Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Alaris Health At Kearny during CMS and state inspections, most recent first.
The facility failed to properly store, label, and handle food during kitchen and tray preparation activities. Surveyors observed undated open ice cream containers, dented canned food, a freezer without a thermometer, items stored improperly in dry storage, and dust and peeling around a ceiling vent. During lunch prep, a dietary aide touched food and food-contact items with the same gloves used on other surfaces, and another aide handled broken plates and changed gloves without hand hygiene; the FSD and Regional Director confirmed several of these practices were not appropriate.
A facility failed to verify an RN's license before hire for 1 of 17 newly hired licensed staff reviewed. The file showed the license verification was dated after the date of hire, while the BOM stated verification is usually completed before hire. Although the LNHA said the RN attended orientation and did not start on the unit that day, the time card showed the RN punched in and out on the hire date.
A resident with a history including TIA, cerebral infarction, atrial fibrillation, traumatic subdural hemorrhage, and dementia had an unplanned hospital transfer and was admitted with an intracranial hematoma. The record contained no evidence that the resident or resident representative received written bed hold notification. The DSS and LNHA stated that bed hold notices were only provided to LTC residents, and the LNHA further stated the notice was only for Medicaid residents.
A resident with severe cognitive impairment, dementia, heart failure, and metabolic encephalopathy was inaccurately coded on the MDS for eating assistance. Surveyors observed an untouched lunch tray while the CNA assignment listed the resident as a feeder, the RN/UM said the resident was only set up, and an LPN stated the resident sometimes needed feeding help. Review of CNA task documentation showed substantial/maximal assistance for eating, and the MDSC confirmed the MDS was coded inaccurately.
Inadequate supervision of a high-elopement-risk resident: A resident with severe cognitive impairment, wandering behavior, and a wander guard order was not consistently monitored using the transmitter tester described in the manufacturer’s guide. Instead, staff described checking the bracelet by bringing the resident near the elevator or door to see if the alarm activated, and staff were inconsistent about knowing where the tester was kept. The resident’s record identified high elopement risk, and the care plan and eTAR included wander guard use and every-shift checks for function and placement.
A resident with an indwelling urinary catheter, cerebral infarction, neuromuscular bladder dysfunction, and intact cognition had catheter drainage tubing and a bag left hanging on the bed side, disconnected and uncapped, rather than properly stored after a switch to a leg bag. Staff interviews confirmed the tubing should have been capped and placed in a bag, and the DON stated it should not have been left in the room. The facility policy addressed catheter care and weekly bag changes but did not include storage instructions.
Oxygen therapy and saturation monitoring were not documented as ordered. One resident had an active PO for O2 by nasal cannula at 2 LPM, but the care plan, monthly nursing summary, and progress notes did not reflect the O2 therapy. Another resident with a trach and continuous O2 had a care plan that included monitoring O2 saturation q shift, but there was no separate PO for that monitoring and the last documented O2 saturation results were only found in the vital signs section through 2/7, with no corresponding progress note documentation.
A resident with ESRD, HTN, and severe cognitive impairment received carvedilol on dialysis days at an 8:00 AM med pass despite a 6:00 AM dialysis chair time and return to the facility around late morning. The DON confirmed the resident could not receive 8:00 AM meds while out for dialysis and stated med times should be adjusted to accommodate dialysis, but the eMAR still showed the dialysis-day carvedilol documented as given at the regular 8:00 AM time. The CP’s med regimen reviews noted no concerns, and the RCP stated the dialysis conflict should have been reviewed.
A facility failed to provide enough CNA coverage to ensure residents received feeding help as outlined in their care plans. Surveyors observed one resident with severe dementia, dysphagia, and a care plan for 1:1 feeding assistance left alone with an untouched meal, and another resident with severe cognitive impairment and a feeding tube eating only small amounts without staff help despite being listed for eating assistance on the CNA assignment sheet. The DON and RD acknowledged both residents sometimes needed assistance, redirection, or total feeding help, but staff were not consistently providing it.
Improper Documentation of Controlled Substance Inventory: An RN failed to sign the declining inventory for three CDS medications for three residents until after the surveyor observed the omission. The RN said the meds had been given earlier that morning and that they had simply forgotten to sign, while the DON stated the declining inventory should be signed immediately upon removal of the medication. Facility policies reviewed did not include guidance on signing out CDS meds on a declining inventory.
A resident with DM2 and COPD was found to be receiving Primidone without documentation of a diagnosis, indication, or benefit-versus-risk rationale. The EMR, including MD/NP notes, psychiatrist consult, neurologist consult, and consultant pharmacy MRRs, did not show seizures, essential tremors, or other support for the med order, and the order itself listed only “overactive nerves” as the reason for use.
