Deficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
282% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
97% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A follow-up to a previous recertification survey and a follow-up to a previous Life Safety survey were conducted at the facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 30, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding the facility's failure to protect resident identifying information, adherence to physician orders for oxygen administration, offloading of heels, use of hand splints, nutritional status maintenance, medication labeling and storage, food safety, environmental cleanliness, and nurse aide training.
Complaint Details
The visit was complaint-related, triggered by concerns about resident privacy breaches, treatment non-compliance, nutritional neglect, medication management, food safety, environmental cleanliness, and staff training deficiencies. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to protect resident identifying information, non-compliance with physician orders for oxygen therapy and offloading, inadequate monitoring and notification of severe weight loss, improper medication storage and labeling, unsafe food storage and handling, unclean air conditioning units, and insufficient nurse aide training hours.
Deficiencies (7)
Failed to protect identifying information for 3 of 4 current residents identified in the survey results binder.
Failed to ensure residents received treatment and care in accordance with professional standards, including continuous oxygen administration for 2 residents, offloading heels for 1 resident, and applying a hand splint for 1 resident.
Failed to maintain acceptable nutritional parameters for 1 resident who experienced actual weight loss without proper reweigh or notification to dietician or physician.
Failed to store and label drugs and biologicals in accordance with professional principles; medications were expired, not dated, or discontinued but still present.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; expired, undated, and exposed food items were observed in the kitchen.
Failed to maintain a safe, functional, and comfortable environment; window air conditioning units had visible accumulation of black matter.
Failed to develop, implement, and maintain an effective in-service training program ensuring nurse aides received at least 12 hours of training per year for 2 of 4 nurse aides reviewed.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Nurse aides affected: 2
Weight loss percentage: 7.82
Weight loss pounds: 8.6
Weight measurements: 118
Weight measurements: 118.6
Weight measurements: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Acknowledged oxygen administration and offloading deficiencies. |
| Director of Nursing Services | Interviewed multiple times regarding expectations and inability to provide evidence of compliance. | |
| Staff B | Certified Medication Technician (CMT) | Acknowledged discontinued medication not discarded. |
| Registered Dietician | RD | Provided assessments and noted reweigh requests; unaware reweigh was completed. |
| Nurse Practitioner | NP | Unaware of extent of resident's weight loss; authored note with plan for labs and supplements. |
| Food Service Manager | FSM | Acknowledged expired and undated food items should have been discarded. |
Inspection Report
Annual Inspection
Census: 30
Capacity: 31
Deficiencies: 12
Date: May 30, 2025
Visit Reason
A recertification and complaint survey was conducted at Avalon Nursing Home from 05/27/2025 through 05/30/2025 to determine compliance with federal regulations for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The survey included a complaint investigation referenced by ACTS number 100587.
Findings
Deficiencies were identified in multiple areas including resident rights, comprehensive care plans, nutrition and hydration, medication labeling and storage, immunizations, personnel background checks, emergency preparedness, and life safety code compliance. The facility failed to protect resident identifying information, maintain acceptable nutritional status, ensure proper medication management, and maintain a safe and functional environment.
Deficiencies (12)
Facility failed to protect identifying information for 3 of 4 residents reviewed.
Facility failed to ensure residents received treatment and care according to professional standards related to oxygen administration, offloading heels, and splint use.
Facility failed to maintain acceptable nutritional status for 1 resident with severe weight loss and failed to obtain timely reweighs and notify dietitian or physician.
Facility failed to properly label and store drugs and biologics, including expired medications and improperly dated vials.
Facility failed to ensure residents received required influenza and pneumococcal immunizations and documentation.
Facility failed to perform criminal background checks within one week of employment for 3 of 8 staff reviewed.
Facility failed to maintain effective in-service training program for nurse aides.
Facility failed to ensure quarterly evaluations for medication technicians were completed.
Facility failed to maintain emergency preparedness compliance with 42 CFR §483.73.
Facility failed to maintain fire alarm system, sprinkler system, and electrical systems in accordance with NFPA Life Safety Code requirements.
