Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Rehab And Care Center during CMS and state inspections, most recent first.
Failure to date and label refrigerated food items was identified during an observation with the DM. Open carrots, lettuce, limes, and pie shells were found in the main refrigerator without date labels, and two limes had visible white spots. The DM confirmed that opened refrigerated foods should be dated and stated there was no schedule for checking food for date labels or expired items.
Failure to Maintain Resident Privacy During Bed Bath: A resident with dementia, a femur fracture, and limited mobility was observed during a bed bath lying in bed undressed from the waist down, uncovered, and exposed while the CNA left the room to get supplies. The privacy curtain was not used, the door was open, and the resident’s private area remained exposed while the bath was in progress.
Failure to Provide Advance Directive Information: The facility did not inform or provide written information to multiple residents about the right to accept or refuse treatment and to formulate an advance directive. Records for residents with intact, moderately impaired, and severely impaired cognition showed no documentation of advance directive education or an offer of assistance, and staff interviews confirmed that the facility relied on POLST, POA, or family-provided documents rather than documenting advance directive discussions.
PASARR Level I screenings were not accurately completed for two residents with documented psychiatric diagnoses. One resident had bipolar disorder and another had schizoaffective disorder, bipolar type/schizophrenia, but both PASARR Level I assessments failed to identify serious mental illness. The SW stated she misread the instructions when completing the screenings, and the Administrator confirmed the diagnoses should have been included.
Failure to provide ADL grooming and hygiene assistance: Multiple residents who were dependent on staff or needed partial to maximum ADL help were observed with unmet grooming needs, including facial hair, untrimmed nails with debris, and stained clothing. Interviews with CNAs and unit management showed grooming and personal hygiene were part of CNA ADL tasks, but staff reported they were not shaving residents and were hesitant to trim nails for a resident who resisted care. The facility policy stated residents unable to perform ADLs independently should receive services to maintain grooming and personal/oral hygiene.
An LPN entered a resident's room while wearing gloves but without a gown, then completed a blood sugar check and exited. The resident had diabetes, a chronic wound, and was on EBP. The LPN stated a gown was only needed for wound care, and the IP said gowns were not needed for blood sugar checks, although the facility's EBP policy required gown and gloves before entering the room or beginning high-contact care.
A resident with schizophrenia and mild intellectual disabilities had their in-room phone removed due to a history of non-emergency 911 calls, with staff allowing phone use only at the nurse's station. The care plan was not updated to reflect this change or to document alternative arrangements for private communication, and staff could not explain how privacy was maintained, contrary to facility policy requiring private telephone access.
The facility failed to provide residents with transfer notices that included appeal rights information. Four residents were transferred to the hospital for various medical conditions without receiving proper documentation on how to appeal the transfer. The facility's policy requires such information, but it was not included in the notices, as confirmed by the Regional Nurse.
The facility failed to provide written bed hold notices to residents or their representatives during emergent hospital transfers. Four residents were transferred for medical emergencies, such as respiratory failure and acute renal failure, without receiving the required notices. The facility's policy requires these notices within 24 hours of an emergency transfer, but records lacked documentation of compliance.
A facility failed to revise a resident's care plan quarterly, as required. The resident, with diagnoses including type 2 diabetes and depression, was not invited to care conferences after January 2024, despite expressing a desire to participate. The DSS, responsible for scheduling, started in July 2024, and the MDSC followed the MDS schedule for conferences. The DON stressed the importance of these meetings for updating residents on their medical status.
Failure to Date and Label Refrigerated Food Items
Penalty
Summary
The facility failed to date, label, and/or cover food products stored in the kitchen. During an observation of the main refrigerator with the Dietary Manager, 56 carrots were found in an open plastic bag with no date label, two halves of lettuce heads were in plastic wrap with no date label, an open cardboard box contained ten limes with no date label, and two of the limes had visible white spots. Four opened pie shells were also found with no date label. During interview, the Dietary Manager confirmed that staff should date all refrigerated products once food items are opened and stated there was no schedule for checking all food for date labels or expired food. Facility policy titled Pinnacle Dietary Global states that all opened, cut, peeled, or prepared vegetables must be dated when prepared/opened and that the Food Service Director or designee shall verify date labels.
