Avalon Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Avalon Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 13, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 13, 2024

  Based 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. […]

• Actual harm, isolatedF760Oct 24, 2025

  Based 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… […]

• Actual harm, isolatedF656Aug 7, 2025

  Based 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. […]

• Actual harm, isolatedF684Mar 11, 2025

  NJ00181366, 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: Acute and Chronic Respiratory Failure with Hypercapnia (the body… […]