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 26 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
19D
5E
1F
Potential for minimal harm
0A
0B
0C
May 7, 2026Standard inspection, Complaint inspection · 11 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteComplaint #2790808Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) ensure a Registered Nurse (RN) immediately assessed a resident who had fallen and complained of pain. On [DATE], Resident #3 had an unwitnessed fall. The Licensed Practical Nurse (LPN #1) responded to the fall and did not call an RN to assess the resident. The resident complained of pain and was transferred back to bed by two Certified Nursing Assistants (CNAs). On [DATE], 4 days later, the resident was transferred to the emergency room (ER) for an unrelated medical concern and was diagnosed with a right hip fracture. The facility further failed to b.) ensure that a resident (Resident #10) who experienced an acute change and decline in their medical condition was properly assessed and treated in a timely manner. [...]
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on an interview and review of other pertinent facility documentation, it was determined that the facility failed to fully implement the antibiotic stewardship program, including ongoing monitoring and use of surveillance criteria when antibiotics were prescribed. This deficient practice was identified for 5 of 5 months of antibiotic stewardship records reviewed and was evidenced by the following:On 5/5/2026 at 11:19 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the facility's Antibiotic Stewardship Program (efforts to ensure that antibiotics were used only when necessary and appropriate). The IP stated that the facility used the McGeer's and Loeb's criteria (clinical and laboratory findings used to define and track infections) for each resident when an antibiotic was prescribed, to ensure that each resident met the criteria for antibiotic usage. [...]
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide the provision of respiratory care in accordance with professional standards of practice specifically by: a.) not having a physician's order for oxygen administration. b.) not storing an oxygen mask and nasal cannula (NC, a tube used to deliver supplemental oxygen directly into a patient's nostrils) in a protective bag and c.) not ensuring that oxygen equipment, and the humidification bottle was dated. [...]
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to adjust a resident's medication administration schedule to accommodate dialysis treatments. This deficient practice was identified for 1 of 2 residents (Resident #6) reviewed for dialysis services. This deficient practice was evidenced by the following:On 5/3/2026 at 10:07 AM, the surveyor observed the resident awake in bed. A tray containing covered dishes was in front of him/her. The resident appeared weak. The resident stated that they went to dialysis (a life-sustaining medical treatment that performs the function of failing kidneys by filtering wastes, toxins, and excess fluid from the blood). The surveyor reviewed the medical record for Resident #6. [...]
- E
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, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a medication was administered per the physician's order (PO) within the required timeframe. This deficient practice was identified for 1 of 1 resident (Resident #15) reviewed for insulin and was evidenced by the following:On 5/5/2026 at 11:10 AM, the surveyor observed Resident #15 in the room in bed. The resident was fully dressed and well groomed. The surveyor asked the resident if they received their medication daily and they responded Yes. When the surveyor asked if the medications were administered timely, the resident told surveyor they do not remember. [...]
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a significant change assessment was completed for Resident #43, 1 of 30 residents reviewed for an evaluation of a significant change in the resident's condition. This deficient practice was evidenced by the following:A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to inclusion body myositis (progressive muscle disease), hypertension (high blood pressure), and chronic pain syndrome. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 3/31/26, indicated that Resident #43 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated that the resident had moderate cognitive impairment. [...]
- D
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 observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to develop and implement an Individualized Comprehensive Care Plan (ICCP) for a.) a resident on contact precautions (Resident #114) and b.) a resident who utilized an abdominal binder and a heel relief shoe (Resident #28). This deficient practice was evidenced by the following:1.) On 5/3/2026 at 10:52 AM, during tour, the surveyor observed transmission-based precaution signage posted on Resident #114's door and a personal protective equipment (PPE) cart located outside the resident's room. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) obtain an order for nursing care for a resident admitted with an intravenous (IV) access, b.) obtain a physician's order for an assistive device and update the care plan accordingly. This deficient practice was identified for 2 of 2 residents (Resident #28 and #110) reviewed for hydration, and wound (s), and 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
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 pertinent facility documents, it was determined that the facility failed to ensure all medications and biologicals were stored and labeled properly in medication carts. This deficient practice was identified for 1 of 2 medication carts reviewed under the Medication Storage and Labeling Task. The deficient practice was evidenced by the following: On 5/5/2026 at 1:12 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1) checked medication cart #1 on the second floor. During the inspection the surveyor observed the following: One tube of Hydrocortisone cream 2.5%, more than half used, with no label and were not dated. Sodium Chloride 5% eye ointment tubes, with no labels and were not dated. Cyclosporine 0.05%, 2 (two) eye droppers, with no resident names and were not dated. [...]
