Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Alaris Health At Cedar Grove during CMS and state inspections, most recent first.
A resident with dementia, chronic kidney disease, GERD, and severe cognitive impairment, who relied on a feeding tube for nutrition, received multiple medications and enteral feedings via tube without documented auscultation of bowel sounds beforehand. An LPN administered several oral solutions and tablets via the tube along with ordered bolus feeds and water flushes, later reporting no recall of checking bowel sounds and believing there was no specific protocol requiring it. Subsequently, an NP documented severe abdominal distention and absent bowel sounds, and the resident was transferred to the hospital for altered mental status and abdominal distention. Interviews showed that while the RN unit manager, NP, and medical director expected bowel sound assessment before tube feeding and the facility’s pre-enteral protocol required it, nursing staff did not consistently follow or recognize this requirement.
Surveyors found that staff did not consistently document bowel and bladder continence and movements in required DSR entries for three dependent, cognitively impaired residents with complex medical conditions, including those with gastrostomy status, dementia, and chronic kidney disease. Despite care plans identifying self-care deficits and incontinence, multiple day, evening, and night shifts in a single month lacked any documentation of continence status or bowel movements. Interviews with the NP, MD, CNA, and DON confirmed that all ADL and incontinence care was expected to be fully and accurately documented each shift, and facility policies required complete, timely documentation of care provided.
A resident with diabetes mellitus and intact cognition had no documented PPN from February through July in the eHR/hybrid record, and the RN/UM could not provide the missing records when asked by the surveyor. The LNHA later stated the PPN were available in the e-record under the miscellaneous tab after being obtained from the physician's office and uploaded after the surveyor's inquiry.
A resident with multiple serious diagnoses, fully dependent for ADLs and cognitively intact, reported being dropped by ambulance transport on two occasions. The facility's investigation was incomplete, lacking a timely RN assessment after the reported fall and failing to obtain statements from the second transport company, contrary to facility policy.
A resident with dementia, diabetes, and CHF who was dependent for eating did not receive individualized nutritional care, as the care plan did not match the assessment and staff documentation often indicated independence during meals. Required weekly weight monitoring was not performed, and the effectiveness of increased nutritional supplements was not measured, resulting in inadequate monitoring of the resident's nutritional status.
A resident with Alzheimer's disease and severe cognitive impairment was observed in bed with the call device placed out of reach, including between the siderails and later hanging on the side of the bed. The resident's record showed a BIMS score of 0/15 and dependence on staff for daily living activities, while the care plan encouraged calling for assistance but did not specify that the call device be kept within reach. Staff and facility policy stated the call bell should be within the resident's reach.
A resident with hemiplegia, hemiparesis, type 2 DM, and impaired cognition had orders for insulin glargine and heparin, but the comprehensive care plan did not include insulin or anticoagulant use. An LPN and the RN/UM both stated these medications should have been addressed in the care plan, but the record review showed no such care plan entries.
A resident with ESRD receiving HD had inconsistent pre-dialysis assessments, including missing vital signs and incomplete documentation of AV fistula checks and access-site care. The resident also had an order for Midodrine prior to HD with hold parameters, but the eMAR and dialysis notes did not consistently show blood pressure documentation or communication to the dialysis center when the medication was held or given. The RN/UM stated that if no information was sent, it meant there were no issues, and could not show evidence of communication with the HD center.
Late Dating of Physician Progress Notes: A resident with severe cognitive impairment and total dependence on staff had multiple MD progress notes entered with effective dates that did not match the created dates. The record showed numerous late entries across several months, while an LPN and RN/UM confirmed the physician visits regularly but did not explain the delayed documentation. Facility policy required progress notes and orders to be written, signed, and dated at each physician visit.
Controlled substance accountability was not maintained for two residents when an LPN failed to sign out clonazepam and morphine after administration, and a separate alprazolam count discrepancy was not identified during shift-to-shift inventory. An outgoing nurse also destroyed a loose pill in the medication cart without a witness because he did not realize it was a controlled substance, despite policy requiring controlled meds to be counted each shift and all destructions to be witnessed by two qualified staff.
The facility failed to verify the credentials of three newly hired licensed staff members before their date of hire, as required by policy. A Social Worker, a Registered Nurse, and a CNA had their licenses verified after their hire dates or lacked documented evidence of timely verification. Interviews with staff revealed inconsistencies in the verification process, with the LNHA admitting to missing the verification.
A facility failed to ensure that a resident received face-to-face visits from the supervising physician every 60 days, as required by policy. The resident, with multiple medical conditions and moderately impaired cognition, had visit notes completed by an APN instead of the physician. The facility's policy required the physician to see the resident every 60 days, but this was not adhered to, and no additional information was provided by the facility management during the exit conference.
The facility failed to maintain a safe and sanitary environment, with issues such as dust accumulation, stained ceiling tiles, and improperly stored items observed in resident rooms, a shower room, and an electrical room. The Director of Housekeeping acknowledged a lack of documentation for cleaning schedules, contributing to the deficiencies.
A facility failed to maintain full visual privacy for a resident during wound care treatment. An LPN left the resident's body exposed to the hallway by not fully closing the privacy curtain and opening the door to retrieve gloves. The resident had a history of a sacral pressure ulcer and moderate cognitive impairment. The facility's policy emphasizes maintaining physical privacy during medical treatments.
The facility failed to provide written notifications to residents and their representatives about hospital transfers, as well as to the Ombudsman. This deficiency was identified for two residents, with medical records lacking the required documentation. Interviews with staff revealed confusion over responsibility for these notifications, leading to non-compliance with notification protocols.
