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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
21D
6E
1F
Potential for minimal harm
0A
0B
0C
November 24, 2025Standard inspection · 2 citations
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 2 of 2 residents (Residents #31 and #76) reviewed for positioning and mobility, and was evidenced by the following: 1). On 9/25/2025 at 10:48 AM, the surveyor observed Resident #31 awake and alert, resting in bed on a low-air-loss mattress (a mattress used to prevent pressure ulcers), with the weight set between 250 and 280 pounds. On 9/26/2025 at 10:55 AM, the surveyor made a follow-up visit to the resident's room. Resident #31 was observed resting in bed on the low-air-loss mattress. The mattress weight setting was between 250 and 280 pounds. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interviews, it was determined that the facility failed to store and maintain the ice scoopers in a sanitary manner. This deficient practice was identified on 3 out of nursing 4 wings that contained ice coolers (Wings #1, #3, and #4) and was evidenced by the following: On 9/29/2025 between 11:18 AM and 12:20 PM, the surveyor observed the following:Wing #1 had a blue ice cooler that had a white mesh bag attached to it. There was an ice scooper resting in the mesh bag. The bottom of the mesh bag contained a moderate amount of black residue. Wing #3 also had a blue ice cooler with a mesh bag attached to it. Inside of the mesh bag there was an ice scooper resting inside of a foam cup. Within the cup, the surveyor observed a yellow-tinged liquid with black residue. Wing #4 had a blue ice cooler that had a mesh bag attached to it. [...]
April 23, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, medical record review, and review of other pertinent facility documentation on 4/22/25 and 4/23/2025, it was determined that the facility staff failed to a.) consistently document in the Documentation Survey Report v2 (DSR) and b.) follow the facility's Charting and Documentation policy. This deficient practice was identified for 1 of 3 residents (Resident #4) reviewed for documentation. This deficient practice was evidenced by the following: On 4/22/25, at 11:38 A.M., the surveyor observed Resident #4 seated in a wheelchair at the bedside. During interview the resident denied having any care issues at that time. According to the admission Record, Resident #4 was admitted with the following diagnoses, that were not limited to: neoplasm of prostate (growth or tumor in the prostate gland), anxiety disorder, and acute kidney failure. [...]
May 30, 2024Standard inspection, Complaint inspection · 17 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 facility policy review, the facility failed to ensure food and beverages stored in one of one kitchen were dated and did not have expired manufacturer's use by dates. This had the potential to affect 114 of 116 residents who consumed food prepared in the facility's kitchen.
- E
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 facility policy review, the facility failed to ensure seven of eight residents (Resident (R)10, R77, R9, R45, R25, R57, and R83) reviewed for dignity were treated in a dignified manner out of 26 sampled residents. The facility failed to promote a dignified dining experience which included timely meal service, eating food at the same time as tablemates, and items served in non-disposable dishes for six of six residents (Resident (R)10, R77, R9, R45, R25, and R57) reviewed for dignity in dining. Additionally, the facility failed to honor R83's right to a dignified existence and self-determination by making her wear an identification wrist band after she made staff aware that she preferred not to wear the band.
- E
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 record review, the facility failed to ensure there was an adequate supply of linens for 10 (R9, R25, R45, R75, R33, R7, R15, R94, R74, and a resident requesting to remain anonymous) out of 26 sampled and 25 supplemental residents. Specifically, there was an insufficient supply of towels to meet residents' needs.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, record review, facility menu review, and facility policy review, the facility failed to ensure menus were prepared in advance which included a specific vegetable that was to be served for 39 of 56 lunch and supper meals on the facility's four-week menu cycle. This had the potential to affect 114 of 116 residents who consumed food prepared in the facility's kitchen.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, test tray review, record review, review of Resident Council Minutes, and facility policy review, the facility failed to serve food that was palatable and at appetizing temperature for 13 of 13 residents (Resident (R) 26, R67, R81, R10, R86, R100, R105, R83, R84, R30, R45, R25, and R9) reviewed for food palatability out of 26 sampled residents. This failure had the potential to affect all 114 of 116 residents who consumed food prepared from the facility's kitchen.
