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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
21E
6F
Potential for minimal harm
0A
1B
0C
January 30, 2026Standard inspection · 23 citations
- F
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 observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to have a system in place to inform and offer written information regarding the option to formulate an Advance Directive. This deficient practice was identified for 2 of 2 residents (Resident #9 and Resident #69) reviewed for AD, and affected all residents who resided in the facility. The evidence was as follows:a. On 1/28/26 at 10:43 AM, Resident #9 was observed in bed, and they were unable to participate in an interview with the surveyor due to confusion. On 1/28/26 at 10:31 AM, the surveyor reviewed the medical record for Resident #9 which revealed the following: A review of the admission Record (an admission summary) reflected that the resident was admitted with diagnoses which included but were not limited to; [...]
- F
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on interview and review of documents it was determined that the facility failed to ensure residents who required Medicaid were admitted to the facility per the facility SNF/NF (Skilled Nursing Facility/Nursing Facility) designation from the Centers for Medicare/Medicaid (CMS) and per the New Jersey Department of Health (DOH). The deficient practice affected all residents admitted to the facility and was evidenced by the following: On 01/27/26 at 11:04 AM, during the facility entrance conference held with the Licensed Nursing Home Administrator (LNHA), and an Executive [NAME] President (EVP) the surveyor asked what the resident population of the facility was. The LNHA confirmed the residents were all short term, and there were no long-term care residents at the facility. When asked if the facility's residents met and had an organized group meeting (Resident Council Meeting). [...]
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and document review, it was determined that the facility failed to implement a comprehensive, effective data driven Quality Assurance Program (QAPI) that included self-identifying areas for improvement and maintaining documentation of QAPI initiatives. The deficient practice affected all residents who resided at the facility and was evidenced by the following:Refer to F620, F627, F881 On 01/30/26 at 9:12 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding how the facility determines what was reviewed by the QAPI team and how QAPI plans were developed. The LNHA stated skin issues, and fall concerns were reviewed. The LNHA stated trends were reviewed, including the dates and the trends were analyzed. The surveyor asked what all the current facility QAPI initiatives were. [...]
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and document review it was determined that the facility failed to investigate, analyze and monitor adverse events and utilize data to develop activities to prevent further adverse events. This deficient practice had the potential to affect all residents who resided at the facility and was evidenced by the following: On 01/30/26 at 9:12 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding how the facility determines what was reviewed by the QAPI team and how QAPI plans were developed. The surveyor asked if incidents were reviewed, including grievances. The LNHA stated skin issues, and fall concerns were reviewed at QAPI. The LNHA stated trends were reviewed, including the dates and the trends were then analyzed. [...]
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on observation, interview, and record review of pertinent facility documentation, it was determined that the facility failed to ensure a system was in place to utilize an infection assessment tool prior to prescribing antibiotics and ensure the Antibiotic Stewardship program was implemented consistently. This deficient practice was identified for (2) of two (2) residents reviewed for antibiotic stewardship, (Resident #84 and Resident # 69) and was evidenced by the following: a. On 1/28/26 at 12:00 PM, the surveyor reviewed Resident #69's electronic medical record which revealed the following: The admission Record revealed the resident had diagnoses which included, but were not limited to: dementia, retention of urine and benign prostatic hyperplasia (enlargement of the prostate gland). [...]
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, record review and review of pertinent documents, it was determined that the facility failed to honor the right to self-determination related to resident choices for mealtimes for a resident who attended dialysis treatments three times per week. This deficient practice was identified for 1 of 1 resident (Resident # 4) reviewed for dialysis care and was evidenced by the following:On 01/27/26 at 11:49 AM, the surveyor observed Resident #4 in their room and they informed the surveyor that they just returned from dialysis (a treatment that removes impurities from the blood when the kidneys do not function). The surveyor observed an opened breakfast tray on the bedside table and the resident stated that the food was cold. Resident #4 stated that they want to have their breakfast upon return from dialysis and the staff were aware of their preference. [...]