A facility failed to accurately code the MDS for a resident, resulting in a deficiency. The resident, with diagnoses including atrial fibrillation and hypertension, was discharged home with home care services. However, the MDS was incorrectly coded as a transfer to a hospital. The MDSC admitted the error, which was confirmed by facility leadership during a review of closed records.
The facility failed to follow physician's orders for medication administration with parameters for two residents. One resident received Midodrine HCl despite blood pressure readings above the prescribed limit, while another received Hydralazine and Toprol XL when blood pressure was below the required threshold. Nursing staff acknowledged the errors, which were contrary to the facility's Medication Administration Policy.
The facility failed to complete discharge summaries for two residents, as required by their policy. One resident's electronic medical records had multiple sections left blank, and there was no physician discharge summary. Another resident was discharged without a documented discharge summary, and the last physician note lacked discharge information. The facility's policy required a discharge plan and summary, which were not completed, leading to the deficiency.
A facility failed to consistently apply and document the use of a hand splint for a resident with decreased range of motion, as required by their care plan. The resident's physician order for a Functional Maintenance Program was not properly transferred to the Treatment Administration Record, leading to inconsistent application of the splint. Interviews with staff revealed confusion and lack of documentation, particularly on days when the Restorative Nurse Aid was not present, resulting in a deficiency.
A facility failed to develop an appropriate incontinence care plan for a resident with frequent urine and occasional bowel incontinence. Despite the resident's MDS assessment indicating the need for a care plan, no focused plan with specific goals and interventions was created. The CNA checked on the resident based on personal experience, and the RN and RN/UM were unsure if incontinence should be care planned. The MDS Coordinator confirmed the absence of a care plan, contrary to facility policy.
A facility failed to ensure a non-certified NA did not work beyond 120 days without completing required training and certification. NA #1 was employed for more than 120 days without certification, as revealed during a review of employee files. Interviews with the BOM and DON showed a lack of clarity in the policy for employing non-certified NAs, and the facility's policy did not address the certification requirement within 120 days.
The facility failed to post the 24-hour Nursing Home Resident Care Staffing Report in a prominent place accessible to residents and visitors. The surveyor found the reports missing on two consecutive days, and the receptionist confirmed they were usually posted behind her. The Staffing Coordinator, who was responsible for posting, was off one day and had printer issues. The LNHA acknowledged the issue and stated that staff were inserviced.
A resident was administered Tamsulosin for overactive bladder without a diagnosis of BPH, contrary to the manufacturer's approved use. The facility's documentation was inconsistent regarding the resident's incontinence condition, and there was no justification for the off-label use of the medication. The pharmacy consultant's recommendations did not address this issue, and late entries in physician notes failed to provide adequate documentation of the medication's necessity.
The facility had a medication administration error rate of 12%, exceeding the acceptable 5% threshold. An LPN administered a 100 mg dose of Docusate without a specified dosage in the eMAR and signed for Enoxaparin without administering it during observation. Another LPN left oral meds unattended on a cart, violating facility policy.
The facility failed to properly store and label medications, including an unlabeled Retacrit vial and improperly stored Novolin R Flex Pen. Expired BD Viral transport tubes and inadequate temperature logging for vaccine storage were also noted. Additionally, an opened Ipratropium/Albuterol nebulizer solution lacked a date, contrary to manufacturer instructions. The facility's Medication Administration Policy was not adhered to, and no storage policy was provided upon request.
The facility failed to maintain complete and accessible medical records for residents, leading to a deficiency. A resident with a history of mental disorders exhibited aggressive behavior, but the facility did not document preventive measures or interventions. Another resident's medical records lacked timely physician visit notes, with additional notes only added after surveyor inquiry. The facility's delayed collection of staff statements further contributed to the deficiency.
A facility failed to follow proper infection control practices, including improper storage of a urinary drainage bag and inadequate hand hygiene during a wound treatment. A resident's urinary catheter bag was placed on the mattress instead of below bladder level, and an LPN did not perform hand hygiene correctly during wound care, also wearing a PPE gown in the hallway. These actions were inconsistent with the facility's policies and CDC guidelines.
The facility did not have a dedicated Infection Preventionist (IP) from May 2023 to January 2024, with the Director of Nursing (DON) assuming the role. This absence was noted during QAPI meetings, where infection control reports were inadequately reviewed. The facility's policies required a part-time IP, but recruitment efforts were unsuccessful, leading to non-compliance with infection control standards.
A facility failed to offer and document influenza and pneumococcal vaccinations for a resident with complex medical conditions. The resident's medical records lacked evidence of vaccine offers or refusals, and there was no documentation of education provided to the resident or their representative. Interviews with staff revealed inconsistencies in the facility's protocol for tracking and documenting immunizations, highlighting a deficiency in the implementation of vaccination policies.