Meal slip and food preference failures were observed for two residents during meals. An LPN fed one resident without serving milk, cookies, or ice cream listed on the diet slip, despite the resident’s severe cognitive impairment and care plan noting food preferences and nutritional support. In another meal observation, a CNA fed a resident without serving sherbet listed on the tray’s diet slip, and the RN stated the resident likes it. Both residents had documented nutritional risks and severely impaired cognition, and the facility’s meal ID card/ticket policy required food preferences to be honored during meal service.
Surveyors observed multiple residents being served meals without hand hygiene before or after dining, and no hand wipes were available in the dining room. An RN was also observed administering medications to a resident while wearing gloves without performing hand hygiene before gloving or after glove removal. The LNHA and DON acknowledged hand hygiene expectations, and facility policies reviewed by surveyors required hand hygiene before and after resident contact, before gloving, after glove removal, and before and after meals.
Unsafe and Unsanitary Environmental Conditions: The surveyor observed dust accumulation on ceiling vents in a 3rd floor tub room and toilet room, a shower cubicle without a privacy curtain or posted use sign, privacy curtain rods not properly hooked in two resident rooms, and damaged wood in the 4th floor nourishment area. The RN/UM confirmed the dusty vents and missing curtain, and RM acknowledged the nourishment area condition could be a safety issue for residents, staff, and visitors.
The facility failed to honor residents' choices to have their food reheated after 7:00 PM, affecting 99 residents. Only dietary staff were allowed to reheat food, and they were unavailable after 7:00 PM. This policy contradicted the facility's Resident Rights policy, leading to the deficiency.
A resident with severe cognitive impairment and a history of falls had their call light repeatedly placed out of reach, contrary to their care plan and physician orders. Staff interviews confirmed the responsibility to ensure call light accessibility, yet observations showed the call light was often inaccessible, indicating a deficiency in accommodating the resident's needs.
A facility failed to create a comprehensive care plan for a resident on apixaban, an anticoagulant for atrial fibrillation. The resident's care plan lacked focus areas, measurable goals, or interventions for the medication, despite the facility's policy requiring individualized plans with measurable objectives. The DON confirmed the necessity of monitoring for abnormal bleeding in residents on blood thinners.
A resident with moderate cognitive impairment and requiring substantial assistance for showering received inadequate care, with only four showers documented out of 16 scheduled opportunities. Observations showed unmet hygiene needs, and facility policies on shower documentation were not followed, leading to a deficiency.
A resident undergoing dialysis was not provided with snacks or fluids on dialysis days, potentially leading to hypoglycemic incidents. The facility's policy to provide snacks was not followed, and there was a lack of communication with the dialysis center regarding the resident's nutritional needs. Additionally, the resident's meal intake was inaccurately documented, which could affect nutritional assessments.
A resident with hypertension received antihypertensive medications despite having a systolic blood pressure below the physician-ordered parameters. The MAR showed that the medications were administered on multiple occasions, although the RN responsible claimed not to have given them when the SBP was below 110. The facility's policy requires checking vital signs before medication administration, which was not followed.
A resident's bed rails were not regularly inspected or maintained, resulting in a loose and improperly positioned rail. Despite having a physician's order for side rails to assist with mobility, the facility's ineffective communication and maintenance processes led to the oversight of necessary repairs, posing a potential safety risk.
Food Storage and Hand Hygiene Failures During Meal Preparation
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain kitchen sanitation practices, and failed to store and label food in a manner intended to prevent the spread of food borne illness. During a tour of the 3rd floor satellite kitchen, the surveyor observed open boxes of strawberry and chocolate ice cream and an open box of lemon ice in the freezer with no dates showing when they were opened. The Food Service Director (FSD) confirmed that open dates should have been present on those items. In the basement dry storage room, the surveyor observed four boxes of closed plastic utensils stored less than 18 inches from the ceiling, holiday decorations on top shelves touching the ceiling, a ceiling vent with dust accumulation and surrounding tile peeling, and two cans of applesauce with dented lips measuring about 1/2 inch each. The FSD confirmed the dented cans and stated supervisors were responsible for checking items daily. In the 3rd floor Nourishment/Pantry Room, the freezer had no thermometer, and the FSD stated housekeeping was responsible for checking everything and had probably forgotten to put the thermometer back after cleaning. During lunch tray preparation on the 3rd floor, a dietary aide handled food on resident trays while wearing gloves but touched refrigerator handles, plate lids, bread, cheese, and parsley garnish with the same gloves. The Regional Director confirmed the food should not have been touched that way and provided tongs for the bread rolls and garnish. Later, another dietary aide removed gloves, obtained supplies without hand hygiene, put on new gloves, picked up broken plates from the floor, and changed gloves again without hand hygiene. When asked about the process for removing and donning gloves during tray preparation, the FSD stated handwashing should be done and confirmed no handwashing occurred.
License Verification Not Completed Before Hire
Penalty
Summary
The facility failed to ensure that licensed staff credentials were verified upon hire for 1 of 17 newly hired licensed staff reviewed, