Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Kitchen sanitation and food handling deficiencies were observed during a surveyor kitchen tour. The surveyor found a dirty can opener, unlabeled opened spices and vinegar, dust and buildup on cooking equipment, hard water buildup on a hot water dispenser spout, improper staff attire with unsecured hair and hooped earrings, unlabeled personal items in the freezer, unlabeled milk in the walk-in refrigerator, and a Dietary Aide taking the temperature of ground chicken without sanitizing the thermometer first.
The facility did not ensure that residents were seen by their attending physician or NP at the required intervals, nor that progress notes were consistently documented in the EMR. Several residents, including those with severe cognitive impairment and complex medical needs, lacked physician notes for extended periods, and staff confirmed that expected documentation and visits were missing. Facility policy required timely visits and documentation, but these requirements were not met for multiple residents.
A resident with anxiety and severe cognitive impairment had an active PRN alprazolam order that remained in place beyond the 14-day limit, even though it was only administered once. Another resident with dementia and psychotic symptoms had an active quetiapine order, and a psychiatrist recommended a GDR, but the EMR showed no documentation that the recommendation was addressed while the medication continued to be given as ordered. Staff, including the RN, LPN/UM, and DON, acknowledged the orders and the missing documentation.
Failure to Complete Ordered Lab Testing: A resident with severe cognitive impairment, malnutrition, and diabetes had physician-ordered CBC, CMP, urinalysis, and urine C&S testing that was not completed or documented in the record. The resident had reported dysuria, and staff entered the urine orders into the EMR and lab portal, but the chart lacked lab results and urine specimen reports, and staff could not explain why the tests were not obtained.
A facility failed to address monthly CP recommendations for two residents. One resident with anxiety and Alzheimer's had PRN alprazolam and mirtazapine orders, while the CP recommended documenting the Remeron diagnosis as depression and discontinuing Xanax if not being used. Another resident with dementia and major depressive disorder with psychotic symptoms had a Seroquel order, and psych notes recommended GDR and follow-up. RN, LPN/UM, DON, and the CP stated the recommendations were documented and sent to leadership, but they were not addressed.
A resident with dementia and diabetes was repeatedly observed in bed without the required fall mat in place, despite a care plan and physician order mandating its use. Nursing staff confirmed the fall mat should have been on the floor whenever the resident was in bed, but it was found leaning against the wall on multiple occasions.
A resident with ESRD and multiple comorbidities repeatedly missed scheduled medications, supplements, and blood glucose monitoring because administration times conflicted with dialysis appointments. Nursing staff documented missed doses due to the resident being out for dialysis, but there was no evidence that the physician was notified or that orders were adjusted to accommodate the dialysis schedule, contrary to facility policy and professional standards.
Failure to Post Daily Nurse Staffing Information: The facility did not have a process in place to post the daily per-shift nurse staffing report. Surveyor observation found outdated staffing information still posted at the front desk, and staff interviews showed the SHR posted day/evening shifts, the night supervisor posted nights, and weekend staffing was not posted until Monday because weekend supervisors lacked access to the reports. The LNHA stated staffing was supposed to be posted every day and every shift, and acknowledged the posting should have been changed.
Medication labeling and storage were not followed for several insulin pens and a Budesonide inhalation product. Surveyors found insulin devices without dates showing when they were removed from refrigeration or when they expired, and one insulin pen lacked the resident’s name. An opened Budesonide pouch also had no open date. The RN, LPN, and DON acknowledged the missing dates and labeling issues, and the manufacturer instructions and facility policy required proper dating and resident identification.
A resident with hypertension and heart failure did not receive 14 doses of a prescribed antihypertensive medication due to unavailability, with missed doses documented in the MAR and no evidence that the physician was notified. The resident was later transferred to the hospital for uncontrolled hypertension and diagnosed with a hypertensive emergency. Nursing staff confirmed the medication was not available, and facility leadership was unaware of the issue until the survey.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive an initial comprehensive visit from a physician within the required 30-day period after admission. Review of records and staff interviews confirmed that only a "HISTORY AND PHYSICAL" by an APN was available, with no timely physician documentation, in violation of both federal regulations and facility policy.
Staff did not consistently document care provided to a resident in the Point of Care (POC) system, leaving multiple blank entries across several shifts. Interviews confirmed that CNAs are expected to record all ADLs in the POC, and that missing documentation means the policy was not followed. The facility's policy requires complete documentation of care, but this was not done for the resident in question.
The facility did not meet the required CNA-to-resident staffing ratios for 14 consecutive day shifts, consistently scheduling fewer CNAs than mandated by state law for the number of residents present. This deficiency was identified through review of staffing records and interviews, and had the potential to affect all residents.
A resident with respiratory failure and COPD did not receive prescribed continuous oxygen therapy when the oxygen concentrator was found off, resulting in the resident being unresponsive with low oxygen saturation. The care plan lacked documentation of oxygen supplementation, and staff did not ensure the concentrator was operating as ordered.
A resident with severe cognitive impairment required assistance with bathing and dressing but frequently refused care, leading to family concerns about hygiene. Although staff were aware of the refusals and communicated with the family, the facility failed to document the grievance or follow its policy for investigating and responding to complaints, and the Administrator was not informed.
A resident with respiratory diagnoses and an order for oxygen therapy did not have their care plan updated to reflect the use of oxygen, despite documentation in the medical record and physician orders. Staff interviews confirmed that the care plan should have been revised to include this intervention, in accordance with facility policy.
A resident with severe cognitive impairment and multiple respiratory diagnoses was found to be receiving oxygen at 3 L/min instead of the physician-ordered 2 L/min. The discrepancy was identified when the nasal cannula was observed out of the nostrils and the concentrator set incorrectly. Staff interviews revealed that the oxygen flow rate was not checked as required by facility policy, resulting in a failure to follow the physician's order.
