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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
12D
5E
4F
Potential for minimal harm
0A
0B
0C
May 13, 2026Complaint inspection · 1 citation
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteComplaint 2962681Based on interviews, review of the medical records, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that a resident (Resident #2) was free from significant medication errors on 03/21/26. On 3/21/26 at approximately 11:55 AM the LPN administered the wrong medications; Amlodipine 10 mg (milligrams) (a prescription medication to treat high blood pressure), Aspirin 81 mg, Divalproex Na 125 mg (a prescription medication used to treat certain types of seizures/epilepsy), Zoloft 50 mg (a prescription medication used to treat Major Depressive Disorder (MDD), Obsessive-Compulsive Disorder (OCD), Panic Disorder, Posttraumatic Stress Disorder (PTSD), Premenstrual Dysphoric Disorder (PMDD), and Social Anxiety Disorder), and Iron 325 mg intended for another resident (Resident #1) to Resident #2. [...]
March 10, 2026Standard inspection · 11 citations
- J
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to initiate a complete and thorough investigation after a cognitively intact resident made an allegation of staff-to-resident verbal abuse. This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for abuse. On [DATE] at 11:36 PM, Resident #11 sent an email to the Licensed Nursing Home Administrator (LNHA) alleging verbal abuse which included LPN #1 screaming and using expletives towards Resident #11. Interviews with the LNHA confirmed receipt of the email and confirmed that after the allegation was made, a thorough investigation was not completed which included interviewing witnesses and other residents, collecting statements and completion of a summary and conclusion due to the resident having a history of allegations that were unfounded. [...]
- F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on observation, interviews, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being for allegations of staff-to-resident verbal abuse that occurred on [DATE], and [DATE], by failing to a.) protect all residents from an alleged perpetrator pending a thorough investigation for an allegation of staff-to-resident verbal abuse. The deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for abuse and was evidenced by the following: [...]
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interviews, record review, and review of facility documents, it was determined that the facility failed to utilize an infection assessment tool for residents who were prescribed an antibiotic medication at the facility for 14 of 14 months reviewed. This deficient practice was evidenced by the following:A review of the facility's Antibiotic Tracking for January 2025 through February 2026 revealed antibiotics were prescribed as follows:In January 2025, nineteen antibiotics were prescribed. In February 2025, eight antibiotics were prescribed. In March 2025, eleven antibiotics were prescribed. In April 2025, twelve antibiotics were prescribed. In May 2025, ten antibiotics were prescribed. In June 2025, twelve antibiotics were prescribed. In July 2025, eight antibiotics were prescribed. In August 2025, nine antibiotics were prescribed. [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation and interview on 3/3/26, 3/4/26 and 3/5/26, in the presence of the Maintenance Director (MD), it was determined the facility failed to ensure the hot water supplied to resident rooms and showers were by means of the proper equipment capable of maintaining safe and comfortable temperatures. This deficient practice had the potential to affect all residents and was evidenced by the following: Observations on 3/3/26 at 10:00AM of the boiler room revealed, the hot water heater was broken and disconnected. The hot water for rooms and showers was piped from the boiler that made the hot water for heating the building. The boiler comes on and off, heating the water according to the air temperature at the thermostat, not the water temperature. In an interview at the time, the MD confirmed the observation and stated they needed to replace the hot water heater. [...]
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident verbal abuse that allegedly occurred on [DATE] and [DATE], for a cognitively intact resident (Resident #11). This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for abuse and was evidenced by the following: 1. On [DATE] at 11:05 AM, during the initial tour of the facility, the surveyor interviewed Resident #11 who alleged that Licensed Practical Nurse (LPN) #1 was nasty to them and stated that if the resident kept ringing their call bell, she was going to light the resident on fire. The resident stated that the allegation was reported to facility staff. [...]
- E
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 observations, interview, record review and review of pertinent facility documentation it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for a.) a resident with a diagnosis of Post Traumatic Stress Syndrome (PTSD) (Resident #11), b.) for resident that had a diagnosis of dementia (Resident #4) and c.) a resident who was prescribed continuous oxygen therapy (Resident #78) This deficient practice was identified for 3 of 26 resident records reviewed and was evidenced by the following:1. On 3/3/2026 at 11:05 AM during the initial tour of the facility, the surveyor interviewed Resident #11 who alleged that Licensed Practical Nurse (LPN) #1 was nasty to them and stated that if the resident kept ringing their call bell, she was going to light the resident on fire. The resident stated that the allegation was reported to staff. [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to ensure residents were protected after a cognitively intact resident made an allegation of staff-to-resident verbal abuse. This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for abuse and was evidenced by the following: Refer to F610On [DATE] at 11:05 AM, during the initial tour of the facility, the surveyor interviewed Resident #11 who alleged that Licensed Practical Nurse (LPN) #1 was nasty to them and stated that if the resident kept ringing their call bell, she was going to light the resident on fire. The resident stated that the allegation was reported to facility staff. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to a.) ensure a continuity of care for a resident who was admitted to the facility with chronic venous hypertension with ulcer of bilateral lower extremity (a condition caused by prolonged, high pressure in the leg veins due to incompetent valves, resulting in chronic wounds, swelling (edema), and skin changes) and edema (swelling), and b.) ensure transportation was provided for an an outside medical appointment . This deficient practice was identified for 1 of 1 resident (Resident #8) reviewed for positioning and mobility. 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: [...]
