Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adroit Care Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with cognitive impairment, altered mental status, and ADL assistance needs was verbally abused by staff during care. A family recording and staff statements supported that the resident resisted care, care continued anyway, and a CNA made inappropriate comments; the facility’s investigation concluded the incident was verbal abuse/inappropriate language.
Surveyors found that personal refrigerators in multiple resident rooms lacked thermometers or temperature logs, had improper temperatures, and contained expired, undated, or unlabeled food items. Some units had visible debris, spilled food, or were warm to the touch, and one unit was frozen at 9 F. The LPN/UM said staff did not routinely monitor or document temperatures and that residents handled expiration checks and cleaning, while the DOM said CNAs were responsible for daily checks and cleaning. The facility policy required labeling, discarding expired food, and daily monitoring and weekly cleaning of resident room refrigerators.
Improper Disposal of Soiled Materials and Unclean Linen Storage: Surveyors observed soiled linen, PPE, and gloves discarded on top of a trash receptacle and on the floor in a room with EBP signage. For a resident with dementia, muscle weakness, and an unhealed stage 4 pressure ulcer, surveyors also found clean linens and incontinence supplies sitting on top of a trash bin cover. The CNA, LPN, DON, and IP all confirmed that PPE and linen were not being stored or discarded as required by facility practice.
Unlabeled Tube Feeding Bags: Two residents receiving continuous TF were observed with feeding bags that lacked required labels, including the resident name, room number, start time, and infusion rate. One resident had dysphagia, aphasia, gastrostomy status, and severely impaired cognition, while the other had gastrostomy status and received most calories through TF. Orders specified continuous pump feedings with set rates and start times, and the DON confirmed that TF bags should be labeled with resident information, formula, and rate.
Unlocked Medication Cart and Improper Insulin Storage: A surveyor observed a B-side medication cart left unlocked and unattended in a hallway, and an RN later locked it after being approached. The DON stated medication carts must be locked when not being attended to. The surveyor also found insulin lispro, insulin glargine, and an unopened Lantus vial box stored in a cart drawer instead of refrigerated, even though the manufacturer instructions required refrigeration until use; an LPN confirmed the insulin should be refrigerated.
Infection control failures were observed involving a resident with COPD who had oxygen therapy and nebulizer orders, where oxygen tubing was left hanging and the nebulizer mask was found open to air instead of stored in protective covering. A second resident on Contact Precautions for C. auris had a CNA enter the room without a gown, remove a basin, and then enter another resident's room; the DON and IP stated that nebulizers should be stored in a plastic bag and PPE should be worn before room entry.
A resident with vascular dementia and moderate cognitive impairment was allowed outside unescorted, contrary to their care plan requiring escort. The nurse failed to document the physician's order for an out on pass, and the care plan was not updated after the resident eloped, was found wandering on a highway, and experienced a syncopal episode requiring emergency care. Facility policies requiring timely care plan updates after incidents were not followed.
A resident with vascular dementia and moderate cognitive impairment was allowed by nursing staff to go outside, after which the resident left the premises unaccompanied and was later found by police. The incident was not reported to the NJDOH as required, and there was no physician's order in the medical record authorizing the resident to go out on pass unescorted at the time of the event.
A resident with vascular dementia and moderate cognitive impairment was allowed to leave the facility without a documented physician's order for an out on pass, resulting in the resident leaving the premises and requiring emergency care after a syncopal episode. Additionally, required psychiatric and psychological consults were not completed as ordered, with one consult delayed for months and the other not obtained at all.
A resident's family member, who was the primary contact and had full PHI access, requested the resident's medical records. The facility received the request and was informed by their contracted provider that more documentation was needed, but did not notify the family member of this requirement for about two weeks, resulting in a failure to provide the records within the required two-day timeframe.
The facility failed to maintain a clean and sanitary environment in two shower rooms, with issues such as tiles on the floor, brown stains, and improperly stored items. Housekeeping staff and the Director of Housekeeping acknowledged the problems, attributing some to water harshness. Facility policies emphasized the importance of sanitation and regular audits.
A facility failed to provide dignified ADL care by not ensuring privacy for a resident with moderately impaired cognition. A CNA was observed assisting the resident with a transfer and removing their pants without closing the door or pulling the privacy curtain, exposing the resident's lower body. The facility's policy requires maintaining privacy during such care.
A resident with quadriplegia and peripheral vascular disease had incomplete treatment records, with numerous blanks in the Treatment Administration Record (TAR) over several months. The resident expressed concerns about wound care not being completed when staffing was low. The DON confirmed that blanks indicate treatments may not have been documented or performed, contrary to facility policy requiring complete documentation.