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, interview, record review, and review of the facility's meal service times the facility served meals later than scheduled to residents who resided on four of five facility hallways which included five residents (Resident (R) 10, R57, R211, R30, and R25) of 26 sampled residents. This had the potential to affect 114 of 116 residents who consumed meals that were prepared from the kitchen.
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure guardianship documentation to support advanced directive decision making was in place for one of three residents (Resident (R) 66) reviewed for advanced directives of 26 sampled residents. R66 was not capable of making healthcare decisions and was documented as having a legal guardian. The facility did not have the guardianship documentation for R66.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 24 reviewed for abuse was free from verbal abuse by a staff member of 26 sampled residents. This had the potential to affect resident safety at the facility.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a Level One PASARR (Pre-admission Screening and Resident Review) was revised for one of two residents (Resident (R) 16) reviewed for PASARR after the resident was newly diagnosed with a major mental illness (MMI) of 26 sampled residents. This failure created the potential for residents to receive inadequate mental health services.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that two of 26 sampled residents (Residents (R) 9 and R100) care plans were revised to reflect the residents care needs. R9's care plan was not revised to reflect the physician ordered emergency dialysis dressing supplies to be maintained at the resident's bedside. Additionally, R100 was not allowed to participate in the scheduled care plan meetings.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident reviewed for activities (Resident (R) 74) was provided with a meaningful activity program of 26 sampled residents. An assessment of R74's activity preferences was lacking; the care plan was not specific to R74's interests, and R74 was not provided with sufficient activities to prevent boredom.
- 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 interview, record review, and facility policy review, the facility failed to change an indwelling urinary catheter every month as ordered for one of three residents (Resident (R) 26) reviewed for urinary catheter care out of 26 sampled residents. Failure to provide urinary catheter care as ordered can result in a resident developing a urinary tract infection.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that one of one resident (Resident (R) 9) reviewed for dialysis of 26 sampled residents had emergency dressing supplies at the bedside according to the physician orders. The failure has the potential to delayed response to resident bleeding excessively from the dialysis port.
- 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 record review, interviews, and facility policy review, the facility failed to ensure one of six residents (Resident (R) 105) reviewed for accidents had appropriate physicians' orders, was provided informed consent, and was appropriately assessed for his use of side rails of 26 sampled residents. This failure had the potential to affect resident safety at the facility.
- 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 interview, record review, and facility policy review, the facility failed to ensure one of five residents reviewed for unnecessary medications (Resident (R58)) had a documented response to the Pharmacist's recommendations. Specifically, the Pharmacist made recommendations for dose reductions of an antidepressant medication, Lexapro, for R58 due to an irregularity. The Physician failed to document that the identified irregularity had been reviewed and what, if any, action was taken to address it, or the rationale to make no changes to the medication.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility served known food allergies and food dislikes to three of four residents (Resident (R) 102, R77, and R81) reviewed for food allergies and food choices out of 26 sampled residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure proper infection control for one of two residents (Resident (R) 107) reviewed for respiratory services of 26 sampled residents. R107's oxygen tubing and humidification cannister were not changed weekly to ensure sanitary administration of the resident's oxygen.
March 22, 2022Standard inspection · 8 citations
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interviews, review of medical records and other facility documentation, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS, an assessment tool), within 14 days of completing the resident's assessment. This deficient practice was identified for 13 of 16 residents reviewed (Residents #16, #20, #15, #2, #9, #12, #14, #1, #8, #4, #3, #11, #10), from system selected for MDS over 120 days for late submissions and for 2 of 28 residents reviewed (Residents #25, #24) for MDS completion and transmission. This deficient practice was evidenced by the following: During an interview with the surveyor on 03/04/22 at 11:50 AM, the Licensed Nursing Home Administrator (LNHA) stated that the MDS Coordinator left the facility a few months ago and he was unable to fill the position despite posting it. [...]
