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
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
16D
6E
0F
Potential for minimal harm
0A
0B
0C
January 22, 2026Standard inspection, Complaint inspection · 8 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review, interview, and document review, the facility failed to ensure three of three residents and their resident representatives (R)10, R159, R1 and R164) reviewed for emergent hospital transfer out of a total sample of 31 residents were provided with a written bed hold policy and transfer notice that contained the appeal process. This failure had the potential to affect the resident and their resident representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation record review and interview, the facility failed to ensure a resident's rights (R59) was honored when staff attempted to transfer the resident after the resident refused, causing a skin tear for one resident (Resident (R)59) of one resident reviewed for dignity in the sample of 31 residents. This had the potential to affect all residents receiving care.
- 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 protect the resident's right to be free from physical abuse by staff for one of five residents (Resident (R)178) reviewed for abuse out of 31sample residents. This had the potential to affect residents in the facility who were at risk for abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, interviews, document review and policy review, the facility failed to report an allegation of injury of unknown origin for one (Resident (R) 104) of two abuse allegations reviewed in the sample of 31 residents to the State Agency (SA) immediately, but no later than 2 hours after the incident. This failure had the possibility to negatively impact residents currently residing at the facility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interviews, record review and policy review, the facility failed to thoroughly investigate an allegation of an injury of unknown origin for one (Resident (R) 104) of one resident and failed to thoroughly investigate an allegation of physical abuse for R178, out of two residents reviewed for abuse in a sample of 31 residents. This failure had the potential to negatively impact all residents residing at the facility.
- 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 for one resident (Resident (R) 9 one of resident reviewed for PASARR out of 31 sampled residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure an active physician order for oxygen administration for one of one resident (Resident (R) 93) reviewed for oxygen administration of 31sample residents This failure had the potential for the residents to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, policy review, and interviews, the facility failed to ensure that staff changed gloves when going from a soiled to a clean area while providing wound care for one of two residents (Resident (R) 78) reviewed for wound care to prevent possible cross contamination. In addition, the facility failed to ensure that staff cleansed the indwelling urinary catheter and changed gloves when going from a soiled to a clean area, for one of two residents (R78) observed for catheter care, to prevent possible urinary tract infections.
November 5, 2025Complaint inspection · 2 citations
- G
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteCOMPLAINT #: 2648245 Based on interviews, review of medical records, and review of pertinent facility documents, it was determined the facility failed to a.) assess and document a resident's pain level; b.) obtain orders for pain management; and c.) re-evaluate and document the effectiveness of pain management in accordance with professional standards of practice. This deficient practice was identified 1 of 3 residents reviewed for pain management (Resident #3), and was evidenced by the following:A review of Resident #3's Closed Medical Record's admission Record revealed that Resident #3 was admitted to the facility with diagnoses which included but were not limited to acidosis, unspecified (condition in which there is too much acid in the body fluids); major depressive disorder, recurrent, unspecified (mood disorder that causes a persistent feeling of sadness and loss of interest); [...]
- 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: 268245 Based on interviews, review of medical records, and review of pertinent facility documentation, it was determined that the facility failed to notify the resident's physician of a change in condition for 1 of 3 residents (Resident #3) reviewed. This deficient practice was evidenced by the following:A review of Resident #3's Closed Medical Record's admission Record revealed that Resident #3 was admitted to the facility with diagnoses which included but were not limited to acidosis, unspecified (condition in which there is too much acid in the body fluids); major depressive disorder, recurrent, unspecified (mood disorder that causes a persistent feeling of sadness and loss of interest); difficulty in walking, not elsewhere classified; muscle weakness (generalized); need for assistance with personal care; other lack of coordination; [...]
August 19, 2024Standard inspection, Complaint inspection · 6 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint #NJ00172165 REFER to F610 Based on observations, interviews and record review, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) and follow facility policy and procedures for reporting for a) allegations of abuse (Sampled Resident #6, unsampled Resident #25 and #54), and b) a missing wallet with a resdient's identification (Resident #15). The deficient practice was identified for four (4) of nine (9) residents reviewed for investigations and was evidenced by the following: 1. On 8/5/24 at 12:10 PM, the surveyor observed Resident #6 participating in conversation and eating lunch at a table with three other residents. The resident stated that they were willing to talk with the surveyor at another time. The surveyor reviewed the medical record for Resident #6. [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteREFER to F609 Based on observation, interview and record review, it was determined that the facility failed to conduct a timely and thorough investigation for three (3) of nine (9) residents, (Resident #6 and unsampled Residents #25 and #54), reviewed for alleged violation investigations. The deficient practice was evidenced by the following: On 8/5/24 at 12:10 PM, the surveyor observed Resident #6 participating in conversation and eating lunch at a table with three other residents. The resident stated that they were willing to talk with the surveyor at another time. On 8/6/18 at 10:06 AM, the surveyor reviewed a Complaint/Grievance Form, dated 5/23/24, provided by the Licensed Nursing Home Administrator (LNHA). The form was completed by the Social Worker (SW) and revealed that Resident #6 reported issues and concerns with two CNAs, (CNA#1 and CNA#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 other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/05/2024 from 09:30 AM to 10:01 AM, the surveyor, accompanied by the Food Service Director (FSD) of another facility, toured the kitchen, and observed the following: In the walk-in freezer, the surveyor observed two opened packages of biscuits with no dates or labels. The surveyor also noted a tied shut, clear plastic bag of spinach lasagna rolls with no label or dates when opened. The FSD stated there should be opened and use by labels and dates on all opened food in the freezer. [...]
