Avalon Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. On 11/20/25 at 9:15 AM, the surveyor in the presence of the Food Service Director (FSD#1) observed the following during the kitchen tour:1. In preparation area #1, the surveyor observed a can opener with a reddish caked-on debris on the handle and can opener blade. Also observed on the spice rack; 16-ounce (oz) garlic powder, 16oz taco seasoning, 16oz poultry seasoning, 16oz old bay seasoning, 16oz plastic bottle with a yellowish oil-like substance, and 26oz container of salt all opened and without a use by or discard labels. [...]

Inspectors wroteRefer to 756Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that a physician's order for an as needed (PRN) anti-anxiety medication was limited to 14 days for 1 of 6 residents (Resident #89) and b.) follow up on a physicians recommendation for a gradual dose reduction (GDR) of an antipsychotic medication for 1 of 6 residents (Resident #27) reviewed for unnecessary medications. This deficient practice was evidenced by the following:1. On 11/20/2025 at 11:45 AM, the surveyor observed Resident #89 sitting in front of the nurse's station. The surveyor reviewed the electronic medical record (EMR) for Resident #89. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observations, record reviews, interviews and review of pertinent facility documents, it was determined that the facility failed to ensure that blood and urine lab testing ordered by the physician was completed to monitor and potentially identify changes in a resident's health. This deficient practice was identified for one (1) of one (1) resident, Resident #4, reviewed for completion of ordered lab tests. The deficient practice was evidenced by the following: On 11/20/25 at 12:31 PM, during the initial tour, the surveyor observed Resident #4 lying in bed with their eyes closed and a sheet pulled up to their chest. The surveyor reviewed the electronic medical records (EMR) for Resident #4. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint # NJ2666691 Based on observations, interviews, record review, and pertinent facility documents it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission and b.) were seen by the attending physician or Nurse Practitioner (NP) every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 4 of 4 residents (Resident #2, #6, #10, and #125) reviewed for physician visits. This deficient practice was evidenced by the following:1. On 11/20/25 at 10:57 AM, the surveyor observed Resident #10 sitting in their chair with their eyes closed. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #10. [...]

Inspectors wroteRefer to F 605Based on observations, interviews, review of the medical record, and review of other facility documentation, it was determined that the facility failed to respond to the monthly Consultant Pharmacist (CP) recommendations. This deficient practice was identified for 2 of 6 residents reviewed for unnecessary medications (Resident #89 and #27). The deficient practice was evidenced by the following: 1. On 11/20/2025 at 11:45 AM, the surveyor observed Resident #89 sitting in front of the nurse's station. The surveyor reviewed the electronic medical record (EMR) for Resident #89. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observations, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to follow fall prevention interventions as written on the resident's plan of care. This deficient practice was identified for 1 of 4 residents (Resident #120) reviewed for accidents. This deficient practice was evidenced by the following: On 11/20/2025 at11:50 AM, the surveyor observed Resident #120 in bed. There was a fall mat on the floor to the right side of the bed. The surveyor reviewed the electronic medical record (EMR) for Resident #120. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint # NJ 2601539 Based on observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication, nourishment supplementation and monitoring administration times to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times and was not administered on nine (9) dialysis days from an admission in August 2025 until discharged in September 2025. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to have a process in place to post the daily per shift nurse staffing report. This deficient practice was identified on 11/24/2025. This deficient practice was evidenced by the following: On 11/24/2025 at 8:30 AM, the surveyor observed nurse staffing posted at the front receptionist desk for Friday 11/21/25, day shift. On 11/25/2025 at 9:50 AM, the surveyor interviewed the Staffing/Human Resource (SHR) staff member, who stated she posted the staffing at the desk for day and evening shifts and the night supervisor posted the night shifts. The surveyor asked who posted the staffing on the weekend, the SHR stated I do when I come in on Monday. She added the weekend supervisors do not have access to the reports so she did it on Monday, so it was the real count. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a.) insulin pen devices were dated when opened and had expiration dating on the label in two (2) of four (4) medication carts inspected, b.) a medication for inhalation (Budesonide) was labeled when opened and had expiration dating in one (1) of four (4) medication carts inspected, and c.) an insulin pen device was labeled appropriately with a resident's name (Resident #178) in one (1) of four (4) medication carts inspected. The deficient practices were evidenced by the following: On 11/25/25 at 10:32 AM, the surveyor, in the presence of another surveyor, inspected the 200 Hall medication cart in the presence of the Registered Nurse (RN #1). [...]