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interviews and document review, it was determined that the facility failed to consistently follow a system to ensure a) prior to hire, all employees were pre-screened to ensure that they had not been found guilty in a court of law of abuse, neglect, or misappropriation, or had findings entered into the state nurse aide registry or against a professional license, and b) a process was in place to maintain documentation to confirm an appropriate pre-screening had occurred for all contracted facility employees which including dietary and housekeeping. The deficient practice was identified for 2 of 39 employee files reviewed that were provided by the facility. [...]
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a thorough investigation was completed to determine abuse or neglect had not occurred after a resident sustained a fall while attempting to transfer self to the bathroom. Resident #55 reported rough handling by the Licensed Practical Nurse (LPN) who assisted them from the floor to the wheelchair. This deficient practice was identified for 1 of 1 resident (Resident #55) reviewed for accidents and was evidenced by the following:On 1/27/26 at 10:58 AM, during the initial tour, the surveyor observed Resident #55 seated in a wheelchair in their room. Resident #55 stated, on 1/25/26, I had to go to the bathroom, I rang the call bell and called out for help. No one responded to the call bell for 45 minutes. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to a.) initiate a wound treatment order for a newly identified skin tear (Resident #9), and b.) upon admission to the facility, transcribe a resident's (Resident #7) allergy information documented on a hospital discharge summary. This deficient practice was identified for 1 of 1 resident (Resident #9) who was reviewed for skin conditions and for 1 of 2 residents (Resident #7) reviewed for choices and was evidenced by the following:a. On 1/28/26 at 10:43 AM, Resident #9 was lying in bed he was confused and unable to participate in an interview. The surveyor observed a large bloody gauze type dressing, undated and observed on their left upper arm. On 1/28/26 at 10:31 AM, the surveyor reviewed the medical record for Resident #9 which revealed the following: [...]
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a physician order was followed to ensure a resident's heels for a resident who was at risk for skin breakdown. This deficient practice was identified for 1 of 1 resident (Residents #4) reviewed for pressure ulcers and was evidenced by the following:During the initial tour of the 500 Unit on 1/27/26 at 11:30 AM, the surveyor observed Resident #4 lying in bed with the head of bed (HOB) slightly elevated. The surveyor observed that Resident #4's bilateral lower extremities were not offloaded and that Resident #4's feet were lying directly on the mattress. When interviewed, at that time, Resident #4 informed the surveyor that they just returned from dialysis and reported discomfort to the feet. [...]
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview, record review and review of pertinent documentation it was determined that the facility failed to ensure that appropriate care and services were provided for a resident with a physician order for a bladder scan upon removal of a indwelling urinary catheter. The deficient practice occurred for 1 of 1 resident reviewed for unplanned hospitalization and urinary tract infection (Resident #69). The evidence was as follows: On 1/28/26 at 12:00 PM, the surveyor reviewed Resident #69's electronic medical record which revealed the following: The admission Record revealed the resident had diagnoses which included, but were not limited to: dementia, retention of urine and benign prostatic hyperplasia (enlargement of the prostate gland). A Progress Note (PN) documented by the Unit Manager (UM) dated 12/23/25 at 7:04 AM which revealed: [...]
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services for a resident with a tracheostomy (trach; a device inserted into a surgically created opening in the neck into the windpipe to help with breathing) in accordance with standard of practice. This deficient practice was identified for one (1) of one (1) resident reviewed for respiratory/tracheostomy care (Resident #77) and was evidenced by the following:On 1/27/26 at 11:42 AM, during the initial tour, Resident #77 was observed asleep, in bed, the head of the bed was elevated and was receiving oxygen (O2) via tracheostomy tube. The surveyor reviewed the medical record for Resident #77. [...]
