Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Nursing Home Inc during CMS and state inspections, most recent first.
The facility failed to ensure that all staff received and completed required training on abuse, neglect, and exploitation. Review of an abuse in-service sign-in sheet showed that less than half of listed nursing staff signed for attendance, and only a few completed post-tests, with no inclusion of social work, dietary, housekeeping, or maintenance staff. A housekeeping/dietary aide and a nursing assistant reported never receiving abuse-related training. The DNS was unable to account for missing post-tests for multiple staff who had signed the in-service sheet and could not produce a post-test for a nursing assistant who had signed. The DNS also stated he was unaware that abuse training was required for all facility staff, not just nursing staff.
A resident reported to an RN that a NA had been too rough during care, including twisting the resident’s arms while transferring from a chair to bed, and later a small blue bruise of unknown cause was noted on the resident’s outer thigh. The RN documented the complaint and indicated she would speak to the DNS but did not report the allegation as required by facility policy, which mandates contacting leadership at the time of the incident and reporting to the Department of Health within two hours. Another RN, returning from several days off, later discovered the note and submitted the incident report to the state, but this occurred well beyond the required reporting timeframe, and the Administrator could not show evidence of timely reporting.
A resident with bipolar disorder, anxiety, and insomnia, who was cognitively intact, reported that a NA was too rough during a transfer, including twisting the resident’s arms, and was later found to have a small blue mark on the outer thigh of unknown cause. The facility’s abuse investigation did not include statements from the RN who first received the allegation or from the RN assigned during the shift when the alleged incident occurred, and the NA’s written statement only briefly denied the allegation without further detail. Despite the report and the facility’s policy requiring a full investigation, the NA was removed from caring for this resident but was allowed to continue working and providing care to other residents while the investigation was ongoing.
The facility failed to report allegations of abuse involving two residents to the RIDOH within the required timeframe. One resident alleged inappropriate sexual behavior by a staff member, while another reported pain caused by a staff member squeezing their leg. Both incidents were not reported within the 2-hour requirement, despite the facility's policy.
The facility failed to maintain food safety standards in the main kitchen. A microwave was found with dried food particles, and improperly stored red meat was observed in a refrigerator with red liquid at the bottom. Additionally, opened nectar thickened juices were not dated as required, which was acknowledged by staff and the Administrator.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper management of residents with MDROs and inadequate use of PPE during Foley catheter removal. Additionally, the facility did not implement a comprehensive water management program to prevent Legionella growth, with unused sinks and a shower not being flushed regularly.
A resident with end-stage renal disease did not receive dialysis services consistent with professional standards due to missing physician's orders and an unsigned care coordination agreement. The resident's records lacked documentation specifying the dialysis center, type, and schedule, which was confirmed by a nurse. Additionally, the care coordination agreement with the dialysis center was not signed or dated, as acknowledged by the DON.
The facility failed to maintain an effective training program for staff, as four staff members did not receive mandatory education in 2023. Additionally, two staff members did not receive annual performance evaluations or required in-service training. The DON could not provide evidence of these trainings or evaluations.
A resident requiring dialysis did not receive the prescribed double portions of protein with each meal, as observed during a survey. Despite a physician's order, the resident's meals often lacked the necessary protein portions. Interviews revealed that staff were unaware of the dietary requirements, and the Registered Dietitian expected alternative protein options to be provided if needed.
The facility failed to notify the State LTC Ombudsman of two residents discharged to the hospital. One resident had syncope, COPD, and hypertension, while the other had a stroke, rhabdomyolysis, and lumbar spondylosis. The DON was unaware of the notification requirement.
The facility failed to provide a comprehensive activity program tailored to residents' preferences, as observed by surveyors. Activities were inconsistently scheduled, with some not occurring as planned. Residents expressed interest in more group activities, including pet therapy and current events, which were not offered. The lack of activities aligned with residents' care plans and preferences was confirmed through interviews and record reviews.