A resident in a long-term care facility reported being pushed by a CNA, causing hot coffee to spill on them. Despite the resident's cognitive intactness and clear report of the incident, the facility failed to investigate or report the abuse in a timely manner, allowing the CNA to continue working. This failure to follow the facility's abuse prevention policy resulted in Immediate Jeopardy.
Two residents suffered burns due to inadequate supervision and safety measures while handling hot liquids. One resident experienced burns on two occasions while heating coffee in an unlocked nutritional room, and another resident sustained a burn while transporting coffee from the dining room. Both residents had intact cognition, but the facility failed to enforce safety policies, leading to these incidents.
The facility failed to secure a medication cart and remove expired items from a storage room. An unlocked cart was left unattended at a nurses' station, and several expired medical supplies were found in a storage room. The RN responsible was unaware of the unlocked cart, and the Unit Manager missed the expired items during routine checks.
The facility failed to accurately complete Medicare Part A forms for a resident and two residents, omitting essential information such as TTY numbers, QIO names, and facility contact details. The facility's policy lacked instructions on completing these forms, leading to deficiencies in notifying residents about their Medicare coverage and potential liabilities.
A resident, who was cognitively intact, was involved in an altercation with a CNA, resulting in a coffee spill. The resident alleged that the CNA pushed him, causing the spill. Despite the facility's policy requiring immediate reporting of such incidents, the alleged abuse was not reported to the state agency or Ombudsman within the required timeframe. The DON and Administrator confirmed the incident was not reported, citing an internal conclusion of the investigation.
A resident accused a CNA of pushing him, causing hot coffee to spill on his lap. The facility failed to conduct a thorough investigation, as required by policy, leading to a deficiency finding. The Director of Nursing initially dismissed the need for further investigation but later acknowledged the oversight.
A facility failed to ensure the PASARR Level I screen was completed correctly for a resident with schizoaffective disorder. The resident was admitted with a diagnosis of schizoaffective disorder and a BIMS score indicating moderately impaired cognition. However, the PASARR form incorrectly stated there was no major mental illness, which was acknowledged by the Social Services Director. This oversight potentially failed to identify necessary specialized services and appropriate placement.
A resident with major depressive disorder and other health issues did not have an activity care plan reflecting their preference for one-to-one activities. Despite being cognitively intact and dependent on staff for daily activities, the resident's care plan did not include their desire for individualized activities, as revealed through staff interviews and record reviews.
A resident with a complex medical history sustained a second-degree coffee burn while transporting hot coffee in a wheelchair. The facility failed to update the resident's care plan to include necessary interventions, such as reminders for the resident to seek assistance and staff education on cooling hot liquids. Interviews with staff confirmed the oversight, which did not align with the facility's policy on revising care plans as resident conditions change.
A resident with multiple diagnoses, including anoxic brain injury and diabetes, was not weighed according to physician orders, leading to unmonitored weight changes. The facility failed to document weights on several occasions, and the RD was not informed of any weight issues due to the lack of documentation. The Unit Manager's abrupt leave contributed to the oversight, and the facility's policy on weight documentation was not followed.
A resident on Enhanced Barrier Precautions due to an open wound was not provided care with the appropriate PPE by staff. A CNA and an LPN were observed not wearing gowns while providing direct care, despite clear signage and available PPE. The LPN admitted to forgetting the gown in a rush to administer pain medication.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices during a kitchen tour observed by the surveyor with the Food Service Director. In preparation area #1, the surveyor observed a can opener with reddish caked-on debris on the handle and blade, multiple opened spice containers and a 1-gallon container of distilled vinegar without use-by or discard labels, and the Dietary Aide stated the can opener should be cleaned after each use and items should be labeled with open/use-by dates. In the cooking area, the surveyor observed dust-like debris on the top of a standing dish warmer and standing steamer, a sticky substance on top of a dual stack oven, and blackish burnt-on debris inside the bottom oven. The Food Service Director stated the cooking equipment was due to be cleaned later that day after dinner. The surveyor also observed a whitish buildup on the hot water dispenser spout, and the Food Service Director identified it as hard water buildup that would be cleaned immediately. A Dietary Aide was observed wearing four hooped earrings and with hair not fully restrained under the hairnet, despite the facility staff attire policy requiring hair to be confined and jewelry limited to a plain band. In the freezer, three plastic cups with frozen liquid and a 20 oz lemonade were observed unlabeled and identified by the Food Service Director as personal-use items that should not have been left there. In the walk-in refrigerator, two boxes were stored above 18 inches from the ceiling and a 2-gallon container of whole milk was opened without an opened or use-by label. Prior to lunch, a Dietary Aide checked the temperature of ground chicken without sanitizing the thermometer first, and the Food Service Director discarded the food after the surveyor observed the contamination issue.
Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by their attending physician or nurse practitioner at the required intervals, and that appropriate progress notes were documented in the electronic medical record (EMR). For four residents reviewed, there were significant gaps in physician documentation and visits. One resident with severe cognitive impairment and multiple diagnoses, including diabetes and asthma, had no progress notes from the attending physician for a ten-month period. Another resident, also severely cognitively impaired, lacked both a history and physical (H&P) note upon initial admission and re-admission, as well as progress notes from the attending physician for several months. A third resident, who was cognitively intact and had diagnoses of low back pain and anemia, had an H&P and a single progress note from the attending physician, but there were no physician or nurse practitioner notes for several consecutive months, nor evidence of consistent alternating monthly visits as required. This resident also experienced two hospitalizations, after which the expected H&P documentation upon re-admission was missing. The fourth resident, with moderately impaired cognition and diagnoses including anxiety disorder and anemia, had an H&P and a progress note from the physician, but no further notes from either the physician or nurse practitioner for multiple months, and no evidence of the required visit schedule being followed. Interviews with nursing staff and review of facility policy confirmed that the expectation was for physicians to see new admissions within 24-48 hours, complete H&P documentation, and make regular progress notes during rounds. However, staff were unable to locate the required documentation in the EMR for the residents reviewed, and confirmed that the expected physician visits and notes were not present for extended periods. The facility's policy aligned with state and federal regulations, but was not followed in practice for these residents.