Failure to Maintain Resident Privacy During Bed Bath
Penalty
Summary
The facility failed to ensure that one resident with dementia with agitation, a left femur fracture, peripheral vascular disease, and moderately impaired cognition was treated with dignity and respect during personal care. The resident’s care plan included sponge bathing when a full bath or shower could not be tolerated and required max assistance by two staff for turning and repositioning every two hours and as needed. During an observation, the resident was found in bed undressed from the waist down without a sheet or blanket covering the body, and the privacy curtain was not in use while a CNA was gathering additional supplies from outside the room during a bed bath in progress. The resident remained exposed while asleep as the brief was opened, exposing the resident’s private area. The social worker observed that the resident’s private area was exposed and that the privacy curtain had not been pulled. The CNA later stated that she should have brought everything into the room before starting the bath, should have closed the door, and should have closed the curtain to protect the resident’s privacy.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information to 13 of 19 residents regarding 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 an advance directive. The residents identified in the deficiency included R9, R10, R11, R15, R17, R19, R36, R92, R99, R117, R121, R140, and R142. The report states that the failure had the potential to affect the residents' and their legal representatives' right to participate in and be informed of treatment. Record review showed that several of the affected residents had intact or only mildly to moderately impaired cognition, including R10 with a BIMS of 13, R36 with a BIMS of 13, R92 with a BIMS of 14, R117 with a BIMS of 15, R140 with a BIMS of 15, R142 with a BIMS of 14, R11 with a BIMS of 15, and R15 with a BIMS of 15. Other residents had moderate to severe impairment, including R17 with a BIMS of 9, R19 with a BIMS of 0, R99 with a BIMS of 5, R121 with a BIMS of 12, and R9 with a BIMS of 2. Review of the EMR for these residents found no evidence that education or discussions about advance directives were provided to the residents or their legal representatives, and for R140, R142, R9, R11, and R15 there was no documentation that information, education, or an offer of assistance to create an advance directive was offered. During interviews, the SW stated that the facility only gave the education part of advance directives and did not provide them, saying families normally provided POA or living will documentation. The DON stated that advance care planning was discussed during baseline care plan meetings and that advance directives were in the binder, but surveyors verified that the binder contained POLST forms, not advance directives. The ADON stated that the facility asked residents or families if they had a POLST or advance directive, documented the POLST, but never documented the advance directive education. The facility policy titled Advance Directives stated that upon admission the resident would be provided with information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chose to do so.
PASARR Level I Screening Not Accurate for Two Residents
Penalty
Summary
PASARR Level I screening was not accurately completed for two residents with psychiatric diagnoses. One resident was admitted with bipolar disorder, had a BIMS score of 15 indicating cognitive intactness, and the MDS documented bipolar disorder with no Level II PASARR. The resident’s care plan also identified impulsive behavior related to bipolar disorder, but the facility’s PASARR Level I assessment dated 05/12/26 did not identify a serious mental illness. A second resident was admitted with schizoaffective disorder, bipolar type, and the annual MDS documented schizophrenia with no Level II PASARR. The resident was severely impaired for daily decision making according to staff assessment, and the care plan identified shouting and schizophrenia. However, the facility’s PASARR Level I assessment dated 04/10/26 did not identify a serious mental illness. During interview, the SW stated she had read the instructions wrong when completing the Level I screenings for both residents, and the Administrator confirmed the severe mental illness diagnoses should have been included.
Failure to Provide ADL Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living for five residents reviewed for ADLs, including grooming, nail care, and personal hygiene. The report states that residents who were unable to perform ADLs independently were to receive services necessary to maintain grooming and personal/oral hygiene, yet observations and interviews showed unmet grooming needs for multiple residents. The deficiency was identified during observation, interview, record review, and policy review. R140 was cognitively intact with a BIMS score of 15 and was dependent on staff for ADLs, with no documentation of refusing care. Despite this, R140 was observed on multiple days with facial hair approximately 1/2 inch long, and stated they would send their son to get razors. R16, who had severe cognitive impairment with a BIMS score of 3 and required substantial to maximum assistance for ADLs, was observed with facial hair greater than 1/2 inch on the chin on two days. R6, who had dementia and a BIMS score of 8 and was dependent on staff for ADLs, was observed needing a shave and with fingernails greater than 1/4 inch over the fingertips with brown debris under and around the nail beds on two days; a CNA stated R6 fights staff and that it takes two staff to do anything, and said she was afraid to cut the nails because she might cut the resident. R9, who had severe cognitive impairment with a BIMS score of 2 and required partial/moderate assistance for ADLs, was observed with facial hair greater than 1 inch in length and a blouse stained with food, and still had facial hair on later observations. R36, who had intact cognition with a BIMS score of 15 and required partial to moderate assistance for oral care and personal hygiene, was observed on multiple occasions with chin hair and stated they did not know the hair was on their face and wanted it removed. Interviews with unit management and CNAs indicated that grooming and personal hygiene were part of the CNA ADL task, but staff reported they were not shaving residents and that facial hair was not being removed unless the resident refused. The facility policy stated residents unable to carry out ADLs independently should receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Improper PPE Use for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper PPE was donned by an LPN before entering the room of a resident on Enhanced Barrier Precautions. R92 was admitted with diagnoses including osteomyelitis of the ankle and foot, a non-pressure chronic ulcer of the left heel and midfoot, and type II diabetes. The quarterly MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and the resident required partial to moderate assistance for bed mobility and transfers. The care plan included an intervention for Enhanced Barrier Precautions related to dialysis and a chronic wound. During observation, the LPN entered R92's room wearing gloves and carrying supplies for blood sugar testing, completed the blood sugar check at the bedside, removed the gloves, and exited the room without wearing a gown. When interviewed, the LPN stated a gown was not needed because only blood sugar was checked and believed the gown was only required for wound care. The Infection Preventionist stated staff did not need gowns for blood sugar checks for residents on Enhanced Barrier Precautions for a wound and diabetes, and the facility policy stated that for Enhanced Barrier Precautions, staff are to don a gown and gloves before entering the resident's room or beginning high-contact care.
