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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
18D
8E
0F
Potential for minimal harm
0A
0B
0C
April 17, 2026Complaint inspection · 1 citation
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interviews and review of pertinent facility documentations on 4/13/26, 4/16/26, and 4/17/26, it was determined that the facility Social Worker (SW) failed to review an electronic mail (email) message dated 4/10/26 about an alleged verbal abuse. The deficient practice was identified for 1 of 5 residents (Resident #1) reviewed for abuse and neglect and was evidenced by the following: A review of the Minimum Data Set (MDS), an assessment tool dated 2/25/26, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating the resident's cognition was moderately impaired. The MDS further revealed that the resident required assistance from staff for completion of their activities of daily living (ADLs). On 4/16/26 at 12:18 PM, the surveyor interviewed Resident #1 concerning the 4/9/26 incident. [...]
February 4, 2026Complaint inspection · 2 citations
- J
Ensure that residents are free from significant medication errors.
Inspectors wroteComplaint #: 2728562, 2728912 Based on interviews, medical record review, and review of pertinent facility documents on 1/27/26, 2/2/26 and 2/4/26, it was determined that the facility failed to ensure that a resident was free from significant medication error. This occurred on 1/23/26, when a Licensed Practical Nurse Unit Manager (LPN/UM) incorrectly used a medication list belonging to another resident (Resident #6) to reconcile Resident #5's medications. Review of Resident #5's January 2026 Medication Administration Record (MAR) revealed incorrect medications were listed and the staff administered the wrong medications to Resident #5 on these dates as follows: [...]
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteComplaint # 2723777 Based on interviews and record review it was determined that the facility failed to allow a resident with an infectious diagnosis that required Enhanced Barrier Precautions to return after being hospitalized despite the facility's ability to provide that care. This deficient practice was identified for 1 of 2 residents (Resident #2) reviewed for discharges. This deficient practice was evidenced by the following:According to Resident #2's admission Record (AR), the resident was admitted with diagnoses including but not limited to: compartment syndrome (increased pressure in an area of the body that compromises blood flow and tissue function), unspecified, subsequent encounter; paraplegia (impairment or loss of motor and sensory function in the lower half of the body), unspecified; muscle weakness (generalized); and need for assistance with personal care. [...]
October 31, 2025Complaint inspection · 3 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteComplaint # 2638227 Based on observation, interview, and record review it was determined that the facility failed ensure staff consistently documented care/services provided to residents in accordance with professional standard. This deficient practice was identified for 2 (two) of 3 (three) residents (Resident #1 and #3) reviewed for reviewed for accident/incident, and was evidenced as follows: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
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteComplaint #2585508 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey State Department of Health (NJDOH) an injury of unknown origin and implement facility's policy for accidents and incidents by not thoroughly updating the care plan after an assessment. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed for accident/incident, and was evidenced as follows: On 10/31/25 at 9:00 AM, during an interview with the surveyor, the Assistant Director of Nursing (ADON) informed the surveyor that there were no reportable events (report filed with the NJDOH) found on file for Resident #3. The surveyor reviewed the medical record for Resident #3. [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteComplaint # 2638227 Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure the accuracy of a resident's weight and monitor the resident's food intake in accordance with the resident's care plan. This deficient practice was identified for 1 of 3 closed records reviewed (Resident #1) and was evidenced by the following: The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included Alzheimer's disease, dementia (memory loss with cognitive decline) with psychotic disturbances, and type 2 diabetes (high blood sugar). [...]
August 14, 2025Standard inspection · 4 citations
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure three of three residents (Resident (R) 172, R204, and R218) rights to a dignified dining experience. The residents were unable to protect their right to dignity due to their impaired cognitive status creating the potential for feeling of embarrassment or frustration.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one of one residents (Resident (R) 16) reviewed with contractures out of 35 sample residents received a splint on her hands per the care plan. Failure to use the hand splints has the potential for the resident to develop skin breakdown in the palms of her hands.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure proper glove use and hand washing was used during one of one meal services observed. One of one cook (Cook (C) 1) and two of three dietary aides (DA) (DA2 and DA4) touched ready-to-eat foods and the inside of coffee cups without performing hand hygiene when moving between tasks. The failure to ensure proper hand washing and glove use could contaminate the food served to the residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure one of one Licensed Practical Nurse (LPN) (LPN 4) and one of one Certified Nursing Assistant (CNA) (CNA 13) used proper glove technique when providing wound care and personal care for one of one residents (Resident (R) 18) observed for wound care of 35 sample residents. This practice placed the resident at an increased risk for infections.
