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
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
8E
2F
Potential for minimal harm
0A
0B
0C
July 29, 2026Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteComplaint #: 3009338 Based on interviews, record reviews, and review of pertinent facility documents, it was determined that the facility failed to conduct and document a thorough investigation of an allegation of resident neglect. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #3). The deficient practice was evidenced by the following:A Facility Reportable Event (FRE) form, submitted by the facility to the New Jersey Department of Health (NJDOH), was reviewed. The FRE revealed that on 05/06/2026 at 11:30 AM, a Nurse Investigator (RN #1) from [a state agency] conducted an investigation at the facility in response to allegations of neglect and weight loss made by Resident #3's visitor. The FRE revealed that the resident's medical records were reviewed by RN #1 and the resident's weight was noted to be stable. [...]
May 12, 2025Standard inspection, Complaint inspection · 11 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 a.) maintain kitchen equipment in a clean and sanitary manner and b,) maintain 2 of 6 nourishment room refrigerators in a sanitary manner. The evidence was as follows: On 4/29/25 at 10:20 AM, in the presence of the Food Service Director (FSD) and the Regional FSD, the surveyor observed the following during kitchen tour: 1. The steamer unit floor drain was filled with debris and sediment. The FSD acknowledge it was not properly cleaned according to facility policy. 2. Two convection ovens were soiled with baked on brown coloring on the glass doors and interior of the unit. The FSD acknowledged and stated, it was not cleaned according to facility policy. 3. Two steamer units were drained into a floor trap and the trap screen had debris covering it. [...]
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to administer ten doses of an anti-convalescent medication (clonazepam) prescribed for seizures according to physician's orders. This deficient practice was identified for 1 of 35 residents reviewed for quality of care (Resident #47), and was evidenced by the following: On 4/29/25 at 11:324 AM, during initial tour of the facility, the surveyor observed Resident #47 lying in their bed with the bed positioned low with a fall mat located at the side. On 4/30/25 at 10:49 AM, the surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]
- D
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 a.) to treat each resident with respect and dignity and b.) care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life recognizing each resident's individuality. This deficient practice was identified for 1 of 35 residents reviewed for dignity (Resident #206), and was evidenced by the following: On 4/29/25 at 11:09 AM, during initial tour of the facility, the surveyor observed a Certified Nurse Aide (CNA #1) walking alongside Resident #206 in the hallway towards the shower room. CNA #1 and Resident #206 entered the shower room, and the door closed. The surveyor then heard Resident #206 begin to yell inside the shower room. [...]
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order to carry out a resident's wishes for code status. This deficient practice was identified for 2 of 38 residents reviewed for code status and advanced directives (Residents #167 and #230), and was evidenced by the following: 1. On 4/29/25 at 12:34 PM, the surveyor reviewed Resident #167's electronic medical record (EMR). A review of the admission Record face sheet (an admission summary) indicated that the resident was re-admitted to the facility with diagnosis which included but were not limited to; malignant neoplasm of colon (malignant colon cancer), malignant neoplasm of the liver (liver cancer), and malignant neoplasm of the lung (lung cancer). [...]
- 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 #NJ183871, NJ183873 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan for a.) a resident who was receiving dialysis (a medical procedure that acts as an artificial kidney filtering waste and excess fluid from the blood) treatments and b.) a resident with a surgical wound. This deficient practice was identified for 2 of 35 residents reviewed for care plans (Resident #73 and Resident #531), and was evidenced by the following: 1. On 4/29/25 at 12:13 PM, the Resident #73 was observed in bed with a blanket pulled over their head. The resident did not want to be interviewed. The surveyor reviewed the medical record for Resident #73. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure recommendations by the wound care consultant were implemented to prevent worsening of a pressure ulcer. This deficient practice was identified in 1 of 4 residents reviewed for pressure ulcers (Resident #333), and was evidenced by the following: The surveyor reviewed the medical record for Resident #333. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; kidney failure, hypertension (high blood pressure), and pneumonia. [...]
- 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 documentation, it was determined that the facility failed to a.) store all drugs and biologicals in locked compartments and b.) properly store medications and maintain clean and sanitary medication storage areas. This deficient practice was identified in 1 of 1 observed treatment cart and 2 of 6 observed medication carts, and was evidenced by the following: 1. On 4/30/25 at 12:12 PM, the surveyor observed a wound treatment cart on the Second-floor nursing unit by the nurse's station in front of the elevators which was unattended and left unlocked. The surveyor remained near the treatment cart and observed two nursing staff members walk past the treatment cart and did not acknowledge or identify that the treatment cart was unsecured. [...]
- 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 4 of 5 observed resident pantry rooms as evidence by the following: On 5/6/25 at 1:00 PM, the surveyor toured the 1st floor Subacute unit pantry room in the presence of the Food Service Director (FSD). The surveyor observed the following: the counter around the sink and backsplash had black discoloration. The caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet. On 5/6/25 at 1:11 PM, the surveyor toured the 2nd floor, 2A, and Chinese unit pantry room, in the presence of the FSD. The surveyor observed the following: [...]