Failure to Provide and Document Abuse and Neglect Training for All Staff
Penalty
Summary
The facility failed to provide required abuse and neglect training to all staff, as evidenced by incomplete attendance and testing records and staff reports of never receiving such education. Record review of the most recent abuse in-service training sign-in sheet dated 1/5/2025, titled "Staff Sign Off Sheet for Abuse and Neglect," showed that only 13 of 28 listed nursing staff had signed for attendance, and only three post-tests were completed despite 23 signatures indicating attendance. The sign-in sheet and associated materials did not include the Social Worker, dietary, housekeeping, or maintenance staff. In interviews, a housekeeping/dietary aide (Staff E) and a Nursing Assistant (Staff B) each stated they had never received abuse-related training at the facility. During an interview, the DNS could not explain why 10 staff members who signed the in-service sheet had no completed post-test and could not provide evidence of a completed post-test for Staff B, despite her signature. The DNS also stated he was unaware that abuse training was required for all facility staff and believed it applied only to nursing staff until informed otherwise by the surveyor. No residents or specific patient conditions were mentioned in the report, and the deficiency centers on the facility’s failure to ensure comprehensive and documented abuse, neglect, and exploitation training for all categories of staff.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported immediately, and no later than two hours after the allegation was made, as required by its policy and state reporting requirements. The facility’s policy dated 8/2020, titled “Reporting Patient Abuse,” states that any person who has reason to believe a patient has been abused should contact the charge nurse, DNS, and/or Administrator at the time of the incident, and that the incident will be reported to the Department of Health within two hours. For one resident reviewed for abuse, the clinical record showed that the resident complained that a nursing assistant was too rough during care on the 3:00 PM to 11:00 PM shift, including twisting the resident’s arms while pivoting from chair to bed. A subsequent skin check identified a small blue mark on the resident’s right outer thigh of unknown etiology. A nursing progress note dated 3/4/2026 at 6:22 AM, authored by an RN, documented that the resident complained that the nursing assistant was being too rough and did not want that staff member to care for them any longer. The RN stated she would speak to the DNS about the allegation but later revealed she did not report the allegation of abuse to the DNS. Another RN, who had been off work for several days and returned on 3/5/2026, reviewed the resident’s progress notes and, after seeing the documented allegation, reported it to the state health department. The facility-reported incident was submitted to the Rhode Island Department of Health on 3/5/2026 at 1:39 PM, which was not within the required two-hour timeframe from when the allegation was made. During interview, the Administrator was unable to provide evidence that the allegation of abuse had been reported immediately or within two hours after it was made.
Failure to Thoroughly Investigate Abuse Allegation and Restrict Alleged Perpetrator
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and to prevent further potential abuse involving a cognitively intact resident with bipolar disorder, anxiety, and insomnia. The resident, admitted in June 2022, reported to an RN on the 3:00 PM to 11:00 PM shift on 3/4/2026 that a NA had been too rough with him/her during care on the prior 3:00 PM to 11:00 PM shift, stating that the NA hurried him/her to bed and twisted his/her arms while pivoting from chair to bed. The facility’s abuse policy required that anyone suspecting abuse notify the charge nurse, DNS, and/or Administrator at the time of the incident and that a full investigation be conducted, including written statements from witnesses and the resident. However, the investigation initiated after another RN returned from several days off and reviewed the progress notes did not contain a statement from the RN who originally received the allegation (Staff A) or from the RN assigned to the resident during the shift when the alleged incident occurred (Staff D). The only written statement from the alleged perpetrator, the NA, simply denied twisting the resident’s arm and leg and did not provide further detail about the events. The facility also failed to prevent further potential abuse while the investigation was in progress. A facility-reported incident submitted to the state agency documented that a small blue mark of unknown etiology was later noted on the resident’s right outer thigh during a skin check. Although the facility indicated that the NA would no longer be assigned to care for this resident, the staffing schedule showed that the NA continued to work in the facility on the evenings of 3/4/2026 and 3/5/2026, providing care to other residents after the allegation had been made. During interview, the Administrator acknowledged that key staff statements were not obtained and that the NA was allowed to continue working with other residents after the abuse allegation was reported.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the Rhode Island Department of Health (RIDOH) within the required timeframe. According to the facility's policy, any suspected or actual abuse must be reported to the RIDOH within 2 hours if it involves abuse. However, the facility did not adhere to this policy. The first incident involved a resident who alleged inappropriate sexual behavior by a staff member while in the shower. This resident, admitted in February 2024 with heart failure and myocardial infarction, had moderately impaired cognition. The allegation was made on August 21, 2024, but was not reported to the RIDOH until the following day. The second incident involved another resident who reported that a staff member caused pain by squeezing their leg. This resident, admitted in March 2021 with acute kidney failure and an absence of certain toes, had intact cognition. The incident occurred on August 4, 2024, but was not reported to the RIDOH until August 14, 2024. During interviews, the Director of Nursing Services acknowledged awareness of both allegations but admitted to not reporting them within the required 2-hour timeframe.