The facility failed to remove expired Covid-19 vaccines from the medication room inventory. During a survey, a surveyor found expired Moderna Covid-19 vaccine syringes in a refrigerator, which the LPN confirmed should have been removed by the overnight shift. The ADON and IP also acknowledged the oversight, and the facility's policy requires monthly checks to ensure medications are not expired.
The facility failed to ensure proper disposal of PPE in rooms with Enhanced Barrier and Contact Precautions. PPE gowns were found discarded in residents' personal trash bins and on the floor, contrary to the facility's procedures requiring disposal in red biohazard bags. Staff interviews confirmed the expectation for correct disposal, and the facility's Infection Control Manual outlined these procedures.
Verbal Abuse Toward a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident who required assistance with transfers and other ADLs was free from verbal abuse by staff. The resident had diagnoses including metabolic encephalopathy, altered mental status, muscle weakness, cognitive communication deficit, depression, anxiety disorder, and osteoarthritis. The care plan identified moderate cognitive impairment and required one-person physical assistance for transfers, including pivot transfers with one-person assist. A family member reported to police that inappropriate comments were made by facility staff to the resident during care. The facility’s reportable event record stated that the family alleged a recording captured staff being verbally inappropriate during care. Staff statements indicated the resident resisted care and that care continued despite the resistance, and one CNA reportedly made an inappropriate comment. The facility’s investigation concluded that verbal abuse/inappropriate language toward the resident occurred, and the surveyor confirmed that the LNHA acknowledged the audio recording showed CNA #1 making inappropriate comments to the resident.
Failure to Monitor and Sanitize Resident Personal Refrigerators
Penalty
Summary
The facility failed to ensure that food stored in residents’ personal refrigerators was maintained in a safe and sanitary manner. During a tour of rooms with personal refrigerators, surveyors found that several units did not have thermometers, no temperature logs were available, and some refrigerators had visible debris or spilled food inside. In one room, a thermometer was present but the unit read 50 F, and in another room the refrigerator was warm to the touch. One refrigerator was observed at 9 F with food frozen inside, and the resident’s family was reported to adjust the temperature control. Surveyors also found multiple expired or undated food items in the refrigerators. Examples included expired pudding, mixed fruit, turkey sandwiches, mustard, soda, sliced cheese, cream cheese, ketchup, dressing, sandwich meat, rum punch, lemon Jell-O, apple juice, and other sandwiches that were either expired or not labeled and dated. These findings were identified in all 6 resident rooms reviewed for personal refrigerator use. During interviews, the LPN/UM acknowledged that thermometers were not routinely placed in residents’ personal refrigerators and that staff did not monitor or document temperatures. The LPN/UM also stated that residents, rather than staff, checked expiration dates and cleaned the refrigerators. The DOM stated that CNAs were responsible for monitoring, cleaning, and discarding expired items, while the LNHA stated the facility was not responsible for residents’ personal refrigerators and that no specific policy existed. The facility policy reviewed by surveyors stated that food items were to be labeled, expired food discarded by nursing staff, refrigeration units monitored, and resident room refrigerators checked daily and cleaned weekly.
Improper Disposal of Soiled Materials and Unclean Linen Storage
Penalty
Summary
The facility failed to provide a clean environment by improperly disposing of soiled materials and PPE in a room with Enhanced Barrier Precautions (EBP) signage posted. During observation, surveyors saw soiled bed linen with other items wrapped inside and a blue disposable chuck placed on top of a garbage receptacle, and a disposable glove turned inside-out discarded on the floor. On a later observation in the same room, surveyors again saw a pair of disposable gloves turned inside-out on the floor. Staff interviews confirmed that soiled linen should be placed inside the trash receptacle and that gloves and other PPE should not be discarded on the floor or on top of the trash bin. The RN/IP stated that used PPE should be discarded in a red trash bin or a regular trash receptacle lined with a red bag if needed, and that hand hygiene should follow disposal. The facility also failed to keep clean bed linen and incontinence supplies maintained in sanitary condition for Resident #16, who was admitted with diagnoses including local infection of the skin and subcutaneous tissue, dementia, and muscle weakness, and whose MDS reflected an unhealed stage 4 pressure ulcer on the left hip. Surveyors observed a covered red plastic trash bin at the foot of the resident’s bed with folded blue disposable chuck, folded cream-colored incontinence brief, and several layers of folded linen and garments sitting directly on top of the trash bin cover. The resident’s care plan included a focus on the stage 4 pressure ulcer and a goal of showing no signs of infection to the site. The DON and IP both stated that clean linens should not be placed on top of the trash bin, and the IP stated that red trash bins were for soiled PPE of residents on EBP and that clean linens should be bagged and not left on top of trash bins.
