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 25 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
13D
8E
1F
Potential for minimal harm
0A
1B
0C
November 6, 2025Complaint inspection · 3 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident's plan of care was followed and communicated to all facility staff to prevent falls. Resident #2 fell and sustained head trauma with a laceration to the head with active bleeding which required transferring Resident #2 to the hospital. This deficient practice was identified for one of three residents (Resident #2) reviewed for accidents and incidents. This deficient practice was evidenced by the following:On 11/6/25 at 10:15 AM, the surveyor reviewed Resident #2's closed electronic Medical Record (EMR). A review of the Face Sheet (an admission summary) reflected that Resident #2 was admitted to the facility with diagnoses which included but were not limited to; [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review and review of pertinent documents it was determined that the facility failed to ensure a thorough investigation was conducted to identify the causal factor of a fall for a severely cognitively impaired resident who was found lying on the floor in a pool of blood, that resulted in a hematoma and laceration to the head, and required emergent transfer to the hospital on 9/5/25. This deficient practice occurred for 1 of 3 residents (Resident #2) reviewed for accidents and incidents, and was evidenced by the following:On 11/6/25 at 11:30 AM, the surveyor reviewed the closed medical record (Electronic and Paper) for Resident #2. According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to; [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, record review and review of other pertinent facility documentation it was determined that the facility failed to treat and manage a resident's pain consistent with professional standards of practice. This was identified for 1 of 4 residents (Resident #1) reviewed for pain and was evidenced by the following:A review of the resident admission Record (admission summary) indicated that Resident #1 was admitted to the facility with the diagnoses which included but was not limited to Alzheimer's Disease, chronic obstructive pulmonary disease (COPD-a group of lung diseases that cause airflow obstruction and breathing difficulty) and osteoporosis (causes bones to become thinner, weaker and more likely to fracture). [...]
August 5, 2025Standard inspection, Complaint inspection · 6 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 record review, 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 7/25/2025 from 09:49 AM to 10:14 AM the surveyor accompanied by the Food Service Director (FSD), observed the following in the kitchen:1. In the walk-in freezer a frozen lasagna was wrapped in plastic wrap with a use by date of 7/25/25. When asked if lasagna should be used, the FSD replied No, I'm going to take it out right now. The expired food was removed by FSD.2. In the walk-in refrigerator a container of chicken noodle soup wrapped in plastic wrap with a use by date of 7/28/25. [...]
- E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, the facility failed to ensure that food brought to residents by family and other visitors were stored, handled, and consumed in a safe and sanitary manner. This deficient practice was identified for 4 of 6 residents (Resident # 9, Resident # 13, Resident # 26 and Resident # 51) who had personal refrigerators in their bedrooms. The deficient practice was evidenced by the following:On 07/31/2025 at 10:23 AM, the surveyor observed that Resident # 26's personal refrigerator, located in room [ROOM NUMBER]-W temperature log had not been filled out since July 18th. On 07/31/2025 at 10:24AM, the surveyor observed that Resident # 9's personal refrigerator, located in room [ROOM NUMBER]-W, was missing temperature log entries for the whole month of July. [...]
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteNumber of residents sampled:Number of residents cited:This deficient practice was evidenced by the following:A review of Resident # 14's admissions record revealed that, Resident # 14 was admitted with but not limited to Heart Failure, and Peripheral Vascular Disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). A review of Resident #14's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 06/27/2025 revealed under section N that the resident was ordered an anticoagulant (a medication that helps thin the blood). A review of Resident #14's Electronical Medical Record revealed a physician's order with a state date of 05/26/2025 for apixaban (a medication that helps thin the blood) 5 milligrams to be given every twelve hours. [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living specifically by not turning the resident in bed every two hours to prevent skin deterioration. The deficient practice was identified for 2 of 5 residents (Resident # 179, 152) investigated for Activities of Daily Living. The deficient practice was evidenced by the following: A review of Resident # 179’s Minimum Data Set (MDS; an assessment tool) dated 9/15/2024 revealed under section “GG” that he/she has lower extremity impairment on both sides. Further, the MDS revealed under section, “M” that he/she is at risk of pressure ulcers/injury. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, record review, and other pertinent facility documents, it was determined that facility to failed to ensure residents received the appropriate pain management by administering pain medications according to the physician's ordered pain level parameters. This deficient practice was identified in 2 of 4 residents reviewed for pain (Resident #7 and #49) and was evidenced by the following: 1. On 7/29/2025 at 10:47 AM, during the initial tour Resident #7 was in the room in bed. The resident's left leg was elevated on pillows and the resident appeared comfortable to the surveyor. The surveyor reviewed the medical record for Resident #7. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; fracture of the lower extremity, diabetes (high blood sugar), and depressive disorder. [...]