Failure to Follow Pre-Enteral Protocol for Bowel Sound Assessment Prior to Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to consistently auscultate bowel sounds prior to administering medications and tube feedings to a resident who was dependent on enteral nutrition. A closed record review for Resident #5, who was not present in the facility at the time of survey, showed that the resident had dementia, chronic kidney disease, and gastro-esophageal reflux disease, and was severely cognitively impaired and rarely/never understood, according to the MDS dated 11/9/25. The MDS and care plan documented that the resident required a feeding tube to meet nutritional needs, with interventions directing that tube feedings and flushes be provided as ordered. Review of the MAR for January 2026 showed that on the morning of 1/28/26, an LPN administered multiple medications via the feeding tube at 9 AM, including ascorbic acid liquid, buspirone, quetiapine, valproic acid solution, and Ativan, followed by ordered enteral feedings and water flushes at 10 AM. The MAR also indicated that the LPN signed off on tube feed flushes before and after each medication pass and after completion of formula at 7 AM. There was no documentation that bowel sounds were assessed prior to these administrations. Later that day, a nurse practitioner progress note at 12:40 PM documented severe abdominal distention and absence of bowel sounds on auscultation, and the resident was transferred to the hospital for further evaluation due to altered mental status and abdominal distention, as recorded on the New Jersey Universal Transfer Form. Interviews with nursing staff and facility leadership revealed inconsistent understanding and implementation of bowel sound assessment prior to tube feeding and medication administration. One LPN stated that residents with enteral feeding should be checked for bowel sounds and that tube feeding should be held and a supervisor notified if no bowel sounds were present, but also stated he only assessed bowel sounds once a shift and did not recall specifics of this resident’s care. The LPN who administered the medications and feedings on the morning in question stated there was no protocol requiring bowel sound assessment for tube-fed residents and did not recall checking this resident’s bowel sounds that morning. In contrast, the RN unit manager, NP, and medical director all stated that they expected staff to auscultate bowel sounds prior to administering tube feedings. The DON provided the facility’s Pre-Enteral Administration protocol, which included auscultating for bowel sounds prior to administering medications and feedings, and the facility’s written policy and protocol indicated that pre-enteral assessment steps, including bowel sound auscultation, were required, demonstrating that the established protocol was not consistently followed for this resident.
Failure to Maintain Complete Bowel and Bladder Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with accepted professional standards, specifically related to documentation of bladder and bowel continence and movements in the Documentation Survey Report v2 (DSR) for three residents. For one resident admitted with traumatic subdural hematoma, gastrostomy status, and benign prostatic hyperplasia, the comprehensive MDS showed the resident was rarely/never understood and dependent on staff for all ADLs, with a care plan focus on self-care performance deficit. Review of this resident’s January DSR revealed missing documentation of bladder continence on multiple specified day, evening, and night shifts, and missing documentation of bowel continence and movements on several listed shifts, despite the requirement that these items be documented each shift. A second resident, admitted with protein-calorie malnutrition, gastrostomy status, and hypertension, was also assessed on the MDS as rarely/never understood and dependent on staff for all ADLs, with a care plan focus on self-care performance deficit. For this resident, the January DSR similarly required shift-by-shift documentation of bladder and bowel continence and movements. However, there was no evidence of documentation for numerous identified day and night shifts throughout the month for both bladder continence and bowel continence/movements. A third resident, admitted with dementia, chronic kidney disease, and gastroesophageal reflux disease, had an MDS indicating the resident was rarely/never understood, totally dependent on staff for toileting hygiene, and requiring partial assistance with toilet transfers, with a care plan focus on incontinence and total dependence on staff for toileting needs. This resident was transferred to a hospital for altered mental status and abdominal distention later in the month. Review of the January DSR showed that required documentation of bladder continence and bowel continence/movements was absent on multiple specified day and night shifts, including an entire day, evening, and night sequence on one date. Interviews with the NP, MD, CNA, and DON confirmed that all care, including bowel and bladder monitoring, was expected to be fully, accurately, and timely documented in the medical record, and facility policies on incontinence care management and general documentation required individualized care and complete documentation of care provided.
Missing Physician Progress Notes in Resident Record
Penalty
Summary
The facility failed to maintain and provide readily accessible medical documents for one resident reviewed for medical records. The resident was admitted with diagnoses including diabetes mellitus due to underlying conditions, and the quarterly MDS dated 7/19/25 indicated a BIMS score of 15 out of 15, showing intact cognition. A review of the electronic and hybrid medical record found no documented evidence that Physician Progress Notes were completed by the primary physician or an alternating advanced practice nurse from February 2025 through July 2025. During the survey, the RN/Unit Manager stated she would obtain the records from the medical record room and said the PPN should be in the medical record, but she could not explain why they were not in the resident's hybrid record. The RN/UM did not provide the PPN to the surveyor. When the concern was later discussed with the LNHA, DON, and Regional RN, the LNHA stated that the PPN from February through July 2025 were now available in the electronic record under the miscellaneous tab and that they had been obtained from the doctor's office and uploaded after the surveyor's inquiry.
Incomplete Investigation of Resident Fall During Transport
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who alleged being dropped by ambulance transport on two separate occasions. The incident was initially reported after the resident experienced pain in their elbow and shoulder while reaching for a urinal, which led to a hospital transfer. Upon return, the resident later disclosed to staff that they had been dropped by both transport teams but had not reported it earlier to avoid getting anyone in trouble. The facility's investigation did not include immediate assessment by a Registered Nurse after the fall was reported, and only a Licensed Practical Nurse performed a skin assessment. Additionally, there was no evidence that the facility made an effort to contact the second transport company to obtain statements or further investigate the allegation. The resident involved had significant medical conditions, including multiple myeloma, fatigue fracture of the vertebrae, pathological fracture in neoplastic disease, and malignant neoplasm of the bone. The resident was fully cognitively intact and dependent on staff for all activities of daily living, including transfers. The facility's policy required that investigations include interviews with staff, residents, and witnesses, with statements attached to the incident report and kept on file. However, the investigation was incomplete, lacking both a Registered Nurse assessment and documentation of contact with the second transport company.