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly review dialysis communication sheets post dialysis and informed the physician of new recommendations based on laboratory chemistry obtained at dialysis treatment, and ensure the care plan addressed the care of the dialysis access site. This deficient practice was identified for 1 of 1 residents (Resident #4) reviewed for dialysis and was evidenced by the following: a. On 1/27/26 at 11:30 AM during the initial tour of the facility, the surveyor observed Resident #4 in bed. The resident informed the surveyor they just returned from dialysis treatment. On 1/27/26 at 12:10 PM, the surveyor inquired regarding the dialysis communication book and obtained the communication book from the nurse assigned to the unit. [...]
- E
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of all Certified Nursing Aides (CNAs) on an annual basis. This deficient practice was identified for 3 of 5 CNAs whose personnel records were reviewed and was evidenced by the following:On 1/29/26 at 1:33 PM, the surveyor reviewed the Annual Staff Performance Appraisals for five randomly selected CNAs. CNA#1, with a date of hire of 5/24/23, had their most recent Annual Staff Performance Appraisal signed as completed on 3/20/24. CNA#2, with a hire date of 9/8/20, had their most recent Annual Staff Performance Appraisal signed as completed on 4/8/24. CNA#3, with a hire date of 3/27/23, had their most recent Annual Staff Performance Appraisal signed as completed on 8/24/24. [...]
- 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 ensure a.) Lokelma (sodium zirconium cyclosilicate, a potassium binder for those with high potassium) a medication was administered in accordance with manufacturer's specifications for one (1) of four (4) nurses observed b.) Questran (cholestyramine used to lower cholesterol), a medication was labeled with cautionary instructions for proper administration, for one (1) of four (4) residents observed during the medication pass, c.) quality control testing (calibration) was conducted for the blood glucose (bg) monitors, both used for residents as per manufacturer's specifications, for two (2) of two (2) medication carts inspected, d.) consistent disposition (destruction), reconciliation, and accountability of the controlled dangerous substance (narcotic; [...]
- E
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 ensure the Consultant Pharmacist identified irregularities during the drug regimen review of a newly admitted resident. The deficient practice was identified for one (1) of four (4) residents observed during the medication pass (Resident #55). Refer to 755. Reference:According to the manufacturer's specifications for Lokelma section 2.3 Reconstitution and Administration: In general, Lokelma should be administered at least 2 hours before and 2 hours after Lokelma. According to the manufacturer's specifications for Questran under Drug Interaction; since Questran may bind other drugs given concurrently, it is recommended that patients take other drugs at least one hour before or four (4) to 6 hours after Questran (or at as great an interval as possible) to avoid impeding their absorption. [...]
- 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 perform appropriate hand hygiene for 2 of 2 staff observed and disinfect shared medical equipment prior to and after use, in accordance with facility infection control policy. This deficient practice was evidenced by the following:On 1/27/26 at 11:30 AM, the surveyor observed a signage posted at the entrance door of Resident #4's room. The signage indicated Enhanced Barrier Precaution. There was a Personal Protective Equipment box hung outside the door that included gowns and gloves. The surveyor then observed the LPN approached the room with the medication cart and a blood pressure machine. The LPN placed the medication cart next to the entrance door. The LPN, donned (put on) gloves and a gown and entered the room without first performing hand hygiene. [...]
- E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that a) Certified Nursing Aides (CNAs) received 12 hours of mandatory annual in-service training for 2 of 5 CNAs reviewed and b) CNA education included abuse training for 3 of 5 CNA education files reviewed. The deficient practice was evidenced by the following:On 1/29/2026 at 1:33 PM, the surveyor reviewed the in-service education hours for five randomly selected CNAs, which were provided by the facility. The [Name Redacted] Transcripts provided showed the following: CNA#1, with a hire date of 5/24/23, had 3.4 hours of education from 5/24/24 - 5/24/25, which did not include training on abuse. The last abuse training documented was 7/3/24. CNA#2, with a hire date of 9/8/20, had 4.98 hours of education from 9/8/24 - 9/8/25. [...]