- J
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint #NJ182121Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident physical abuse for a cognitively intact resident (Resident #381) who reported being roughly handled by a Certified Nursing Assistant (CNA #1). This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381). A review of the Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381, a cognitively intact resident, reported to the Registered Nurse (RN #1) that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). [...]
- J
Respond appropriately to all alleged violations.
Inspectors wroteComplaint #NJ182121Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy by thoroughly investigating an allegation of staff-to-resident physical abuse to a cognitively intact resident (Resident #381) who reported the allegation to the Registered Nurse (RN #1) on 12/28/24. This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381). A review of the Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381, a cognitively intact resident, reported to the Registered Nurse (RN #1) that they were fearful of staff at the facility due to an incident that had occurred two days prior (12/26/24). [...]
- E
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteComplaint #NJ182121, NJ183873 Based 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 a.) administering pain medications according to the physician's ordered pain level parameters and b.) obtaining and administering pain medications as ordered by the physician. This deficient practice was identified for 2 of 2 residents reviewed for pain management (Residents #381 and Resident #531), and was evidenced by the following: 1. The surveyor reviewed the closed medical record for Resident #381. A review of the admission Record face sheet (admission summary) reflected that Resident #381 was admitted to the facility with the diagnoses that included but were not limited to; [...]
July 25, 2024Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteComplaint # NJ160740, NJ166295, NJ167271, NJ169912 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/24/2024, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 3 residents (Resident #3) . The facility also failed to follow its policy titled Administering Medications. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. [...]
March 10, 2023Standard inspection · 9 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 a.) provide privacy and promote dignity during podiatry care for 3 of 3 residents observed (Residents #180, #205 and #264) and b.) provide care and services in a dignified and respectful manner during dining in 1 of 4 dining rooms observed. This deficient practice was evidenced by the following: 1. During the initial tour of the 2A unit on 2/21/23 at 11:13 AM, the surveyor observed the facility's podiatrist and his assistant enter Resident #205's room. Resident #205 was awake and seated in their wheelchair. The podiatrist sat on the floor in front of the resident, put on gloves and removed the resident's socks exposing the resident's toe nails. The Podiatrist opened a blue pad, chux (a disposable under pad) and placed it on the floor underneath the resident's feet. [...]
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to: a.) accurately transcribe a physician's order for enteral flushes for 1 of 2 residents reviewed for tube feeding (Resident #23), b.) accurately transcribe a physician's order for contractures for 1 of 3 residents reviewed for range of motion (Resident #77), c.) follow a physician's order for weekly weights for 1 of 5 residents reviewed for weights (Resident #183), d.) ensure urinary output was accurately documented in the medical record for 1 of 3 residents reviewed for foley catheters (Resident #199), and e.) ensure neurological assessments neuro checks were completed for 2 of 4 residents reviewed for accidents (Residents #130 and #264). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis schedule for 1 of 2 residents (Resident #71) reviewed for dialysis. This deficient practice was evidenced by the following: During the initial tour of the facility on 02/21/23 at 11:22 AM, the Licensed Practical Nurse (LPN) #3 informed the surveyor that Resident #71 had begun dialysis (the process of removal of excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) approximately one month ago and was presently out of the facility for dialysis treatment. [...]
- 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 policy 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 2/21/23 at 9:43 AM, the surveyor, in the presence of the Dietary Director (DD), observed the following during the kitchen tour: 1. In the food preparation area, Dietary Aide #1 and Dietary Aide #2 were observed wearing baseball caps with their hair at the back of the head exposed and were not wearing hairnets. The DD acknowledged the dietary aides should have been wearing hairnets. 2. In the food preparation area, Dietary Aide #2 was observed wearing a surgical mask above his chin area and his facial hair was exposed. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) perform hand hygiene before and after podiatry care for 3 of 3 residents (Residents #180, #205 and #264). This deficient practice was evidenced by the following: 1. During the initial tour of the 2A unit on 2/21/23 at 11:13 AM, the surveyor observed the facility's podiatrist and his assistant enter Resident #205's room. Resident #205 was awake and seated in their wheelchair. The podiatrist sat on the floor in front of the resident, put on gloves and removed the resident's socks exposing the resident's toe nails. The Podiatrist opened a blue pad, chux (a disposable under pad) and placed it on the floor underneath the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. [...]
- 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 wroteBased on observation, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that a resident's mattress was maintained in a clean, sanitary, and homelike manner on 1 of 8 nursing units (Memory Care Unit). This deficient practice was evidenced by: During the initial tour of the facility on 02/21/21 at 11:08 AM, the surveyor observed Resident #108 seated in a wheelchair at the bedside beside his/her bed which was stripped. The mattress was heavily stained and soiled, with deep creases noted to the upper portion of the mattress. There was a strong smell of urine in the resident's room. The resident appeared well groomed and dressed and was not able to be interviewed due to his/her cognitive status. [...]