April 9, 2024Standard inspection · 3 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteNJ #165993 Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 35 residents, Resident #200 and #655 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 4/02/24 at 09:33 AM, the surveyor interviewed Resident #200 in their room. Resident #200 stated they take an antidepressant medication and have for a few years. On 4/4/24 at 9:10 AM, the surveyor reviewed Resident #200's hybrid (paper and electronic) medical records. [...]
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the primary physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 1 of 35 (Resident #658) reviewed for physician visits and was evidenced by the following: On 4/4/24 at 12:40 PM, the surveyor reviewed the closed paper and electronic medical record for Resident #658. The admission Record (a summary of important information about a resident) documented that Resident #658 had diagnoses that included but were not limited to, generalized anxiety disorder and major depressive disorder. A review of physician progress notes revealed the following: On 9/12/22, a medical visit note was completed by the resident's primary physician. [...]
- 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 wroteComplaint NJ #165993 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behaviors for the number of episodes, behavioral interventions, and its outcomes for the use of psychotropic medications (mood altering medications) in accordance with facility policy. This deficient practice was identified for one (1) of six (6) residents (Resident #656) reviewed for abuse in a resident-to-resident interaction, and was evidenced by the following: A review of the reportable event record/report (FRI; Facility Reported Incident) that was called in on 7/23/23 at 1:10 PM. The FRI occurred on 7/23/23, at approximately 11:22 AM, and was reported an incident of a resident-to-resident abuse. The event description included the following: [...]
January 19, 2022Standard inspection · 14 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) document and carry out a Physician's Order (PO) for a urine and stool culture within an appropriate time frame and b.) notify the resident's physician that staff was unable to obtain the urine and stool sample. This deficient practice was identified for 1 of 35 residents, (Resident #84) reviewed for quality of care and was evidenced by the following: On 1/05/22 at 11:44 AM, the surveyor was approached by an alert and oriented resident, Resident #34 who was the roommate of Resident #84. Resident #34 stated that his/her roommate was recently admitted to the hospital. Resident #34 stated that he/she was very close with his/her roommate and they looked after one another like family. [...]
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased off observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) place a splinting device on a resident who had a Physician's Order (PO) for one and b.) maintain accurate and consistent accountability for the use of the splinting device for the months of November 2021, December 2021, and January 2022. This deficient practice was identified for 1 of 4 residents, (Resident #43) reviewed for position and mobility. The deficient practice was evidenced by the following: On 01/04/22 at 10:02 AM, the surveyor observed Resident #43 glide to the front of the nurse's station on the 3 [NAME] unit in his/her motorized wheelchair. The surveyor further observed that the resident had a splinting device secured around on his/her left hand. The surveyor attempted to interview the resident; [...]
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) receive a Physician's Order (PO) for a change in a resident's dialysis schedule and b.) plot medications to be administered according to the resident's dialysis schedule. This deficient practice was identified for 1 of residents, (Resident #15) reviewed for dialysis and was evidenced by the following: On 1/04/22 at 10:26 AM, the surveyor observed Resident #15 lying in bed. The resident closed his/her eyes when the surveyor entered the resident's side of the room. The surveyor asked the resident if he/she went to dialysis and the resident stated, no. The surveyor did not attempt to further interview the resident because the resident's body language indicated that he/she did not want to further communicate with the surveyor. [...]
- 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 appropriate pharmaceutical services which included ensuring accurate administering and reconciliation of all drugs, in accordance with professional standards. This deficient practice was identified for 3 of 4 residents (Resident #47, #156 and #812) during the medication administration observation with 2 of 2 nurses during the medication observation pass. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
- E
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a physician's order was clarified with the physician to prevent an antipsychotic medication (Zyprexa) being administered in excess of the recommended manufacturer's total daily dosage and increased the antipsychotic dosage by doubling the total daily dose from 12/22/21 to 1/5/22 (fifteen days). This deficient practice was identified for 1 of 5 residents (Resident #70) reviewed for unnecessary medications and the evidence was as follows: On 1/3/22 at 12:30 PM, the surveyor observed Resident #70 walking in the hallway. The resident was dressed and appeared groomed. The resident informed the surveyor that he/she was walking to their room. The surveyor reviewed the medical record for Resident #70. [...]
- 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 wroteBased on observation, interview, and review of facility provided documentation, the facility failed to a.) ensure that incontinence care was provided in a timely manner for 1 of 10 residents (Resident #43) reviewed for incontinence care, b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 23 of 23-day shifts and 1 of 14 overnight shifts reviewed and c.) ensure call bells were answered timely for 1 of 35 residents (Resident #154) 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. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility staff failed to a.) appropriately don (put on) and doff (remove) Personal Protective Equipment (PPE), in accordance with Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting a resident's room who was on Transmission Based Precautions (TBP) due to being a Person Under Investigation (PUI) for 1 resident on 1 of 5 units, (Resident #20), b.) appropriately perform hand hygiene and wear PPE at the appropriate time on 1 of 5 units by staff in the nursing department and recreation department, and c.) appropriately disinfect multiuse medical equipment for 1 of 4 nurses during the medication pass. These deficient practices were evidenced by the following: [...]
