Inspection Reports for Avalon Rehabilitation And Healthcare Center
1059 Edinburg Road, Hamilton, NJ, 08690
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
148 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, including how personal health information may be used and disclosed, and the rights individuals have regarding their health information.
Findings
The notice explains the types of information covered, the circumstances under which health information may be used or disclosed, the legal duties of the department, and the rights of individuals to access, amend, and restrict their health information.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 4
Date: May 29, 2025
Visit Reason
The inspection was conducted in response to Complaint #NJ176793 to investigate compliance with physician visit requirements and staffing ratios at Avalon Rehabilitation and Healthcare Center.
Complaint Details
Complaint #NJ176793 was substantiated. The facility failed to meet physician visit frequency requirements and staffing ratios, affecting resident care and documentation.
Findings
The facility was found not in substantial compliance with federal and state regulations due to failure to ensure timely initial comprehensive physician visits and failure to meet staffing ratios for Certified Nursing Assistants (CNAs) during multiple day shifts. Deficient practices were identified for Resident #2 and staffing deficiencies were noted for all residents.
Deficiencies (4)
Failure to ensure the physician responsible for supervising resident care conducted an initial comprehensive visit within the initial 30-day time period.
Failure to consistently document care provided in the Documentation Survey Report and follow the facility's Point of Care (POC) Documentation policy.
Failure to maintain resident-identifiable information confidentiality and proper medical record standards.
Failure to ensure staffing ratios were met for 14 of 14 day shifts reviewed, affecting all residents.
Report Facts
Census: 148
Sample Size: 9
Staffing Deficiency Count: 14
Certified Nursing Assistants (CNAs) on 05/11/25: 15
Residents on 05/11/25: 142
Staffing Wage Increase: 2
Inspection Report
Complaint Investigation
Census: 158
Deficiencies: 5
Date: Mar 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00181366 and NJ00175401, with survey dates of 03/11/2025 and 03/12/2025.
Complaint Details
Complaint numbers NJ00181366 and NJ00175401 triggered the investigation. The facility was found not in substantial compliance with requirements based on the complaint visit. Family concerns regarding Resident #4 were not adequately addressed, and deficiencies were substantiated in grievance handling and care planning.
Findings
The facility was found not in substantial compliance with federal requirements related to grievances, care plan timing and revision, quality of care, and respiratory/tracheostomy care and suctioning. Deficiencies were identified in addressing family concerns, updating care plans, and ensuring proper respiratory care.
Deficiencies (5)
Failure to address family concerns of Resident #4 regarding grievances and care.
Failure to update and revise a resident's comprehensive care plan for Resident #1.
Failure to ensure quality of care including following physician's orders and monitoring for Resident #1.
Failure to administer correct respiratory/tracheostomy care and suctioning for Resident #2.
Failure to ensure staffing ratios met regulatory requirements during complaint staffing periods.
Report Facts
Census: 158
Sample Size: 6
Deficiencies cited: 4
Staffing ratios: 1
Staffing ratios: 1
Inspection Report
Annual Inspection
Census: 124
Deficiencies: 10
Date: Apr 13, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to accuracy of assessments, quality of care, bowel/bladder care, pharmacy services, food preferences, food safety, garbage disposal, infection prevention and control, and staffing ratios.
Deficiencies (10)
Facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 2 residents reviewed for accidents.
Facility staff failed to complete neuro checks for a resident who sustained a head injury.
Facility failed to consistently document care according to physician's orders for a resident with urinary incontinence.
Facility failed to administer medication in accordance with a physician's order for 1 nurse on 1 unit observed during medication pass.
Facility failed to act on or respond to comments made by the Consultant Pharmacist in a timely manner during the Medication Regimen Review.
Facility failed to ensure resident dietary preferences were accurately identified and implemented for 1 of 5 residents reviewed for dining.
Facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness.
Facility failed to provide a sanitary environment by failing to cover the opening of 2 of 3 outside garbage dumpsters.
Facility failed to ensure staff wore appropriate PPE and performed proper hand hygiene for a resident on Transmission Based Precautions and during medication pass.
Facility failed to maintain required minimum direct care staff-to-resident ratios for the day shift as mandated by the State of New Jersey.
Report Facts
Census: 124
Deficiency counts: 10
Staffing ratio: 15
Staffing ratio: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed administering medication and failed to follow up on missing medication; did not perform hand hygiene between residents |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control, hand hygiene, and staffing |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed delivering lunch tray without full PPE and not performing hand hygiene |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Interviewed about PPE use for resident on isolation |
| Food Service Director | Food Service Director | Interviewed regarding food safety and kitchen sanitation |
| Dietician | Dietician | Interviewed regarding resident food preferences and dislikes |
| District Manager | Dietary Manager | Interviewed regarding food tray preparation and resident preferences |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing ratios and use of agency staff |
Inspection Report
Life Safety
Deficiencies: 2
Date: Apr 7, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 04/07/2022 and 04/08/2022 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant due to failure to provide a battery backup emergency light above the emergency generator's transfer switch and failure to maintain the integrity of smoke barrier partitions with penetrations observed in two smoke barrier walls.
Deficiencies (2)
Failed to provide a battery backup emergency light above 1 of 1 emergency generator's transfer switch, independent of the building's electrical system and emergency generator.
Failed to maintain the integrity of the smoke barrier partitions for 2 of 7 smoke barrier walls, with penetrations ranging from two inches up to 10 inches in diameter.
Report Facts
Smoke barrier walls with penetrations: 2
Emergency generator transfer switches: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Support Services (DSS) | Interviewed and confirmed findings related to emergency lighting and smoke barrier penetrations |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint NJ: #14754) focusing on COVID-19 infection control practices at the facility.
Complaint Details
Complaint NJ: #14754. The facility was found not in compliance with infection control regulations related to COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B for long term care facilities based on the complaint visit; however, it was not in compliance with 42 CFR §483.80 infection control regulations related to the implementation of CMS and CDC recommended practices for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Abbreviated Survey
Census: 103
Deficiencies: 1
Date: Jun 9, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to follow policies for Personal Protective Equipment (PPE) usage and hand hygiene, which could lead to the spread of infection. Observations included a Certified Nursing Assistant not wearing required PPE and failing to perform hand hygiene when handling linens in a resident's room under transmission-based precautions.
Deficiencies (1)
Failure to follow policy for Personal Protective Equipment usage and hand hygiene to prevent the possible spread of infection during a COVID-19 focused survey.
Report Facts
Census: 103
Sample size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Observed not wearing gown or gloves and failing to perform hand hygiene when handling linens in Resident #6's room | |
| Licensed Practical Nurse (LPN) | Interviewed regarding PPE requirements and hand hygiene for Resident #6 | |
| Unit Manager | Interviewed regarding PPE requirements for CNA on PUI unit | |
| Assistant Director of Nursing (ADON)/Infection Preventionist | Interviewed regarding PPE and hand hygiene policies and potential contamination of linen cart | |
| MDS Coordinator | Interviewed about COVID-19 outbreak status and PPE requirements |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: May 13, 2021
Visit Reason
The inspection visit was conducted in response to a complaint (Complaint#: NJ138089) to assess compliance with regulatory requirements for long term care facilities.
Complaint Details
Complaint#: NJ138089. The facility was found to be in substantial compliance based on this complaint visit.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 115
Deficiencies: 0
Date: Mar 30, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 112
Deficiencies: 0
Date: Jan 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
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