Avalon Rehab: Missing Heart Medication Sent Resident to ER - NJ
The medication was Entresto, a drug used to treat heart failure and high blood pressure. According to hospital records reviewed by a federal surveyor during an October complaint inspection, the hospital itself questioned why Resident 3 had become suddenly hypertensive, given that the patient was supposed to be receiving their medications. The answer, as the surveyor pieced together, was that the Entresto had not been available and had not been administered, and not a single person at the facility had documented that fact or flagged it to nursing leadership.
When the surveyor asked the Assistant Director of Nursing whether the facility had known the Entresto was unavailable before the resident was sent out, the ADON said they had not been made aware of missing medications.
The surveyor then asked the facility's Licensed Nursing Home Administrator a pointed question: does the facility wait to find out if insurance will pay for a medication before actually providing it? The administrator said no, that the facility purchases and provides required medicine.
What the administrator could not explain was why, in this case, the medication hadn't been provided at all.
The administrator said they had interviewed LPN 1 following the inspection. That nurse confirmed there was no documentation about the Entresto being unavailable. No further information was provided.
That is the full account the facility offered: a nurse confirmed there was no paperwork, and nothing else was forthcoming.
The inspection was classified as causing actual harm to the resident. Not potential harm. Not a paperwork deficiency. The surveyor's finding was that a real person experienced a real medical consequence, an emergency room visit for a hypertensive crisis, because a medication they needed had quietly disappeared from the system with no record, no alert, and no response from the staff responsible for catching exactly that kind of gap.
Entresto is not an obscure or optional drug. It is prescribed to patients whose hearts require it to manage pressure and function. Missing a dose is not the same as missing a vitamin. For a patient already on the medication for a reason, the absence of it can produce precisely what happened here: a blood pressure spike serious enough to require emergency care.
What makes this finding particularly stark is not just that the medication was unavailable. It is that no one wrote it down. In a nursing facility, when a medication cannot be given, that fact is supposed to be recorded. The record exists so nurses on the next shift know what happened. It exists so the physician can be notified. It exists so the pharmacist can be contacted. It exists so that a resident does not end up in an ambulance while a hospital doctor stares at their chart wondering why their blood pressure is in crisis if they've supposedly been taking their heart medication.
None of that happened.
The ADON learned the medication had been missing only when a federal surveyor arrived and told them. The administrator's explanation, that the facility provides required medications without waiting on insurance, does not account for why this one wasn't provided. No one at the facility answered that question. LPN 1 confirmed there was no documentation. The administrator confirmed the interview happened. And then, as the inspection report states plainly, no further information was provided.
Resident 3 came back from the emergency room. The inspection report does not say what happened after that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Rehabilitation and Healthcare Center from 2025-10-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
AVALON REHABILITATION AND HEALTHCARE CENTER in HAMILTON, NJ was cited for violations during a health inspection on October 24, 2025.
The medication was Entresto, a drug used to treat heart failure and high blood pressure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.