Failure to Provide Private Telephone Access for Resident
Penalty
Summary
The facility failed to provide reasonable access to a telephone with privacy for a resident diagnosed with schizophrenia and mild intellectual disabilities, who had a moderate cognitive impairment as indicated by a BIMS score of 12 out of 15. The resident's phone was removed from their room after a history of calling 911 for non-emergency situations, a decision reportedly agreed upon by the resident's representative. However, the resident's care plan was not updated to reflect the removal of the phone or to document any substitute arrangements for private communication. Observations confirmed that the resident did not have a phone in their room, and staff interviews revealed that the resident was only allowed to use the phone at the nurse's station. Facility staff, including the unit manager and DON, acknowledged that the care plan was not revised to address the change and could not explain how privacy was ensured when the resident used the nurse's station phone. The facility's own policy requires access to a telephone and the ability to communicate with privacy, which was not met in this instance.
Failure to Provide Appeal Rights in Transfer Notices
Penalty
Summary
The facility failed to provide residents with written transfer or discharge notices that included the option to appeal the transfer or discharge. This deficiency was identified for four residents who were transferred to the hospital for various medical reasons. The notices issued by the facility did not contain the necessary information about the residents' appeal rights, including the contact details of the entity that receives appeal requests and instructions on how to obtain and submit an appeal form. Resident 123 was transferred to the hospital due to increased confusion, lethargy, and aggressive behavior, and was later diagnosed with delirium with dementia and acute kidney injury. Similarly, Resident 110 experienced multiple hospital transfers for respiratory failure and congestive heart failure, but the notices provided to them also lacked the required appeal information. Resident 50 was sent to the emergency room for low blood pressure and other symptoms, and Resident 57 was transferred due to abnormal blood work, both without receiving proper appeal rights information in their transfer notices. The facility's policy on transfer or discharge notice, revised in March 2021, mandates that residents and their representatives be given a notice that includes an explanation of their right to appeal. However, the review of the facility's issued documents revealed that this policy was not followed, as the notices did not include the necessary details for residents to understand and exercise their appeal rights. This oversight was confirmed by the Regional Nurse during the review of the notices.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives during facility-initiated emergent hospital transfers. This deficiency was identified for four residents who were transferred to the hospital for various medical emergencies, including increased confusion, lethargy, respiratory failure, congestive heart failure, and acute renal failure. The electronic medical records for these residents were reviewed and found to be silent regarding the issuance of bed hold notices at the time of their transfers. The facility's policy, revised in March 2022, mandates that all residents or their representatives receive written information about the facility's bed-hold policies during periods of absence, such as hospitalization or therapeutic leave, within 24 hours of an emergency transfer. However, the records for the residents in question did not contain any documentation of such notices being provided. This oversight was confirmed by the Regional Nurse during a review of the discharges and transfers.
Failure to Revise Care Plan Quarterly for Resident
Penalty
Summary
The facility failed to revise the care plan quarterly for a resident, identified as R103, who was reviewed for care plan revision. The facility did not schedule quarterly care conferences or invite R103 to the scheduled care conferences, which is a requirement according to the facility's policy. The policy states that residents, their families, and/or legal representatives should be encouraged to participate in the development and revisions of the care plan. R103, who has medical diagnoses including type 2 diabetes, depression, and muscle weakness, expressed during an interview that she was unaware of any care conferences and had never been invited, although she wished to participate. The review of R103's records showed that she attended care conferences in October 2023 and January 2024, but there was no documentation of her attendance at any care conferences after January 2024. Interviews with the Director of Social Services (DSS) and the MDS Coordinator (MDSC) revealed that the DSS, who started working at the facility in July 2024, was responsible for scheduling care conferences and inviting residents. The MDSC stated that care conferences were scheduled quarterly following the MDS schedule, and the Director of Nursing emphasized the importance of these conferences for updating residents on their medical status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Careone At Wayne | 0.6 mi | ★★★★★ | 8 | 0 |
| Atrium Post Acute Care Of Wayne | 1.7 mi | ★★★★★ | 0 | 0 |
| Llanfair House Care & Rehabilitation Center | 2 mi | ★★★★★ | 0 | 0 |
| Lincoln Park Care Center | 2.8 mi | ★★★★★ | 44 | 1 |
| Lincoln Park Renaissance | 2.8 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.