Unaddressed PRN psychotropic order and missed antipsychotic GDR follow-up
Penalty
Summary
The facility failed to ensure that a PRN anti-anxiety medication order for one resident was limited to 14 days. The resident was admitted with anxiety disorder and Alzheimer’s disease, had a BIMS score of 2 out of 15, and had an active order for alprazolam 0.25 mg every 6 hours as needed for anxiety starting 9/16/2025. The medication was administered once on 9/17/2025 and then not given in October or November, yet the order remained active in the EMR beyond the 14-day limit described in the facility’s psychotropic medication policy. The facility also failed to follow up on a psychiatrist’s recommendation for a gradual dose reduction of an antipsychotic medication for another resident. That resident was admitted with unspecified dementia with behavior disturbance and major depressive disorder with psychotic symptoms, and had a BIMS score of 00 out of 15. The resident had an active order for quetiapine 50 mg three times daily, and a psychiatric progress note recommended discontinuing the current order and reducing the dose to 50 mg in the morning, 25 mg in the afternoon, and 50 mg in the evening, with the recommendation held pending POA consent. Survey review found no documentation in the progress notes that the GDR recommendation was addressed. The MARs for September, October, and November 2025 showed the quetiapine continued to be administered as ordered three times daily. Facility staff, including the RN, LPN/UM, and DON, acknowledged the active orders and the lack of documentation regarding the GDR recommendation, and the DON stated that such recommendations should usually be done the same day or next day.
Failure to Complete Ordered Lab Testing
Penalty
Summary
The facility failed to ensure that physician-ordered blood and urine laboratory testing was completed for a resident with multiple medical conditions, including muscle wasting and atrophy, adult failure to thrive, moderate protein-calorie malnutrition, and type 2 diabetes mellitus with unspecified complications. The resident’s MDS reflected severe cognitive impairment with a BIMS score of 6 out of 15. The care plan included interventions to obtain and monitor lab and diagnostic work as ordered and to report abnormal findings to the practitioner. Progress notes showed that the resident’s representative reported painful urination, and the MD ordered a urinalysis and urine culture and sensitivities. The record also reflected weekly CBC and CMP orders beginning in August 2025. Review of the MAR showed an X for all dates for the weekly CBC and CMP orders, and the lab results section did not contain chemistry or hematology results for multiple Mondays between August and November 2025. The record also did not contain urine specimen reports, and there was no documentation explaining why the labs or urine specimens were not obtained. During interviews, staff stated that lab orders were entered into the EMR and the lab portal, with request forms placed in a binder for the lab technician. However, the unit clerk stated lab results would automatically appear in the EMR, and the LPNs were unable to explain why the urine culture was not obtained or how to verify specimen collection. The DON acknowledged that the urine specimen ordered for the resident was not completed and stated there was nothing else available beyond what was provided. The facility policy stated that staff would process test requisitions and arrange for tests.
Monthly pharmacist recommendations were not addressed for two residents
Penalty
Summary
The facility failed to respond to monthly Consultant Pharmacist recommendations for 2 of 6 residents reviewed for unnecessary medications. For one resident with anxiety disorder and Alzheimer's disease, the record showed orders for alprazolam PRN and mirtazapine at bedtime, with the pharmacist noting that the diagnosis should be made for Remeron as depression and recommending discontinuation of PRN Xanax if it was not being used. The September medication record showed alprazolam was administered once, while the October and November records showed it was not administered, and the pharmacist's October and November recommendations remained the same. For another resident with dementia and major depressive disorder with psychotic symptoms, the record showed an order for quetiapine three times daily and a psychiatric progress note recommending gradual dose reduction and a change in the Seroquel regimen, pending POA consent. The pharmacist's October and November notes again identified the psychiatric recommendation and asked for follow-up, but the same recommendation remained in place across both months. The surveyor observed the resident in the day room with eyes closed and head resting on the wall at the time of review. Interviews with RN, LPN/UM, DON, and the Consultant Pharmacist showed that the pharmacist documented recommendations in the EMR and sent monthly reports to facility leadership and unit managers, and that unit managers were responsible for reviewing and addressing them. The DON and LPN/UM reviewed the records and acknowledged that the recommendations for both residents from October and November were not addressed, and the Consultant Pharmacist stated the facility had changes in unit managers and the monthly recommendations had not been addressed.
Failure to Follow Fall Prevention Interventions as Ordered
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the resident's care plan and physician orders. Specifically, a resident with diagnoses including unspecified dementia and Type 2 Diabetes Mellitus with chronic kidney disease was observed multiple times in bed without the required fall mat in place. The care plan and physician order both specified that a fall mat should be positioned on the exit side of the bed at all times when the resident was in bed. However, on several occasions, the fall mat was observed leaning against the wall rather than on the floor as required. Interviews with nursing staff, including an RN and the DON, confirmed that the fall mat should have been in place whenever the resident was in bed, in accordance with the physician's order. The RN stated that the mat was not on the floor due to a broken bed, but could not explain why this prevented the use of the fall mat. The DON and LPN/Unit Manager both affirmed that the fall mat was necessary for resident safety and should be used as ordered. The deficiency was identified through observations, interviews, and review of the resident's medical record and care plan.