Inspectors wroteBased on interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a significant medication error did not occur by failing to administer 14 doses of a physician ordered antihypertensive (medicine used to control high blood pressure) medication to a resident who was subsequently transferred to the hospital for uncontrolled hypertension on 8/12/25 and was diagnosed with a Hypertensive Emergency. This deficient practice was identified for 1 of 2 residents reviewed for change in condition (Resident #3) and was evidenced by the following: On 10/24/25 at 10:00 AM, the surveyor reviewed the electronic medical record for Resident #3 which revealed the following: An Emergency Department hospital record with a Physician (MD) History and Physical dated 8/12/2025 at 21:09 (9:09 PM) revealed: Chief Complaint: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents on 8/7/25, it was determined that the facility failed to follow a resident's care plan interventions to provide safe transfer of a resident utilizing a mechanical lift. Resident #2 was assessed by the facility to weight bear as tolerated and required the use of a mechanical lift for transfers. On 3/11/2025, Resident #2 requested staff transfer the resident from a chair to their bed. The resident became anxious and did not want to wait for the mechanical lift to be transferred. Resident #2 began to slide themself forward from the chair. Two staff members transferred the resident to bed without the use of the mechanical lift. After this transfer occurred, the resident began to complain of pain and a diagnosis of fracture of right distal tibia/fibula was made. [...]

Inspectors wroteComplaint: NJ176793 Based on interviews, medical record review, and review of pertinent facility documentation on 5/27/25 and 5/29/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit with in the initial 30 day time period. The facility also failed to follow its policy titled, Physician Visits. This deficient practice was identified for 1 of 9 residents (Resident #2). This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) on 5/27/25 and 5/29/25 was as follows: According to Resident #2's admission Record (AR), the resident was admitted to the facility in October 23, 2023, with diagnoses that included but were not limited to: Schizophrenia, Asthma, and Diabetes. [...]

Inspectors wroteComplaint: NJ176793 Based on interviews, record review, and review of other pertinent facility documentation on 05/29/2025, it was determined that the facility staff failed to a.) consistently document the care provided in the Documentation Survey Report v2 (DSR) b.) follow the facility's policy titled, Point of Care (POC) Documentation. for a resident (Resident #2). This deficient practice was identified for 1 of 9 residents (Resident #2) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to Resident #2's admission Record (AR), the resident was admitted to the facility with diagnoses that included but were not limited to: Schizophrenia, Asthma, and Diabetes. [...]

Inspectors wroteNJ00181366, NJ00175401. Based on observation, record review of the medical records, and other pertinent facility documents on 3/11/25 and 3/12/25, it was determined that the facility failed to ensure that a resident received care in accordance with professional standards of practice, 1.) failing to follow Physician's order; 2.) failing to monitor a resident that required continuous oxygen; and 3.) failing to ensure that a resident's oxygen concentrator was on . This deficient practice was identified for 1 of 6 residents, (Resident #1), reviewed for oxygen usages and was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but not limited to: [...]

Inspectors wroteC#: NJ 00181366, NJ00175401 Based on interviews, record review, and review of other pertinent facility documents on 03/11/2025, 03/12/2025, it was determined that the facility failed to address a family concern of resident #4 with bathing and changing of clothes. This deficient practice was identified for 1 of 6 residents, Resident #4, and was evidenced by the following: According to the admission Record (AR), Resident #4 was admitted on [DATE] with diagnoses that included but were not limited to Psychoactive Substance Dependence with Psychoactive Substance-Induce Mood Disorder, (depressive, anxiety, psychotic, or manic symptoms that occur as a physiological consequence of the use of substances of abuse or medications), Muscle Wasting and Atrophy (is a loss of muscle and strength). [...]

Inspectors wroteNJ00181366, NJ00175401. Based on observation, record review of the medical records, and other pertinent facility documents on 3/11/25 and 3/12/25, it was determined that the facility failed to update and revised a resident's Comprehensive Care Plan for 1 of 6 residents (Resident #1), reviewed for oxygen. The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered. According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but not limited to: Acute and Chronic Respiratory Failure with Hypercapnia (the body can't adequately remove carbon dioxide, leading to a buildup in the blood), Pneumonia (lung infection) and Chronic Obstructive Pulmonary Disease The Minimum Data Set (MDS), an assessment on, 01/04/2024 re-admitted to facility on 2/05/2024 and was discharged . [...]

Inspectors wroteNJ00181366, NJ00175401. Based on observation, interview, and record review it was determined that the facility failed to administer the correct oxygen dose as order according to the Physician's order for 1( Resident#2) of 6 resident reviewed for respiratory care and services. The deficient practice was evidenced by the following information: On 3/11/2025 at 10:10 a.m.,the Surveyor and Unit Manager (UM) entered Resident #2 room and observed resident in bed with nasal cannula out of both nostrils and concentrator towards the wall in resident room. According to the gauge on the concentrator (indicate how much oxygen was being delivered to the resident). The Surveyor observed the gauge at 3 liters of oxygen per minute. The Surveyor interviewed UM at this time, she confirmed the oxygen rate was set at 3 liter per minute. [...]

