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 23 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
6E
1F
Potential for minimal harm
0A
0B
0C
September 22, 2025Standard inspection · 6 citations
- E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure a.) the bed hold-policy that was provided to the Resident or Resident's Representative (RR) included information about the reserve bed payment policy plan, the explanation of the right to appeal the transfer, and the Resident and/or RR's information for 2 of 2 residents (Residents #2 and #16) reviewed for hospital transfer and b.) the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution, including the discharge summary for 1 of 1 resident (Resident #15) reviewed for transfer. The deficient practice was evidenced by the following: 1. On 9/15/25 at 1:24 PM, Surveyor #1 (S#1) reviewed the electronic medical records (eMR) of Resident #2, and revealed: [...]
- D
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 licensed staff credentials were verified upon hire for 3 of 7 licensed staff of the total 10 newly hired staff reviewed, Staff Member (SM) #6, #7 and #8. The deficient practice was evidenced by the following:On 9/18/25 at 12:40 PM, the surveyor reviewed the facility provided employee files of 10 randomly selected newly hired employees of which 7 were licensed staff which included the following: 1. A review of Staff Member #6 (SM#6), a Certified Nursing Assistant (CNA), hired on 6/12/24, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which was not dated. [...]
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the admission Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 1 resident (Residents #4) reviewed for timing of assessments. This deficient practice was evidenced by the following:Reference: According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2024, page 2-17, the Comprehensive admission assessment must be completed no later than the admission date + 13 calendar days. [...]
- 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 residents Attending Physician visited and documented monthly visits, every other month when the Advanced Nurse Practitioner (ANP) visited on the subsequent month for 1 of 28 residents reviewed (Resident #11). This deficient practice was evidenced by the following:On 9/17/25 9:31 AM, the surveyor reviewed Resident #11's hybrid (paper and electronic) medical record which revealed that the resident's attending physician had no documented visit from 5/1/24 through 12/31/24. The remaining documented visits in the resident's electronic medical record were done by the ANP for the same time frame. A review of Resident #11's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; [...]
- 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 review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 3 medication carts observed on 1 of 2 nursing units of the facility. 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, accurately documented, readily accessible, and systematically organized medical records. This deficient practice was identified for 2 of the 28 residents reviewed (Residents #2 and #15). This deficient practice was evidenced by the following:1. On 9/15/25 at 1:24 PM, The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #2, and revealed:A review of the admission Record (AR; an admission summary) or face sheet, revealed Resident #2 had been admitted with diagnoses which included but were not limited to; [...]
April 24, 2024Standard inspection · 12 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, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen environment and equipment in a sanitary 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 4/18/24 at 9:52 AM, in the presence of the Dietary Director (DD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed seven of seven oven knobs and the oven handle soiled with a brown colored substance, which was able to be lifted with the tip of a pen. [...]
- E
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 interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 6 of 24 residents (Resident #12, #16, #22, #111, #13, and #62) reviewed and occurred over several months. This deficient practice was evidenced by the following: 1. A review of the hybrid medical record for Resident #12 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2024, February 2024, and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature. 2. [...]
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteREPEAT DEFICIENCY Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that manufacturer's specifications were followed for the administration time and sequence of a medication Alendronate Sodium (Fosamax)(a medication used to treat and prevent osteoporosis/low bone mass) from October 2023 until surveyor inquiry. This occurred for one (1) of 11 residents, (Resident #25), reviewed for medication management. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
- 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 wroteREPEAT DEFICIENCY Based on observation, interviews, record review and a review of pertinent facility documents, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities to the physician and the facility regarding a.) a rationale for the length of therapy for a medication (Enoxaparin)(a medication used to reduce the risk of blood clots) from August 2023 until surveyor inquiry, b.) the appropriate documentation of vital sign parameters for a medication (Metoprolol)(a medication used to treat high blood pressure) as ordered by the physician according to standards of clinical practice and facility practice, c.) a rationale for the continued off-label use of a medication (Flomax) (a medication used to treat urinary retention usually in males) from January 2024 until surveyor inquiry and d.) following a cautionary warning [...]
- E
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 by failing to document on the effectiveness, appropriate indication, or benefit vs risk statement for an unapproved use for one (1) of eleven (11) residents reviewed for medication management (Resident #103). The deficient practice was evidenced by the following: On 4/15/24 at 10:40 AM the surveyor attempted to interview Resident #103. The resident was in a wheelchair watching television. The resident was not able to answer basic questions posed by the surveyor. The surveyor was unable to conduct an interview due to the resident's cognitive status. The surveyor reviewed the electronic medical record (EMR) for Resident #103. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call light was readily accessible. The deficient practice was identified for 1 resident (Resident #5) of 24 reviewed for the reasonable accommodations of needs/preferences as evidenced by the following. On 4/15/24 at 10:35 AM and 4/16/24 at 9:10 AM, the surveyor observed the resident in bed awake, able to answer the surveyor's inquiry. The surveyor asked the resident if she could reach her call light cord. The resident tried to reach for it three times and said they still could not get it. The call light cord was under the resident's right chest on both days. A review of the medical record revealed the following information. [...]
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 4 of 24 residents (Resident #2, 5, 35, and #225). This deficient practice was evidenced by the following: 1. Resident #2 was observed to have a Quarterly MDS (QMDS) with an Assessment Reference Date (ARD) on 1/15/24, which was due to be transmitted to CMS no later than 1/29/24. However, the QMDS was not submitted to CMS until 2/9/24. 2. [...]