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to maintain a Hospice Communication Record which included a Certified Nursing Assistant (CNA) care plan for 1 of 1 resident (Resident #43) reviewed for Hospice Services. This deficient practice was evidenced by the following: On 5/05/2026 at 10:27 AM, the surveyor observed Resident #43 in bed. The resident told the surveyor that they do not get out of bed due to being paralyzed. During the observation the resident appeared well groomed and was dressed in personal clothing. The resident stated a hospice aide came to the facility to provide care. On 5/6/2026 at 9:35 AM, the surveyor requested the hospice communication binder for Resident #43. The Assistant Director of Nursing (ADON) provided the surveyor with the resident's paper chart. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection: a.) by ensuring proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP-infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) b.) during the provision of a wound treatment for a resident with a stage 4 pressure ulcer wound (full-thickness tissue loss with exposed bone, tendon, or muscle) and c.) by failing to clean and disinfect a blood pressure cuff after use between residents and perform hand hygiene after resident contact during the medication pass observation. [...]
October 24, 2025Complaint inspection · 1 citation
- 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, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and sanitary environment. The deficient practice was identified for 2 of 2 units reviewed for environment. This deficient practice was evidenced by the following:On 10/24/25 at 9:25 AM, the two surveyors conducted a unit tour on the first floor and second floor units. The following was observed during the tour:1. At 9:25 AM, the surveyors observed in room [ROOM NUMBER] the floor was soiled with a dried, unknown substance. 2. At 9:40 AM, the surveyors entered room [ROOM NUMBER], and observed an unsampled resident's room, who stated their bathroom shower drain had been clogged and when they took a shower, the water did not drain well. 3. At 9:42 AM, the surveyors entered room [ROOM NUMBER] and observed a resident in their bed. [...]
January 10, 2025Standard inspection, Complaint inspection · 9 citations
- E
Respond appropriately to all alleged violations.
Inspectors wroteNJ Complaint NJ #: 177087 Based on interview and review of pertinent facility documents, it was determined that the facility failed to investigate allegations of verbal abuse emailed to the facility on 8/7/24, by both a resident (Resident #145) and their representative, that an unidentified nurse verbally abused the resident and it was not investigated until surveyor inquiry. This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #145), and was evidenced by the following: On 1/6/25 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) all reportable events, grievances, accidents, and incident reports for Resident #145. On 1/7/25 at 1:15 PM, the LNHA provided the surveyor with the requested documents for Resident #145. The documentation included the following: [...]
- D
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 wroteComplaint NJ #: 177087, 178121 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment by ensuring resident bathroom doors were in good repair. This deficient practice was observed in 1 of 2 nursing units and was evidenced by the following: On 1/6/25 at 12:27 PM, during initial tour of the facility, the surveyor observed the bathroom door of Resident room [ROOM NUMBER] to be deformed with a bow causing the top corner and the bottom corner of the handle side to be bowed out from the frame when the door was completely closed. Only the latch was able to fully be seated in the door frame with the top and bottom corners pulled away allowing the surveyor to see into the bathroom with the door closed. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint NJ #: 177087 Based on observations, interviews, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to report an allegation of abuse within two hours to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #145), and was evidenced by the following: On 1/6/25 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) all reportable events, grievances, accidents, and incident reports for Resident #145. On 1/7/25 at 1:15 PM, the LNHA provided the surveyor with the requested documentation for Resident #145. This documentation included the following: An internal compliance hotline call from the resident dated 7/27/24. A fall accident report and investigation dated 9/26/24. [...]
- D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteComplaint NJ #: 173483 Based on interview, medical record review, and review of other pertinent facility documentation, it was determined that the facility failed to obtain admission diet orders for a resident identified as a nutritional risk. This deficient practice was identified for 1 of 19 residents reviewed for physician's orders (Resident #146), and was evidenced by the following: A review of the admission Record face sheet (an admission summary) indicated that Resident #146 was admitted to the facility with the diagnoses which included but was not limited to; malignant neoplasm of the urethra (cancer of the tube that carries urine out of the body), absence of the left upper arm limb (left upper arm (LUA) amputation), and right left below the knee amputation (BKA). [...]