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteComplaint # NJ00172812Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide access to the call system while a resident was in bed. The deficient practice was identified for 2 of 8 residents investigated under the Environment Task. (Resident # 2 and Resident # 77)On 07/29/2025 at 10:29 AM, during the initial tour of the facility, the surveyor observed Resident # 2 asleep in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed. On the same date at 10:37 AM, the surveyor observed Resident # 77 awake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed. On 07/30/2025 at 10:29 AM, the surveyor observed Resident # 77 wake in bed. [...]
January 24, 2024Standard inspection, Complaint inspection · 11 citations
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed a.) conduct quarterly Interdisciplinary Care Plan (ICP) meetings and b.) to consistently maintain documentation showing that the resident's representative (RR) was invited or attended ICP meetings in accordance with the facility practice and policy. This deficient practice was identified for two (2) of 36 residents (Resident #67, #81) reviewed, and was evidenced by the following: On 01/22/23 at 10:30 AM, the surveyor reviewed the admission Record (AR) for Resident # 67 which reflected that the resident was admitted to the facility with diagnoses that included but was not limited to dementia with mood disturbances, major depressive disorder, recurrent and cognitive communication deficit. [...]
- 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 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 one (1) of four (4) units ([NAME] Glen) was evidenced by the following: The surveyor conducted a tour of the [NAME] Glen Unit on 1/10/24 at 9:52 AM. The surveyor interviewed Registered Nurse/Unit Manager (RN/UM #1) who explained that the [NAME] Glen Unit was comprised of dementia (cognitively impaired) residents and some residents that had behavioral disturbances related to dementia. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteComplaint NJ#: 165482 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to a.) ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Residents #65, #84, #89) observed for incontinence care on 1 of 2 units ([NAME] Glen and Laurel Creek units) and b.) provide nail care to a resident who required extensive assistance from the staff for activities of daily living (ADLs) for 1 of 5 residents, (Resident #114) reviewed for ADLs. a.) ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Residents #65, #84, #89) observed for incontinence care on 1 of 2 units ([NAME] Glen and Laurel Creek units). This deficient practice was evidenced by the following: 1. [...]
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice related to pain management. Specifically not a.) obtaining a physician's order for severe pain and administering pain medication according to the appropriate pain level, b.) administering pain medications as ordered by a physician and c.) appropriately assessing, monitoring, and recognizing verbal and non-verbal signs and symptoms of pain during a wound care treatment. This deficient practice was identified for three (3) of 3 residents (Resident #52, #114 and #200) reviewed for pain management. The deficient practice was evidenced by the following: a.) On 01/10/24 at 11:07 AM, during the initial tour, the surveyor observed Resident #52 lying in bed watching the television. [...]
- 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, interviews 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 01/10/24 at 09:43 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD#1) for the Assisted Living unit and the Regional Director of Dining Services (RDDS). FSD#1 stated that the FSD#2 for the Long-Term Care unit would be on site shortly. The tour commenced and the following was observed: 1. At handwashing sink #1, there was a step-lid trashcan with no plastic trash bag, with trash and debris observed inside the can. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteComplaint NJ #: 168814 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) follow appropriate hand hygiene practices during a wound treatment observation by One (1) of two (2) nursing staff observed for 1 of 1 resident reviewed for wound treatments (Resident # 114); [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) for 1 of 2 residents (Resident #103) reviewed for abuse. This deficient practice was evidenced by the following: On 01/16/24 at 10:25 AM, the surveyor observed Resident #103 ambulate into the day room and begin conversing with the other residents. At that time, the Assistant Director of Nursing (ADON) entered the day room and redirected the resident. According to the admission Record, Resident #103 had diagnoses which included, but were not limited to, encephalopathy (condition that causes brain dysfunction), unspecified dementia with agitation, depression, cognitive communication deficit, anxiety, and insomnia. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 residents (Resident #103) reviewed for abuse. This deficient practice was evidenced by the following: On 01/16/24 at 10:25 AM, the surveyor observed Resident #103 ambulate into the day room and begin conversing with the other residents. At that time, the Assistant Director of Nursing (ADON) entered the day room and redirected the resident. According to the admission Record, Resident #103 had diagnoses which included, but were not limited to, encephalopathy (condition that causes brain dysfunction), unspecified dementia with agitation, depression, cognitive communication deficit, anxiety, and insomnia. [...]
