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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
6E
1F
Potential for minimal harm
0A
0B
0C
May 7, 2026Standard inspection, Complaint inspection · 11 citations
- F
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 facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/27/26 at 11:33 AM, in the presence of the Regional Food Service Director (RFSD), the surveyor observed the cook take the temperature of Veal [NAME] without sanitizing the food thermometer prior to use. The cook stated, I forgot to sanitize the thermometer before using. The Veal [NAME] was thrown away in the garbage by the RFSD.On 4/28/26 at 11:08 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor a facility policy titled, Temperature Monitoring During Meal Service with a reviewed date of 1/2026. The procedure section of the policy revealed, 3. How to take temperature; [...]
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a specialty low air loss mattress (a medical-grade mattress that uses continuous airflow to keep the skin dry, cool, and pressure-free, helping prevent and treat pressure injuries) was accurately set and monitored according to the resident's weight for 6 of 8 residents (Resident #3, #4, #11, #12, #123, and #127). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
- E
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 ensure that medications were stored appropriately, according to manufacturer's guidelines and standards of practice. This deficient practice was identified in 2 of 2 medication refrigerators inspected. This deficient practice was evidenced by the following: On 4/28/26 at 12:56 PM, the surveyor began inspecting the medication (med) storage room located on the facility 1st floor in the presence of the 1st floor Unit Manager (UM1). The surveyor accessed the med refrigerator located in the med room. The surveyor observed the thermometer inside the med refrigerator that reflected twenty-five (25) degrees Fahrenheit (F). The surveyor asked the UM1 to verify the temperature, and what range the temperature should be. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 5 residents (Resident #85 and #126) observed for incontinence care on 1 of 3 Nursing units (3rd floor). This deficient practice was evidenced by the following:On [DATE] at 7:55 AM, the surveyor conducted an incontinence tour on the 3rd floor Nursing Unit and observed the following: 1. On [DATE] at 8:00 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1), observed Resident #126 in bed. CNA #1 exposed Resident #126's incontinence brief and observed that the brief was saturated with urine. CNA #1 confirmed that the brief was saturated. The surveyor reviewed the medical record for Resident #126. [...]
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that a resident received proper assistance in using hearing assistive devices for one (1) of twenty-two (22) residents reviewed, (Resident #6). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, record review and review of facility policy it was determined that the facility failed to ensure the Registered Dietitian (RD#1) completed a nutritional reassessment for a resident who was readmitted to the facility in a timely fashion. This deficient practice was identified for 1 of 4 residents reviewed for Nutrition (Resident #123), and was evidenced by the following: On 4/23/26 at 11:08 AM, the surveyor observed Resident #123 in bed with their eyes open, resident noted with confusion. On 4/23/26 at 11:13 AM, the surveyor interviewed Resident #123's Licensed Practical Nurse (LPN#1), who stated the resident had recently been readmitted to the facility. A review of the Resident #123's admission Record ((AR) an admission summary) indicated that the resident was admitted to the facility with diagnoses that included: [...]
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents completed monthly progress notes. This deficient practice continued over several months for 1 of 22 residents, Resident #6, reviewed for physician progress notes and current physician orders. This deficient practice was evidenced by the following: On 4/28/26 at 12:20 PM, the surveyor observed Resident #6 in bed in their room. The resident was alert, oriented and conversed with the surveyor. The surveyor reviewed the electronic medical record (EMR) of Resident #6 which revealed the following: An admission Record (AR) reflected that Resident #6 was admitted to the facility with medical diagnoses that included but were not limited to; [...]
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to a.) maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey, and b.) failed to ensure that sufficient and competent staff were available to provide appropriate incontinence care to dependent residents for 2 of 5 residents (Resident #85 and #126) on 1 of 3 units (3rd floor) Nursing unit. This deficient practice was evidenced by the following:Refer to F677 Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. [...]
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on observation, interview, record review, and review of facility policies it was determined that the Consultant Pharmacist (CP) failed to clarify medication route for a resident during the monthly medication reviews for 1 of 6 Residents, (Resident #3). On 4/23/26 at 10:54 AM, the surveyor observed Resident #3 awake in bed, the resident stated they were currently on a tube feeding ((TF), also known as enteral feeding, delivers liquid nutrition through a flexible tube directly into your stomach or small intestine) and does not consume anything by mouth. On 4/23/26 at 11:55 AM the surveyor reviewed Resident #3's electronic medical record (e-MAR) which revealed the following: A review of the Resident #3's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included: [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication, by diagnosis, indication and effectiveness, for one (1) of twenty-two (22) residents reviewed, (Resident #6). The deficient practice was evidenced by the following: The surveyor reviewed Resident #6's electronic medical record (EMR) which revealed the following: An admission Record (AR) reflected that Resident #6 was admitted to the facility with medical diagnoses that included but were not limited to bullous pemphigoid (a chronic autoimmune skin disorder), anemia, and essential hypertension. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more during medication administration, four (4) nurses administered meds to six (6) residents. There were twenty-eight (28) opportunities for error, two (2) errors were observed which calculated to a medication administration error rate of 7.1%. This deficient practice was identified for 2 of 6 residents, (Resident #125, Resident #129), that were administered meds by 2 of 4 nurses observed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
March 27, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteComplaint # NJ184029 Based on interview, review of the medical record, and pertinent facility documents, it was determined that the facility failed to ensure staff documented on the Treatment Administration Record (TAR) according to the physician's orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing Statutes for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3). This deficient practice was evidenced by the following: According to the admission Record received on 3/27/25, Resident #1 was admitted to the facility on [DATE], with diagnoses that included but not limited to Acute Pyelonephritis, Depression, Hypertension, and Chronic Kidney Disease. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/4/25, indicated that the resident was cognitively intact and required assistance with activities of daily living (ADLs). [...]