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure residents were free from abuse for one (1) of five (5) residents (Resident #13) reviewed for abuse. In addition, this failure has the potential to affect 143 other residents residing in the facility who were not protected from the alleged perpetrator. The facility's failure to ensure all residents were free from abuse, by not investigating an allegation of abuse reported by Resident #13 posed a likelihood of serious harm to Resident #13 and all residents. This resulted in an Immediate Jeopardy (IJ) situation. On 06/11/24 at 9:50 PM, the Administrator and Director of Nursing (DON) were notified that the failure to identify and protect one resident from alleged abuse which constituted an Immediate Jeopardy to the health and safety of all residents in the facility at F 600: [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that two (2) of two (2) residents (Resident #13 and Resident #40) reviewed for accident hazards were given adequate supervision while transporting hot liquids. This failure caused Resident #13 to have a first degree burn on the pelvic area on 01/05/24 and a first degree burn to the abdomen with second degree burns on the left thigh and penis on 05/10/24. Both burns resulted from Resident #13 heating up coffee in the unit microwave which was located in the unlocked nutritional room on the unit. On 11/01/23, Resident #40 suffered a second degree burn to the right hip from self-transferring coffee from the dining room. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure one of seven medication carts was secured and failed to remove expired supplements and blood equipment from one of two medication storage rooms. This failure has the potential to expose residents to hazards of unsecure medications and expired equipment.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to accurately complete Medicare Part A form Centers for Medicaid and Medicare Services (CMS)-10123 Notice of Medicare Non-Coverage (NOMNC) for one of three residents (Resident (R) 6) and accurately complete CMS Skilled Facility Nursing Advanced Beneficiary (SNFABN) CMS-10055 form for two of three residents (R6 and R79) reviewed for beneficiary notices of 29 sample residents. The forms were used to notify Medicare Part A beneficiaries when their skilled therapy or skilled nursing services were ending.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to ensure an incident of alleged physical abuse by one of five residents (Resident (R) 13) reviewed for abuse out of 29 sampled residents was reported to the state agency (SA) within two hours of knowledge of the alleged physical abuse. This failure placed R13 at risk for serious injury, serious harm, serious impairment, and/or death.

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to ensure an incident of alleged physical abuse was thoroughly investigated for one of five residents (Resident (R) 13) reviewed for abuse of 29 sampled residents This failure placed R13 at risk for serious injury, serious harm, serious impairment, and/or death.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the Pre-admission Screen and Resident Review (PASARR) level one screen was completed correctly prior to admission for one of one resident (Resident (R) 112) reviewed for PASARR of 29 sampled residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that an activity care plan was developed for one of 29 sampled residents (Resident (R) 49) that included the preference for one-to-one activities. This failure had the potential to cause the resident to experience increased depression.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that the care plan was revised to reflect a sustained coffee burn for one of two residents (Resident (R) 40) reviewed for accident hazards of 29 sample residents. This failure had the potential to affect resident safety resulting in potential reoccurrence of coffee burns.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to provide quality care in accordance with physician orders for one of one resident (Resident (R) 78) of 29 sample residents. Specifically, the facility failed to weigh R78 as ordered. This placed R78 at risk for an unmonitored weight loss.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) while providing care for one of five residents (Resident (R) 49) reviewed on Enhanced Barrier Precautions of 29 sample residents. This failure could promote the spread of multi drug resistant organisms throughout the facility.

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to consistently document urinary catheter care according to the physician's orders. This was identified for 1 of 2 residents (Resident #8) reviewed for urinary catheters. This deficient practice was evidenced by the following: The surveyor observed Resident #8 sitting up in bed with a urinary catheter bag and tubing at the side of the bed on the following dates and times: 04/01/22 at 11:53 AM, 04/05/22 at 9:39 AM, 04/06/22 at 9:50 AM, 04/08/22 at 9:45 AM, 04/11/22 at 10:12 AM, and 04/12/22 at 9:35 AM. According to the admission Record, Resident #8 had diagnoses that included, but were not limited to, Chronic Kidney Disease, unspecified (kidney failure). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to act on or respond to comments made by the Consultant Pharmacist (CP) in a timely manner during the Medication Regimen Review (MRR). This deficient practice was identified for 1 of 6 residents (Resident #42) reviewed for MRR and was evidenced by the following: According to the Resident Profile, Resident #42 had diagnoses that included, but were not limited to, Dementia, Anxiety, and Depressive Disorder. Review of the February 2022 CP report, dated 02/02/22, revealed that the CP reviewed Resident #42's medication management and recommended to Make PRN Ativan order for 14 days & then evaluate continued need. The CP report had a handwritten notation of Hospice med [medication]. Will discuss with hospice nurse. [...]