- 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 interviews, observation, and review of pertinent facility documents it was determined that the facility failed to complete individual comprehensive care plans for three residents with urinary and bowel incontinence. This deficient practice was identified for 3 of 3 resident reviewed for incontinence (Resident #42, #47, and #52), and was evidenced by the following: 1. On 1/9/25 at 9:00 AM, the surveyor conducted incontinence rounds on the Second-Floor long term care nursing unit with the Certified Nursing Assistant (CNA #1). During the incontinence rounds, CNA #1 removed Resident #47's incontinence brief which was dry and the surveyor observed that the resident had a white towel within the incontinence brief. CNA #1 told the surveyor that the resident requested a towel within the incontinence brief. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteComplaint NJ #: 173135; 173483 Based on observation, interview, review of medical records, and review of other pertinent facility documents, it was determined that the facility failed to a.) obtain a physician's order for a replacement nutritional supplement after the facility identified that there was a national shortage of the resident's (Resident #146) current nutritional supplement; b.) consistently document the assessment and dressing changes to a resident's (Resident #195) peritoneal dialysis site (kidney treatment that filters waste and excess fluid from the blood using the lining of the abdomen); c.) appropriately administer intravenous (IV) antibiotic medication in accordance to the physician's order; and d.) document communication with the physician in accordance with professional standards of practice. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, review of facility medical records and other pertinent facility documents, it was determined that the facility failed to document the necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. This deficient practice was identified for 1 of 2 residents reviewed for pressure ulcers (Resident #4), and was evidenced by the following: A review of the admission Record face sheet (an admission summary) Resident #4 was admitted to the facility with the diagnoses that included but not limited to; dementia, diabetes mellitus and severe protein calorie malnutrition. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/19/24, indicated that Resident #4 had severe cognitive impairment and was dependent on staff for all aspects of activities of daily living (ADLs). [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure dialysis communication forms between the facility and the contracted dialysis facility were consistently completed. This deficient practice was identified for 1 of 3 residents reviewed for dialysis (Resident #68), and was evidenced by the following: On 1/6/25 at 12:25 PM, during initial tour of the facility, the surveyor observed Resident #68 in their bedroom sleeping. On 1/7/25 at 9:00 AM, the surveyor reviewed the medical record for Resident #68. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but not limited to; [...]
- 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 facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents. This deficient practice was identified for 1 of 1 observed medication storage room, and was evidenced by the following: On 1/8/25 at 9:49 AM, the surveyor toured the medication room on the Subacute unit in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor observed the following: debris on the medication room floor and brown substance build up in the corners; debris (appeared to be a tea bag) in the drain of the sink, brown discoloration in the basin, along the edge of the sink, behind the sink, and around the faucet; in the cabinet housing the sink, the surveyor observed brown, black, and orange substance towards the back of the cabinet under pipes. [...]
December 28, 2023Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteC #: NJ00169890 Based on interviews, medical record review, and review of other pertinent facility documents on 12/28/23, 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 resident according to facility policy and protocol for 2 of 3 residents (Resident #1 and Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility admission Record (AR), Resident #2 was admitted on [DATE], with diagnoses that included but were not limited to: Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), gout, and chronic kidney disease. [...]
November 13, 2023Standard inspection · 4 citations
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to notify the Ombudsman of the transfer to the hospital for three of three residents (Resident (R) 15, R35, R66) reviewed for hospital transfers, out of a total sample of 28 residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for two of 44 sampled residents (Resident (R) 19 and 68). Staff failed to accurately code dialysis for R19 and hospice for R68. Failure to code the MDS correctly can lead to inaccurate federal reimbursement and inaccurate assessment and care planning of the resident.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly maintain clean filters on oxygen concentrators for three of four residents sampled for respiratory care (Resident (R) 15, R21, and R35). The facility failed to ensure residents had active orders for oxygen use for one resident R353.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure that one of the 24 sampled residents (Resident (R)23) medical records from a sample of 24 residents were maintained in a complete, and accurately documented manner. Specifically, R23 Suprapubic Catheter was observed to have bright red blood in the line and urine specimen bag with no documentation identified in the electronic medical record (EMR).
Fire safety inspections
9 fire safety citations on file: 3 on May 7, 2026, 5 on January 10, 2025, 1 on November 13, 2023.
Every fire safety citation9 citations
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · May 7, 2026 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · May 7, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 7, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 10, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 10, 2025 · 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 · January 10, 2025 · Corrected (the home has a date of correction)
- D
Provide at least two remote exits on each floor or fire section of the building.
K 252 · January 10, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 10, 2025 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · November 13, 2023 · Corrected (the home has a date of correction)