- 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 observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified resident behavior and preferences. This deficient practice was identified for 1 of 36 residents (Resident #45) reviewed for care plans and evidenced by the following: On 1/10/24 at 10:44 AM, the surveyor observed the resident lying in bed, but permitted the surveyor to enter. The surveyor observed the bottom of the room's radiator unit broken, open and exposed. The surveyor located the resident's call bell in the bottom, closed nightstand drawer. The surveyor also observed a sign that depicted a call bell on Resident #45's closet door that stated, press the red button for help from nurse. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteComplaint NJ #: 168814 Based on interview, record review, and review of facility documents, it was determined that the facility failed to address recommendations from the Wound Care Consultant (WCC) in a timely manner for 1 of 5 residents (Resident #502) reviewed for pressure ulcers. This deficient practice was evidenced by the following: According to the admission Record, Resident #502 had diagnoses which included, but were not limited to, COVID-19, diabetes mellitus, and dementia with anxiety. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/12/23, included the resident's Brief Interview for Mental Status score was 14, which indicated the resident's cognition was intact. [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteComplaint #160989 Based on observation, interview and review of the medical record and other facility documentation, it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practices for one (1) of 36 residents reviewed (Residents #505). This deficient practice was evidenced by the following: On 1/10/24, the surveyor team entered the facility for the annual recertification survey. Resident #505 was not a resident in the facility and was discharged on 01/20/23. The admission Record (AR) indicated that Resident #505 was admitted to the facility with the diagnoses which included but was not limited to retention of urine, altered mental status and seizure disorder. [...]
October 19, 2023Complaint inspection · 1 citation
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteComplaint #: NJ165363, NJ165497, NJ168316 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/17/2023 and 10/19/2023, it was determined that the facility failed to provide a safe environment and supervision of a ambulatory cognitively impaired resident on a secured unit. The facility failed to identify that a staff member didn't follow the policy for storage of personal items. It was determined on 9/7/2023 that an Activity Assistant (AA) left her Cambridge fanny pack (a facility issued fanny pack with zipper provided to staff during orientation to carry around items securely.) unsupervised on the second shelve of a three-tier activity cart and the resident ( Resident #2) took it. [...]
September 7, 2023Complaint inspection · 2 citations
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteComplaint #: NJ00159128 Based on observation, interview, and review of facility documentation on 09/06/23 and 09/07/23 it was determined that the facility failed to obtain a timely reweigh for a resident with an identified significant weight loss. and contact the Registered Dietitian in writing regarding a resident with an identified significant weight loss. The facility also failed to follow their policy for, Weight Assessment and Intervention for 1 of 3 residents (Resident #2) reviewed for weight loss. The deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteComplaint #: NJ00159128 Based on interviews, medical record review, and review of other pertinent facility documentation on 09/06/23 and 09/07/23, it was determined that the facility staff failed to consistently document on the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents according to the facility policy, Activities of Daily Living (ADLs), Supporting for 1 of 2 residents (Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: [...]
September 15, 2021Standard inspection · 2 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 record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/8/2021 from 9:14 AM to 10:12 AM the surveyors, accompanied by the Director of Dining Services (DODS) observed the following in the kitchen: 1. During observation of the high temperature dish machine the surveyor observed unidentified debris on the top of the dish machine, on the temperature gauge panel and below the power and motor switches. Unidentified white, dried, splash type stains were observed on the door of the machine. When interviewed the DODS stated, It gets cleaned weekly but should be wiped down daily. [...]
- B
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure that an accurate Minimum Data Set (MDS), an assessment tool, was completed. This deficient practice was identified for 1 of 23 sampled residents, (Resident #103). This deficient practice was evidenced by the following: During the initial tour of the Hartford Unit on 9/08/21 at 11:03 AM, Resident #103 was observed lying in bed on an air mattress. A review of the Electronic Medical Record (EMR) revealed Resident #103 was admitted to facility with diagnoses including but not limited to Fractured Hip. [...]
Fire safety inspections
13 fire safety citations on file: 8 on August 5, 2025, 5 on September 15, 2021.
Every fire safety citation13 citations
- 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 · August 5, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 5, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · August 5, 2025 · Past noncompliance: already fixed when inspectors found it
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 5, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · August 5, 2025 · Past noncompliance: already fixed when inspectors found it
- F
Have simulated fire drills held at unexpected times.
K 712 · August 5, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 5, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · August 5, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 15, 2021 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 15, 2021 · 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 15, 2021 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · September 15, 2021 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 15, 2021 · Corrected (the home has a date of correction)