Failure to Adjust Medication and Supplement Administration for Dialysis Schedule
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident requiring dialysis by not adjusting medication administration times, nourishment supplementation, and monitoring to accommodate the resident's scheduled dialysis sessions. The resident, who had multiple diagnoses including end stage renal disease (ESRD), diabetes, heart failure, and was dependent on hemodialysis, had medication and supplement orders that conflicted with the times the resident was out of the facility for dialysis. Despite the resident's dialysis schedule being known (Tuesday, Thursday, and Saturday afternoons), there were no physician orders specifying alternative administration times for these days, and medications and supplements were repeatedly not administered as ordered on at least nine dialysis days during the resident's stay. Review of the electronic medication administration record (EMAR) and nursing progress notes revealed that medications such as Hydralazine, Novolog, Coreg, Gabapentin, Prosource, and Nepro, as well as blood glucose monitoring, were not given at scheduled times because the resident was out of the facility for dialysis. Documentation codes and nursing notes indicated the reason for missed doses was the resident's absence for dialysis, but there was no evidence that the physician was notified or that orders were adjusted to accommodate the dialysis schedule. The facility's own policies required that medication administration times be determined by resident need and benefit, and that staff be educated on timing and administration of medications, particularly before and after dialysis. Interviews with nursing staff, the unit manager, the DON, and the administrator confirmed that nurses were expected to review and adjust medication orders with the physician for residents attending dialysis, and that documentation should not simply state that medications were missed due to dialysis. The DON acknowledged that the physician should have been notified to obtain appropriate orders and that the EMAR should not reflect missed medications for scheduled dialysis absences. The deficiency was identified through review of records, interviews, and facility policy, and was specific to one resident reviewed for dialysis services.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to have a process in place to post the daily per-shift nurse staffing report. 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 Staffing/Human Resource staff member stated she posted staffing at the desk for day and evening shifts, and the night supervisor posted the night shifts; she also stated that on weekends she did not post the staffing until Monday because weekend supervisors did not have access to the reports, so Monday reflected the real count. On 11/25/2025 at 10:00 AM, the LNHA stated nurse staffing was supposed to be posted at the receptionist desk every day and every shift, and that on weekends the supervisor was supposed to post it. After being informed of the observation showing the day shift staffing for 11/21/25 still posted on Monday morning, the LNHA acknowledged the staffing should have been changed. Review of the facility policy, revised 8/2022, stated the facility would post nursing data on a daily basis for each shift and, within 2 hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care would be posted in a prominent location in a clear and readable format.
Medication Labeling and Dating Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled in accordance with accepted professional principles in multiple medication carts. During an inspection of the 200 Hall medication cart, an insulin lispro pen for Resident #179 was observed without a date showing when it was removed from refrigeration, and the RN stated she had not administered insulin to that resident and acknowledged the pen should have both a date when opened and an expiration date on the label. During inspection of the 700 Back Hall medication cart, several insulin pen devices were observed without required dating. An insulin aspart pen for Resident #59 had a date on the baggie but no date when opened or expiration date on the pen. A Lantus Solostar pen for Resident #176, a Basaglar pen for Resident #177, and an insulin lispro pen for Resident #176 also lacked dates showing when they were removed from refrigeration and lacked expiration dates. The insulin lispro pen also did not have the resident’s name on the pen device, although the baggie had a first initial and last name. The LPN stated the date removed from refrigeration should be on the pen device and that the resident’s name should be on the pen device. The surveyor also observed a box of Budesonide Inhalation Suspension ampules for Resident #175 with a handwritten date on the box, but the opened foil pouch inside had no date showing when it was opened. The LPN stated the date the pouch was opened should be on the foil pouch and reviewed the manufacturer instructions indicating unused ampules are shelf-stable for 2 weeks once the envelope is opened. The DON later acknowledged the insulin pens had no date when removed from refrigeration, the Budesonide pouch had no date, and the resident’s name should be on the pen device. The facility policy required medication labels to include an expiration date when applicable and the resident’s name, and the manufacturer instructions for the insulin products and Budesonide required dating after opening and refrigeration removal.
Failure to Administer Antihypertensive Medication Resulting in Hospital Transfer
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension and heart failure did not receive 14 doses of a physician-ordered antihypertensive medication, Entresto, over several days. The medication was documented as not administered or unavailable on multiple occasions, with corresponding entries in the Medication Administration Record (MAR) and progress notes. Despite the repeated lack of administration, there was no documentation that the physician was notified about the unavailability of the medication, and the medication was not obtained from the pharmacy or backup supply in a timely manner. The resident subsequently experienced uncontrolled hypertension, presenting with symptoms such as dizziness, generalized weakness, and markedly elevated blood pressure, which led to an emergency hospital transfer. Hospital records indicated a diagnosis of hypertensive emergency, and the medical team questioned compliance with prescribed medications, noting the absence of an exact substitute for Entresto. Interviews with nursing staff confirmed that the medication was not available and not administered, and that there was no documentation of physician notification regarding the missed doses. Further review revealed inconsistencies in MAR documentation, such as doses being marked as administered when the medication was not available, and the use of codes without corresponding physician orders. The Director of Nursing and other facility leadership acknowledged that medication should not be checked off as administered if not given and that the physician should be contacted if a medication is unavailable for several days. However, there was no evidence that the facility conducted a timely review or investigation of the incident prior to the survey, and leadership was unaware of the missed medication administration until informed by surveyors.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Complete Timely Initial Physician Visit
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of a resident conducted an initial comprehensive visit within the required 30-day time period after admission. Review of the electronic medical record and progress notes revealed that the initial physician visit for the resident was not completed within 30 days of admission, as required by federal regulations. The only available documentation was a "HISTORY AND PHYSICAL" signed by an advanced practice nurse, with no further documentation from the physician since the resident's arrival. Interviews with facility staff confirmed that there were no additional physician notes available for the resident during the required timeframe. The facility's own policy, which aligns with federal requirements, states that the attending physician must visit patients at least once every 30 days for the first 90 days following admission. This policy was not followed in the case of the resident identified in the report.