Failure to Individualize and Implement Nutritional Care Plan
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including dementia, diabetes, congestive heart failure, and a history of pulmonary embolism, did not receive individualized and consistent nutritional care. The resident was assessed as being dependent for eating and required a mechanically altered diet due to swallowing difficulties. However, the care plan only indicated assistance with meals as needed, which was inconsistent with the comprehensive assessment. Documentation by CNAs showed that the resident was frequently recorded as independent or only receiving minimal assistance during meals, despite being assessed as fully dependent. Further review revealed that the resident's nutritional status was not adequately monitored. The care plan included an intervention to monitor, record, and report significant weight loss, specifically a loss of more than three pounds per week, but only one weight measurement was documented in the medical record. The facility's point-of-care system also failed to consistently document the required level of assistance provided during meals, and the intervention for weekly weight monitoring was not followed. Additionally, when the resident's nutritional supplement was increased in response to family concerns and poor intake, there was no documented method to measure the effectiveness of this intervention. The registered dietician acknowledged that the care plan was generic and not individualized, and that the required weekly weight monitoring was not performed. Facility policies required integration of assessment findings into care planning and regular weight monitoring, but these were not implemented for this resident.
Call Device Not Within Resident Reach
Penalty
Summary
The facility failed to ensure that Resident #13's call device was readily accessible. On 9/10/2025 at 10:42 AM, the resident was observed in bed, awake, and unable to answer the surveyor's inquiry, with the call device located between the siderails and out of reach. On 9/11/2025 at 10:45 AM, the call device was again observed hanging on the side of the bed and not within the resident's reach. Record review showed that Resident #13 was admitted with Alzheimer's disease and had a significant change MDS dated 8/29/25 indicating a BIMS score of 0 out of 15, reflecting severe cognitive impairment. The resident was also dependent on staff for daily living activities. The care plan focused on oxygen therapy related to respiratory illness and included encouragement to call for assistance, but did not indicate that the call device should be within the resident's reach. Staff interviews confirmed that the call device should have been placed within reach, and the facility policy stated that call bells should be within reach of the resident.
Missing Care Plan for Insulin and Anticoagulant Use
Penalty
Summary
A comprehensive, person-centered care plan was not developed for a resident receiving long-term insulin therapy. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes mellitus. The quarterly MDS completed on 8/18/25 indicated a BIMS score of 5 out of 15, reflecting impaired cognition, and also documented that the resident was receiving insulin injections and anticoagulant medications. Record review of the resident’s comprehensive care plan showed no care plan for the use of insulin or anticoagulant medication. The order summary listed insulin glargine 10 units subcutaneously daily, starting 8/8/25, and heparin sodium 5000 units subcutaneously every 8 hours, starting 8/7/25. During interviews, an LPN stated there should be a care plan for insulin and anticoagulant medications, and the RN/UM stated the care plan should include insulin injections and anticoagulant medications, but no further explanation was provided for why these items were not included in the resident’s care plan.
Inconsistent pre-dialysis assessment and missing communication for dialysis medication
Penalty
Summary
Safe, appropriate dialysis care/services were not consistently provided for a resident with end stage renal disease who received hemodialysis three times weekly and had a left upper arm AV fistula. The resident’s care plan included monitoring bruit and thrill, ensuring attendance at dialysis, and monitoring labs. However, the electronic treatment record showed multiple charting blanks for ordered checks of the AV fistula bruit and thrill, assessment of the dialysis access dressing for bleeding after return from dialysis, and removal of the dialysis access dressing four hours post-treatment. The record also showed that on multiple hemodialysis days, the resident was not assessed prior to leaving the facility for dialysis, with no documented vital signs before departure on several dates in August and September 2025. The resident had an order for Midodrine 10 mg prior to dialysis on Monday, Wednesday, and Friday, with instructions to hold the medication if systolic blood pressure was higher than 140. The eMAR reflected several instances where Midodrine was not administered and blood pressure was not documented, and one instance where it was administered with documented blood pressure readings. Dialysis progress notes did not reflect documentation of the Midodrine doses that were held or the pre-dialysis assessments conducted. During interview, the RN/UM stated that if no information was sent with the resident to the dialysis center, it meant there were no issues, and that any issue would result in a phone call. The RN/UM could not show evidence that communication with the dialysis center occurred when Midodrine was held or administered. The DON, LNHA, and regional RN were informed of the concern, and the regional RN stated the dialysis progress note was used as the communication form, but the dialysis center did not have access to the facility’s eMR where the assessment information was documented.
Late Dating of Physician Progress Notes
Penalty
Summary
The facility failed to ensure that the resident’s primary physician accurately dated Physician Progress Notes during visits for Resident #13. The resident was admitted with Alzheimer’s disease and, on the significant change MDS dated 8/29/25, was assessed with a BIMS score of 0 out of 15, indicating severe cognitive impairment. The same assessment showed the resident was dependent on staff for daily living activities. A review of the electronic health record and hybrid medical record showed numerous physician progress notes with effective dates that did not match the created dates, indicating the notes were entered late rather than on the date of the physician visit. Examples included notes with effective dates in January, February, March, April, May, June, July, and August 2025 that were created weeks or months later, as well as some notes with created dates earlier or later than the effective date. The report identified 51 physician progress notes with this dating issue. During interviews, an LPN stated that the physician comes into the facility regularly and writes notes in the eHR. The RN/unit manager stated that the physician visits residents regularly and documents progress notes in the computer, but did not explain why the progress notes were late entries. The primary physician was contacted for interview but did not return the call. The facility policy titled Physician Visits and Services stated that progress notes and orders must be written, signed, and dated at each physician visit.