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interviews, review of medical records an other facility documentation, it was determined that the facility failed to complete the Comprehensive Minimum Data Set assessment in a timely manner for 3 of 16 residents reviewed (Residents #7, #13 and #17) for system selected MDS over 120 days for late submissions. This deficient practice was evidenced by: During an interview with the surveyor on 03/04/22 at 11:50 AM, the Licensed Nursing Home Administrator (LNHA) stated that the MDS Coordinator left the facility a few months ago and he was unable to fill the position despite posting it. He stated that a Regional MDS Coordinator completed them in the interim and provided the surveyor with her contact information and an additional preferred contact. [...]
- 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 a comprehensive care plan for the use of oxygen for 1 of 2 residents reviewed for oxygen therapy, Resident # 57. This deficient practice was evidenced by the following: On 02/24/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident # 57,in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to an oxygen concentrator that was set at 2 lpm (liters per minute). On 03/01/22 at 12:50 PM the surveyor observed Resident #57 in bed with oxygen delivered through a nasal cannula at 2 lpm. A review of the admission Records (an admission summary) indicated Resident # 57 was admitted to the facility 02/2021 and had diagnoses, which included but were not limited to; [...]
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review and review of facility documents, it was determined that the facility failed to obtain physician orders to provide oxygen for 2 of 2 residents, Resident # 57 and #136, reviewed for oxygen in accordance with nursing professional standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interviews, record review, and review of facility policy, it was determined the facility failed to implement a physician's order for wound care to prevent the worsening of a left heel pressure ulcer and sacral pressure ulcer for 1 of 1 residents reviewed for pressure ulcers, Resident #122. This deficient practice was evidenced by the following: According the admission Record, Resident #122 was admitted to the facility in 1/2022 for rehabilitation. On 2/9/22 the resident was sent to an acute hospital and was readmitted on [DATE]. The resident had diagnoses that included, but were not limited to; [...]
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to a.) properly label and date food products stored in the walk-in refrigerator/freezer and b.) ensure that kitchen staff wore a hair restraint that fully covered their hair during food preparation in the kitchen in order to prevent foodborne illness for 1 of 1 staff member observed with improper hair restraint usage. This deficient practice was evidenced by: On 02/24/22 from 09:39 AM until 10:16 AM, the surveyor observed the following in the presence of the Director of Dining (DOD): 1. In the walk-in freezer: a. On the second shelf from the top of a four-tiered wired rack, the clear plastic outer packaging of a block of Swiss cheese was not secured and the cheese was opened and exposed to the air within the freezer. The DOD stated that he would re-wrap it correctly. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to maintain appropriate infection control practices for a.) maintaining the cleanliness of an oxygen concentrator and a feeding tube pump pole, for 1 of 2 residents reviewed for oxygen, Resident #57 and b.) the use of required personal protective equipment (PPE) on 1 of 5 units. This deficient practice was evidenced by the following: 1. On 02/24/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident # 57 in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to an oxygen concentrator that was set at 2 lpm (liters per minute). There was a feeding pump pole next to the oxygen concentrator. [...]
- D
Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of COVID-19, a contagious respiratory infection. This deficient practice was identified for 3 of 3 partially vaccinated staff, and 1 of 2 unvaccinated staff, and was evidenced by the following: On 03/07/22 at 11:33 AM, the surveyor observed a Licensed Practical Nurse (LPN) working on unit 2 wearing a surgical mask and goggles. During an interview at that time, the LPN stated that she believed she was scheduled to receive her second dose of the vaccine on 3/18/22. On 03/07/22 at 11:46 AM, the surveyor observed a Certified Nursing Assistant (CNA), working on unit 3 wearing a surgical mask and goggles. [...]
Fire safety inspections
25 fire safety citations on file: 11 on November 24, 2025, 9 on May 30, 2024, 5 on March 22, 2022.
Every fire safety citation25 citations
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · November 24, 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 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for the installation and maintenance of electrical systems.
K 911 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · November 24, 2025 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · November 24, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · May 30, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · May 30, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 30, 2024 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 30, 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 · May 30, 2024 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · May 30, 2024 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · May 30, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 30, 2024 · Corrected (the home has a date of correction)
- E
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · May 30, 2024 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · March 22, 2022 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · March 22, 2022 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 22, 2022 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · March 22, 2022 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 22, 2022 · Corrected (the home has a date of correction)