Unlabeled Tube Feeding Bags
Penalty
Summary
The facility failed to ensure that residents receiving enteral feedings were provided appropriate care and services by not completing formula labels for tube feeding bags. This deficient practice was identified for 2 of 3 residents reviewed for tube feeding, including Resident #114 and Resident #49, both of whom were observed asleep in bed while receiving continuous tube feedings with unlabeled feeding bags. For Resident #114, the resident had diagnoses including dysphagia, aphasia, and gastrostomy status, and the quarterly MDS showed a BIMS score of 0 out of 15, indicating severely impaired cognition. The care plan identified the resident as requiring tube feeding related to dysphagia, failure to thrive, malnutrition, and risk for aspiration. The physician's order directed Peptamen 1.5 cal. via gastrostomy at 60 mL/hr by pump, with a total volume of 1000 mL per 24 hours, and required staff to document the feeding start time each shift and verify the infusion rate each shift. During observation, the TF bag was not labeled with the resident's name, room number, date and time the feeding was initiated, or the prescribed infusion rate. For Resident #49, the resident had gastrostomy status and the annual MDS indicated that 51% or more of total calories were received through tube feeding. The EMR included an order for Glucerna 1.2 at 75 mL/hr via pump, with a total volume of 1,550 mL and initiation at 5:00 PM until the total volume was infused. During observation, the TF bag was also not labeled with the resident's name, room number, date and time the feeding was initiated, or the prescribed infusion rate. The DON confirmed that TF bags should be labeled with the resident's information, date, time, formula, and rate, and the facility policy directed staff to fill in the label with the resident's name, room, start time, and rate.
Unlocked Medication Cart and Improper Insulin Storage
Penalty
Summary
The facility failed to store medications securely inside medication carts by leaving a B-side 2nd floor medication cart unlocked when it was unattended. During the initial tour, the surveyor observed the cart unlocked in the hallway with no medications on top and no residents, visitors, or staff present nearby. A nurse later came out of a resident room, approached the cart, and locked it. In interview, the RN confirmed responsibility for the cart and stated that medication carts need to be locked at all times, and the DON stated that nurses must lock medication carts if they are not behind them. The facility policy titled Medication Storage, reviewed on 1/28/2026, did not include keeping medication carts locked when not being attended to. The facility also failed to ensure proper temperature control for insulin stored on the 2nd floor central medication cart. The surveyor observed one multi-dose vial of insulin lispro 100 units, one insulin glargine 100 units/mL, and one unopened box of Lantus multi-dose vial 100 units in the top drawer of the cart, with the protective caps intact and the box unopened. The surveyor reviewed the manufacturer instructions, which stated the insulin should be refrigerated at 36 degrees F to 46 degrees F until time of use, and the second floor medication room had a refrigerator for medications. The LPN confirmed that the insulin vials should be refrigerated and confirmed the condition of the vials and unopened box. The facility policy titled Medication Storage-Insulin, last reviewed 1/28/26, stated that the facility follows manufacturer recommendations for proper storage and temperature controls of medications including insulin.
Infection Control Failures With Respiratory Equipment and Contact Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed two infection control failures. For Resident #50, who was admitted with COPD and had an order for oxygen therapy and nebulizer treatments for shortness of breath, the surveyor found oxygen tubing hanging from the bedside table and, after opening the top drawer with the resident's permission, observed the resident's nebulizer with the mask left open to air rather than stored in protective covering between uses. The DON stated that when nebulizers were not in use they should be stored in a plastic bag. For Resident #75, who had a physician's order for Contact Precautions and a care plan focus related to C. auris after a positive swab, the surveyor observed contact precaution signage on the door instructing staff to put on a gown before room entry. At the same time, a CNA entered the room without a gown, removed a basin from the room, and then entered another resident's room. The CNA stated she removed the basin because the resident's water took too long to warm. The IP stated that PPE should be applied before entering the resident's room and that residents on contact precautions should have dedicated supplies that do not go in and out of the room.