Inspectors wroteBased on observation, interview, and review of other facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 04/01/22 at 10:40 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. A food service worker (FSW) was observed prepping food. The FSW had a beard and was not wearing a beard guard. 2. The surveyor requested to be directed to the designated handwashing sink. The surveyor observed there was no plastic bag lining the trash can. When interviewed, the FSD stated there was usually a bag inside of the trash can. 3. [...]

Inspectors wroteBased on interview, record review, and review of other facility documents, it was determined that facility staff failed to complete neurological checks for a resident who sustained a fall with head injuries. This deficient practice was identified for 1 of 3 residents (Resident #83) reviewed for incidents and accidents and was evidenced by the following: During the initial tour of the 800 Unit on 04/01/22 at 11:47 AM, the surveyor observed Resident #83 sitting in a wheelchair visiting with a family member. The surveyor observed that Resident #83 had a wound and bruising to his/her forehead. The resident was pleasantly confused and was unable to provide any additional information about his/her injuries. According to the Resident Profile, Resident #83 had diagnoses that included, but were not limited to, Anemia, history of falling and muscle wasting (wasting of muscle tissue). [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer medication in accordance with a physician's order. This deficient practice was identified for 1 of 1 nurse, on 1 of 5 units (300 Unit) observed during the medication pass and was evidenced by the following: 1. The surveyor observed the Licensed Practical Nurse #2 (LPN) administer medication to Resident #66 on 04/04/22 at 8:44 AM. The resident's medications included Naproxen 375 milligrams (mg), a medication used to treat pain. During the medication pass, LPN #2 stated that the Naproxen was not available in the medication supply, and she would need to obtain it from the automated pharmacy dispensing machine, where back-up supplies of medication are stored. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure that resident dietary preferences were accurately identified and implemented for 1 of 5 residents (Resident #84) reviewed for dining. This deficient practice was evidenced by the following: On 04/01/22 at 12:22 PM, during the initial tour of the facility, the surveyor observed Resident #84 seated in a wheelchair at the bedside. The surveyor noted that the resident's meal tray was on an overbed table outside of the room in the hallway and appeared to have been untouched. When interviewed, the resident stated that the chicken was inedible because it was too hard. The resident's Certified Nursing Assistant #1 (CNA) observed that the resident had not eaten and offered an alternative meal selection, but the resident refused. [...]

Inspectors wroteBased on observation, interview, and review of other facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to cover the opening of 2 of 3 outside garbage dumpsters. This deficient practice was evidenced by the following: On 04/01/22 at 10:40 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and requested to see the outside garbage receptacle area. The surveyor observed three garbage containers (GC) on a cement slab. The surveyor observed that one of the three GC was uncovered and exposed to the elements. The GC had a closed lid on the right-side, but the left-side lid was open exposing multiple trash bags inside. When interviewed at that time, the FSD stated the GC lids should be closed when not in use. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to a.) ensure that staff wore the appropriate Personal Protective Equipment (PPE) and performed proper hand hygiene for a resident on Transmission Based Precautions (TBP) and b.) follow appropriate infection control procedures related to hand hygiene during the medication pass. This deficient practice was identified for 1 of 1 residents (Resident # 420) reviewed for TBP and 1 of 1 nurse, on 1 of 5 units (300 Unit) observed during the medication pass and was evidenced by the following: 1. During entrance conference with the Team Coordinator (TC) on 04/01/22 at 9:15 AM, the Director of Nursing (DON) stated that the facility had one new admission on the 700 Unit who was unvaccinated for COVID-19 and was on TBP (isolation). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 2 residents (Resident #32) reviewed for accidents. This deficient practice was evidenced by the following: According to the admission Record, Resident #32 was admitted with diagnoses that included, but were not limited to, Alzheimer's disease, Dementia, muscle wasting and atrophy, and difficulty in walking. Review of the resident's Quarterly MDS, an assessment tool used to facilitate the management of care, dated 01/28/22, revealed in Section J, Health Conditions, that the resident had no falls since admission/entry or reentry or the prior assessment, whichever was more recent. Review of the resident's MDS list included that the last MDS assessment prior to the 01/28/22 Quarterly MDS was dated 10/31/21. [...]