Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
4E
1F
Potential for minimal harm
0A
0B
0C
January 29, 2026Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteComplaint # 430386Based on interviews, medical record review, and review of the facility's policy, the facility failed to protect Resident (R)5's right to be free from physical abuse by a staff member. This deficient practice was identified for R5, 1 of 3 residents reviewed for staff-to-resident abuse. Review of R5's undated admission Record in the resident's electronic medical record (EMR) revealed that the resident was admitted to the facility on [DATE]. R5 had diagnoses which included dementia without behavioral disturbances. Review of R5's quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 2 out of 15, which indicated the resident was severely cognitively impaired. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint# 430386 and 2595402Based on interviews, record review, and facility policy review, the facility failed to ensure allegations of staff-to-resident abuse were reported timely, and in accordance with federal reporting requirements, to the State Survey Agency (SSA) for two of two sampled residents (Resident (R) 3 and R5) reviewed for allegations of abuse. The facility's failure to promptly report allegations of abuse limited regulatory oversight and had the potential to delay protective interventions for residents.
March 7, 2025Standard inspection, Complaint inspection · 8 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteComplaint #: NJ 172818 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a.) hot water temperatures were maintained at safe levels to protect residents from third degree burns and/or serious injury. This deficient practice was identified on 1 of 3 nursing units (the Long-Term Care (LTC) unit). Hot water temperatures obtained on 3/4/25, in resident's rooms on the LTC unit registered between 138 degrees Fahrenheit (F) and 140 degrees F. Interviews with the Director of Maintenance (DM) confirmed that the water temperatures should be below 120 degrees F to be at a safe level. The facility's failure to ensure that residents were protected from excessive hot water temperatures posed the likelihood of serious harm and injury from third degree burns. This resulted in an Immediate Jeopardy (IJ) situation. [...]
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure policies, procedures, and effective systems were implemented to maintain each resident's highest practicable wellbeing. The deficient practice had the potential to affect all residents who resided on 3 of 3 units and was evidenced by the following: Refer to F689 and F812 A review of the Administrator's job description provided by the facility revealed the following: The Administrator's primary purpose is to direct the day-to-day functions of the center in accordance with current federal, state, and local standards, guideline, and regulations that govern nursing centers to assure that the highest degree of quality care can be provided to the residents at all times. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 3/3/25 from 8:09 AM to 9:02 AM, the surveyor observed the following in the presence of the Dietary Assistant Supervisor (DAS): In the Reach-in Refrigerator: 1. A five (5) pound container of hummus which was previously opened, was not labeled or dated with an opened or use-by date. The DAS discarded the container of hummus. The DAS stated that the hummus should have had an opened date and a used by date. 2. A pan of ground beef which was sealed with aluminum foil, dated 2/27/25, had a tear in the aluminum foil exposing the ground beef to the air. The DAS discarded the ground beef. [...]
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteComplaint #: NJ171573, NJ170867 Based on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident hospitalization for 1 of 1 resident (Resident #176) reviewed for hospitalization. This deficient practice was evidenced by the following: On 3/3/25 at 11:05 AM, the surveyor reviewed the closed medical record for Resident #176. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteComplaint #: NJ171573 Based on interview, record review, and review of facility documents, it was determined that the facility failed to initiate physician's orders for an enteral tube feeding formula (liquid nutritional products that provide nutrients directly into the gastrointestinal tract through a surgically created opening in the abdominal wall) in a timely manner in accordance with professional standards of practice for 1 of 2 residents (Resident #176) reviewed for tube feeding administration. This deficient practice was evidenced by the following: On 3/3/25 at 11:05 AM, the surveyor reviewed the closed medical record for Resident #176. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow a physician's order to provide humidified oxygen and ensure respiratory equipment was stored in an appropriate way to prevent the spread of infection for 1 of 3 residents (Resident #89) reviewed for respiratory care. This deficient practice was evidenced by the following: On 3/3/25 at 8:29 AM, during the initial tour, the surveyor observed Resident #89 awake and alert, seated on the bed, wearing a nasal cannula (tubing) attached to an oxygen concentrator (a medical device that provides concentrated oxygen). The concentrator was set between three (3) and four (4) liters (L) of oxygen. Resident #89 stated, My nose is so congested. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain a medication error rate of less than 5%. This deficient practice was identified for 2 of 4 residents (Resident #38 and #91), during the medication pass observation on 3/4/25, the surveyor observed four (4) nurses, administer 27 doses of medication to five (5) residents and there were two (2) errors, which resulted in a medication error rate of 7%. The deficient practice was evidenced by the following: 1. On 3/4/25 at 8:35 AM, during the medication administration observation, the surveyor observed Licensed Practical Nurse (LPN) #3 prepare to administer medications to Resident #91, which included a multivitamin with minerals. [...]
