failure had the potential for the residents to be denied return to their original room or denial of the resident returning to the facility.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure a care plan was revised quarterly for one of 36 residents (Resident (R) 103) reviewed for care plan revision. Specifically, the facility failed to schedule quarterly care conferences or invite R103 to the scheduled care conferences.

Inspectors wroteC#NJ 148344 C#NJ 148677 Based on observation, interview, and facility policy review, the facility failed to ensure window screens were in good repair, open windows had screens; and failed to ensure walls and floors in resident rooms were maintained in clean condition for 10 of 53 rooms. This failure created a non-homelike environment.

Inspectors wroteC#NJ 148344 Based on observation interview, and facility policy review, the facility failed to ensure the meal menu was followed. This failure had the potential to result in weight loss and/or continued hunger for 40 of 119 residents.

Inspectors wroteC#NJ 172626 Based on observation, record review, interview, and review of the facility's policy, the facility failed to ensure an Injury of Unknown origin was immediately reported to the State Survey Agency in accordance with the required timeframes for one of five residents (Resident (R) 20) reviewed for injuries of unknown origin out of a total sample of 24. R20 was found with redness and swelling to the right foot on 03/26/24 which resulted in a fracture of the fifth metatarsal bone. The facility did not report the injury of unknown origin until 03/29/24, which was four days later. This failure placed the resident at risk of possible abuse when.

Inspectors wroteBased on observation, interview and review of the facility's policy, the facility failed to ensure medications were locked in a secure storage area and only authorized personnel had access to the medications. Observation revealed medications delivered by the pharmacy was left at a nurses' station where residents, visitors, and unauthorized employees had access to the medications. This had the potential to cause injury to residents who would ingest them or to residents who need them in the event they are stolen due to not being supervised. This had the potential to affect the 93 residents residing on the second floor with a census of 119.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow physician orders for blood pressure (BP) parameters according to standards of clinical practice for one of 24 residents reviewed (Resident #18). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to routinely and accurately post the nurse staffing information on four of 10 days during the survey period in a place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 11/28/22 at 8:48 AM, upon entry into the facility, the surveyor observed that the Nursing Home Staffing Report Form (NHSRF) that was posted in the reception area of the lobby showed a staffing report dated 11/28/22 with the census of 115 for Day Shift 7 AM - 3 PM. On that same date and time, the Licensed Nursing Home Administrator (LNHA) provided a copy of the facility's census in the presence of the Regional LNHA (RLNHA) and the Regional Director of Nursing (RDON). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to perform handwashing appropriately for two of five staff (agency Certified Nursing Aide (aCNA) and Supply Clerk/CNA) observed during incontinence care in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for infection control and facility policy. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines, Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 01/18/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and apply for a change in ownership upon 30 days of their sale in April 2022 in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. [...]