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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
28D
5E
2F
Potential for minimal harm
0A
1B
0C
June 22, 2026Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteCOMPLAINT# 3043799, 3045753 Based on interviews, review of medical records and other pertinent facility documentation on 6/22/26, it was determined that the facility failed to follow professional standards of practice when they: a) failed to implement Provider's verbal wound treatment order for Nystatin and b) transcribe the verbal order for Nystatin onto the resident's Treatment Administration Record (TAR). This deficient practice was identified for 1 of 3 residents reviewed (Resident #1), and was evidenced by the following: Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. According to the admission Record, Resident #1 was admitted with diagnoses that included, but were not limited to: encephalopathy (brain dysfunction), cachexia (a condition that causes significant weight loss and muscle loss), and hyperlipidemia. [...]
November 18, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteIntake ID: 2636901Based on interviews, review of closed medical records and other facility documentation, it was determined that the facility failed to perform an initial full body skin assessment and implement timely interventions for a resident upon admission to the facility in accordance with the facility Skin Assessment Policy to prevent altered skin integrity. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for pressure injury prevention and was evidenced by the following:On 10/23/25 at 10:28 AM, the surveyor reviewed the closed electronic medical record for Resident #1. A review of the admission Record, an admission summary, revealed the resident was admitted to the facility with diagnosis that included but were not limited to; [...]
August 7, 2025Standard inspection, Complaint inspection · 15 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 policy review, the facility failed to ensure the kitchen was clean and staff performed handwashing between glove use and task changes. These failures had the potential to affect 103 residents who consumed food prepared by the facility's kitchen.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure the dumpsters' lids were closed, the plugs were in place, and used gloves and debris was picked up off the ground. This failed practice had the potential to allow trash and animals to enter and leave the dumpster and cause sanitary issues.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to assess one resident (Resident (R) 7) of 33 sampled residents to self-administer medications prior to leaving medications at the bedside. This had the potential for the resident not to receive their ordered medications.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview, and review of policy, the facility failed to ensure a resident's dignity was maintained when he laid in bed with his backside exposed to anyone walking in the hallway outside of his room for one resident (Resident (R) 102) out of a total sample of 33 residents. This failure had the potential to cause distress to the resident and other residents and visitors who might witness the exposure.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents were free from resident-to-resident abuse for two residents of three residents (Resident (R8 and R55) reviewed for abuse out of a sample of 33 residents.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to monitor target behaviors for the use of Risperdal (an antipsychotic medication) for one of five residents (Resident (R)5) reviewed for unnecessary medications out of a total sample of 33. This had the potential for R5 to receive medication without being assessed if behaviors had improved or declined.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to report an allegation of resident-to-resident abuse for two of three residents (Resident (R) 8 and R55) reviewed for abuse out of 33 sampled residents. This failure had the potential to allow for continued abuse.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure written notice of the transfer to the hospital and the bed hold policy were provided to the resident and the resident's representative upon transfer for three (Resident (R)25, R88, and R4) of four residents reviewed for hospitalization out of a sample of 33 residents. This failure had the potential to cause confusion or distress upon transfer and a lack of understanding of appeal rights or bed hold should the resident not be permitted to return or disagree with the reason for transfer.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for one resident (Resident (R)8) out of 33 sampled residents. This failure increased the risk for the resident not receiving specialized services as determined by a Level II prompted by a Level I that indicated mental illness.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the medical staff documented the correct indication for the use of an antipsychotic medication and instead documented a diagnosis of Schizophrenia in the medical record for one resident (Resident (R) 6) out of five residents reviewed for unnecessary medications out of a total sample of 33 residents. This failure had the potential to cause psychological distress and impact treatment.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound treatments as ordered by the physician for one (Resident (R) 80) of 33 sampled residentsFindings include: Review of R80's admission Record located in the electronic medical record (EMR) under the Admission tab revealed R80 was admitted to the facility on [DATE] with diagnoses including cellulitis of other sites and type 2 diabetes mellitus with other circulatory complications. During an observation and interview on 08/04/25 at 11:15 AM, revealed R80 had an ace bandage on his lower right leg. R80 stated the bandage had not been changed since 08/01/25 and it was supposed to be changed daily. During an observation and interview on 08/04/25 at 11:23 AM, Licensed Practical Nurse (LPN1) revealed R80 had a white bandage under an ace bandage dated 08/01 with LPN1's initials. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, interviews, and policy review, the facility failed to ensure a resident utilizing supplemental oxygen (Resident (R) 65) had orders and a plan of care for its use and a resident (R31) had clean oxygen concentrator filters out of two residents reviewed for oxygen use out of a total sample of 33 residents. This failure had the potential to cause impaired respiratory function.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure documentation of assessment prior to, and upon return from, dialysis and failed to ensure communication forms were used between the facility and the dialysis center for one of one resident reviewed for dialysis (Resident (R) 2) out of 33 sampled residents. This had the potential to affect the health of residents receiving dialysis.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails and that assessments were completed for the risk of entrapment for one of four residents (Resident (R)59) reviewed for side rails out of 33 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure a medication was ordered upon admission from the hospital for one resident (Resident (R) 113) out of a total sample of 33 residents. This failure increased the risk that the resident would have unrelieved pain.