Food Safety and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the main kitchen. During the initial tour, a microwave was found with dried food particles on the inside surfaces, indicating a lack of cleanliness. Additionally, in the Defrosting Fridge located in the basement, two pieces of red meat were improperly stored directly on the shelves, and the bottom of the refrigerator was covered in red liquid, both stained and wet. These observations highlight a failure to maintain food-contact and non-food-contact surfaces in a clean and sanitary condition as required by the Rhode Island Food Code. Further deficiencies were noted in the handling of ready-to-eat, time/temperature control for safety foods. In the [NAME] Fridge/Freezer, several opened nectar thickened juices were found without date markings, contrary to the manufacturer's instructions which require use within 10 days of opening. Staff B acknowledged the oversight during an interview, and the Administrator also recognized the need for cleanliness and proper date marking. These findings indicate a lapse in following proper food storage and safety protocols, as outlined in the Rhode Island Food Code.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Two residents with multidrug-resistant organisms (MDROs) were not managed according to the required contact precautions. Resident ID #6, who tested positive for Vancomycin-resistant Enterococci (VRE), was observed to have staff entering their room without wearing the necessary personal protective equipment (PPE), such as gowns and gloves, despite clear signage indicating the need for contact precautions. Similarly, Resident ID #28, who had a positive urine culture for extended-spectrum beta-lactamase (ESBL), was not placed on contact precautions or enhanced barrier precautions after completing antibiotic treatment, contrary to facility policy and CDC guidelines. Additionally, the facility did not adhere to proper infection control practices during the removal of a Foley catheter for Resident ID #3, who was admitted with acute kidney failure. The nurse involved in the procedure was observed wearing only gloves, without a gown, which is required under enhanced barrier precautions. This oversight was acknowledged by the Director of Nursing Services (DNS), who confirmed that the resident should have been on enhanced barrier precautions and that the nurse should have worn both a gown and gloves during the procedure. The facility also failed to implement a comprehensive water management program to prevent Legionella growth, as recommended by the CDC. Despite the administrator's claim that all rooms were in use, surveyors found unused sinks and a shower that were not being flushed regularly. The facility's water management binder lacked documentation of a complete water flow assessment and evidence of flushing maintenance for these unused fixtures. The administrator and DNS were unable to provide evidence of a water management program based on industry standards and the CDC toolkit, which is essential for preventing the transmission of Legionella and other waterborne pathogens.
Failure to Ensure Proper Dialysis Care for Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, admitted in March 2021 with end-stage renal disease, was scheduled to receive dialysis three times a week. However, a review of the resident's records revealed the absence of a physician's order specifying the dialysis center, type of dialysis, and scheduled days for the treatment. This lack of documentation was confirmed by a registered nurse during an interview. Additionally, the facility's policy on the care of residents with end-stage renal disease requires agreements with contracted dialysis centers to manage the resident's care. A review of the Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement showed it was not signed or dated by either the dialysis center or the nursing facility. The Director of Nursing Services acknowledged this oversight and admitted to being unaware of the requirement for a physician's order for dialysis.