Plan Of Correction
1. Resident #2's initial comprehensive physician visit was completed on 01/07/2024, and as recently as 6/11/25, no negative concerns were identified. 2. All residents have the potential to be affected by this practice. An audit was completed of all current residents to ensure that physician visits occurred within the required time frame. Any inconsistencies were addressed immediately. 3. The facility's admission process has been updated to include a physician visit tracker that flags any upcoming 30-day deadlines for new admissions. U.S. FOIA (b) (6) educated Ex Order 26. 4B1 and medical staff, on facility policy regarding the timeliness of physician visits. 4. The DON or designee will monitor all new admissions weekly for 4 weeks, followed by a monthly audit for 3 months to ensure a physician visit occurs in accordance with facility policy and reported to the Committee for review and action. The QAPI Committee, including the NHA, DON, Medical Director, and Admissions Coordinator, will evaluate trends and determine whether additional interventions or education are needed.
Failure to Document Resident Care in Point of Care System
Penalty
Summary
Facility staff failed to consistently document care provided to a resident in the "Documentation Survey Report v2 (DSR)" and did not follow the facility's policy on Point of Care (POC) documentation. Specifically, for one resident, there were multiple instances where documentation was missing for care provided across several dates and shifts. The electronic medical record review revealed blank spaces in the POC documentation, indicating that care was either not provided or not recorded as required. Interviews with staff, including LPNs and other facility personnel, confirmed that the expectation is for CNAs to document all activities of daily living (ADLs) in the POC system for every shift. Staff stated that refusals of care should be documented in both the care plan and progress notes, and that blank spaces in the POC indicate a failure to document. The staff also acknowledged that the facility's policy was not followed, as documentation was missing for the identified periods. The facility's policy requires CNAs to document resident care in accordance with each resident's individualized plan of care, including self-performance and support for ADLs such as toileting and personal hygiene, as well as bowel and bladder continence. The lack of documentation for the resident in question was confirmed by both record review and staff interviews, establishing that the required documentation was not completed as per policy and regulatory requirements.
Plan Of Correction
1. Resident #2 was assessed that NJ Ex Order 26. 4B1 was provided by licensed nursing staff. The residents continue to receive appropriate care per the plan of care. 2. All residents have the potential to be affected by incomplete or inconsistent documentation by not documenting that incontinent care was provided. A facility-wide audit was completed to ensure POC is completed for all current residents. Any inconsistencies were addressed immediately, and all charts were updated accordingly. 3. All Certified Nursing Assistants were re-educated on the facility's policy titled "Point of Care (POC) Documentation," with emphasis on timely and complete documentation of care tasks, including incontinence care and toileting hygiene. Education will be completed on orientation and as part of annual competencies. 4. The Director of Nursing (DON) or designee will conduct daily audits of POC documentation prior to CNA end of shift for all residents for 5 consecutive days, followed by weekly audits for 3 weeks, and then monthly audits for 3 months. Results of the audits will be documented and reviewed during the facility’s monthly QAPI (Quality Assurance and Performance Improvement). The QAPI Committee, comprised of the NHA, DON, Infection Preventionist, and Medical Director, will oversee the effectiveness of these interventions and recommend additional actions if necessary.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during a 14-day review period. According to the findings, the facility was required to have at least one CNA for every eight residents on the day shift. However, for each of the 14 day shifts reviewed, the number of CNAs scheduled was consistently below the required minimum. For example, on multiple days, only 15 or 16 CNAs were present for 141 to 145 residents, when at least 18 CNAs were needed to meet the mandated ratio. This deficiency was identified through interviews and a review of facility staffing documents. The shortfall in CNA staffing was present on every day shift reviewed within the specified two-week period, affecting all residents in the facility. The report does not provide specific details about individual residents or their medical conditions, but it notes that the deficient practice had the potential to affect all residents due to the facility's failure to comply with state staffing requirements.
Plan Of Correction
1. Corrective Action for Residents Found to Have Been Affected: All staffing coordinators, unit managers, and scheduling personnel were re-educated on state staffing mandates and compliance tracking by the DON on 06/20/2025. 2. Identification of Other Residents Who May Be Affected: All residents in the facility during the day shift may have been affected by insufficient CNA staffing. 3. Measures and Systemic Changes to Prevent Recurrence: Staffing Recruitment: The facility has entered a new collective bargaining agreement as of 06/01/2025 with its union to increase wages $2.00 per hour. Daily Staffing Audits: The Director of Nursing (DON) or designee will review staffing ratios daily by shift and maintain a record to ensure compliance. Recruitment Campaign: A CNA recruitment initiative was launched including sign-on bonuses, referral incentives, job fairs, and outreach to local training programs including tuition sponsorship of nursing assistants, which has had successful outcomes. Through the sponsorship of Nursing Assistant training programs, the facility has successfully recruited and retained nursing assistants who received their Certified Nursing Assistant certification. A new recruiter started on 06/09/2025 who is actively engaging applicants through social media and on-the-spot interviews including weekends. Daily weekday meetings are held to discuss recruitment efforts. Retention Campaign: An employee survey was conducted of 95% of all staff, and results were received to facilitate feedback on actionable insights that help the facility understand, predict, and improve employee satisfaction and engagement to improve staff retention. Additionally, the facility has deployed human resource software through Retain. This software plays a proactive role in keeping employees engaged, utilized, and aligned with organizational goals. It minimizes turnover by addressing the root causes of attrition—overwork, disengagement, lack of growth, and misalignment between employee goals and business needs. Additionally, the facility has an active Employee of the Month program as well as team-building events to foster camaraderie and employee satisfaction. 4. Monitoring of Corrective Actions to Ensure Effectiveness: QAPI Oversight: Staffing ratio compliance will be tracked as a monthly Quality Assurance Performance Improvement (QAPI) indicator and results forwarded to the facility’s QAPI committee. Weekly Review: The DON will present a weekly staffing compliance summary to the Administrator for validation by 06/24/2025 for 30 days. 30-Day Audit: A 30-day audit (ending 07/24/2025) of CNA staffing ratios will be completed and submitted to the QAPI Committee for review and validation.