Facility failed to maintain safe, functional, and comfortable environment including air conditioning units and oxygen cylinder storage.
Facility failed to maintain required in-service training for nurse aides.
Report Facts
Capacity: 31
Census: 30
Weight loss percentage: 7.82
Staff reviewed: 8
Staff with late background checks: 3
Nurse aides reviewed: 4
Nurse aides without required training: 2
Medication technicians reviewed: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 28, 2024
Visit Reason
The inspection was conducted due to allegations of abuse involving two residents, Resident ID #1 and Resident ID #2, including sexual abuse and staff-to-resident physical abuse.
Complaint Details
The complaint investigation involved two residents alleging abuse: Resident ID #1 reported sexual abuse by Staff A on 8/21/2024, and Resident ID #2 reported physical abuse by Staff B on 8/4/2024. Both allegations were not reported to the Rhode Island Department of Health within the required 2-hour timeframe. The Director of Nursing Services acknowledged the delay in reporting.
Findings
The facility failed to report alleged abuse incidents to the Rhode Island Department of Health within the required 2-hour timeframe for both residents. Resident #1 alleged inappropriate sexual behavior by Staff A, and Resident #2 alleged that Staff B caused pain by squeezing his/her leg. The Director of Nursing Services acknowledged awareness of the allegations but did not report them timely.
Deficiencies (2)
Failure to timely report suspected abuse involving Resident ID #1's sexual abuse allegation to the Rhode Island Department of Health within 2 hours.
Failure to timely report suspected abuse involving Resident ID #2's allegation of staff squeezing left leg causing pain to the Rhode Island Department of Health within 2 hours.
Report Facts
Date of sexual abuse allegation: Aug 21, 2024
Date of physical abuse allegation: Aug 4, 2024
Date incident reported to RIDOH: Aug 22, 2024
Date incident reported to RIDOH: Aug 14, 2024
Brief Interview for Mental Status score: 12
Brief Interview for Mental Status score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in sexual abuse allegation involving Resident ID #1 | |
| Staff B | Named in physical abuse allegation involving Resident ID #2 | |
| Director of Nursing Services | DNS | Acknowledged awareness of abuse allegations and failure to report within required timeframe |
| Minimum Data Set Assessment Coordinator | Interviewed by surveyor and reported Resident ID #1's disclosure of abuse |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
An off-site desk audit was conducted on July 10, 2024, to review all previous deficiencies cited on May 31, 2024, and a follow-up Life Safety Code survey was conducted on July 5, 2024 to verify correction of previous deficiencies.
Findings
All previous deficiencies cited in the May 31, 2024 inspection were corrected based on acceptable plans of correction and supporting documentation. No new deficiencies were identified during the follow-up Life Safety Code survey.
Inspection Report
Routine
Deficiencies: 6
Date: May 31, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications, dialysis care, nutritional needs, food safety, infection prevention and control, water management, and staff training at Avalon Nursing Home Inc.
Findings
The facility was found deficient in multiple areas including failure to notify the State Long-Term Care Ombudsman of resident discharges, lack of physician orders for dialysis, failure to provide ordered nutritional protein portions, inadequate food safety practices, lapses in infection control precautions, absence of a water management program to prevent Legionella, and failure to maintain mandatory staff training and performance evaluations.
Deficiencies (6)
Failed to provide written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for 2 residents discharged to hospital.
Failed to ensure residents requiring dialysis received services consistent with professional standards; missing physician orders and unsigned dialysis service agreement.
Failed to meet nutritional needs of dialysis resident by not providing ordered double portions of protein at meals.
Failed to ensure food was stored and distributed in accordance with professional standards; dirty microwave and refrigerator, undated opened nectar thickened juices.
Failed to maintain infection prevention and control program; lapses in contact precautions for residents with MDROs, improper PPE use during foley catheter removal, and lack of water management program to prevent Legionella.