- 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 pertinent facility documents, it was determined the facility failed to accurately document the wasting of a controlled medication for 1 sampled resident (Resident #28) identified upon inspection of 1 of 2 medication carts (Unit 3-A cart). The evidence was as follows:On 3/4/2026 at 12:50 PM, the surveyor in the presence of Licensed Practical Nurse #3 (LPN #3) inspected medication cart A on Unit 3A. A review of the narcotics located in the secured and locked narcotic box and reconciled to the controlled drug administration record, a declining inventory sheet, revealed Resident #28's lorazepam 1 milligram (mg) tablet, a medication used for anxiety, did not match. [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to properly dispose of garbage and refuse in 1 of 2 (one of two) garbage disposal areas. This deficient practice was evidenced by: On 3/3/26 at 8:49 AM, upon arrival at the facility, the surveyor observed the facility's garbage disposal area #1. The surveyor observed cigarette butt receptacles, three (3) grills, two (2) gas cylinders, seven (7) red and green crates, a flattened cardboard box, multiple plastic pails, a plastic bottle, and an intravenous (IV) pole stored in and around the garbage disposal area rather than being properly discarded of or stored in an appropriate designated area. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that a handwashing sink was in a resident's (Resident #3) room (room [ROOM NUMBER]) was functional. This deficient practice was identified on 1 (one) of 2 (two) units (Unit #3). This deficient practice was evidenced by the following:On 3/9/26 at 12:37 PM, the surveyor entered Resident #3's room. Resident #3 was observed sitting upright in bed, eating their lunch. At that time, the surveyor noted that the resident's faucet was wrapped with clear tape. The resident stated that they were very particular about keeping their hands clean. Resident #3 added that when they needed to perform hand hygiene, they would call the staff for a wet cloth. [...]
October 8, 2024Standard inspection · 7 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 pertinent facility documents, it was determined that the facility failed to a.) discard potentially hazardous foods past their date of expiration; b.) ensure potentially hazardous foods were stored at least six inches from the floor; c.) maintain multiuse food-contact surface cutting boards in a manner to prevent microbial growth; d.) maintain kitchen and storage areas in a sanitary manner; and e.) perform hand hygiene to prevent food borne illness. This deficient practice was evidenced by the following: Upon arrival to the facility on [DATE] at 8:45 AM, the surveyor observed eight boxes of bread that were delivered and placed directly on the ground in the parking lot. The bread boxes were stacked in two piles with two boxes directly on the pavement. [...]
- E
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 documents, it was determined that the facility failed to maintain residents' living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 1 of 2 nursing units reviewed for environment (300 unit), and was evidenced by the following: 1. On 10/1/23 at 12:24 PM, during initial tour of the facility, the surveyor entered onto a ramp that led to the 300 nursing unit, and observed the following: 1. The handrail on right side of wall going up the ramp had three areas where it was not connected to itself, which left a gap in the system where the metal framing was exposed. This presented a safety hazard for residents that were unsteady on their feet. 2. The wallpaper was peeling and bubbling throughout the entire entrance to the 300 nursing unit. 3. [...]
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to properly dispose and maintain waste in garbage dumpster areas. This deficient practice was identified for 1 of 1 garbage disposal areas, and the facility was previously cited for this during their last standard survey on 9/1/23. The evidence was as follows: On 10/1/24 at 10:46 AM, the surveyor and the Food Service Director (FSD) toured the facility's outside garbage disposal area and observed the following: 1. The cardboard dumpster had no lid and garbage debris was around it. The FSD stated the facility was trying to get the company to replace the lid. 2. The other three dumpsters had paper and food waste around it. 3. A storage container in the area had food and paper debris, wooden boards, and an unidentifiable large object around it. 4. [...]