- D
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.
Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to store medications under acceptable temperatures and sanitary conditions. This deficient practice was observed in 1 of 2 medication storage rooms (Long-Term Care medication room) and was evidenced by the following: On 3/6/25 at 11:18 AM, the surveyor observed the Long-Term Care (LTC) medication storage room in the presence of Licensed Practical Nurse (LPN) #4 and LPN #5. At that time, the surveyor observed two small chunks of ice fell to the floor upon opening the medication refrigerator door. The thermometer hanging on the wire shelf inside of the refrigerator read 26 degrees Fahrenheit (F). [...]
December 29, 2023Complaint inspection · 2 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteComplaint # NJ 160965 Based on observation, interview, record review, and review of facility investigation and policies, the facility failed to ensure a fall risk assessment was completed upon admission and quarterly for one of three residents (Resident (R) 1) reviewed for falls out of 15 sample residents. This failure placed the resident at risk of repeated falls and a diminished quality of life.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteComplaint #: NJ 165790 Based on interview, record review, and review of facility policy, it was determined that the facility failed to ensure the medical record was accurate in accordance with acceptable standards of practice for one of 15 residents (Resident (R) 5) whose medical records were reviewed. The facility failed to ensure the SBAR [situation, background, assessment, recommendation-documentation that is used to facilitate prompt and appropriate communication] was completed by the staff person who witnessed the event. This failure placed residents at risk for unmet care needs and falsification of documentation.
February 17, 2023Standard inspection · 7 citations
- E
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to: a.) administer Tube Feedings (nutrition received through a flexible tube surgically inserted into the stomach) per physician's order. This deficient practice was identified for two (2) of 2 resident's, (Resident #99 and Resident #158) reviewed for receiving nutrition via Tube Feeding and was evidenced by the following: 1.) On 02/07/23 at 11:36 AM, the surveyor entered Resident #158's room and observed the resident sitting upright in his/her bed with his/her resident representative in the room. The surveyor observed that the resident had an undated Tube Feeding (TF) formula hanging on a pole, not attached to a TF pump, and not flowing. [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: 1.) On 2/07/23 from 9:27 AM to 10:04 AM, the surveyor accompanied by the Director of Dining Services (DODS), completed the Initial Tour of the Kitchen, observed and reviewed the refrigerator and freezer temperature logs with the following missing entries: Kitchen Reach in Refrigerator Temperature Log. Location: Milk Fridge; Month/Year: [DATE]. Days1 through 5 not completed. Kitchen Reach in Refrigerator Temperature Log. Location: Trayline Fridge; Month/Year: [DATE]. Days 1 through 5 not completed. Kitchen Reach in Refrigerator Temperature Log. Location: Health Shakes; Month/Year: [DATE]. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation it was determined that the facility failed to provide a resident with respect and a dignified existence by failing to provide adequate colostomy (a surgical operation in which a piece of the colon is moved to an artificial opening in the abdominal wall to bypass a damaged part of the colon) care. This deficient practice was identified for one (1) of 21 resident's, (Resident #159) reviewed for respect and dignity and was evidenced by the following: Refer to F691 On 02/07/23 at 12:05 PM, the surveyor entered Resident #159's room and observed the resident lying flat in bed. [...]