- D
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure the admission Agreement did not required residents to waive their right to receive 30-day written notice of discharge. This deficient practice was identified for 1 of 1 residents reviewed for appropriate discharge (Resident # 71) and was evidenced by the following: On 1/27/26 at 1:05 PM, the surveyor reviewed the facility entrance binder (a binder that contained the required recertification survey documentation per the Centers for Medicare and Medicaid-CMS- entrance conference requirements) that was provided by the LNHA. A 44 Page Welcome Packet was identified as the facility admission Agreement. The Notice of Resident's Rights Regarding Transfer or discharge: You may be transferred or discharged for one of the following reasons: 1. [...]
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on interview, record review and review of pertinent documents it was determined that the facility failed to ensure an appropriate discharge process was in place for residents who had a change in payor source. This deficient practice occurred for 1 of 1 resident reviewed for appropriate discharge (Resident #71) and was evidenced by the following: On 01/27/26 at 11:04 AM, during the facility entrance conference held with the Licensed Nursing Home Administrator (LNHA), and an Executive [NAME] President (EVP) the surveyor asked what the resident population of the facility was. The LNHA stated the residents were all short term, and there were no long-term care residents at the facility. When asked if the facility held resident council meetings, the LNHA stated there was no resident council meeting held at the facility. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 19 residents reviewed (Resident #71, Resident # 72, and Resident #74). This deficient practice was evidenced by the following:On 1/28/2026 at 9:25 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #71 which revealed an admission record (face sheet) with diagnoses that included but not limited to hemiplegia and hemiparesis (weakness) following CVA (stroke) affecting the right dominant side and dysphagia (difficulty swallowing). [...]
- 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, and record review, it was determined that the facility failed to develop or initiate a comprehensive, person-centered care plan to address a.) the care of a Foley catheter. This deficient practice was identified for 1 of 27 residents (Resident #80) reviewed for a comprehensive Care Plan (CP) and was evidenced by the following:On 1/27/2 at 11:45 AM, the surveyor observed Resident #80 in the room sitting in a wheelchair by the bed. Resident #80 was awake and alert and able to answer the surveyor's inquiry. The resident informed the surveyor that they were in Physical therapy this morning and they were admitted to the facility for rehabilitation. The surveyor observed that Resident #80 wore a urinary catheter leg bag. The surveyor reviewed the Electronic Health Record (EHR) of Resident #80. [...]
- D
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nursing staffing report daily. This deficient practice was evidenced by the following: On 1/27/26, on entrance and initial tour, the survey team did not observe the nursing staffing report to be posted in the facility. On 1/28/26 at 12:56 PM, the surveyor did not observe the nursing staffing posted in the lobby, on the second floor, or on the fifth floor. On 1/28/2026 at 1:06 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) about the posted staffing. She stated it is posted on floors two and five by the time clock. LNHA walked with surveyor to the second-floor time clock, staffing was not observed to be posted there. The LNHA stated she observed it posted there yesterday. admitted that it should be posted there. [...]
September 6, 2024Standard inspection · 5 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and review of other pertinent facility documentation, it was determined that the facility who had been in an active COVID-19 (potentially, deadly virus) outbreak since 08/21/24, failed to conduct complete and thorough contact tracing (method used to identify COVID-19 exposure and prevent transmission) upon the identification of a single new case of COVID-19 in a resident or staff member in accordance with the facility policy, Centers for Disease Control (CDC), Local Health Department, State Health Department and all current guidance related to infection control. This deficient practice was identified for 1 of 1 resident, (Resident #21) reviewed for COVID-19. This deficient practice was evidenced by the following: [...]
- 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 pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food to prevent food borne illness. This deficient practice was evidenced by the following: On 09/03/24 at 8:46 AM, during the initial tour of the kitchen, the surveyor observed the following in the walk-in meat freezer in the presence of two (2) Food Service Directors (FSD #1 and FSD #2). 1. An opened slab of roast beef on the top shelf was not labeled or dated. 2. An opened bag containing six (6) salisbury patties was not labeled or dated. At that time, during an interview with the surveyor, FSD #1 stated, everything that is in the freezer should have dates. Once it is opened, it should be dated. FSD #2 discarded the roast beef and salisbury patties. [...]