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased off observation, interview, and record review it was determined that the facility failed to maintain respect and dignity for a resident prior to providing incontinence care. This deficient practice was identified for one of three residents, (Resident #43) reviewed for respect and dignity and was evidenced by the following: On 01/10/22 at 10:17 AM, the surveyor walked by Resident #43's room and observed the resident's Certified Nursing Aide (CNA) in the room with the resident. Resident #43's bed was closest to the door in the room. The surveyor observed that the door to the resident's room was open, the resident's privacy curtain was drawn open, and the resident's genital area was exposed. The surveyor observed a white sheet placed just below the resident's genitals. At that time, the surveyor made the CNA aware that incontinence care was going to be observed. [...]
- 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 pertinent facility documentation it was determined that the facility failed to: a.) maintain a resident's motorized wheelchair in a clean and sanitary manner and, b.) maintain a resident's tube feeding pole in a clean and sanitary manner. This deficient practice was identified on 1 of 5 nursing units, 3 West, for 1 of 35 residents reviewed, (Resident # 42) for cleanliness of wheelchairs, and for 1 of 5 residents reviewed, (Resident #15) who were receiving artificial nutrition via a tube feeding. The deficient practice was evidenced by the following: 1. On 01/04/22 at 10:02 AM, the surveyor observed Resident #43 glide up to the front of the nursing station while seated in his/her motorized wheelchair. The surveyor observed that the residents motorized wheelchairs was covered in yellow, brown, and white caked on dust and debris. [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow physician's orders by administering as needed narcotic pain medications based on pain scale parameters for the prescribed tramadol and oxycodone in accordance with professional standards of practice. This deficient practice was identified for 1 of 2 residents (Resident #154) reviewed for pain. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to obtain the appropriate physician orders for the care of a resident with a tracheostomy (an opening surgically created through the neck into the trachea). This deficient practice was identified for 1 of 1 residents (Resident # 210) reviewed for respiratory care. This deficient practice was evidenced by the following: On 1/3/22 at 1:00 PM, the surveyor observed Resident # 210 inside his/her room. The resident was observed with a tracheostomy. The resident was able to speak. The tracheostomy dressing was clean and intact. On 1/4/22 at 10:45 AM, the surveyor observed the resident in his/her room. The resident did not wish to speak with the surveyor. The surveyor reviewed the medical record for Resident #210. [...]
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased 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 observation on 1/6/22 and 1/10/22, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 33 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.06 %. This deficient practice was identified for 1 of 4 residents (Resident #47), that were administered medications by 1 of 2 nurses and was evidenced by the following: 1. On 1/6/22 at 11:03 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor. [...]
- 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, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) identify and remove expired medications from an active medication cart and b.) maintain a completed temperature log for a medication storage refrigerator. This deficient practice was identified for 1 of 5 observed medication carts (2 East) and 1 of 3 observed medication storage rooms (3 West) and was evidenced by the following: 1. On 1/10/22 at 9:53 AM, the surveyor interviewed the Licenced Practical Nurse/Unit Manager (LPN/UM) regarding the process for checking medication storage. The LPN/UM stated that the nurses and her were responsible for checking medication storage to ensure there were no expired medications or items. The LPN/UM further stated that expired medications and items were given back to central supply to discard. [...]
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to maintain a functioning call bell system. This deficient practice was identified on 2 of 5 nursing units (3 [NAME] and 3 East) and for 2 of 35 residents (Resident #27 and Resident #38) reviewed and was evidenced by the following: 1. On 1/5/22 at 11:39 AM, the surveyor observed Resident #38 seated in a wheelchair in his/her room. The resident stated that his/her call bell had not been working for a couple of days and the facility gave him/her a tap bell to use. The surveyor observed the tap bell on the residents overbed table. On 1/6/22 at 12:07 PM, the surveyor stood outside of Resident #38's room and observed the call bell light blinking over the door to the residents room. [...]
Fire safety inspections
13 fire safety citations on file: 1 on August 14, 2025, 3 on April 9, 2024, 9 on January 19, 2022.
Every fire safety citation13 citations
- F
Have an enclosure around a vertical opening shaft.
K 311 · August 14, 2025 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · April 9, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · April 9, 2024 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · April 9, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 19, 2022 · 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 · January 19, 2022 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · January 19, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 19, 2022 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · January 19, 2022 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · January 19, 2022 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · January 19, 2022 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · January 19, 2022 · Corrected (the home has a date of correction)
- D
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · January 19, 2022 · Corrected (the home has a date of correction)