Failed to develop, implement, and maintain an effective training program for new and existing staff; missing mandatory education and performance evaluations for 4 staff members.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 31
Staff members reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged no physician order for dialysis and improper PPE use during foley catheter removal |
| Staff B | Cook | Acknowledged nectar thickened juices were not dated |
| Staff C | Registered Nurse | Observed obtaining vital signs without PPE; missing mandatory education in 2023 |
| Staff D | Physical Therapist Assistant | Entered resident room without PPE despite contact precautions signage |
| Staff F | Certified Medication Technician | Missing mandatory education and performance evaluation |
| Staff G | Nursing Assistant | Missing mandatory education and performance evaluation |
| Director of Nursing Services | Director of Nursing Services | Acknowledged multiple deficiencies including lack of dialysis orders, infection control lapses, and missing staff training documentation |
| Staff E | Registered Nurse | Missing mandatory education in 2023 |
Inspection Report
Annual Inspection
Census: 30
Capacity: 31
Deficiencies: 9
Date: May 31, 2024
Visit Reason
A recertification survey was conducted at Avalon Nursing Home from 5/29/2024 through 5/31/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to failure to provide written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman, dialysis services, nutritional adequacy, food safety, infection prevention and control, training requirements, employee immunization and screening, and life safety code compliance including fire alarm system and sprinkler system maintenance.
Deficiencies (9)
Facility failed to provide written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for 2 residents discharged to hospital.
Facility failed to ensure dialysis services were provided consistent with professional standards for 1 resident.
Facility failed to meet nutritional needs related to increased protein for 1 dialysis resident.
Facility failed to ensure food safety requirements including dated food items and clean equipment in kitchen.
Facility failed to maintain an infection prevention and control program to prevent transmission of communicable diseases for multiple residents.
Facility failed to develop and maintain an effective training program for all new and existing staff including mandatory education and performance evaluations.
Facility failed to obtain evidence of immunity for all health care workers as required by regulations.
Facility failed to maintain fire alarm system and sprinkler system maintenance and testing as required by NFPA codes.
Facility failed to maintain emergency power supply system in accordance with NFPA standards.
Report Facts
Census: 30
Total Capacity: 31
Residents reviewed for dialysis: 1
Residents reviewed for infection control: 3
Staff reviewed for immunization: 6
Residents impacted by fire alarm deficiency: 30
Residents impacted by sprinkler system deficiency: 30
Residents impacted by emergency power supply deficiency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to oversight of dialysis services and plan of correction |
| Administrator | Administrator | Named in relation to oversight of deficiencies and plans of correction |
| Registered Nurse Staff A | Registered Nurse | Interviewed regarding dialysis services and infection control practices |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding dialysis services and infection control |
| Cook Staff B | Cook | Interviewed regarding food safety and immunization records |
| Staff C | Registered Nurse | Interviewed regarding infection control and immunization records |
| Staff F | Certified Medication Technician | Named in relation to immunization record deficiency |
| Staff G | Nursing Assistant | Named in relation to immunization record deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 16, 2024
Visit Reason
The inspection was conducted in response to a community reported complaint submitted to the Rhode Island Department of Health on 2024-05-08 alleging that there were no activities for residents at the facility.
Complaint Details
Complaint was submitted on 2024-05-08 alleging no activities for residents. The complaint was substantiated by surveyor observations and interviews.
Findings
The facility failed to provide an ongoing program of activities that meet the interests and well-being of residents based on their comprehensive assessments, care plans, and preferences. Observations on 2024-05-14 and 2024-05-16 showed no evidence of scheduled group activities, and interviews confirmed that activities such as Bingo on 2024-05-15 did not occur. The activity program did not include pets, current events, or non-denominational religious services, and the Administrator could not provide evidence of an activity program developed based on resident preferences.
Deficiencies (1)
Failed to provide activities to meet all resident's needs based on comprehensive assessment, care plan, and preferences for 3 of 5 residents reviewed.