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement Program's (QAPI) sources of quantitative data was being analyzed to evaluate program effectiveness and implement new processes. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to S1410 On 09/03/24 at 08:32 AM, during the entrance conference the surveyor requested the facility's QAPI book. On 09/06/24 at 08:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the QAPI book. [...]
- E
Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure full implementation of the antibiotic stewardship program, including ongoing monitoring and use of a nationally recognized surveillance criteria prior to consulting the prescriber. This deficient practice was identified for 1 of 1 resident reviewed for antibiotic stewardship, (Resident #27). This deficient practice was evidenced by the following: On 09/04/24 at 9:38 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the facility Antibiotic Stewardship Program (efforts to ensure that antibiotics are used only when necessary and appropriate). The IP stated that she had worked at the facility for nearly one year and had worked as an IP since 2019. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the administration of a resident's enteral tube feeding (allows liquid food to enter the stomach or intestine through a tube) was consistently documented to indicate if it were administered or held on the Medication Administration Record. This deficient practice was identified for 1 of 1 resident, (Resident #27) reviewed for tube feedings. This deficient practice was evidenced by the following: During the initial tour of the facility on 09/03/24 at 8:38 AM, the surveyor observed Resident #27 lying awake in bed. The resident stated that their tube was clogged four to five weeks ago. A review of Resident #27's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but was not limited to: [...]
June 2, 2023Standard inspection · 10 citations
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a) ensure that meals were consistently delivered on time as per resident's preferences for seven (7) of 21 residents (Resident #5, #18, #147, #199, #202, #203 and #204) which represented two (2) of two (2) units reviewed for mealtime preferences and b) make reasonable accommodation of needs and preferences for 1 of 21 residents reviewed, (Resident #244). This deficient practice was evidenced as follows: 1. On 5/23/23 at 10:10 AM, a resident council meeting was conducted with five residents. Five out of five residents stated that the meals were not delivered on time and were consistently late. On 5/23/23 at 12:00 PM, the surveyor observed Resident #147 seated in a wheelchair in his/her room and was agreeable to be interviewed. [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteNJ00161372 Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards a.) accurately transcribe a physician order, for 1 of 2 residents observed during medication pass (Resident #150), b.) ensure that residents' medications were available for medication administration for 2 of 2 residents observed during medication pass (Resident #149 and Resident #150) and c). ensure that all routine medications on the physician order's sheet (POS), and medication administration record (MAR) had a corresponding medical indication for 10 of 21 residents reviewed (Residents #150, #149, #5, #18, #35, #147,#145, #146, #248 and #249). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot and cold food and drink served to the residents. This deficient practice was identified for four (4) of five (5) residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 6/2/21 for 2 of 2 nursing units tested for food temperatures by four surveyors and was evidenced by the following: On 5/23/23 at 10:10 AM, the surveyor met with five (5) residents for council meeting. Four out of five residents stated that they were displeased with food temperatures and that hot food items were not served hot. [...]
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently identified and implemented for eight (8) of eight (8) residents (Resident #5, #18, #145, #147,#199, #202, #203 and #204) which represented two (2) of two (2) units reviewed for dietary preferences. This deficient practice was evidenced as follows: On 5/23/23 at 10:10 AM, a resident council meeting was conducted with five residents. Five of five residents stated that they did not receive food that they ordered from the menu and that items were missing from their meal trays. In addition, five of five residents stated that someone brings them menus to fill out, but the menus are often not picked up. Resident # 202 stated that the following occurred: [...]
- E
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteNJ00161372 Based on observations, interviews, and review of facility provided documentation, the facility failed to a.) ensure call bells were answered timely for 4 of 21 residents reviewed (Residents #151, #204, #244 and #246) and b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 32 of 48-day shifts and 2 of 48 evening shifts reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: [...]