Controlled Substance Count and Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not maintaining consistent accountability and reconciliation of controlled medications for two residents. During inspection of the narcotic box in a medication cart, Resident #95’s clonazepam 0.5 mg bingo card contained 47 tablets while the declining inventory log showed a balance of 48 tablets, and the LPN stated she had administered the medication that morning but forgot to sign it out of inventory. The same resident’s morphine 20 mg/ml declining inventory log showed a balance of 26 mL and had last been signed the prior evening, but the eMAR reflected a 9:00 AM administration that was not documented on the declining inventory log; the LPN stated she had given the morphine and forgot to sign it out because she was distracted. Resident #151’s alprazolam 0.5 mg bingo card contained 69 tablets while the declining inventory log reflected a balance of 70 tablets, and the discrepancy was not identified during the shift-to-shift count. During the investigation, the outgoing 11-to-7 nurse reported destroying a loose pill found in the medication cart in the drug buster without a witness because he did not realize it was a controlled substance. The facility policy required controlled substances to be counted by the oncoming and outgoing nurses at each shift change, discrepancies to be reported to the DON, and all medication destructions to be witnessed by at least two qualified persons.
Failure to Verify Staff Credentials Upon Hire
Penalty
Summary
The facility failed to ensure that the credentials of newly hired licensed staff were verified upon hire, as required by their policy. This deficiency was identified for three out of five newly hired licensed staff members reviewed. Specifically, a Social Worker hired on 8/21/23 had their license verified only on 10/02/23, after their date of hire. Similarly, a Registered Nurse hired on 8/25/23 had their license verified on 10/02/23 and 11/14/23, both dates post-hire. Additionally, a Certified Nurse Aide hired on 10/23/23 had a license verification printout with no visible date, indicating a lack of documented evidence that the verification was completed before the date of hire. Interviews with facility staff, including the Business Office Manager (BOM), Director of Nursing (DON), and Licensed Nursing Home Administrator (LNHA), revealed inconsistencies in the verification process. The BOM, who was responsible for checking licenses before orientation, was not employed at the facility at the time of the oversight. The LNHA, who acted as a stand-in BOM, admitted to missing the verification. The facility's policy mandates that potential hires of professional staff have their licenses verified by their licensing boards prior to hire, which was not adhered to in these cases.
Failure to Conduct Required Physician Visits
Penalty
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days, as required by the facility's policy and procedure. This deficiency was identified for one resident, who was admitted with multiple diagnoses including hypotension, traumatic subdural hemorrhage, cerebral infarction, atrial fibrillation, hemiplegia, secondary hypertension, depression, and anxiety disorder. The resident's most recent assessment indicated moderately impaired cognition. Despite these conditions, there was no documented evidence of physician visits and examinations every 60 days from January 2024 through June 2024. The surveyor's investigation revealed that the resident's visit notes for January and March 2024 were completed by an Advance Practice Nurse (APN), with no further notes found in the resident's medical records. During interviews, the facility's Registered Nurse Coordinator and Licensed Nursing Home Administrator confirmed that the facility's policy required the primary physician to see the resident every 60 days, with the APN conducting alternating visits. However, the facility failed to adhere to this policy, as evidenced by the lack of physician documentation in the resident's records. The facility management did not provide additional information or refute the findings during the exit conference.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the Behavioral Unit, affecting multiple resident rooms, a shower room, and a motor access room. During a tour, surveyors observed several issues, including an accumulation of dust on air vent covers, a stained ceiling tile, and a piece of clothing left in a bathroom after a resident transfer. Additionally, dry debris was found hanging from a window, and rust was noted on toilet paper holders. A urine collection container was improperly left on the floor, and a smoke detector was found detached and hanging from the ceiling. Further observations revealed an unlocked electrical room with a dried-up substance and a discolored blanket on the floor. In the eyewash station room, a shower stall had a missing part to close an opening, and an air vent was uncovered with dust accumulation. The Director of Housekeeping admitted to a lack of documentation for cleaning schedules and rounds, indicating a failure in maintaining cleanliness and safety standards as per the facility's policy.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain full visual privacy for a resident during a wound care treatment. On the specified date, a Licensed Practical Nurse (LPN) was observed performing treatment on a resident's sacral wound with the assistance of a Certified Nurse Aide (CNA). During the procedure, the privacy curtain was only partially drawn, leaving the resident's body exposed to the hallway when the LPN opened the door to retrieve gloves from a treatment cart outside the room. This action compromised the resident's privacy as the back side of the resident's body was visible from the hallway. The resident involved had a history of urinary tract infection, a sacral pressure ulcer wound, and epilepsy, with a moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. The facility's policy on resident rights to privacy and confidentiality emphasizes the importance of maintaining physical privacy during medical treatments. However, the LPN acknowledged the lapse in ensuring the resident's privacy during the treatment, which was confirmed during an interview with the surveyor.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for their transfer to the hospital, as well as failing to notify the Office of the State Long-Term Care Ombudsman. This deficiency was identified for two residents who were transferred to an acute care hospital. The medical records of these residents did not contain the required written notifications, indicating a lapse in the facility's adherence to notification protocols. Interviews with various staff members, including the Director of Social Services, Admissions Director, Regional Director of Case Management and Admissions, Director of Nursing, Licensed Nursing Home Administrator, and medical records staff, revealed a lack of clarity and responsibility regarding who was accountable for providing these notifications. Each department denied responsibility, and there was no established process in place to ensure compliance with the notification requirements. This lack of coordination and communication among the staff contributed to the failure to provide the necessary notifications.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency in compliance with federal guidelines. The error involved Resident #142, whose discharge MDS was incorrectly coded as a transfer to an acute hospital, despite documentation indicating the resident was discharged home with home care services. The resident's admission record included diagnoses such as unspecified atrial fibrillation, anxiety disorder, and essential hypertension. On the day of discharge, the resident was noted to be in no distress, had their vitals taken, and was discharged home with a representative, as documented in the progress notes and discharge summary. The MDS Coordinator (MDSC) acknowledged the mistake during an interview, confirming that the resident was discharged home and not to a hospital. This error was further confirmed during a meeting with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Vice President of Operations (VPoO), who reiterated that the MDS was inaccurately coded. The deficiency was identified during a review of closed records, highlighting a lapse in the facility's adherence to proper coding procedures for resident assessments.
