Cycle 1
Health 2024-12-19 · Fire 2024-12-19
4 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Wayne, NJ
Avalon Rehab and Care Center
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2020 Route 23 North, Wayne, NJ
(973) 305-8400
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
170
Certified beds
Average residents
154
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Accela Healthcare
Operator or chain grouping
Approved since
1990-01-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,128
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.80
Baseline 18.11% · Performance 19.67% · Measure score 3.80 · Achievement 3.80 · Improvement 0
Healthcare-associated infections
0
Baseline 6.68% · Performance 8.26% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.17
Baseline 45.55% · Performance 58.88% · Measure score 1.17 · Achievement 1.17 · Improvement 0
Adjusted total nurse staffing
0.53
Baseline 3.60 hours · Performance 3.23 hours · Measure score 0.53 · Achievement 0.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.51% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 6.17% · Lower 95% interval 6.31% |
| Discharge to community | 53.11% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 46.51% · Lower 95% interval 42.55% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.95% |
95.27%
3.7 pts better
|
Numerator 94 · Denominator 95 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 95 |
| Discharge self-care score | 59.68% |
53.69%
6 pts better
|
Numerator 37 · Denominator 62 |
| Discharge mobility score | 51.61% |
50.94%
0.7 pts better
|
Numerator 32 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 2.11% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 95 · Adjusted rate 1.96% |
| Healthcare-associated infections requiring hospitalization | 8.26% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 12.73% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 28.82% |
8.2%
20.6 pts better
|
Numerator 49 · Denominator 170 |
| Staff flu vaccination coverage | 98.71% |
42%
56.7 pts better
|
Numerator 153 · Denominator 155 |
| Discharge function score | 56.45% |
56.45%
About the same
|
Numerator 35 · Denominator 62 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 3.77% |
25.2%
21.4 pts worse
|
Numerator 2 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.1
0.4 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 67.5% |
93.0%
25.5 pts worse
|
93.4%
25.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.3% · Q2 73.3% · Q3 63.7% · Q4 53.0% · 4Q avg 67.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.0% |
97.2%
6.2 pts worse
|
95.5%
4.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.4%
0.8 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.7% · Q3 0.0% · Q4 2.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
11.4%
10.1 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 1.8% · Q4 1.7% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
4.6%
2.2 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.0% · Q3 1.7% · Q4 4.1% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
19.0%
3.2 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 17.0% · Q3 13.8% · Q4 16.7% · 4Q avg 15.8% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.6% |
9.8%
6.2 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 3.5% · Q3 0.0% · Q4 2.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
9.7%
4.4 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 2.0% · Q3 2.8% · Q4 7.9% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.6% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 3.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.1% |
15.9%
4.8 pts better
|
19.8%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 9.6% · Q3 10.5% · Q4 11.8% · 4Q avg 11.1% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.0%
1 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.0% · Q3 5.7% · Q4 6.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 10.9% |
78.7%
67.8 pts worse
|
81.7%
70.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.5% · Q3 10.1% · Q4 10.8% · 4Q avg 10.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
8.2%
About the same
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.9% |
80.1%
24.2 pts worse
|
79.7%
23.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
25.4%
6.6 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 19.2% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-13 · Fire 2022-12-13
8 health deficiencies
Top issue: Administration (1 deficiency)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2020-09-30 · Fire 2020-09-30
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-02-06
F · Potential for more than minimal harm
2024-12-19
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-30
F · Potential for more than minimal harm
2024-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-07
F · Potential for more than minimal harm
2024-12-19
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-01-30
F · Potential for more than minimal harm
2024-12-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-06
F · Potential for more than minimal harm
2022-12-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-13
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-12-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-13
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-22
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-11-25
E · Potential for more than minimal harm
2024-12-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-30
E · Potential for more than minimal harm
2024-12-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-02-06
D · Potential for more than minimal harm
2024-12-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-23
E · Potential for more than minimal harm
2024-05-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-30
E · Potential for more than minimal harm
2024-05-17
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-30
D · Potential for more than minimal harm
2022-12-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-16
C · Minimal harm
2022-12-13
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-01-16
D · Potential for more than minimal harm
2020-09-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-10-09
D · Potential for more than minimal harm
2020-09-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-10-10
Penalties and ownership
What sits behind the stars
Ownership
Khawly, Mary
5% Or Greater Indirect Ownership Interest · Individual
Tufariello, Vincent
5% Or Greater Indirect Ownership Interest · Individual
Zois, Elia
5% Or Greater Indirect Ownership Interest · Individual
Burris, William
5% Or Greater Indirect Ownership Interest · Individual
Hook, Gregory
Corporate Officer · Individual
Kbwb Operations-Atrium
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Careone At Wayne
Wayne, NJ
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Alps at Wayne Rehab & Care Center
Wayne, NJ
3-star overall rating with 3-star inspections with $14,507 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Llanfair House Care & Rehabilitation Center
Wayne, NJ
2-star overall rating with 2-star inspections with $72,775 in total fines with 10 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
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