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
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
6E
0F
Potential for minimal harm
0A
0B
0C
July 16, 2026Standard inspection · 7 citations
- 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 and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) a system to ensure discrepancies of controlled substances were documented and rectified for four controlled substances, Ambien, Klonopin, Percocet, and Ultram and, b.) accurately account for and document the administration of a controlled medication, liquid morphine sulfate. This deficient practice was identified for 4 medications stored in the Automated Dispensing System (ADS) and on 1of 4 medication carts reviewed and was evidenced by the following: 1. On 7/9/26 at 11:30 AM, the surveyor requested a copy of the discrepancy report for the ADS from the Assistant Director of Nursing (ADON). The report was provided and included Ambien, Klonopin, Percocet, and Ultram; [...]
- 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 facility provided documents, it was determined that the facility failed to maintain proper kitchen sanitation practices to prevent the development of food borne illness. The deficient practice was evidenced by the following: On 7/9/26 at 10:47 AM, during the kitchen tour with the Food Service Director (FSD), the surveyor observed a utility rack with stacked pans on each shelf, all turned upside down. The FSD identified this as the dried pot and pan storage rack. The surveyor observed seven pans stacked together on the third shelf from the top. The FSD identified these as 4-inch deep full-size pans. The FSD separated all seven pans, and the 1st, 2nd, 3rd, and 4th pans in the stack revealed a clear, thin liquid dripping onto the floor. The pans were visibly wet on the inside and outside surfaces. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint # 3091573Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to report an allegation of verbal abuse to the New Jersey Department of Health (NJDOH) within 2 hours for one of one resident (Resident # 19) reviewed for abuse. This deficient practice was evidenced by the following:A review of the admission Record (an admission summary) for Resident #19 revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on observations, interviews, and review of medical records and other facility documentation, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits in the appropriate time frame. This deficient practice was identified for 1 of 2 residents reviewed for hospice (Resident # 11). This deficient practice was evidenced by the following:On 7/09/2026 at 10:23 AM, the surveyor observed Resident #11 in a wheelchair. The resident stated hospice was going well. The surveyor reviewed the resident's electronic medical record (EMR), which revealed an admission Record that reflected Resident #11 had medical diagnoses which included, but were not limited to, cancer. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and review facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy for 1 of 2 residents (Resident #5) reviewed for respiratory care. The deficient practice was evidenced by the following:On 7/9/26 at 10:40 AM, during the initial tour, the surveyor observed Resident #5 sitting in a wheelchair in their room. The surveyor observed an oxygen concentrator (a device that generates oxygen) located near the resident's bed, with a nasal cannula (tubing that delivers the oxygen from the concentrator to the nose) placed on the oxygen concentrator. The resident stated that they wear oxygen while in bed at night. The surveyor reviewed the electronic medical record (EMR) for Resident #5. [...]
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview, record review, and review of other pertinent facility documentation, it was determined that the facility Medical Director (MD) failed to attend mandatory quarterly Quality Assurance and Performance Improvement (QAPI) meetings for two out of five quarterly meetings. This deficient practice was evidenced by the following: On 07/09/26 at 10:05 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) during the Entrance Conference. The surveyor requested a copy of all quarterly QAPI sign-in sheets since the last survey, a list of QAPI Committee Members, and the QAPI policies and procedures. A review of the list of QAPI Committee Members revealed that the Medical Director was listed as a member. A review of the facility-provided QAPI sign-in sheets revealed the following:QAPI 2025 4th Quarter (dated 12/31/25): [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure contracted hospice staff utilized proper personal protective equipment (PPE: clothing or gear worn to protect both those providing and receiving care from potential harm) during care of a resident on enhanced barrier precautions (EBP: infection control measures using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms). The deficient practice was identified for 1 of 1 resident (Resident #22) reviewed for infection control and was evidenced by the following:On 7/9/26 at 10:05 AM, the surveyor observed an EBP sign on the resident's door with the letter B written in black ink on it and a PPE bin outside of the room. [...]
June 19, 2025Complaint inspection · 1 citation
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteComplaint #: NJ186666 Based on interview and record review, it was determined that the facility failed to ensure physician's orders were obtained for a.) weekly cleaning and tubing changes for a resident's continuous positive airway pressure (CPAP) machine and b.) filling the chamber of the CPAP machine with distilled water daily from March 2025 through the resident's discharge from the facility in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
March 6, 2025Standard inspection, Complaint inspection · 10 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteComplaint #: NJ162242 Based on observation, interview, record review, and review of the facility's policy, the facility failed to implement their abuse policies and procedures by ensuring a resident (Resident #239) was free from verbal abuse. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #239). Resident #239, who had diagnoses of bipolar, schizoaffective disorder, and anxiety, was observed by staff at an Ear, Nose, and Throat (ENT) doctor's office appointment being verbally abused and exploited by their facility escort, Housekeeping Aide (HA #1), who recorded the resident with their cell phone while they verbally abused the resident. The ENT staff who witnessed the incident reported that HA #1 was belittling and yelling at the resident. [...]
- J
Respond appropriately to all alleged violations.
Inspectors wroteComplaint #: NJ162242 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse and exploitation by a Housekeeping Aide (HA #1) who was observed being verbally abusive and videotaping the incident. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #239). Resident #239, who had diagnoses of bipolar, schizoaffective disorder, and anxiety, was observed by staff at an Ear, Nose, and Throat (ENT) doctor's office appointment being verbally abused and exploited by their facility escort, HA #1, who recorded the resident with their cell phone while they verbally abused the resident. The ENT staff who witnessed the incident reported that HA #1 was belittling and yelling at the resident. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteComplaint #: NJ162242 Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident's rights were protected when a staff member video recorded the resident without the resident or their representative's consent. This deficient practice was identified for 1 of 1 resident reviewed for resident rights (Resident #239).