Report Facts
Residents reviewed: 5
Residents affected: 3
BIMS scores: 15
BIMS scores: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Activities Assistant | Unable to provide evidence of morning activities and described activity program limitations |
| Director of Nursing Services | Revealed no group activities on 2024-05-15 | |
| Administrator | Unable to provide evidence of an activity program developed based on assessments, care plans, and resident preferences |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: May 10, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey of Avalon Nursing Home Inc to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, promote resident self-determination, conduct timely assessments, implement comprehensive care plans, ensure professional quality of services, maintain nutritional status, provide dental services, ensure food safety, and monitor antibiotic use.
Deficiencies (9)
Failed to provide reasonable accommodation of resident needs and preferences related to call light accessibility for Resident ID #28.
Failed to assure resident's right to self-determination with services inside the facility relative to activities for Resident ID #12.
Failed to conduct periodic accurate, standardized reproducible assessments of residents' functional capacity for Residents ID #5 and #12.
Failed to implement a comprehensive person-centered care plan relative to fluid restrictions for Resident ID #20.
Failed to ensure services met professional standards of quality for blood sugar monitoring for Resident ID #6.
Failed to maintain acceptable nutritional status relative to dietary supplements for Residents ID #7, #18, and #28.
Failed to assist a resident in obtaining routine and emergency dental services for Resident ID #13.
Failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.
Failed to establish an antibiotic stewardship program that includes antibiotic use protocols and monitoring for Residents ID #2 and #8.
Report Facts
Weight loss: 8
Blood sugar levels: 518
Blood sugar levels: 65
Blood sugar levels: 29
Blood sugar levels: 548
Fluid restriction: 1500
Antibiotic dosage: 500
Antibiotic dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Acknowledged resident unable to reach call light |
| Staff B | Activities Staff | Indicated resident was not offered to attend bingo |
| Staff C | Registered Nurse | Unable to explain why resident did not attend activity |
| Staff D | Nursing Assistant | Acknowledged magic cup supplement was not provided |
| Staff E | Registered Nurse | Expected magic cup supplement to be provided |
| Staff F | Cook | Acknowledged expired food items and improper sanitizer concentration |
| Staff G | Nursing Assistant | Acknowledged house supplement was not provided |
| Director of Nursing Services | Director of Nursing Services | Acknowledged multiple deficiencies including call light accessibility, activity attendance, fluid intake recording, blood sugar monitoring, dietary supplement provision, dental services, and antibiotic stewardship |
| Administrator | Administrator | Unable to provide evidence of comprehensive reassessment and expected food safety compliance |
| Registered Dietitian | Registered Dietitian | Discussed weight loss intervention and inability to explain discontinuation of supplement order |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 2, 2022
Visit Reason
An off-site desk audit was conducted on May 2, 2022, to review all previous deficiencies cited on April 7, 2022.
Findings
Based on an acceptable plan of correction, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 29
Capacity: 31
Deficiencies: 6
Date: Apr 7, 2022
Visit Reason
A Recertification of hour & Complaints Investigation Survey was conducted from 04/03/2022 to 04/07/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Complaint Details
This visit was triggered by complaints and a recertification survey to investigate compliance with federal and state regulations.
Findings
Deficiencies were cited related to baseline care plans, food service and safety, employee immunization and screening, personnel records, and in-service education. The facility failed to develop baseline care plans within 48 hours for residents, ensure food was prepared and served properly, maintain required immunization records for employees, and provide adequate staff training.
Deficiencies (6)
Facility failed to develop and implement a baseline care plan within 48 hours of admission for 2 residents.
Facility failed to assure residents receive and consume food in the appropriate form for 4 of 12 residents observed.
Facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.
Facility failed to obtain evidence of immunity for 3 of 8 employees reviewed.
Facility failed to obtain evidence of active licensing for 1 of 8 employees reviewed.
Facility failed to provide evidence of in-service training for staff related to infection control, food services and sanitation, fire safety, confidentiality, and residents' rights.
Report Facts
Census/bed count: 29
Total licensed capacity: 31
Employees lacking immunization evidence: 3
Employees lacking active license: 1
Residents observed with food form issues: 4
Residents reviewed for baseline care plans: 2
Viewing
Loading inspection reports...