Failure to Provide Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident with acute and chronic respiratory failure, pneumonia, and COPD did not receive care in accordance with physician orders and professional standards. The resident was admitted with an order for continuous oxygen at 5 liters per minute via nasal cannula, but the care plan did not mention oxygen supplementation. On the morning in question, the resident was found unresponsive, diaphoretic, and with blue nailbeds; the pulse oximeter showed an oxygen saturation of 50%. The oxygen concentrator was discovered to be off, though it was plugged in, and had to be turned on by the LPN. The resident required two-person assistance for repositioning and was reportedly unable to reach the concentrator, which was located at the bedside. Staff interviews revealed that the LPN received a report from the previous shift indicating no changes overnight, and the CNA observed the resident with oxygen tubing in place during morning rounds. However, the oxygen concentrator was not operating at the time the resident was found unresponsive. Facility policy required nursing staff to follow physician orders and document care accordingly, but the care plan lacked documentation of the oxygen order, and the facility's oxygen administration policy did not include guidelines for concentrator use. This series of actions and omissions resulted in the resident not receiving prescribed oxygen therapy.
Failure to Address Family Grievance Regarding Resident Hygiene
Penalty
Summary
The facility failed to properly address a family member's concern regarding a resident's bathing and changing of clothes. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 1/15, and required supervision and assistance with bathing and dressing. Documentation showed that the resident frequently refused showers and changes of clothing, and staff reported that the resident would only accept care from a specific CNA. Despite these refusals, the family expressed concerns about the resident's hygiene, which were communicated to the Social Worker (SW). The SW informed the family that efforts were being made to resolve the issue, including working with the CNA to assist the resident. However, the SW did not document the conversation with the family, and the Administrator, who served as the facility's grievance officer, was not made aware of the family's concern. The facility's grievance policy required that all grievances be investigated, documented, and responded to in writing, with findings reported to the Administrator within five working days. This process was not followed in this case. Interviews with various staff members, including the Unit Manager, LPN, CNA, and DON, confirmed that the resident often refused showers and changes of clothing, and that refusals were to be documented and communicated. However, there was a lack of documentation regarding the family’s grievance and the facility’s response, and the required notification and investigation procedures outlined in the facility’s grievance policy were not followed. This resulted in the facility failing to honor the resident's right to have grievances addressed without discrimination or reprisal.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident who was receiving oxygen therapy. The resident, who had diagnoses including acute and chronic respiratory failure with hypercapnia, pneumonia, and COPD, was admitted and re-admitted to the facility on multiple occasions. Despite physician orders and progress notes indicating the resident was receiving oxygen at 5 liters per minute via nasal cannula, the care plan did not reflect the use of oxygen. The omission was confirmed during interviews with the Unit Manager, Director of Nursing, and Licensed Nursing Home Administrator, all of whom acknowledged that the care plan should have been updated to include oxygen therapy upon the resident's admission or return to the facility. A review of the facility's policy on comprehensive person-centered care plans indicated that care plans are to be revised as information about the resident and their condition changes. However, the care plan for this resident did not include any mention of oxygen use, despite clear documentation in the medical record and physician orders. The failure to update the care plan was identified through observation, record review, and staff interviews during the survey.
Failure to Administer Oxygen at Physician-Ordered Rate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of acute and chronic respiratory failure, hypoxia, hypercapnia, and COPD was observed receiving oxygen at a rate of 3 liters per minute via nasal cannula, despite a physician's order specifying 2 liters per minute. The surveyor and unit manager found the nasal cannula out of the resident's nostrils and the oxygen concentrator set at 3 liters per minute. The unit manager confirmed the discrepancy after checking the physician's order and adjusted the oxygen flow to the correct rate. The resident's pulse oximeter reading was 99% at the time of observation. Further interviews revealed that the LPN had seen the resident earlier with the nasal cannula in place but did not check the oxygen flow rate. The CNA reported that the oxygen concentrator appeared to be working during rounds. The facility's policy requires nursing staff to follow physician orders and verify oxygen administration procedures, including checking the flow rate. The failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and facility policy.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, reported that the CNA pushed them, causing hot coffee to spill on their lap. This incident was not properly investigated or reported by the facility, leading to a situation of Immediate Jeopardy. The incident occurred when the resident was in the nutrition room heating up food and coffee. The CNA entered the room to get ice for other residents, and a confrontation ensued. The resident accused the CNA of pushing them, which resulted in the coffee spill. Despite the resident's report of physical abuse, the facility did not suspend the CNA or report the incident to the appropriate authorities in a timely manner. The facility's policy on abuse prevention was not followed, as the incident was not reported within the required two-hour timeframe, and the CNA continued to work for several days after the allegation. The Director of Nursing (DON) acknowledged the failure to act appropriately and confirmed that the incident should have been reported and the CNA suspended immediately.