Failure to Implement and Update Care Plan Following Resident Elopement
Penalty
Summary
The facility failed to implement and update a comprehensive care plan for a resident with vascular dementia and a mood disorder, who had a moderately impaired cognitive status as indicated by a BIMS score of 12 out of 15. The resident was allowed to sit outside unescorted after expressing a desire to do so, and the nurse verbally agreed and intended to obtain a physician's order for an out on pass, but failed to document the order or update the care plan. The resident subsequently left the facility grounds unaccompanied, was found wandering on a multi-lane highway by a passerby, and was later brought to a police precinct where the resident experienced a syncopal episode and required transfer to the emergency room. Review of the resident's care plan revealed it included an intervention for community pass with escort only, but the plan was not updated following the incident or after the resident's quarterly MDS assessment. The facility's policies required care plans to be reviewed and updated after significant incidents and changes in condition, but this was not done. Staff interviews confirmed that the care plan was not revised post-incident, and the required physician's order for the out on pass was not documented, resulting in a lack of communication and appropriate interventions for the resident's safety.
Failure to Report Resident Elopement to State Authorities
Penalty
Summary
The facility failed to report a resident elopement to the New Jersey Department of Health (NJDOH) as required. A resident with vascular dementia and a moderately impaired cognitive status, as indicated by a BIMS score of 12, was observed by nursing staff preparing to go outside. The nurse allowed the resident to sit outside and documented that the physician was informed to obtain an out on pass order. However, the resident left the premises unaccompanied and was later found by police, who transported the resident to a precinct. While at the precinct, the resident experienced a syncopal episode and was transferred to the emergency room for evaluation. The facility's investigation concluded that the resident, who was alert and oriented, had verbalized a desire to go for a walk and sit outside, and an out on pass order was obtained and signed after the fact. However, a review of the medical record did not show a physician's order for the resident to go out on pass unescorted at the time of the incident. During interviews, facility leadership stated they did not report the elopement to NJDOH, believing it was unnecessary due to the out on pass order. The facility's policy requires reporting such incidents to state agencies within five working days, but this was not done.
Failure to Document Physician Orders and Complete Required Consultations
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice by not documenting a physician's order for a resident to leave the facility on pass and by not following physician's orders for psychiatric and psychological consultations. Specifically, a resident with vascular dementia and a moderately impaired cognitive status was allowed to go outside after the nurse verbally obtained, but did not document, a physician's order for an out on pass. The resident subsequently left the premises, was found by police, and experienced a syncopal episode requiring transfer to the emergency room. Review of the medical record confirmed that no physician's order for the out on pass was documented at the time of the incident. Additionally, the facility did not follow through on physician's orders for psychiatric and psychological consultations for the same resident. Although orders for both consults were present upon admission, the psychiatric consult was not completed until nearly three months later, after the resident's elopement, and there was no evidence that the psychological consult was ever obtained. The DON confirmed that the orders were not followed as written, and the facility's policies required both obtaining and documenting such orders in the medical record.
Delay in Providing Medical Records to Authorized Family Member
Penalty
Summary
The facility failed to provide a requested medical record for a discharged resident within two days of a written request, as required. The family member of a resident with severe cognitive impairment, as indicated by a BIMS score of 3 and diagnoses including Alzheimer's Disease, Dementia, Respiratory Disorder, and COPD, submitted a written request for the resident's medical records. The family member was listed as the primary contact and designated with full PHI access. The request was received by the facility and forwarded to the contracted provider, who responded the same day that additional documentation was needed to confirm the requestor's authority. Despite receiving this information, the facility did not promptly communicate the need for additional documentation to the family member. The Administrator waited approximately two weeks before informing the family of the requirement for further documentation, resulting in a delay that exceeded the two-day regulatory timeframe. The deficiency was identified through interviews, record reviews, and examination of facility documentation, and was specific to the handling of this single resident's record request.
Failure to Maintain Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two shower rooms, as observed by a surveyor. On multiple occasions, the surveyor noted various issues in the shower rooms, including tiles on the floor, hygienic products left in the whirlpool tub, brown stains on the walls and floor tiles, an empty can of aftershave, a leaking shower head in a plastic bag, a broken faucet, and improperly stored incontinence products. Additionally, the surveyor found clothing and tissues on the floor, and trash cans without bag linings. Interviews with housekeeping staff and the Director of Housekeeping revealed that housekeeping is responsible for cleaning the shower rooms, while CNAs are expected to clean up after residents. The Director of Housekeeping attributed the brown stains to the harshness of the water and mentioned that the Regional Director of Housekeeping had been notified for guidance. The Licensed Nursing Home Administrator confirmed the water's harshness as the cause of the stains and acknowledged that the shower area should have been cleaned. Facility policies emphasized the importance of sanitation in high-risk areas like bathrooms and the need for regular audits to ensure cleaning standards are met.