- D
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.
Inspectors wroteBased on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to provide a clean, comfortable, homelike environment for two (2) out of 21 resident's, (Resident #99 and Resident #158) reviewed and on one (1) unit, (subacute unit) out of three (3) nursing units. The deficient practice was evidenced by the following: On 02/07/23 at 11:36 AM, the surveyor entered Resident #99 and Resident #158's room on the sub-acute unit at the facility and observed that the room was unkept. There was a crack in floor in the center of the resident's room, an another large, long crack which extended up the wall in the center of the resident's room. The surveyor observed that Resident #99 had tannish brown colored splatter underneath his/her Tube Feeding (TF) pole on the floor and directly on the base of the TF pole. [...]
- D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation it was determined, that the facility failed to: a.) provide appropriate care for a resident with a new colostomy (a surgical operation in which a piece of the colon is moved to an artificial opening in the abdominal wall to bypass a damaged part of the colon) in accordance with professional standards of nursing practice. This deficient practice was identified for one (1) of 1 resident, (Resident #159) reviewed for colostomy care and was evidenced by the following: Refer to F550 On 02/07/23 at 12:05 PM, the surveyor entered Resident #159's room and observed the resident lying flat in bed. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to: a.) appropriately follow physician orders for the care of respiratory equipment and b.) store respiratory equipment in a manner to prevent infection. This deficient practice was identified for two (2) of 2 residents, (Resident #99 and Resident #158) reviewed for tracheostomy (a surgically created role in your windpipe that provides an alternative way of breathing) respiratory care. The deficient practice was evidenced by the following: 1.) On 02/07/23 at 11:39 AM, the surveyor observed Resident #158 sitting upright in bed, with a tracheostomy. The resident's representative was in the room with the resident. The surveyor further observed that all the respiratory and oxygen tubing in the resident's room was not dated or labeled. [...]
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to maintain: a.) mechanical lifts with scales in accurate operating condition and b.) a functional tube feeding pump, an essential piece of equipment that administered nutrition to a resident. This deficient practice was identified for two (2) of 21 resident's reviewed, (Resident #81 & Resident #158). This deficient practice was evidenced by the following: 1.) On 02/07/23 at 10:11 AM, during the initial tour on the Memory Lane unit, Surveyor #1 observed Resident #81 supine in bed, alert, nonverbal. On 02/08/23 at 11:48 AM, Surveyor #1 reviewed the resident's electronic medical record (EMR.) The resident was admitted with diagnoses which included dysphagia (inability to swallow) and dementia with other behavioral disturbance. [...]
November 30, 2020Standard inspection · 1 citation
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview, in the presence of facility's Maintenance Director and Laundry Director, it was determined that the facility failed to maintain 4 of 4 commercial clothes dryer drums in a safe operating condition. This deficient practice was evidenced by the following: On 11/25/2020 at 11:52 AM, the surveyor observed that only 1 of 4 commercial clothes dryers were in operation. Commercial dryers #1, #2 and #4 were out of order and the #3 dryer was the only currently working unit. The surveyor observed that all of the dryers (#1, #2, #3 and #4) had a coating of an unknown brown plastic-like substance embedded into the rotating steel drum along with 30 plus clothes labels that were stuck to the rotating drum blocking many of the vent holes. [...]
Fire safety inspections
21 fire safety citations on file: 12 on March 7, 2025, 8 on February 17, 2023, 1 on November 30, 2020.
Every fire safety citation21 citations
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 7, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
K 929 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · February 17, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 17, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 17, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 17, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 17, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 17, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 17, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 17, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 30, 2020 · Corrected (the home has a date of correction)