- 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 were administered without error of 5% or more. During the medication observation on 8/6/24, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 26 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.69 %. This deficient practice was identified for one (1) of four (4) residents, (Resident # 268), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced as follows: On 8/6/24 at 8:57 AM, the surveyor observed the Registered Nurse (RN) preparing to administer the morning medications to Resident #268. [...]
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for one of seven Quality Assurance and Performance Improvement (QAPI) meetings and was evidenced by the following: A review of the facility provided QAA (Quality Assessment and Assurance) Committee Information updated 06/07/24 revealed: Name: Vacant; Title: Infection Preventionist. A review of the the facility provided In-Service Attendance; Date: 7/12/24; Topic: Q 2024 QAPI Meeting sign in sheet had not revealed the IP attended the meeting. [...]
- D
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interviews and review of pertinent facility documents, it was determined that the facility failed to have an Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) who worked at least part-time and had completed specialized training in infection control and prevention (ICP) from 06/08/24 to present. This deficient practice was evidenced by the following: Reference: According to the NJ Executive Directive 21-012 (revised 12/22/22) included The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. [...]
November 7, 2022Standard inspection · 7 citations
- E
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 ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified in 1 of 3 nursing units during 4 of 4 meal observations and was evidenced by the following: 1. On 10/26/22 from 12:11 PM to 12:52 PM, the surveyor made the following meal observations in the dining room on the Third-Floor: There were 18 residents observed, who were all seated at dining tables. The Licensed Practical Nurse/ Unit Manager (LPN/UM) stated that the first lunch truck usually arrived around 11:30 AM. At 12:14 PM, the surveyor observed the first dining truck arrived in the Third-Floor dining room. The staff began serving the trays immediately. [...]
- E
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 11 out of 14 day shifts reviewed during a two-week period prior to survey and for 3 of 5 day shifts observed on the Third-Floor nursing unit. This deficient practice was evidenced by the following: 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. The following ratio(s) were effective on 02/01/2021: [...]
- D
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) provide privacy when receiving and delivering mail and b.) deliver mail within a reasonable timeframe. This deficient practice was identified for 2 of 31 residents reviewed for privacy and timeliness with their mail delivery (Resident #13 and #80) and was evidenced by the following: On 11/1/22 at 10:13 AM, the surveyor interviewed Resident #13 who stated that he/she had ordered some items from their insurance company's catalog about a month ago and he/she still had not received the items. At this time, the surveyor interviewed Resident #80 who stated that he/she had also ordered some items from his/ her insurance company's catalog about a month ago and he/she still had not received the items. [...]
- 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 consistently provide wound care in a manner to reduce the spread of infection and promote healing for 1 of 1 resident (Resident #19) observed during wound treatments. The deficient practice was evidenced by the following: On 10/27/22 at 10:05 AM, the surveyor observed Resident #19 in bed with his/her eyes closed. The surveyor reviewed the medical record for Resident #19. The admission Record face sheet (admission summary) reflected that the resident was admitted to the facility in July of 2022 with diagnoses that included dementia, depression, and mild protein-calorie malnutrition. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure the accuracy of a resident's weight who had a history of weight fluctuation. This deficient practice was identified for 1 of 6 residents reviewed for nutrition (Resident #42) and was evidenced by the following: On 10/25/22 at 11:37 AM, the surveyor entered Resident #42's room and observed the resident sitting in a wheelchair, wearing a shirt that appeared loose at the neckline. The resident expressed to the surveyor that he/she ate very little, was not hungry, and had meal choices. The surveyor reviewed the medical record for Resident #42. [...]
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the physician provided an order for routine laboratory blood tests for thyroid hormones for a resident diagnosed with hypothyroidism. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #42) and was evidenced by the following: A review of the manufacturer's specifications for Levothyroxine under section 2.4 titled, Monitoring TSH and/or Thyroxine (T4) levels included: In adult patients with primary hypothyroidism, monitor serum TSH levels after an interval of 6 to 8 weeks after any change in dose. In patients on a stable and appropriate replacement dose, evaluate clinical and biochemical response every 6 to 12 months and whenever there is a change in the patient's clinical status. [...]
- 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 record review, it was determined that the facility failed to ensure medications were administered to a resident in accordance with professional standards of practice. This deficient practice was identified for 1 of 31 residents reviewed for medication management (Resident #57) and was evidenced by the following: On 10/25/22 at 11:30 AM, the surveyor observed Resident #57 lying in bed. Resident #57 informed the surveyor that he/she was having a bad day and requested the surveyor to remove the stool softener (Colace) on their tray table in front of them. The surveyor observed a medication cup which contained one red capsule. The resident informed the surveyor that the nurse (Registered Nurse (RN)) administered the Colace to them thirty minutes ago and he/she informed the RN they did not need to take the Colace. [...]
Fire safety inspections
12 fire safety citations on file: 1 on January 22, 2026, 3 on August 19, 2024, 8 on November 7, 2022.
Every fire safety citation12 citations
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 22, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 19, 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 · August 19, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 19, 2024 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · November 7, 2022 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · November 7, 2022 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · November 7, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 7, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 7, 2022 · Corrected (the home has a date of correction)
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · November 7, 2022 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · November 7, 2022 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · November 7, 2022 · Waiver