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 5 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
3D
1E
1F
Potential for minimal harm
0A
0B
0C
April 9, 2025Standard inspection · 1 citation
- 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, record review and policy review, it was determined that the facility failed to a.) store food in a manner to prevent food-borne illness and, b.) failed to maintain the kitchen environment and equipment in a sanitary and properly functioning manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/3/25 at 8:45 AM, the surveyor toured the main kitchen and four satellite kitchen areas with the Director of Dining (DD) and the Food Service Director (FSD) and observed the following: -A box of 4 -10 pound packages of defrosted chicken thighs in plastic type package and were inside of a box on a shelf in the walk in refrigerator. The box had a printed label that was dated 3/4/25 from the [NAME]. [...]
March 21, 2025Complaint inspection · 1 citation
- D
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Inspectors wroteC #: NJ 00184292 Based on interviews, and record review, as well as review of pertinent facility documents on 3/17/25 and 3/21/25, it was determined that the facility failed to ensure their policy on Medication Transcription was implemented for 1 out 5 residents (Resident #1). This deficient practice was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility on 02/2025, with diagnosis including but not limited to: Immune Thrombocytopenic Purpura (a bleeding disorder that keeps your blood from clotting). The Minimum Data Set (MDS), an assessment tool, dated 3/18/25, showed that the Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, showing resident had intact cognition. [...]
February 15, 2023Standard inspection · 0 citations
November 9, 2020Standard inspection · 3 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 interview and review of facility documents, it was determined that the facility failed to ensure that all Drug Enforcement Administration (DEA) 222 forms were completed with sufficient detail to enable accurate accountability and reconciliation for controlled medications for 5 of 8 DEA 222 forms reviewed in 1 of 1 back up controlled medication storage area. This deficient practice was evidenced by the following: On 11/5/20 at 11:14 AM, the surveyor reviewed all DEA 222 forms provided by the Director of Nursing (DON) for the past twelve months which revealed the following: 1. Review of a DEA 222 form dated 12/03/19, revealed that the portion of the form designated for signature of Purchaser or Attorney or Agent failed to contain a signature of authorization. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to appropriately administer pain medication in accordance with a physician's order for 1 of 2 residents reviewed (Resident #91) for pain management in accordance to professional standards of practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and review of facility documentation it was determined that the facility failed to clean medical equipment between resident use, according to facility policy to prevent the spread of infection. This deficient practice was identified on 1 of 4 nursing units (Birch) and was evidenced by the following: On 10/30/20 at 10:36 AM, the surveyor observed Certified Nursing Aide (CNA #1) walk down the hallway on the Birch unit pushing a Hoyer lift, an assuasive device that allows people to be transferred between bed and chair. CNA #1 entered resident room [ROOM NUMBER] to assist the resident in 123-2 out of the bed to the wheelchair. On 10/30/20 at 10:49 AM, the surveyor observed CNA #1 exit resident room [ROOM NUMBER] with the Hoyer lift and placed the Hoyer in the hallway against the wall between resident rooms #122 and #123. [...]
Fire safety inspections
7 fire safety citations on file: 4 on April 9, 2025, 3 on February 15, 2023.
Every fire safety citation7 citations
- F
Use approved construction type or materials.
K 161 · April 9, 2025 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · April 9, 2025 · Corrected (the home has a date of correction)
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · April 9, 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 · April 9, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · February 15, 2023 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · February 15, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · February 15, 2023 · Corrected (the home has a date of correction)