- 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 interview and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient practice was observed for 2 of 24 residents reviewed, Residents #13 and #25 as evidenced by the following: 1. The surveyor reviewed Resident #13's electronic medical records (EMR). Resident #13 was admitted to the facility with diagnoses which included Myocardial Infarction (heart attack). A review of the Physician's Orders (PO) for Resident #13 revealed that the resident had an order for Eliquis 5 mg 1 tablet by mouth twice daily for blood clot prevention. The surveyor reviewed the resident's current care plans. There was no care plan developed regarding the resident's PO for the anticoagulant medication. [...]
- 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 maintain professional standards of nursing practice by not following physician orders for 2 of the 24 residents reviewed (Residents #5 and #35). The deficient practice was evidenced by the following: 1. On 4/15/24 at 10:35 AM and 4/16/24 at 9:10 AM, the surveyor observed the resident in bed, awake, and able to respond to the surveyor's questions. The resident was not wearing a left-hand elbow resting splint on both days. A review of electronic medical record revealed the following information. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure that all nurses signed the electronic Medication Administration Record (eMAR) when oxygen was administered, and c.) ensure respiratory tubing and cannula was stored properly. This deficient practice was identified for one (1) of one (1) resident (Resident #425) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. 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
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 relevant document review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in one (1) of three (3) medication carts and one (1) one of two (2) medication storage rooms inspected on two (2) of two (2) units. This deficient practice was evidenced by the following: On 4/16/24 at 10:56 AM the surveyor in the presence of another surveyor and the Licensed Practical Nurse (LPN#1) assigned to the medication cart inspected the medication cart identified as the northwest cart. The surveyor observed one (1) brown package containing one (1) vial of latanoprost eye drops (a medication used to treat glaucoma). The brown packaging was labeled with a dispensing pharmacy label which reflected a dispensing date of 3/29/24. [...]
- D
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 establish appropriate infection control practices for environmental cleaning for 1 of 24 residents (Resident #5). This deficient practice was evidenced by the following: On 04/15/24 at 10:40 AM, the first day during rounds in Resident #5 room, the surveyor noticed a splash of a creamy substance on the right-side wall near the metal pole, extending from the resident's bedside table to the electrical outlet. The Registered Nurse (RN) stated that it looked like a tube feeding milk on that wall and added that she would ask housekeeping to clean it. On 4/17/24 at 1:25 PM, the surveyor team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) about the concern regarding the splash of creamy milk-like substance on the wall. [...]
March 8, 2022Standard inspection · 5 citations
- K
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, record review, and other pertinent facility documentation, it was determined that the facility failed to ensure: a.) 2 of 3 anti-seizure medications (Vimpat and Keppra) ordered upon discharge from the hospital were appropriately discussed with the Physician for re-order, reconciled, received from the Provider Pharmacy, and administered in accordance with hospital discharge instructions for a resident with recent seizure activity (Resident #163), and b.) an anti-seizure medication (Vimpat) was available and administered as ordered for a second resident with a history of seizure disorders (Resident #27). This deficient practice was identified for 2 of 3 residents reviewed for anti-seizure medication management (Resident #27 and #163). [...]
- E
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 a.) administer oxygen therapy according to the physician's order and b.) ensure respiratory equipment was stored and dated properly. This deficient practice was identified for 5 of 7 residents (Resident #35, Resident #51, Resident #57, Resident #69, and Resident #363) reviewed for respiratory care and the evidence was as follows: 1. On 2/23/22 at 11:25 AM, the surveyor observed Resident #35 sitting in a wheelchair in their room watching television. The resident was being administered oxygen from a concentrator alongside their bed that was set to one liter per minute (1 lpm) via an undated nasal cannula (tubing used to deliver oxygen through the nose). The resident appeared to be in no distress. The surveyor reviewed the medical record for Resident #35. [...]
- 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 ensure that a Registered Nurse completed full body assessments after a fall prior to being moved in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 resident (Resident #50) reviewed for falls. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]
- D
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 a.) ensure medications were administered to a resident in accordance with professional standards of practice and b.) a controlled anti-seizure medication, Vimpat, was accurately accounted for in accordance with professional standards of practice. This deficient practice was identified for 2 of 24 residents (Resident #51 and Resident #163) reviewed for medication management and the evidence was as follows: 1. On 2/23/22 at 11:02 AM, the surveyor observed Resident #51 alone, lying in bed awake with their tray table directly over the bed. The surveyor observed on top of the tray table, a disposable medication cup that contained five medication pills and an additional medication cup that contained 30 milliliters (mL) of an orange/brownish colored liquid. [...]
- D
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 that a medication used to control seizures was administered in accordance with manufacturer's specifications. This deficient practice was identified for 1 of 3 resident (Resident #27) reviewed for anticonvulsant medications and was evidenced by the following: Reference: VIMPAT Highlights of Prescribing Information: VIMPAT tablets should be swallowed whole with liquid. Do not divide VIMPAT tablets. On 3/7/22 at 10:32 AM, the surveyor observed Resident #27 in bed with Jevity 1.5 (nutrition formula) being administered via a feeding tube (FT; tube surgically inserted through the abdomen to the stomach to provide nutrition). The resident was unable to be interviewed. The surveyor reviewed the medical record for Resident #27. [...]
Fire safety inspections
9 fire safety citations on file: 4 on September 22, 2025, 2 on April 24, 2024, 3 on March 8, 2022.
Every fire safety citation9 citations
- F
Have properly located and lighted "Exit" signs.
K 293 · September 22, 2025 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · September 22, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 22, 2025 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · September 22, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · April 24, 2024 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 8, 2022 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · March 8, 2022 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 8, 2022 · Corrected (the home has a date of correction)