Removal Plan
- Suspending CNA #1 pending investigation
- Notifying the New Jersey Department of Health of the allegation of abuse
- Educating all staff on the facility abuse policy
Inadequate Supervision and Safety Measures for Hot Liquids
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents handling hot liquids, resulting in multiple burn incidents. Resident #13 suffered burns on two occasions while attempting to heat coffee in a microwave located in an unlocked nutritional room. On the first occasion, Resident #13 experienced a first-degree burn on the pelvic area after an altercation with another resident. On the second occasion, Resident #13 sustained more severe burns, including second-degree burns on the left thigh and penis, when a door bumped into their wheelchair, causing the hot coffee to spill. Resident #40 also suffered a second-degree burn while attempting to transport hot coffee from the dining room to their room. The resident placed the coffee cup inside their wheelchair, which led to the spill and subsequent burn. The incident occurred despite the facility's policy that hot beverages should be served with a lid to prevent spills. Both residents involved had intact cognition, as indicated by their BIMS scores, and were capable of making decisions regarding their activities of daily living. However, the facility's lack of supervision and failure to implement adequate safety measures for handling hot liquids contributed to these incidents. The facility's policies and procedures were not effectively enforced, leading to these preventable accidents.
Removal Plan
- Resident education and care plans updated as indicated.
- The interdisciplinary care team met to discuss hot beverages policy, microwave use, and reviewed trends surrounding hot beverage spills.
- Microwaves were removed from the common area by Maintenance staff/designee.
- The resident council president and residents were made aware by unit managers/interdisciplinary team that microwaves were removed from common areas by maintenance staff/designee and that requests should be made to staff for reheating of food and beverages.
- The resident council/food committee was held. Residents were educated on hot beverage safety and the removal of microwaves from common areas. The residents were educated that dietary staff would reheat meals and beverages upon request to minimize the risk of injury and validate appropriate beverage temps before resident consumption and/or transporting of hot beverages.
- Staff education was initiated and remained ongoing.
- Education on monitoring during meals and during resident transport of hot beverages to assist in minimizing the risk of potential injury and following plan of care.
- Staff were educated to request reheating of meals and beverages from dietary staff. Education to dietary staff regarding reheating food and beverages per policy and facility-initiated process.
- A review was completed of resident incidents with identified residents reviewed. Care plans were in place, and no further variances were noted.
- Kitchen audits related to test trays remain ongoing. Variances addressed as indicated.
Medication Security and Expired Items Deficiency
Penalty
Summary
The facility failed to ensure the security of one of its medication carts and did not remove expired supplements and blood equipment from a medication storage room. An unlocked medication cart was observed at the nurses' station between the 800 and 700 halls. During this time, two staff members were in the office with their backs to the window, and the cart was not in their line of sight. Several staff members and two unidentified residents passed by the unlocked cart, and a CNA accessed it for a straw. The RN responsible for the cart was unaware it was unlocked and reported the incident to the Unit Manager. In the medication storage room between the 700 and 800 halls, several expired items were found, including intravenous catheters, a nutritional supplement, specimen collection instruments, and a viral access spike. The Unit Manager, who usually checks the room twice a week, admitted to missing these expired items during her last inspection. The facility's policy requires that expired medications and biologicals be returned or destroyed, and that all compartments containing medications be locked when not in use.
Inaccurate Completion of Medicare Beneficiary Notices
Penalty
Summary
The facility failed to accurately complete the Medicare Part A form CMS-10123 Notice of Medicare Non-Coverage (NOMNC) for one resident and the CMS Skilled Facility Nursing Advanced Beneficiary Notice (SNFABN) CMS-10055 form for two residents. For Resident 6, the NOMNC form was missing the TTY number, which is essential for residents who are hard of hearing or deaf to assist them in filing an appeal. Additionally, the form did not include the name of the Quality Improvement Organization (QIO), which is responsible for reviewing appeal information. The SNFABN form issued to Resident 6 by phone was also incomplete, lacking the facility's telephone number and providing insufficient information in the sections for care, reason Medicare might not pay, and cost. Similarly, for Resident 79, the SNFABN form was completed in the same inadequate manner, missing the facility's phone number and providing vague descriptions in the care, reason Medicare might not pay, and cost sections. The facility's policy on Medicare Advance Beneficiary and Medicare Non-Coverage Notices did not provide instructions on how to complete these forms. The 2018 instructions for the SNFABN form and the undated instructions for the NOMNC form specify the necessary information that should be included, such as the facility's contact details and clear, understandable language for the beneficiary.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged physical abuse involving a resident, identified as R13, to the state agency within the required two-hour timeframe. R13, who was cognitively intact with a BIMS score of 14 out of 15, was involved in an altercation with a Certified Nursing Assistant (CNA1) in the nourishment room. During the incident, R13 reportedly blocked the entranceway and threatened to pour coffee on CNA1. In the ensuing struggle, R13 spilled coffee on himself and later alleged that CNA1 pushed him, causing the spill. Despite these allegations, the incident was not reported to the state agency or the Ombudsman as required by the facility's policy. The Director of Nursing (DON) and the Administrator confirmed that the incident was not reported, with the DON stating that the staff concluded the investigation internally and did not find it necessary to notify the state agency. However, upon reviewing the statements where R13 reported alleged physical abuse, the DON acknowledged that the incident should have been reported within two hours of staff's knowledge. The facility's policy mandates immediate reporting of any suspected abuse, neglect, or exploitation to the Administrator and relevant authorities, which was not adhered to in this case.