Failure to Follow Physician's Orders for Medication Parameters
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration with specific parameters for two residents, leading to a deficiency. Resident #44, who was cognitively intact and diagnosed with conditions including end-stage renal disease and hypotension, was prescribed Midodrine HCl to be administered only if blood pressure was below 120. However, the medication was administered multiple times despite the resident's blood pressure exceeding this threshold, as documented in the electronic Medication Administration Record (eMAR). Similarly, Resident #134, who had moderately impaired cognition and multiple diagnoses including hypotension and cerebral infarction, was prescribed Hydralazine and Toprol XL with specific blood pressure parameters. The eMAR showed that these medications were administered even when the resident's blood pressure was below the prescribed limits. Interviews with the nursing staff revealed that they were aware of the parameters but failed to follow them, resulting in medication errors. The Director of Nursing acknowledged the failure to follow physician's orders and the facility's Medication Administration Policy, which mandates that medications be administered according to prescribed parameters. The policy requires verification of vital signs before administering medications, which was not adhered to in these cases, leading to the deficiency.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that a discharge summary was completed for two residents, as required by their policy and procedure. For Resident #13, the surveyor found that the discharge summary in the electronic medical records was incomplete, with multiple sections left blank, including social services, rehab, dietary, and activities. Additionally, there was no physician discharge summary available. The Director of Nursing and Registered Nurse/Unit Manager confirmed that it was not the facility's practice to have a physician discharge summary, which contributed to the deficiency. For Resident #142, the surveyor discovered that the discharge summary was also missing. The resident was discharged home with home care services, but the last physician note did not include discharge information or a plan. The facility's discharge policy, reviewed in January 2024, required a discharge plan, summary, and instructions to be developed and documented by the interdisciplinary team, which was not adhered to in these cases. The survey team met with facility management multiple times to discuss these findings, and the facility acknowledged the lack of a physician discharge summary. The facility's policy clearly stated the need for a discharge summary, yet it was not completed for the residents in question, leading to the identified deficiency.
Inconsistent Application and Documentation of Hand Splint for Resident
Penalty
Summary
The facility failed to ensure consistent daily treatment for a resident with decreased range of motion and mobility, specifically regarding the use of a hand splint to prevent contractures. The resident, who was observed wearing a splint on their left hand, had a physician's order for a Functional Maintenance Program (FMP) that included passive range of motion exercises and the application of a left hand orthotic device. However, the order was not transferred to the Treatment Administration Record (TAR) for staff signatures, and there was no documented evidence that the care plan was being consistently followed. Interviews with facility staff revealed inconsistencies in the documentation and application of the splint. The Certified Nursing Assistant (CNA) indicated that therapy staff were responsible for the splint when the resident was in therapy, while nursing staff would apply it otherwise. However, the Documentation Survey Report showed no records of splint application by the CNA. The Restorative Nurse Aid (RNA) documented splint application in a binder, but there were numerous days with missing documentation, indicating that the splint was not applied consistently when the RNA was not present. Further interviews with the Director of Rehab (DoR), Registered Nurse/Unit Manager (RN/UM), and Licensed Practical Nurse (LPN) highlighted a lack of clarity and communication regarding the documentation process for the splint. The facility's policy on the Functional Maintenance Program did not address documentation procedures for splints while a resident received skilled therapy, contributing to the deficiency. The absence of documented evidence for splint application on days when the RNA was not at the facility was confirmed by the Director of Nursing (DON), indicating a failure in ensuring the resident's care plan was consistently implemented.
Failure to Develop Incontinence Care Plan
Penalty
Summary
The facility failed to develop an appropriate incontinence care plan for a resident, identified as Resident #134, who was frequently incontinent of urine and occasionally incontinent of bowel. The resident's medical records indicated a significant change in their condition, as reflected in the Minimum Data Set (MDS) assessment, which triggered the need for a care plan addressing urinary incontinence. However, the facility did not create a focused care plan with specific goals and interventions for the resident's bladder and bowel incontinence, despite the assessment's recommendation to proceed with care planning. Observations and interviews conducted by the surveyor revealed that the resident was not on a bladder and bowel toileting program, and the Certified Nursing Aide (CNA) responsible for the resident's care was checking on the resident's incontinence based on personal experience rather than a structured care plan. The Registered Nurse (RN) and the RN/Unit Manager (RN/UM) acknowledged the resident's incontinence but were unsure if it should be formally care planned. The MDS Coordinator/RN confirmed the absence of a care plan for incontinence, which should have been in place according to the facility's policy. The facility's Incontinence Care Policy and Plan of Care and IDCP Team Meeting Policy required individualized care plans for all residents, reviewed and revised after each assessment. Despite these policies, the facility did not implement a care plan for Resident #134's incontinence, as evidenced by the lack of documentation in the electronic medical record system. The survey team informed the facility management of these findings, but no additional information or refutation was provided by the facility.
