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 11 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
1E
0F
Potential for minimal harm
0A
0B
0C
August 12, 2025Standard inspection · 3 citations
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide an environment that is safe, functional, sanitary, and comfortable. This deficient practice was identified for two of three dining rooms (Main and Dogwood). This deficient practice was evidenced by the following: On 8/6/25 at 11:52 AM, the surveyor toured the facility's main dining room in the presence of the Activities Director (AD) and observed a bug in the second drawer of the kitchenette, as well as a black, ground substance in the fourth drawer, which the AD identified as coffee. The fourth drawer was also sticky to the touch. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations, interview, record review, and review of pertinent facility documents it was determined that the facility failed to interact with residents in a dignified and respectful manner by failing to provide privacy to Resident #8 during wound care. This deficient practice was identified for 1 of 44 residents reviewed for dignity and was evidenced by the following:During a tour of the Dogwood Unit on 8/5/2025 at 11:53 AM, the surveyor observed room [ROOM NUMBER] with the door open and two nurses inside performing wound care to Resident #8 whose bed was next to the window. The surveyor noted that resident's privacy curtain was not pulled and the window shades were not pulled down for privacy. The surveyor continued to observe the room and at no time was Resident #8's privacy maintained. [...]
- 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 observations, interview, record review, and review of pertinent facility documents it was determined that the facility failed to provide appropriate and sufficient care urinary catheter care, specifically by having the catheter drain bag not secured in a manner to maintain infection control, outside of a privacy bag, and improperly positioned at the foot of the bed in manner to potentially cause pain to resident. The deficient practice was identified for 1 of 3 Residents (Resident # 13) reviewed for Urinary Catheter or Urinary Tract Infections and was evidenced by the following:During initial tour of the facility on 8/4/2025 at 10:52 AM, the surveyor observed the resident's catheter drainage bag draped over the foot of the Resident #13 bed. The draining catheter bag was not fully contained inside the privacy bag and resident's urine was visible inside the bag. [...]
April 30, 2024Standard inspection, Complaint inspection · 6 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteComplaint NJ # 157609; 157901; 160396 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to administer medications within scheduled time parameters on various shifts for two residents in accordance with professional standards of practice. This deficient practice was identified for 2 of 35 residents reviewed for professional standards of practice (Resident #20 & Resident #213). Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteComplaint NJ# 160883 Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident received showers as scheduled. This deficient practice was identified for 1 of 2 residents reviewed for activities of daily living (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor interviewed Resident #61 who stated he/she did not receive their scheduled shower on Friday 4/12/24 during the 3:00 PM to 11:00 PM (3-11) shift. The resident stated their showers were scheduled weekly for Mondays and Fridays. The surveyor reviewed the medical record for Resident #61. [...]
- D
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 potentially hazardous foods in a manner to prevent food borne illness; b.) maintain kitchen equipment in a clean and sanitary manner; and c.) maintain cold food in acceptable temperatures during meal service. The deficient practice was evidenced by the following: 1. On 4/10/24 at 9:10 AM, the surveyor in the presence of the Food Service Director (FSD) and the Dietary Manager (DM) conducted a kitchen tour and observed the following: 1. In the walk-in freezer, an opened box of sliced cheese pizza. The box contained a bag with two slices of pizza outside of the bag, and the box was unsealed exposing the contents to air. The surveyor observed ice crystals on all the pizza slices. There was no observed date when the box was opened. [...]
- 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, and review pertinent facility documents, it was determined that the facility failed to maintain complete and accurate skin assessments. This deficient practice was identified for 1 of 35 resident medical records reviewed (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor interviewed Resident #61 who stated he/she did not receive their scheduled shower on Friday 4/12/24. The surveyor reviewed the medical record for Resident #61. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure appropriate storage for respiratory equipment for infection prevention. This deficient practice was identified for 1 of 4 residents reviewed for respiratory care (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor observed Resident #61 in bed and their nebulizer mask and tubing placed directly on the nebulizer machine (a device used for producing a fine spray of liquids). Resident #61 informed the surveyor that after their nebulizer treatment (breathing treatment), they removed their nebulizer mask and placed it on the machine. [...]
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 of 4 nursing units (Birch Unit) and was evidenced by the following: On 4/10/24 at 10:35 AM, the surveyor entered resident room Birch #17 and observed the doorknob backplate was not secured properly to the resident's entrance door or bathroom door, which resulted in the backplate hanging loosely with a gap between the doorknob and the door. On 4/10/24 at 10:37 AM, the surveyor entered resident room Birch #15 and observed the doorknob backplate was not secured properly to the resident's entrance door which resulted in the backplate hanging loosely with a gap between the doorknob and the door. [...]
September 12, 2023Complaint inspection · 1 citation
- D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Inspectors wroteCOMPLAINT # NJ162053 Based on interviews, medical records review, and review of other pertinent facility documentation on 9/12/23, it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #1) was involved in an altercation with another resident and sent to the hospital for a behavioral evaluation. When the resident was discharge from the hospital, the facility would not permit a return back to the facility. The deficient practice was identified for Resident #1, 1 of 3 residents reviewed for transfer/discharge and was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to lack of coordination, dementia with behavioral disturbances, schizophrenia, anxiety disorder, and Parkinson's Disease. [...]
December 20, 2021Standard inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and review of facility documentation, it was determined that the facility failed to ensure respiratory equipment was kept in a clean and sanitary condition, and stored properly to reduce the risk of infection for 1 of 1 residents reviewed for respiratory equipment, Resident #18. The deficient practice was evidenced as follows: According to the facility's admission Record, Resident #18 was admitted to the facility in 11/2019 with diagnoses which included but were not limited to: Chronic Obstructive Pulmonary Disease, Unspecified (a group of diseases that causes airflow blockage and breathing related problems). Review of a Quarterly Minimum Data Set (MDS), an assessment tool dated 11/30/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated that the resident's cognition was intact. [...]
Fire safety inspections
14 fire safety citations on file: 5 on August 12, 2025, 7 on April 30, 2024, 2 on December 20, 2021.
Every fire safety citation14 citations
- F
Provide properly protected cooking facilities.
K 324 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 12, 2025 · 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 · August 12, 2025 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · August 12, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 12, 2025 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · April 30, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 30, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 30, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 30, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · April 30, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 30, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · April 30, 2024 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · December 20, 2021 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 20, 2021 · Corrected (the home has a date of correction)