- 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 observations, interviews, and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for the residents. This deficient practice was identified on 1 of 2 nursing units and was evidenced by the following: During the initial tour of the 2nd floor unit on 05/22/23 from 10:06 AM to 01:35 PM, the following was observed by the surveyors: 1. In room [ROOM NUMBER] (double occupancy room): -the wall behind A bed (bed closest to the door) had multiple areas of white substance with multiple open holes and scrape marks -the wall on the opposite side of the room had multiple areas of white substance with multiple open scrapes 2. In room [ROOM NUMBER] (listed as a private room): [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to a.) maintain the necessary care and services for residents who were receiving oxygen (O2) treatment according to standards of practice and b.) ensure a physician's order was obtained for a resident receiving O2. This deficient practice was identified for two (2) of two (2) residents (R # 146 and R # 145) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/24/23 at 12:00 PM, the surveyor observed Resident #146 awake and seated in a wheelchair across from the nurse's station. Oxygen was in use via a nasal cannula (consisting of two hollow prongs projecting from a hollow face piece) at two liters per minute (LPM). The oxygen was attached to a portable oxygen tank attached to the back of the wheelchair. The O2 tubing was undated. [...]
- 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 record review, it was determined that the facility failed to properly secure medications in 1 (one) of 2 (two) emergency crash carts inspected. This deficient practice was evidenced by the following: On 5/31/23 at 11:30 AM, the surveyor inspected the 2nd-floor emergency crash cart that contained the facility's Emergency-Kit (E-Kit) in the presence of a Licensed Practical Nurse/Unit Manager (LPN/UM#1). The surveyor observed the crash cart which was covered and secured by Velcro straps. The surveyor observed LPN/UM #1 remove the covering and then move a handle on the top portion of the crash cart from the locked to unlocked position. The surveyor then observed LPN/UM#1 open each drawer of the crash cart and the surveyor observed the third drawer contained syringes and the 4th drawer contained a E-Kit box that contained 14 medications. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, record review and other pertinent facility documentation, it was determined that the facility failed to maintain proper infection control practices by ensuring a.) appropriate personal protective equipment (PPE) was worn in a room where a resident was on contact precautions (contact precautions are intended to prevent transmission of infectious agents and microorganisms, which are spread by direct or indirect contact with the patient), this was identified on one (1) of two (2) units, b.) housekeeping staff wear gloves appropriately on 1 of 2 units, c.) disposable PPE was appropriately contained in rooms where residents were identified as COVID - 19 positive, this was identified for two (2) of three (3) rooms on the fifth floor unit, and d.) one (1) of (1) resident (Resident #196) identified as exposed to COVID-19 positive nurse staff member was tested [...]
- B
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 and interview, it was determined that the facility failed to provide written notification of the emergency transfer to the resident, resident representative, and the Office of the Long-Term Care Ombudsman (LTCO) for one (1) of one (1) residents' (Resident # 144), reviewed for hospitalizations. This deficient practice was evidenced by the following: The surveyor reviewed the closed medical record of Resident #144. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility on [DATE]. Review of the electronic History and Physical dated 3/13/23, indicated diagnoses which included but not limited to; pleural effusion, paroxysmal atrial fibrillation, unspecified asthma, uncomplicated, hypertension, and diabetes mellitus without complications. [...]
Fire safety inspections
18 fire safety citations on file: 7 on January 30, 2026, 8 on September 6, 2024, 3 on June 2, 2023.
Every fire safety citation18 citations
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Properly install and monitor supervisory attachments on automatic sprinkler systems.
K 352 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 30, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 30, 2026 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 30, 2026 · Corrected (the home has a date of correction)
- F
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · September 6, 2024 · 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 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · September 6, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 6, 2024 · Corrected (the home has a date of correction)
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 6, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · June 2, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 2, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 2, 2023 · Corrected (the home has a date of correction)