Non-Certified Nurse Aide Worked Beyond 120 Days Without Certification
Penalty
Summary
The facility failed to ensure that a non-certified Nurse Aide (NA) did not continue to work beyond the specified 120 days without completing the necessary training and certification. This deficiency was identified during a review of employee files, where it was found that NA #1 was hired on January 30, 2024, and terminated on June 11, 2024, exceeding the 120-day limit. The competency report skills test for NA #1 was dated July 27, 2023, indicating that the NA continued to work beyond the allowed period without completing the required certification. Interviews with the Business Office Manager (BOM) and the Director of Nursing (DON) revealed a lack of clarity and adherence to the policy regarding the employment of non-certified NAs. The BOM mentioned reviewing skills tests within 30-60 days, while the DON stated that NAs should be removed from the schedule if they do not pass the test within 120 days. However, the facility's policy, titled 'Nurse Aide Orientation,' did not include information about the requirement for certification within 120 days or the hiring process for non-certified NAs. This lack of a delineated policy contributed to the oversight in NA #1's employment duration.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the 24-hour Nursing Home Resident Care Staffing Report (NHRCSR) was posted in a prominent place accessible to residents and visitors. On two consecutive days, the surveyor observed that the NHRCSR was not posted in the entrance area of the facility. The receptionist confirmed that the reports were usually posted on the wall behind her but were missing, and the last time she saw them posted was the previous week. The Staffing Coordinator (SC) stated that she was responsible for posting the reports daily but was off the previous day and had issues with the printer. She mentioned that in her absence, a colleague should print the reports, and either the Director of Nursing (DON) or the Licensed Nursing Home Administrator (LNHA) would post them. The surveyor informed the LNHA, DON, and VP of Operations (VPoO) about the missing reports. The LNHA acknowledged the issue and stated that he would post the reports if they were not already posted, and staff were inserviced. The facility's policy requires that nurse staffing information be posted in a prominent place, be clear, readable, up-to-date, and reflect staff absences. The facility did not provide any additional information or corrective actions regarding the deficiency.
Unnecessary Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of Tamsulosin. The resident, who was admitted with diagnoses including type 2 diabetes, anemia, and gastritis with bleeding, was observed to have moderately impaired cognition and was always incontinent. Despite the absence of a diagnosis of benign prostatic hyperplasia (BPH), Tamsulosin was prescribed for overactive bladder, a use not approved by the manufacturer. The facility's documentation, including the resident's electronic medical record and physician's progress notes, showed inconsistencies regarding the resident's incontinence condition and lacked justification for the off-label use of Tamsulosin. The surveyor's investigation revealed that the facility's pharmacy consultant recommendations did not address the use of Tamsulosin for this resident. Interviews with the Licensed Practical Nurse/Unit Manager and the Consultant Pharmacist did not provide further clarification on the medication's use. Additionally, late entries in the physician's notes, created after the surveyor's inquiry, attempted to justify the medication's use but still failed to provide adequate documentation of its effectiveness or necessity. The facility's administrative team was unable to provide further documentation to resolve these inconsistencies, leading to the determination of a deficiency.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 12%, which exceeds the acceptable threshold of 5%. During an observation, a surveyor noted that a Licensed Practical Nurse (LPN) administered a 100 mg dose of Docusate to a resident without a specified dosage in the Electronic Medication Administration Record (eMAR). The LPN assumed the dosage based on the availability of the medication, which was not verified against the order. Additionally, the LPN signed for administering Enoxaparin, an injectable medication, without having administered it during the observation period, claiming it was given earlier. Another incident involved a different LPN who left a dose cup of oral medications unattended on a medication cart while administering other supplements to a resident in a common area. This action was against the facility's policy, which prohibits leaving medications unattended. The facility's policy also requires verification of the right medication, dosage, time, and method before administration, and mandates that the eMAR be signed immediately after administering each medication. The surveyor's review of the facility's policy and interviews with the consultant pharmacist and facility leadership confirmed these deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. In the Pink Unit Medication Room, an unlabeled vial of Retacrit was found in the refrigerator, and a Novolin R Flex Pen was improperly stored outside the refrigerator. The Assistant Director of Nursing confirmed that the insulin pen should have been refrigerated and the Retacrit vial should have been labeled with the patient's information. Additionally, expired BD Viral transport tubes were found in the Pharmacy Room, and the temperature log for the refrigerator containing vaccines was not maintained according to CDC guidelines, as it was only recorded once per day instead of twice. On the Blue Unit, a foil package of Ipratropium/Albuterol nebulizer solution was found without a date of opening, despite manufacturer instructions to dispose of it one week after opening. The facility's Medication Administration Policy requires checking expiration dates and recording the opening date on multi-dose containers, but these procedures were not followed. The facility did not provide a policy for medication storage when requested by the surveyor, and the Director of Nursing, Licensed Nursing Home Administrator, and President of Operations were informed of these deficiencies.