Failure to Implement Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, as evidenced by the lack of mandatory education in 2023 for four staff members. Registered Nurse Staff C, hired in 2019, and Registered Nurse Staff E, hired in 2022, did not receive any mandatory education in 2023. Certified Medication Technician Staff F, hired in 2014, and Nursing Assistant Staff G, hired in 2017, also did not receive any mandatory education for the entire year of 2023. Additionally, Staff F and G did not receive annual performance evaluations or the required 12 hours of in-service training. During an interview with the Director of Nursing Services, it was confirmed that there was no evidence of mandatory education for 2023 for the mentioned staff members, nor was there evidence of annual performance reviews or proof of 12 hours of in-service training for Staff F and G.
Failure to Provide Prescribed Protein Portions for Dialysis Resident
Penalty
Summary
The facility failed to meet the nutritional needs of a resident requiring dialysis, identified as Resident ID #19, by not providing the prescribed double portions of protein with each meal. The resident, admitted in March 2021 with acute kidney failure and obesity, requires dialysis three times a week. A physician's order dated March 15, 2024, specified that the resident should receive double portions of protein at each meal. However, observations during the survey revealed that the resident's meals did not consistently include the required double protein portions. For instance, the lunch tray on May 29, 2024, included shepherd's pie and Brussels sprouts without the double protein portion, and the breakfast tray on May 30, 2024, lacked any protein. Interviews with the resident and staff further highlighted the deficiency. The resident expressed a desire to receive the double protein portions but noted that it rarely happened. Staff interviews revealed a lack of awareness and adherence to the dietary requirements. Cook, Staff M, mentioned that the resident did not receive protein in the morning unless bacon or sausage was available, as the resident disliked eggs. The Registered Dietitian was unaware of the issue and expected staff to provide alternative protein options if the resident disliked the served items. The Director of Nursing Services could not provide evidence that the facility was complying with the physician's order for double protein portions at each meal.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for two residents who were discharged to the hospital. Resident ID #13, admitted in November 2018, had diagnoses including syncope, chronic obstructive pulmonary disease, and hypertension, and was discharged to the hospital on February 2, 2024. Resident ID #14, admitted in November 2021, had diagnoses including cerebral infarction, rhabdomyolysis, and lumbar spondylosis, and was discharged to the hospital on April 10, 2024. During a surveyor interview, the Director of Nursing Services, in the presence of the Minimum Data Set Coordinator, was unable to provide evidence that the Ombudsman was notified of these discharges. The Director also indicated a lack of awareness regarding the requirement to notify the Ombudsman when a resident is discharged from the facility.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, as observed by surveyors and confirmed through record reviews and interviews. The activities calendar for May 2024 listed only one activity per day without specific start or end times, and several scheduled activities did not occur as planned. For instance, on May 14, 2024, a scheduled 'Beach Ball' activity did not take place, and on May 16, 2024, a 'Hangman' activity was also not conducted. Interviews with staff and residents confirmed the lack of group activities and the absence of activities that align with residents' preferences, such as pet therapy and current events. Resident ID #1, admitted in March 2019, has intact cognition and expressed interest in participating in activities if they were available. The resident's care plan highlighted the importance of being around animals, keeping up with the news, participating in religious services, and engaging in group activities. However, the resident reported that no group activities took place on May 15, 2024, and the activity program did not include pets or news-related activities. Resident ID #2, admitted in January 2024, also has intact cognition and expressed a desire for more group activities. The resident's care plan emphasized the need for therapeutic recreation and assistance with upcoming activities. Despite attending the one scheduled activity per day, the resident reported spending most of the day alone and noted the absence of pet-related and news activities. Similarly, Resident ID #3, admitted in June 2022, reported a lack of afternoon group activities and expressed interest in participating if more were offered. The resident's care plan included goals for anxiety management through activity involvement, but the current program did not meet these needs.
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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 Warwick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Shore Health Center Inc | 1.7 mi | ★★★★★ | 0 | 0 |
| Scandinavian Home Inc | 4.1 mi | ★★★★★ | 0 | 0 |
| Sunny View Nursing Home | 4.3 mi | ★★★★★ | 8 | 1 |
| Greenwood Operations Dba Greenwood Center | 4.4 mi | ★★★★★ | 12 | 2 |
| Brentwood Health Center | 4.7 mi | ★★★★★ | 3 | 0 |
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