Inadequate Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident, identified as R13, who was cognitively intact with a BIMS score of 14 out of 15. The incident occurred when R13 was in the nourishment room heating coffee, and a CNA entered the room to get ice. R13 accused the CNA of pushing him, causing hot coffee to spill on his lap. The CNA provided a written statement indicating that R13 blocked her path and threatened her, leading her to squeeze past him, which she claimed resulted in the coffee spill. The investigation into the incident was inadequate, as it lacked comprehensive interviews and documentation. The facility's policy required thorough investigation procedures, including interviews with all involved parties and witnesses, which were not fully conducted. The Director of Nursing initially decided not to pursue the investigation further, citing R13's tendency to fabricate stories, but later acknowledged the need to restart the investigation. Interviews with staff and the resident revealed inconsistencies in the accounts of the incident. The CNA denied returning to the nourishment room a second time, contrary to her written statement. The resident, R13, maintained that the CNA pushed him, causing the spill. The facility's failure to adhere to its abuse investigation policy and the lack of a comprehensive investigation placed R13 at risk and resulted in a deficiency finding.
Failure to Complete PASARR Screening Correctly
Penalty
Summary
The facility failed to ensure the Pre-Admission Screen and Resident Review (PASARR) Level I screen was completed correctly prior to the admission of a resident diagnosed with schizoaffective disorder. The resident, identified as R112, was admitted to the facility from the hospital with a diagnosis of schizoaffective disorder and a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition. Despite this, the PASARR Level I screen submitted by the hospital case worker incorrectly indicated that the resident did not have a diagnosis or evidence of a major mental illness disorder. During an interview, the Social Services Director acknowledged that the PASARR form was filled out incorrectly by the hospital and confirmed that the resident had a long-standing diagnosis of schizophrenia. The facility's policy requires that all new admissions be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASARR process, which was not adhered to in this case. This oversight created a potential failure to identify the specialized or rehabilitative services needed by the resident and whether the placement in the facility was appropriate.
Failure to Develop Activity Care Plan for Resident
Penalty
Summary
The facility failed to develop an activity care plan for a resident, identified as R49, which included the resident's preference for one-to-one activities. This oversight was identified during a review of the resident's records and interviews with facility staff. R49 was admitted with several diagnoses, including major depressive disorder, and was noted to be cognitively intact but dependent on staff for all activities of daily living. The resident's admission activities assessment indicated a preference for one-to-one activities rather than group activities, but this preference was not reflected in the care plan. Interviews with facility staff, including an LPN and the Activity Director, revealed a lack of awareness and follow-through regarding the resident's activity preferences. The LPN was unsure if the resident was on the list for one-to-one visits, and the Activity Director, who was new to the position, admitted to not having developed a care plan that reflected the resident's desires. The facility's policy on comprehensive person-centered care plans was not adhered to, as the care plan did not describe the services needed to maintain the resident's well-being.
Failure to Revise Care Plan After Resident Sustains Coffee Burn
Penalty
Summary
The facility failed to revise the care plan for a resident who sustained a second-degree coffee burn while attempting to transport hot coffee from the dining room to his room. The resident, who had a medical history including diabetes mellitus type II, depression, acute kidney failure, transient ischemic attacks, and cerebral infarct, was not provided with an updated care plan to reflect the incident and the necessary interventions to prevent recurrence. The care plan, last revised in 2014, did not include reminders for the resident to ask for assistance when carrying hot items or the staff education to ensure hot liquids were cooled before being offered to residents. Interviews with facility staff, including an LPN and the DON, confirmed that the care plan should have been updated to include these interventions. The facility's policy on care plans, which mandates ongoing assessments and revisions as resident conditions change, was not adhered to in this case. The failure to update the care plan posed a potential risk to resident safety, as it did not reflect the necessary precautions to prevent similar incidents in the future.
Failure to Document Resident Weights as Ordered
Penalty
Summary
The facility failed to provide quality care in accordance with physician orders for a resident, identified as R78, by not adhering to the prescribed schedule for weighing the resident. R78 was admitted with several diagnoses, including anoxic brain injury and type II diabetes mellitus, and had a feeding tube providing the majority of daily calories. The care plan required weekly weights for four weeks, then monthly weights, to monitor for unplanned weight loss. However, the facility did not document weights as ordered, with missing entries for several dates in May and June. This lack of documentation meant that significant weight changes were not communicated to the Registered Dietitian (RD), who was unaware of any issues due to the absence of recorded weights. Interviews revealed that the RD was not notified of any weight changes because the weights had not been entered into the system. The Unit Manager responsible for documenting weights had left abruptly, leaving work undone, which contributed to the lack of documentation. A Licensed Practical Nurse (LPN) stated that weekly weights were supposed to be recorded by the Unit Manager, and any significant weight differences should have been reported. The facility's policy required weights to be recorded in the medical record, which was not followed, leading to the deficiency.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions. The resident, who was admitted with multiple diagnoses including aftercare for hip replacement surgery, hemiplegia, hemiparesis, diabetes, major depressive disorder, seizures, and cerebral infarct, had an open area on the right buttocks. This condition necessitated Enhanced Barrier Precautions, as indicated by signage outside the resident's room, which instructed staff to perform hand hygiene and don gloves and gowns while providing direct care. During an observation, a Certified Nursing Assistant (CNA) was seen providing a bed bath to the resident without wearing a gown, and a Licensed Practical Nurse (LPN) entered the room to administer pain medication and assist with the bed bath, also without donning a gown. The LPN later admitted to forgetting to wear a gown in the rush to provide timely pain relief. The incident was noted by another LPN, who confirmed the failure to adhere to the PPE requirements. The Infection Preventionist was informed of the incident and conducted a staff in-service on Enhanced Barrier Precautions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 721 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hamilton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Preferred Care At Hamilton | 1.7 mi | ★★★★★ | 0 | 0 |
| Complete Care At Mercerville Llc | 2.1 mi | ★★★★★ | 0 | 0 |
| Spring Hills Post Acute Hamilton | 2.5 mi | ★★★★★ | 2 | 0 |
| Hamilton Grove Healthcare And Rehabilitation, Llc | 2.8 mi | ★★★★★ | 17 | 0 |
| Clover Meadows Healthcare And Rehabilitation Cente | 3.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.