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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
24D
7E
1F
Potential for minimal harm
0A
0B
2C
January 8, 2026Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interviews and review of pertinent facility documents on 01/08/26, it was determined that the facility failed to provide the necessary care to ensure freedom from accidents to a resident (Resident #1) who required two person assistance for care and transfers resulting in the resident sustaining a fractured finger and multiple skin lacerations requiring stitches. This deficient practice was identified for 1 of 5 residents surveyed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid [paper and electronic] medical record of Resident #1. [...]
May 2, 2025Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews, review of medical records, and review of pertinent documentation provided by the facility on 05/02/2025, it was determined that the facility failed to thoroughly investigate an allegation of physical abuse and follow the facility's Resident Abuse policy. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for abuse and was evidenced by the following: A Facility Reported Event (FRE), a document used to report incidents, submitted to the New Jersey Department of Health (NJDOH) by the facility's Director of Nursing (DON) on 04/15/2025 was reviewed. The FRE revealed that on 04/15/2025 at 4:20 P.M., the facility's Executive Director (ED) listened to a voice message left by Resident #2 at 6:29 A.M., the same day. The voice message was described in the FRE as follows: [...]
January 22, 2025Standard inspection · 15 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 review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/15/25 at 9:24 AM, the surveyor in the presence of the Dietary Supervisor (DS#1) and the Registered Dietitian (RD) observed the following during the kitchen tour: 1. The surveyor observed in the dry storage room: a dented can of sliced potatoes in the regular rotation of non-dented canned goods; 3 boxes stored above 18 inches (in) from the ceiling, and the following items were observed opened without an open/use by label: [...]
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for 10 out of 10 newly hired staff (Staff #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed 10 randomly selected new employee files for reference checks for 10 of the 10 new employees revealed the following: A review of Staff #1's file, a Recreation Activity Aide (RA), date of hire (doh) on 10/30/23, showed there were no reference checks in their file. A review of Staff #2's file, a Licensed Practical Nurse (LPN), doh on 1/29/24, showed there were no reference checks in their file. A review of Staff #3's file, a Registered Dietician, doh on 5/28/24, showed there were no reference checks in their file. [...]
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with the federal guidelines. This deficient practice was identified for 17 of 17 system selected residents, Resident #2, #12, #34, #38, #46, #48, #69, #70, #139, #166, #199, #205, #209, #220, #233, #267, and #271) and was evidenced by the following: On 1/21/25 at 9:09 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS assessment. The MDS was a comprehensive tool that was federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. [...]
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more during the medication administration, 4 nurses administered medications to 5 residents. There were 25 opportunities for error, 2 errors were observed which calculated to a medication administration error rate of 8%. This deficient practice was identified for 2 of 5 residents, (Resident #55 and Resident #122), that were administered medications by 2 of 5 nurses that were observed. The 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
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life specifically by ensuring staff able to communicate with the resident in the language that the resident understood and preferred according to plan of care. This deficient practice was identified for 1 of 2 residents, Resident #158, reviewed for communication. This deficient practice was evidenced by the following: On 1/17/25 at 9:40 AM, the surveyor observed Resident #158 laying on an air mattress (a specialized mattress) and the resident spoke Spanish. [...]
- 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 follow standards of clinical practice to ensure, a.) a physician's order (PO) for a heel booties 2 of 2 residents, Residents #72 and #158, were followed, and b.) a PO to document weekly vital signs for 1 of 5 residents was followed, Resident #88, reviewed for unnecessary medications. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the resident receive care and treatment in accordance with professional standards of practice by developing and implementing a comprehensive person-centered care plan (CP), and the resident's choices that included refusal of care. This deficient practice was identified for 1 of 39 residents, (Resident #262), reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; [...]