July 28, 2025Complaint inspection · 2 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteComplaint #: 2569972Based on interviews, medical record review, and review of other pertinent facility documents on 7/28/2025, it was determined that the facility failed to notify a resident's physician of a low blood sugar result, and to follow facility policy titled Notification of Changes. This deficient practice was identified for (Resident #7), 1 of 3 residents reviewed and was evidenced by the following:A review of the closed Electronic Medical Record (EMR) was as follows:According to the admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Diabetes, Hypertension, and Chronic Pain Syndrome. The resident was discharged from the facility on 12/30/2024. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews, medical record reviews, and review of other pertinent facility documentation on 7/28/2025, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents. Also, the facility failed to follow its policy titled ADL Documentation Policy. This deficient practice was identified for 3 of 4 residents reviewed for ADL documentation. This deficient practice was evidenced by the following:1. According to the admission Record (AR), Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Quadriplegia (paralysis of all four limbs), Acute Respiratory Failure, and Dysphagia (difficulty swallowing). [...]
November 7, 2024Complaint inspection · 4 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteComplaint #: NJ00179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to develop a Care Plan (CP) for a resident that had a diagnosis of Diabetes (high blood sugar levels) and was admitted to the facility with elongated(long) toenails. The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered. This deficient practice was identified for 1 of 7 residents (Resident #2) reviewed for care plans. This deficient practice was evidenced by the following: [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteComplaint #: NJ179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to follow standards of clinical practice regarding a.) ensuring a resident was seen by the Podiatrist in a timely manner, b.)ensuring a resident care plan (CP) was developed for a resident that had a diagnosis of Diabetes and was admitted to the facility with elongated (long) toenails, and c.) immediate notification to the Physician of abnormal urine culture results. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed and 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 appropriate foot care.
Inspectors wroteComplaint #: NJ00179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to provide foot care and services for a resident that had a diagnosis of Diabetes (high blood sugar levels) and was admitted to the facility with elongated (long) toenails on 01/18/2024 and was not seen by a Podiatrist until 10/07/2024. The facility also failed to follow its policy titled Podiatry Services. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for foot care. This deficient practice was evidence by the following: [...]
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteComplaint #: NJ00179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to promptly notify the Physician of an abnormal urine culture result. The facility also failed to follow its policy titled Laboratory Services and Reporting. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for laboratory results. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Diabetes (high blood sugar levels), Major Depressive Disorder, and Unspecified Dementia (general decline in cognitive abilities that affects a person's ability to perform everyday activities). [...]
March 13, 2024Standard inspection, Complaint inspection · 8 citations
- 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 facility documentation, it was determined the facility failed to maintain a comfortable and homelike environment for 3 resident rooms (room numbers 211, 212, and 213) on the C/D unit of the facility. The evidence of this deficient practice includes: 1. During the initial tour of the unit on 03/04/24 at 11:32 AM, in room [ROOM NUMBER], the surveyor observed the side table missing the middle drawer handle, the walls behind and next to the bed with gouges, the opposite wall with scratches and missing paint, the closets with scratches and missing laminate on the edges exposing the raw edge, and the closet drawer handle hanging perpendicular to the drawer. In the bathroom, the surveyor observed a brown discolored ceiling tile, a black bucket under the bathroom sink with water in it, and water on the floor under the sink. 2. [...]
- 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 facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 03/04/24 from 09:54 to 11:03 AM, the surveyor toured the kitchen in the presence of the Dietary Director (DD) and observed the following: 1. On a metal rack in the walk-in refrigerator, there were two boxes marked raw chicken drumsticks that were resting on a parchment paper lined metal tray and the paper was marked pull with no date. [...]
- E
Provide and implement an infection prevention and control program.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and review of electronic medical records and other pertinent facility documentation, it was determined that the facility failed to follow professional standards of clinical practice with respect to obtaining a diagnosis for the use of an antibiotic intravenous medication for 1 of 1 residents (Resident #184) reviewed for antibiotics. 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteComplaint # 155679, 165123, and 168629 Based on interviews, review of electronic medical records, and review of other pertinent facility documents, it was determined that the facility failed to a.) obtain a physician order for the treatment of a skin tear that was obtained during a fall and b.) update a resident's Care Plan (CP) with fall prevention interventions after the resident fell on [DATE]. This was deficient practice was identified for 1 of 5 residents (Resident #334) reviewed for accidents and was evidenced by the following: According to the admission Record (AR), Resident #334 was admitted to the facility with the diagnoses that included, but were not limited to, osteomyelitis (infection of the bone), sepsis (occurs when your immune system has a dangerous reaction to an infection), and malignant neoplasm of the brain. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure an indwelling urinary catheter drainage bag did not touch the floor and b.) ensure the urinary catheter drainage bag was kept below the level of the bladder for 1 of 3 residents (Resident #67) reviewed for urinary catheter. This deficient practice was evidenced by the following: On 03/04/24 at 9:58 AM, the surveyor observed Resident #67 lying in bed. The resident had a urinary catheter (a tube placed in the body to empty urine) with a drainage bag secured to the bed. The bottom of the urinary catheter drainage bag was touching the floor. According to the admission Record, Resident #67 had diagnoses which included, but were not limited to, retention of urine. [...]