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with a history of falls at the facility. This deficient practice was identified for 1 of 1 resident reviewed for falls (Resident #53), and was evidenced by the following: On 10/1/24 at 10:17 AM, during the initial tour of the facility, the surveyor observed Resident #53 in bed with blankets over their head. On 10/2/24 at 11:30 AM, the surveyor observed Resident #53 in bed. Resident #53 told the surveyor that they liked to stay in bed and they ate meals in their room. The surveyor asked the resident if they had any history of falling, and the resident said yes, but did not say if they were every injured during a fall. The surveyor observed no fall mats. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who smoked cigarettes was assessed for safety. The deficient practice was identified for 1 of 5 residents reviewed for accidents (Resident #25), and was evidenced by the following: On 10/1/24 at 10:28 AM, during initial tour of the facility, the surveyor observed Resident #25 in their room watching television. Resident #25 stated that they were a smoker and went outside to smoke at 9:00 AM, 1:00 PM, and 4:00 PM. The resident also stated that the activities staff held on to their cigarettes and lighter. On 10/1/24 at 12:26 PM, the surveyor reviewed the medical record for Resident #25. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses including but not limited to; [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interview, and review of pertinent facility documentation, it was determined that the facility failed to label, date, and initial a resident's oxygen tubing. This deficient practice was identified in 1 of 1 residents reviewed for respiratory therapy (Resident #49), and was evidenced by the following: On 10/1/24 at 10:07 AM, during initial tour of the facility, Resident #49 approached the surveyor in the main dining room on the second floor. During the observation, the resident had a walker and a portable oxygen tank. The tubing that supplied the oxygen that went from the resident to the tank did not have a date. The surveyor then entered the resident's room with the resident, and the resident had an oxygen concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95 % pure oxygen) in the room. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to use appropriate hand hygiene and proper disinfection while providing wound care to a resident. The deficient practice was observed for 1 of 1 residents reviewed for pressure ulcers/injury (Resident #8), and was evidenced by the following: On 10/1/24 at 10:40 AM, during initial tour of the facility, the surveyor observed Resident #8 sleeping in their bed. The surveyor observed the resident wearing bilateral heel protectors. On 10/2/24 at 10:08 AM, the surveyor reviewed the medical record for Resident #8. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses including but not limited to; [...]
September 1, 2023Standard inspection · 4 citations
- 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 pertinent facility documents, it was determined that the facility failed to: a.) store, label, and date potentially hazardous foods to prevent food-borne illness, b.) air dry kitchen equipment in a manner to prevent microbial growth, c.) maintain kitchen equipment in a sanitary manner, d.) maintain proper kitchen sanitation practices. This deficient practice was evidenced by the following. On 08/22/23 at 9:35 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and observed the following: 1. In the reach-in refrigerator, sliced yellow American cheese wrapped in clear plastic that was not dated or labeled with a used-by date. The FSD stated that the staff should have labeled and dated when the cheese was sliced. Ten cupcakes in a store-bought plastic container were not labeled or dated. [...]
- 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, and record review, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promotes his/her quality of life. This deficient practice was identified for one (1) of 19 residents (Resident #27) reviewed for resident rights. This deficient practice was evidenced by the following: On 8/24/2023 at 10:32 AM, the surveyor observed Resident #27 seated in their wheelchair across from the nurse's station. Resident #27 asked the Acting Licensed Practical Nurse Unit Manager (LPN UM #1) if they can have their medication. LPN UM #1 responded that they would notify their nurse when they returned from break. Resident #27 stated to LPN UM #1 that there was a medication error and they did not receive their medication in the morning and wanted it now. LPN UM #1 sternly directed Resident #27 to go to their room. [...]
- D
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following: On 8/22/23 at 9:35 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and the designated garbage area and observed the following: There were three dumpsters in the designated area for the facility's garbage. All three lids were opened and several garbage bags were filled with trash on the ground near the dumpsters. There was debris around all the dumpsters, and behind one of the dumpsters, there was furniture such as mattresses, frames for the beds, overbed tables, and dressers. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice by not documenting pertinent clinical documentation on the resident's medical record for a resident who had a change in condition. This was identified for 1 of 18 residents (Resident #68) reviewed and was evidenced by the following. a.) According to Resident #68's medical record, the resident was admitted to the facility with the diagnoses which included but not limited to hypertension (high blood pressure), obstructive uropathy (retention of urine), and cerebral infarction (stroke). [...]
Fire safety inspections
36 fire safety citations on file: 13 on March 10, 2026, 12 on October 8, 2024, 11 on September 1, 2023.
Every fire safety citation36 citations
- F
Use approved construction type or materials.
K 161 · March 10, 2026 · deficient, provider has
- 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 · March 10, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 10, 2026 · 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 10, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · March 10, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 10, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 10, 2026 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · March 10, 2026 · deficient, provider has
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 10, 2026 · 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 10, 2026 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · March 10, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 10, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 10, 2026 · Corrected (the home has a date of correction)
- L
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · October 8, 2024 · fire safety evaluation s
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 8, 2024 · 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 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · October 8, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · October 8, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · September 1, 2023 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 1, 2023 · Waiver
- E
Use approved construction type or materials.
K 161 · September 1, 2023 · Waiver
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · September 1, 2023 · Corrected (the home has a date of correction)
- E
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · September 1, 2023 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · September 1, 2023 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · September 1, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 1, 2023 · Corrected (the home has a date of correction)