Deficiency in Medical Record Maintenance and Incident Documentation
Penalty
Summary
The facility failed to maintain complete, available, and readily accessible medical records for three residents, leading to a deficiency. For Resident #196, the facility did not document evidence of de-escalation, redirection, or monitoring for safety after multiple incidents of aggressive behavior on the same day. Despite the resident's history of mental disorders and a BIMS score indicating cognitive intactness, the facility's records did not reflect adequate preventive measures or interventions following the incidents, including a resident-to-resident altercation. In the case of Resident #134, the facility did not maintain timely and accessible physician visit notes. The resident, who had a history of significant medical conditions including hypotension, cerebral infarction, and anxiety disorder, did not have documented physician visits every 60 days as required. The records showed only two notes from an APN over several months, and additional notes were only added to the chart after the surveyor's inquiry, indicating a lack of proper record-keeping. The facility's failure to maintain complete and accessible medical records was further highlighted by the delayed collection of staff statements related to the incidents involving Resident #196. The LNHA acknowledged that the statements were not gathered promptly, which was necessary for a thorough investigation. This lack of timely documentation and investigation contributed to the deficiency identified by the surveyors.
Infection Control Deficiencies in Catheter Care and Wound Treatment
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by several observations made by the surveyor. One incident involved improper storage of a urinary drainage bag for a resident with a urinary catheter. The drainage bag was observed resting on the resident's mattress instead of being positioned below the bladder level to allow for proper drainage. The CNA responsible for the resident's care acknowledged the mistake, stating that the drainage bag should have been placed in a privacy bag hanging on the side of the bed frame. The LPN and RN/UM also confirmed that the drainage bag should not have been on the mattress, even if the resident was being prepared for transfer. Another deficiency was observed during a wound treatment procedure performed by an LPN. The LPN failed to perform hand hygiene at critical points during the procedure, such as after removing gloves and before donning new ones. The LPN also applied soap before wetting her hands, contrary to the facility's hand hygiene policy. Additionally, the LPN exited the resident's room wearing a PPE gown, which should have been disposed of in the room before leaving. These actions were inconsistent with the facility's infection control policies and the CDC guidelines referenced in the facility's policy. The surveyor's observations highlighted a lack of adherence to established infection control protocols, including proper hand hygiene and PPE usage. The facility's policies clearly outlined the correct procedures for handwashing and the handling of PPE, yet these were not followed during the observed wound treatment. The LPN admitted to not following the correct hand hygiene sequence and acknowledged the error of wearing a PPE gown in the hallway. The Infection Preventionist confirmed the correct procedures and noted the deviations observed during the survey.
Failure to Maintain a Dedicated Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was dedicated solely to the infection prevention and control program (IPCP) and worked at least part-time, as required by the NJ Executive Directive 21-012 and CMS QSO-22-19-NH Memo. The Licensed Nursing Home Administrator (LNHA) acknowledged that there was no IP in the facility from May 2023 until January 2024, during which time the Director of Nursing (DON) was responsible for the IPCP. The absence of an IP was noted during the entrance conference and subsequent interviews, where the LNHA admitted to ongoing but unsuccessful recruitment efforts for an IP. During the period without an IP, the facility's Quality Assurance and Performance Improvement (QAPI) meetings lacked the presence of an IP for two out of three quarters. The LNHA was unable to provide detailed information on infection control reports reviewed during these meetings, aside from COVID-19 statistics. The facility's policies on infection prevention and control, as well as the surveillance plan, outlined the responsibilities of the IP, which were not fulfilled due to the absence of a dedicated IP. The surveyor highlighted the concern that the full-time DON was handling the IP role, which should have been at least a part-time position.
Deficiency in Offering and Documenting Vaccinations
Penalty
Summary
The facility failed to ensure that each resident was offered influenza and pneumococcal immunizations, and that education was provided regarding the benefits and potential side effects of these immunizations. Additionally, the facility did not document that residents or their representatives were given the opportunity to refuse these immunizations unless they were medically contraindicated or previously administered. This deficiency was identified for one of the five residents reviewed, specifically Resident #134, who had a moderately impaired cognition and a complex medical history including conditions such as hypotension, cerebral infarction, and chronic heart failure. The surveyor observed that there was no documentation in the electronic medical record (EMR) for Resident #134 regarding the offering or refusal of influenza and pneumococcal vaccines. The facility's records, including the Immunization tab and the personalized care plan, lacked evidence of any focus on immunization status or education provided to the resident or their representative. Interviews with the Registered Nurse Coordinator (RNC) and the Infection Preventionist Nurse (IPN) revealed inconsistencies and gaps in the facility's protocol for tracking and documenting immunizations, with no clear process for offering vaccines upon admission or during the flu season. Further investigation showed that the facility's policies and procedures for influenza and pneumococcal vaccinations were not effectively implemented. The IPN admitted to not tracking pneumococcal vaccinations and was unable to provide a tracking log for resident vaccinations. The facility's management, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), were informed of these findings, but no additional information or refutation of the findings was provided during the exit conference.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,449 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cedar Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canterbury At Cedar Grove | 0.4 mi | ★★★★★ | 13 | 0 |
| Complete Care At Cedar Grove | 0.7 mi | ★★★★★ | 1 | 0 |
| Complete Care At St Vincents Llc | 1.3 mi | ★★★★★ | 0 | 0 |
| Arbor Glen Center | 1.6 mi | ★★★★★ | 29 | 0 |
| Family Of Caring Healthcare At Montclair | 2.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.