December 5, 2024Standard inspection · 10 citations
- J
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wrotePART A Based on observation, record review, interview, and facility policy review, the facility failed to ensure there was emergency tracheostomy equipment for a resident with a tracheostomy (a surgical opening in the neck to provide an airway and remove secretions from the lungs) at the bedside and readily available for use and ensure staff were trained to use the emergency tracheostomy equipment for one (1) of 1 resident (Resident #86) reviewed with a tracheostomy. Resident #86 was admitted to the facility on [DATE] and had a tracheostomy. Observation and interviews during the survey revealed that emergency tracheostomy supplies were not being kept at the bedside and readily available for use. There was only one obturator (A device that fits inside a tracheostomy tube to guide it during insertion) in Resident #86's room with no extra ones in the storage room. [...]
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents were provided with written transfer/discharge notice that contained the option to appeal the transfer/discharge for nine of nine residents and their representatives (Resident (R) 21, R27, R75, R9, R60, R69, R71, R91, and R86) reviewed for facility initiated emergent hospital transfer of 31 sample residents This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.
- E
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.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents were provided with a written bed hold notice which included the cost per day information for the resident/representative to have informed consent for nine of nine residents and their representatives (Resident (R) 21, R27, R75, R9, R60, R69, R71, R91, and R86) reviewed for facility initiated emergent hospital transfer of 31 sample residents. This failure had the potential for the residents to be denied return to their original room or denial of the resident returning to the facility.
- E
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on record review and interviews, the facility failed to ensure residents had cognitive ability before signing arbitration agreements for four of five residents (Resident (R) 71, R84, R75, and R44) reviewed for arbitration of 31 sample residents. This had the potential to result in resident representatives not being able to resolve disputes with the facility in a court of law.
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to maintain a functional Antibiotic Stewardship Program that followed the McGeer criteria for antibiotic usage for four out of 12 months reviewed for tracking and trending of antibiotics of 88 census residents. This failure had the potential to affect residents being prescribed antibiotics that were potentially unnecessary.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to update a resident's advanced directive in the medical record after the resident decided to change it from full code to a do not resuscitate (DNR) for one of nine residents (Resident (R) 66) reviewed for advanced directives of 31 sample residents. Failure to accurately record a resident's advanced directive in the medical record had the potential to result in the resident receiving cardiopulmonary resuscitation against their wishes.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a written copy of the baseline care plan was provided to the resident and/or responsible party (RP) within 48 hours for one of one resident (Resident (R) 203) reviewed for baseline care plan out of 31 sample residents. This failure had the potential for residents and/or RP not to be informed of the plan of care.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to develop care plans with resident specific goals and interventions for the usage of antipsychotics for one of 31 sample residents (Resident (R) 69) reviewed for care plans. This failure to develop care plans increased the risk for care to be incomplete and/or inconsistent related to antipsychotic medications.
- 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 observations, interviews, and facility policy review, the facility failed to properly store medications with four loose tablets and one loose capsule in the medication cart for the 300 hall rooms 300-314 and ten and a half loose tablets in the medication cart for the 300 hall rooms 315-325 out of seven medication carts reviewed for medication storage of 31 sample residents. This failure increased the potential for drug diversion.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to have a dialysis resident in Enhanced Barrier Precautions (EBP) for one of two residents (Resident (R) 12) receiving dialysis out of 31 sample residents. This failure had the potential for cross contamination of residents, especially the vulnerable residents in the facility that receive dialysis.
December 6, 2023Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteC#: NJ00163892 Based on interviews, and record review, as well as review of pertinent facility documents on 12/6/23, it was determined that the facility staff failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) as required and according to the facility's policy Abuse Prevention Program for 1 of 3 sampled residents (Resident #1) reviewed for incident and accident investigation and reporting. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to: Dementia, Hypertension, Osteophyte Left Shoulder. A Minimum Data Set (MDS), an assessment tool, dated 11/15/23, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated resident was unable to complete interview. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and review of medical records and other pertinent facility documentation on 12/6/23, it was determined that the facility failed to follow professional standards of clinical practice for administration of medications and adhering to the facility's policy for using the Medication Administration Record for 1 of 3 residents (Resident #2) reviewed for medication administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
June 29, 2023Standard inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (Resident (R) 58) of 18 residents reviewed for MDSs in a total sample of 18 residents. This deficient practice increased the potential for missed opportunities of care or services.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteComplaint # NJ 160113 Based on interview, record review and facility policy review, the facility failed to ensure one (Resident (R)186) of six residents for medication services received their prescribed medication. This deficient practice could allow residents to have discomfort or put them at further health issues.
Fire safety inspections
15 fire safety citations on file: 5 on May 7, 2026, 4 on December 5, 2024, 6 on June 29, 2023.
Every fire safety citation15 citations
- 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 · May 7, 2026 · Corrected (the home has a date of correction)
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · May 7, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · May 7, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · May 7, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 7, 2026 · 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 · December 5, 2024 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · December 5, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · December 5, 2024 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · December 5, 2024 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Ensure electrical receptacles or cover plates have distinctive color or marking.
K 917 · June 29, 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 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 29, 2023 · Corrected (the home has a date of correction)