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to respect the right to confidentiality of medical records during medication pass. This deficient practice was identified for 2 of 8 residents observed during medication pass (Resident #38 and Resident #290).
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteComplaint #: NJ162242 Based on observation, interview, record review, and review of the facility's policy, it was determined that the facility failed to ensure residents were free from physical restraints. This deficient practice was identified for 1 of 1 resident reviewed for restraints (Resident #239).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint #: NJ172235 Based on interviews, record review, and facility policy review, it was determined that the facility failed to implement policies and procedures to report an allegation of staff-to-resident sexual abuse to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #289).
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure residents received alternative measures prior to installation of bedrails. This deficient practice was identified for 1 of 1 resident reviewed for bedrails (Resident 78).
- 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 record review, interview, and policy review, it was determined that the facility failed to ensure a physician ordered as needed (PRN) antianxiety medication had a stop date. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #141).
- 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 and interview, it was determined that the facility failed to properly store medications safely and securely during medication administration. The deficient practice was identified for 2 of 8 residents observed during medication pass.
- 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 and interview, it was determined that the facility failed to ensure a resident's medical record was maintained complete, accurately documented, and readily accessible. This deficient practice was identified for 1 of 30 sampled residents (Resident #87).
May 30, 2024Complaint 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 wroteComplaint# NJ00174037 Based on interviews, record review, and review of other pertinent facility documentation on 05/30/24, it was determined that the facility failed to maintain a complete Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident who was sent out for an emergent hospitalization. This deficient practice was identified for Resident #4, 1 of 5 sampled residents, and was evidenced by the following: According to the admission Record, Resident #4 was admitted to the facility with diagnoses which included but were not limited to: Benign Neoplasm of Cerebral Meninges, Hypertension, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus type 2. [...]
February 24, 2023Standard 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 review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 2/16/2023 from 9:30 AM to 10:18 AM the surveyor, accompanied by the Director of Nutrition Services (DONS), observed the following in the kitchen: 1. In the dry storage room on an upper shelf 3 individual, opened cardboard boxes, contained plastic knives, forks, and spoons. The boxes were open to the air and the utensils were exposed to contamination. 2. On an upper rack of a wheeled and multi-tiered can storage rack, a can of applesauce unsweetened had a significant dent on the upper seam. The DONS removed the can to the designated dented can area. 3. [...]
- E
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to maintain garbage off the ground surrounding 2 of 2 garbage dumpster's. This deficient practice was evidenced by the following: On 2/16/2023 at approximately 10:10 AM, the surveyor and the facility Director of Nutrition Services (DONS) went outside the facility to inspect the designated facility garbage area. Upon arriving to the designated garbage area, the surveyor observed 2 green dumpster's with lids open and staff actively dumping garbage. The DONS identified these 2 dumpster's as garbage dumpster's. A third dumpster with its lids closed was determined to be a recycling only dumpster, per the DONS. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a) implement infection control measures for the handling and storage of respiratory equipment for 2 of 2 residents reviewed for oxygen use, (Resident # 30 and Resident # 68) and b) failed to ensure staff wore the appropriate personal protective equipment (PPE) required to enter a resident's room that required transmission-based precautions during wound care. The deficient practice was observed for 1 of 2 residents investigated for Pressure Ulcer/Injury (Resident #97). This deficient practice was evidenced by the following: 1.) During the initial tour of [NAME] unit on 2/16/2023 at 11:29 AM, Resident #30 was observed lying in bed. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to maintain the call device within reach for 1 of 29 sampled residents, (Resident #67). This deficient practice was evidenced by the following: On 2/17/2023 at 8:46 AM the surveyor observed Resident #67 lying in bed. The surveyor observed that Resident #67's call device was on the floor at the foot of the bed. The call device was between the wall and bed. The call device was not accessible to the Resident #67. According to the Resident Face Sheet, Resident #67 was admitted to the facility with the following but not limited to diagnoses: Alzheimer's disease, insomnia, dementia, unspecified severity with behavioral disturbance, and dementia with agitation. [...]
- 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, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean and safe environment for 1 of 3 units, [NAME]. This deficient practice was evidenced by the following: On 2/17/2023 at 12:37 PM, Surveyor #1 observed the following on [NAME] unit: *While walking in the hallway your feet were partially sticking to the floor. *The floor in the unit dayroom/Dining room had dried stains, odor of urine and a large dried stain by the partitioned part of the wall when entering the room to the left. On 2/17/2023 at 12:42 PM, Surveyor #1 observed the following: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow physician orders in accordance with professional standards for the care of Oxygen tubing for 2 of 3 residents reviewed for oxygen use (Resident # 30 and Resident # 68). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]
Fire safety inspections
15 fire safety citations on file: 5 on July 16, 2026, 2 on March 6, 2025, 8 on February 24, 2023.
Every fire safety citation15 citations
- F
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · July 16, 2026 · Corrected (the home has a date of correction)
- E
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 · July 16, 2026 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · July 16, 2026 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 16, 2026 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 16, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 6, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 6, 2025 · Corrected (the home has a date of correction)
- 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 · February 24, 2023 · 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 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 24, 2023 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 24, 2023 · 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 · February 24, 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 · February 24, 2023 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · February 24, 2023 · Corrected (the home has a date of correction)