- D
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 observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the foley urinary catheter drainage bag was stored in a manner to prevent Urinary Tract Infection (UTI) for 1 of 4 residents, Resident #77, reviewed for urinary catheter or UTI. The deficient practice was evidenced by the following: On 1/17/25 at 9:08 AM, the surveyor observed Resident #77's urinary catheter drainage bag hung from the bed's side rail that was in the up position and not in a privacy bag. The tubing leading to the drainage bag was above the bed. On 1/17/25 at 9:09 AM, the surveyor interviewed the Registered Nurse (RN) after the RN also observed Resident #77's urinary catheter drainage bag. The RN stated that the drainage bag and tubing should be lowered. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain proper infection control practices during tracheostomy care. This deficient practice was identified for 1 of 1 resident observed for tracheostomy care, (Resident #92), and was evidenced by the following: On 1/15/25 at 10:46 AM, the surveyor observed Resident #92 in a reclined lounge chair in their room. The resident had a tracheostomy (trach, a surgically made hole through the front of the neck into the trachea (windpipe) with a tube placed through the hole to help the person breathe), which was attached to a ventilation system (a breathing machine that helps or breathes for a person). The surveyor reviewed the medical record for Resident #92. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to; a) complete the Hemodialysis Communication Record (HCR) to include a signature by the facility nurse that acknowledged review of the HCR for 14 of 14 days reviewed; b) document a complete assessment of vital signs and/or disposition of access site post dialysis treatment in the medical record; c) follow a recommendation for a change in medication; and d) had a diet order for 1 of 3 residents, Resident #169. This deficient practice was evidenced by the following: On 1/15/25 at 10:52 AM, the surveyor observed Resident #169 lying in bed, who stated that they were going to dialysis today and that they had a communication binder (binder for HCRs) that they took with to dialysis. [...]
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that due to a shortage of staff, the facility failed to a.) honor the resident's shower schedule for 1 of 5 residents, Resident #141 and b.) ensure residents were provided morning care in a timely manner for 2 of 5 residents, Residents #141 and #213 of Resident Council group. This deficient practice was evidenced by the following: On 1/17/25 at 11:01 AM, the surveyor conducted a resident group meeting with five residents who were alert and oriented and were selected by the facility to attend the group meeting. Resident#141 informed the surveyor that two weeks ago, not this past Monday (1/13/25), the resident did not get showered. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of the receipt of a controlled substance for 4 of 4 Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on three Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for 1 of 7 residents, Resident #43. The deficient practice was evidenced by the following: The surveyor reviewed Resident #43's medical record (MR) and revealed the following: A review of Resident #43's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to acute kidney failure, (when the kidneys are damaged and can't filter blood the way they should) and urinary tract infection. [...]
- 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 a.) label, dispose and secure medications in 3 of 9 medication carts inspected and b.) store medication for 1 of 4 medication carts inspected according to facility's policy and standard of clinical 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: [...]
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain the prior year's Federal and State of New Jersey (State) inspection results and post the location of those results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following. On 1/16/25 at 8:29 AM, the surveyor observed a binder in the reception desk for Licensure Reports (survey results) which the Security Staff (SS) confirmed that the survey results were for date 8/12/21. On 1/16/25 at 11:08 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the facility's most recent Federal and State surveys were from 2023. [...]
January 14, 2025Complaint inspection · 1 citation
- 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 # NJ00 181747 Based on interview, medical records (MR) review, and review of pertinent facility documents on 01/14/2025, it was determined that the facility failed to develop and implement a care plan (CP) focus to include behaviors for residents who were on psychoactive medications. The deficient practice was found in 2 of 4 residents, (Resident #1 and #2), reviewed for behavior monitoring and comprehensive care planning and was evidenced by the following: 1. According to the admission Face Sheet Record (AFSR), Resident #1 had diagnoses which included but were not limited to: Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypothyroidism, Essential Hypertension, and Hyperlipidemia. [...]
November 26, 2024Complaint inspection · 1 citation
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteComplaint#: NJ00179720 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to follow the Medical Emergency Response policy for a resident (Resident #2) in respiratory distress. This deficient practice was identified for 1 of 3 residents reviewed for medical emergency response procedures. The facility also failed to provide the needed emergency transportation services to manage the acute respiratory symptoms of Resident #2, which resulted in the Resident's failure to improve. In addition, the facility failed to develop a policy and procedure for the staff to follow to determine the use of emergency or non-emergency transportation services based on residents presenting symptoms. [...]
March 1, 2024Complaint inspection · 1 citation
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteComplaint #: NJ171754 Based on observation, interview, record review, and review of other facility documentation on 3/1/2024, it was determined that the facility failed to notify and obtain a physician's order to change the form of a medication from liquid to tablets. The Physician order for this medication could not be filled by the Pharmacy because this medication did not come in liquid form. The facility failed to follow its policy titled Prescribing and Ordering of Medications. The deficient practice was identified for 1 of 4 residents( Resident #2) reviewed for medication administration, and was evidenced by the following deficient practice: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
September 8, 2023Standard inspection, Complaint inspection · 12 citations
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint #: NJ157711, NJ159758, NJ162870, NJ162871 Based on interview, record review, and policy review, the facility failed to ensure allegations of abuse / neglect and/or the investigations were submitted to the New Jersey Department of Health (NJDOH) within the time limits of the policy and federal regulation for three of seven residents (Resident (R)18, R409, R458) with NJDOH reportable incidents.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, document review, interviews, and facility policy review, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, there were eight errors observed out of 29 opportunities, resulting in a 27.59% error rate. This had the potential to place one (Residents (R) 410) at risk of not receiving the full benefit of their medication therapy.