- 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 other pertinent facility documents, it was determined that the facility failed to label and dispose of medications in accordance with accepted professional principles for 1 of 1 residents (Resident #184) reviewed for antibiotic therapy. This deficient practice was evidenced by the following: According to the admission Record, Resident #184 was admitted to the facility in March of 2024. The resident did not have a comprehensive Minimum Data Set (MDS) completed at this time. The admission assessment (AA) indicated that Resident #184 was admitted to the facility with intravenous (IV) antibiotic therapy and rehabilitation. The AA indicated that the resident had the diagnoses of cellulitis and that the resident had a single lumen peripherally inserted central catheter (PICC) located in the right upper arm. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteComplaint NJ# 168629 Based on interview and review of medical records and other facility documents, it was determined that the facility failed to maintain an accurately documented and complete medical record for 1 of 22 reviewed (Resident #334). This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #334 was admitted to the facility with diagnoses that included, but were not limited to osteomyelitis (infection of the bone), sepsis (occurs when your immune system has a dangerous reaction to an infection), and malignant neoplasm of the brain. The admission Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 09/07/23, reflected that the resident was cognitively impaired and had a history of falls prior to admission to the facility. [...]
December 8, 2021Standard inspection · 5 citations
- E
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 interview and record review, it was determined that the facility failed to act on or respond to, comments made by the Pharmacist Consultant in a timely manner. This deficient practice was identified for 1 of 7 residents (Resident #31) reviewed for unnecessary medications and was evidenced by the following: According to the Pharmacist Consultant's Therapeutic Suggestions dated 07/26/21, the Pharmacist Consultant (PC) made a recommendation for Resident #31 As per CMS guidelines, is a taper of Zoloft [an antidepressant medication] indicated? If a taper of this medication is contraindicated, include the rationale in your response to this request. A review of the Order Summary Report for Active Orders as of 07/01/2021 revealed that Resident #31 had an order dated 01/12/21 for Sertraline HCL (Zoloft) 100 mg daily, an anti-depressant. [...]
- 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 facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 11/29/21 at 9:52 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. In the dessert refrigerator, an undated turkey and cheese sandwich wrapped in clear plastic was stored on a shelf. 2. In the dessert refrigerator, an undated styrofoam cup containing dessert and an undated styrofoam cup containing lemonade was stored on a shelf. 3. In the dessert refrigerator, an opened bottle of ginger ale was stored on a shelf. 4. In the dessert refrigerator, an opened and undated bottle of water was stored on a shelf. 5. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to a.) consistently monitor fluid restriction instructions in accordance with the physician's order and professional standards of care for 1 of 2 residents (Resident #56) reviewed for dementia care and b.) clarify conflicting physician orders for 1 of 5 residents (Resident #18) reviewed for unnecessary medications. 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 appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow an active physician's order to apply bilateral heel protectors (a cushioned pressure relieving device for heels) (heel protectors) while in bed. This deficient practice was identified for Resident #56, 1 of 2 residents reviewed for pressure ulcers and Resident #24, 1 of 1 resident reviewed for positioning and mobility and was evidenced by the following: On 12/01/21 at 10:58 AM, Surveyor #1 observed Resident #56 asleep with the head of bed elevated. Surveyor #1 observed that the resident had a heel protector applied to the left foot and no heel protector on the right foot. Surveyor #1 further observed a heel protector on the resident's wheelchair which was positioned near the resident's closet. [...]
- B
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to ensure that a.) the Resident Care Staffing Report was posted on 1 of 2 nursing units (C/D unit) and b.) the posted Resident Care Staffing Report was completed for each shift on 1 of 2 nursing units (A/B unit). This deficient practice was evidenced by the following: On 11/30/2021 at 12:33 PM, the surveyor observed the Resident Care Staffing Report for the A/B unit on a bulletin board near the nurses' station. The 7a-3p shift section of the form was not completed. On 12/01/2021 at 9:30 AM, the surveyor was unable to locate the Resident Care Staffing Report at the front entrance. The Receptionist was unaware of where the Resident Care Staffing Report was located. [...]
Fire safety inspections
9 fire safety citations on file: 6 on August 7, 2025, 3 on December 8, 2021.
Every fire safety citation9 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 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 7, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · August 7, 2025 · 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 · August 7, 2025 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 8, 2021 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 8, 2021 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · December 8, 2021 · Corrected (the home has a date of correction)