Failure to Ensure Privacy During ADL Care
Penalty
Summary
The facility failed to provide a resident's activities of daily living (ADL) care in a dignified manner, as observed by a surveyor. On November 7, 2024, a surveyor witnessed a Certified Nursing Assistant (CNA) assisting a resident in transferring from a wheelchair to a bed. During this process, the CNA removed the resident's pants, exposing the resident's lower body and incontinence briefs, without ensuring privacy by closing the door or pulling the privacy curtain. This incident occurred in the resident's private room, and the CNA acknowledged the oversight when questioned by the surveyor. The resident involved had a history of fractures in the humerus and ribs and was assessed with a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. The facility's policy on Resident Rights, last reviewed in June 2024, mandates that residents be treated with respect and dignity, which includes ensuring privacy during ADL care. The Licensed Nursing Home Administrator, Regional Nurse, and Director of Nursing confirmed that the expectation is for staff to maintain privacy by closing the door or using the privacy curtain during such care.
Incomplete Treatment Records and Documentation Deficiency
Penalty
Summary
The facility failed to maintain complete treatment records with staff signatures for a resident, as required by professional standards of clinical practice. The resident, who was admitted with diagnoses including quadriplegia and peripheral vascular disease, was found to have numerous blanks in their Treatment Administration Record (TAR) over several months. These blanks were noted for various treatments to different parts of the resident's body, including the left and right toes, calf, lower leg, and buttock, indicating that the treatments may not have been administered or documented properly. During interviews, the resident expressed concerns that their wound care was not completed when there were only two nurses on the floor. The Director of Nursing confirmed that blanks on the TAR indicate that a nurse did not sign off on the treatment, leaving uncertainty about whether the treatment was performed. The facility's policy requires that all treatments be documented in the TAR, including the treatment ordered, frequency, location, date/time administered, and the staff member who performed the treatment. Any refusals should also be documented, and the physician should be informed.
Expired Vaccines Not Removed from Inventory
Penalty
Summary
The facility failed to ensure that expired vaccines were removed from active inventory upon expiration. This deficiency was identified in one of the two medication rooms during a survey conducted on the second floor medication room of the sub-acute unit. The surveyor, accompanied by the Licensed Practical Nurse Unit Manager (LPNUM #1), discovered a brown bag in the refrigerator containing five prefilled Intramuscular (IM) Moderna Covid-19 vaccine syringes, all of which had expired. LPNUM #1 confirmed that the overnight shift was responsible for checking expiration dates and acknowledged that the expired vaccines should not have been in the refrigerator. Further interviews with the Assistant Director of Nursing (ADON) and the Infection Preventionist (IP) confirmed the oversight, with both acknowledging that the expired vaccines should have been removed. The facility's policy on medication storage, which was last reviewed on an unspecified date, mandates that licensed nurses check medication storage at least monthly to ensure all medications and supplies are checked for labels and expiration dates. The policy also states that any medications nearing expiration should be removed before the expiration date. Despite this policy, the expired vaccines remained in the medication room, indicating a lapse in adherence to the facility's procedures.
Improper PPE Disposal in Precaution Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of infections, as evidenced by improper disposal of Personal Protective Equipment (PPE). During a survey, it was observed that PPE gowns were discarded inappropriately in residents' personal trash bins and on the floor in rooms marked with Enhanced Barrier Precautions and Contact Precautions signs. This was contrary to the facility's established procedures, which required PPE to be disposed of in a red biohazard bag and taken to the soiled trash room. Interviews with staff, including a Licensed Practical Nurse Unit Manager, a Certified Nursing Assistant, and the Infection Preventionist, confirmed that the facility's expectation was for PPE to be disposed of in a red bag and not in resident trash bins or on the floor. The facility's Infection Control Manual and job descriptions for nursing staff also outlined the correct procedures for PPE disposal, which were not followed. The Director of Nursing and other administrative staff acknowledged the improper disposal practices during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rahway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care Connection Rahway | 1.1 mi | ★★★★★ | 12 | 0 |
| Aristacare At Parkside | 1.6 mi | ★★★★★ | 0 | 0 |
| Complete Care At Clark Llc | 2.9 mi | ★★★★★ | 1 | 0 |
| Cranford Park Care | 3.4 mi | ★★★★★ | 12 | 0 |
| Complete Care At Westfield, Llc | 3.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.