- E
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, interview, and review of manufacturer's instructions, the facility failed to ensure bed frames and rails, if present, were inspected and serviced per the Manufacturer's Instructions for Use (MIFU) for three of three residents (Resident (R) 18, R140, and R232) to minimize the risks of bed malfunction or resident injury. This failure had the potential to affect 267 of 267 residents who reside at the facility.
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure six of six Certified Nurse Aides (CNA), two of two Licensed Practical Nurses (LPN), and two of two Registered Nurse's (RN) reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses indicated as admittable in the facility assessment. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 218) of 34 sampled residents were treated with respect and dignity by providing care in a manner to enhance R218's quality of life.
- 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 record review, the facility failed to ensure that tube feeding poles were maintained in a sanitary manner for three (Residents (R) 51, R160 and R203) of 34 sampled residents.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, interview, review of Facility Reported Incidents (FRI), and policy review, the facility failed to ensure that a thorough investigation was conducted regarding staff-to-resident abuse allegations involving one (Resident (R) 409) of 34 sampled residents. There was no evidence that the facility interviewed other current residents regarding the allegations.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to provide to the resident and/or their representative, a written notice of the reason for transfer for two (Residents (R) 191 and R98) of three residents transferred to the hospital and provided that notice to the Ombudsman.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review and interview, the facility failed to provide to the resident and/or their representative, a bed hold policy to two (Residents (R) 191 and R98) of three residents transferred to the hospital.
- 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, record review, and facility policy review, the facility failed to ensure that three of three residents (Resident (R) 18, R140, and R232) and/or Resident Representative (RR) reviewed for bed rail use had documented safety assessment for the use of bed rails and were advised of the risks and/or benefits of rail use. This failure had the potential for residents with bed rails to be uninformed of the risk of severe injury and/or death associated with bed rail use.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure medications were administered in a manner that prevented cross-contamination for one (Resident (R) 410) of 34 sampled residents.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interviews, the facility failed to ensure the daily nursing staffing hours were included in the prominently displayed nurse staffing for residents, visitors, and/or staff. This failure could affect the knowledge of the availability of staff to care for the 50 residents, their family members, or their representatives.
July 14, 2021Standard inspection · 3 citations
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders and resident's lab results. This deficient practice continued over numerous months for 2 of 35 residents reviewed, Resident #54 and #153 residing on two different facility units. The deficient practice was evidenced by the following: 1. On 7/7/21 at 10:47 AM, the surveyor observed Resident #54 seated in a wheelchair with eyes closed. The surveyor approached the resident for an interview, but the resident was not alert or oriented. The surveyor was unable to interview Resident #54. The surveyor reviewed the admission Record Face sheet (one-page summary of important information about a resident) for Resident # 54. [...]
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure in person physician visits were conducted in and documented at required intervals. This deficient practice was identified for 2 of 35 residents, Resident #54, #153 reviewed. The deficient practice was evidenced by the following: 1. On 7/7/21 at 10:47 AM, the surveyor observed Resident #54 seated in a wheelchair with eyes closed. The surveyor approached the resident for an interview, but the resident was not alert or oriented. The surveyor was unable to interview Resident #54. The surveyor reviewed the admission Record Face sheet (one-page summary of important information about a resident) for Resident # 54. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and review of facility documents, it was determined that the facility failed to: a.) utilize disposable dining ware for a resident on Transmission Based Precautions (TBP) in accordance with facility policy; and, b.) practice appropriate use of personal protective equipment (PPE) in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This was identified for 1 of 2 residents reviewed for TBP (Resident #12). This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, included 2. [...]
Fire safety inspections
14 fire safety citations on file: 9 on January 22, 2025, 3 on September 8, 2023, 2 on July 14, 2021.
Every fire safety citation14 citations
- F
Establish staff and initial training requirements.
E 37 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · January 22, 2025 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · September 8, 2023 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · September 8, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 8, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · July 14, 2021 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 14, 2021 · Corrected (the home has a date of correction)