- 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, record review, and review of other facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan to address a resident's contracture for 1 of 3 Residents (Resident #77) reviewed for range of motion. This deficient practice was evidenced by the following: On 2/21/23 at 11:52 AM, Resident #77 was observed in wheelchair with their right hand contracted and bent at wrist with downward flexion. The resident was unable to follow commands. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 1/22/23, identified the resident as severely impaired and with impairments on both sides of the upper and lower extremities. A review of the medical record indicated that Resident #77 was admitted to the facility with diagnoses which included, but not limited to: [...]
- 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, interviews, and record review, it was determined that the facility failed to revise and update the care plan (CP) in a timely manner for residents who had falls. This deficient practice was identified for 2 of 35 residents reviewed for comprehensive care plans, (Residents #130 and #264) and was evidenced by the following: 1. On 2/21/23 at 11:22 AM, Resident #130 was observed sleeping in bed. According to the admission Record, Resident #130 was admitted to the facility in July 2022 with diagnoses which included but were not limited to; unspecified dementia. Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated, 2/13/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 5 out of 15 which indicated that the resident had severely impaired cognition. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure a resident who was dependent on supplemental oxygen via a tracheostomy tube (a surgically created hole (stoma) in the windpipe (trachea)) received supplemental oxygen in accordance with physician orders for 1 of 2 residents reviewed for tracheostomy care (Resident #66). This deficient practice was evidenced by: During the initial tour of the building on 02/21/23 at 12:36 PM, the surveyor observed a stop sign posted outside of Resident #66's room which cautioned that an N 95 mask (filters 95% of particles) was required to enter the resident's room. From the doorway, the surveyor observed Resident #66 lying in bed asleep with the head of bed elevated. The resident had a tracheostomy tube and was noted to have a positive cough. [...]
February 26, 2021Standard inspection · 4 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to don appropriate Personal Protective Equipment (PPE) while in the rooms of residents placed on transmission-based contact and droplet precautions residing on the units designated for Persons Under Investigation (PUI) and on the COVID-19 positive unit. This deficient practice was identified for 6 of 6 staff members observed on 2 of 2 PUI units and for 2 of 2 staff members a COVID-19 positive unit in the facility. The deficient practice was evidenced as follows: 1. On 02/19/21 at 12:48 PM, the surveyor observed lunch meal service on the second floor unit, A/C- wing which had been designated as a PUI area for new and readmissions. The surveyor observed a PUI room with signs on the door which indicated to stop. [...]
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) identify the use of bilateral hand mittens as a physical restraint, b.) assess and implement the least restrictive measures prior to the use of a physical restraint, and c.) obtain a consent with disclosure of risk versus benefits for the use of a physical restraint. This deficient practice was identified for 2 of 2 residents (Residents #131 and #330) who were reviewed for the use of physical restraints and was evidenced by the following: 1. On 02/19/21 at 12:21 PM, the surveyor observed Resident #330 in his/her bed, wearing white hand mittens on both the right and left hands. The hand mitts were tied at the wrist to hold them in place on the resident's hands but were not tied to the side rails or any other surface. [...]
- D
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 observation, interview, and record review, it was determined that the facility failed to address in a timely manner the recommendations made by the Consultant Pharmacist (CP) during the Monthly Medication Review. This deficient practice was identified for 1 of 6 residents reviewed for unnecessary medications (Residents #73) and was evidenced by the following: The surveyor reviewed Resident #73's 08/2020 Physician Order Sheet (POS) which revealed a physician Order (PO) dated 07/03/20 for Voltaren 1% gel (topical gel medication used to treat pain) to be applied twice daily to the left shoulder. The surveyor noted that there was no dosage amount documented for the Voltaren gel. The surveyor noted that both the 09/2020 and 10/2020 POS had the same order for Voltaren 1% Gel and no dosage amount. [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview and record review, and review of other facility documents, it was determined that the facility failed to ensure that residents were free from unnecessary psychoactive medications. This deficient practice was identified for Resident #17, 1 of 2 resident reviewed for psychoactive medications and was evidenced by the following: Review of Resident #17's clinical record revealed that the resident was admitted to the facility with diagnoses which included: Coronary Artery Disease (Heart disease), Hypertension, aphasia (difficulty speaking) and cerebro-cascular accident (CVA- stroke). The resident's Quarterly Minimum Data Set (MDS) an assessment tool dated 02/02/2021, reflected that the resident was severely cognitively impaired. The surveyor observed the resident in bed with eyes closed during the initial unit tour on 02/19/2021 at 11:30 AM. [...]
Fire safety inspections
21 fire safety citations on file: 11 on May 12, 2025, 9 on March 10, 2023, 1 on February 26, 2021.
Every fire safety citation21 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 · May 12, 2025 · Corrected (the home has a date of correction)
- 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 · May 12, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 12, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 12, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 12, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 12, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 12, 2025 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · May 12, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 12, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · May 12, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 10, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 10, 2023 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · March 10, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 10, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 10, 2023 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · March 10, 2023 · 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 · March 10, 2023 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · March 10, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Have elevators that firefighters can control in the event of a fire.
K 531 · February 26, 2021 · Corrected (the home has a date of correction)