Pennsylvania Department of Health
 AVALON CARE CENTER
Patient Care Inspection Results

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AVALON CARE CENTER
Inspection Results For:

There are  118 surveys for this facility. Please select a date to view the survey results.

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AVALON CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Findings of an Abbreviated Complaint Survey completed on February 6, 2026, it was determined that Avalon Care Center was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:


Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 10 residents on the day shift for six of 21 days reviewed (1/18/26, 1/24/26, 1/25/26, 1/26/26, 1/31/26, and 2/1/26; failed to ensure one NA per 11 residents on the evening shift for four of 21 days reviewed (1/24/26, 1/25/26, 1/30/26, 2/1/26); and failed to ensure one NA per 15 residents on the overnight shift for five of 21 days reviewed (1/14/26, 1/18/26, 1/22/26, 1/25/26, and 1/31/26).

Findings include:

Review of facility nursing staffing documents for the time period from 1/13/26, through 2/2/26, revealed the following NA shortages for the day shift:

1/18/26 facility census of 79 residents 6.95 NA's worked and 7.90 were required.
1/24/26 facility census of 77 residents 5.48 NA's worked and 7.70 were required.
1/25/26 facility census of 76 residents 4.57 NA's worked and 7.60 were required.
1/26/26 facility census of 76 residents 5.02 NA's worked and 7.60 were required.
1/31/26 facility census of 77 residents 4.10 NA's worked and 7.70 were required.
2/1/26 facility census of 78 residents 5.18 NA's worked and 7.80 were required.

Review of facility nursing staffing documents for the time period from 1/13/26, through 2/2/26, revealed the following NA shortages for the evening shift:

1/24/26 facility census of 76 residents 6.48 NA's worked and 6.91 were required.
1/25/26 facility census of 76 residents 6.31 NA's worked and 6.91 were required.
1/30/26 facility census of 77 residents 5.57 NA's worked and 7.00 were required.
2/1/26 facility census of 78 residents 5.37 NA's worked and 7.09 were required.

Review of facility nursing staffing documents for the time period from 1/13/26, through 2/2/26, revealed the following NA shortages for the overnight shift:

1/14/26 facility census of 76 residents 4.27 NA's worked and 5.07 were required.
1/18/26 facility census of 79 residents 4.34 NA's worked and 5.27were required.
1/22/26 facility census of 77 residents 3.97 NA's worked and 5.13 were required.
1/25/26 facility census of 76 residents 3.05 NA's worked and 5.07 were required.
1/31/26 facility census of 78 residents 4.09 NA's worked and 5.20 were required.

During an interview on 2/3/26, at 3:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to meet the minimum NA to resident ratio on the above dates and shifts.



 Plan of Correction - To be completed: 03/17/2026

The facility cannot correct that the nurse aide staffing ratio was not met for day shift on 1/18/26,1/24/26,1/25/26,1/31/26, and 2/1/26. On afternoon shift dates 1/24/26,1/25/26,1/30/26, and 2/1/26. Also night shift dates 1/14/26,1/18/26, 1/22/26, 1/25/26, and 1/31/26. There were no adverse effects to residents on the identified dates. The facility is in the process of re-educating scheduler regarding the state ratios by the Nursing Home Administrator/ designee. Nursing administration will be re-educated on staffing ratios by Nursing Home Administrator / designee. Twice a day staffing meeting will be held to review the schedule with ratios. Nursing supervisor will monitor on the weekends. If the facility is projected to not meet staffing ratios the scheduler / designee will call off duty staff to get coverage. The facility has started interviewing and hiring to increase staffing. Nursing Home Administrator/ designee will audit staffing daily for three weeks and monthly for three months to ensure ratios are being met. Avalon will also be offering bonuses to staff as an incentive for picking up additional shifts. Human resource department will survey the local area to make sure we are competitive with wages and benefits in our area. Outcomes will be reported to the Quality Assurance Performance Committee for review and recommendations.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:


Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the 3.2 minimum number of general nursing care hours for each 24-hour period for 14 of 21 days reviewed (1/14/26, 1/16/26 through 1/19/26, 1/21/26, 1/24/26 through 1/26/26, 1/28/26, 1/30/26 through 2/2/26).

Findings include:

Review of facility nursing staffing documents for the time period from 1/13/26, through 2/2/26, revealed the following general nursing care hours was below the minimum 3.2 per patient day (PPD) on the following days:

1/14/26 3.08 PPD
1/16/26 3.09 PPD
1/17/26 3.09 PPD
1/18/26 2.95 PPD
1/19/26 3.12 PPD
1/21/26 3.16 PPD
1/24/26 2.81 PPD
1/25/26 2.51 PPD
1/26/26 2.84 PPD
1/28/26 3.15 PPD
1/30/26 2.97 PPD
1/31/26 2.62 PPD
2/1/26 2.67 PPD
2/2/26 3.17 PPD

During an interview on 2/3/26, at about 3:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility did not meet the 3.2 PPD minimum direct nursing care hours on the above dates.




 Plan of Correction - To be completed: 03/17/2026

The facility cannot correct that the state required per patient daily minimum hours of 3.20 were not met on 1/14/26, 1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/21/26, 1/24/26, 1/25/26, 1/26/26, 1/28/26, 1/30/26, 2/1/26, and 2/2/26. The scheduler will be re-educated regarding per patient daily minimums by the Nursing Home Administrator/ designee. Nursing Administration will be re-educated on state required per patient daily minimums by Nursing Home Administrator/ designee. Twice a day staffing meeting will be held to review state minimum and projected minimums. Nursing supervisor will monitor on weekends. If the facility is projected not to meet the per patient daily minimums the scheduler / designee will call off duty facility staff. The facility has started interviewing and hiring to increase staffing levels. Nursing Home Administrator/ designee will audit staffing for three weeks and monthly for three months to ensure daily needs are met. Avalon will also be offering bonuses to staff as an incentive for picking up additional shifts. Human resource department will complete a survey of this area verifying that we are still competitive with wages and benefits. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

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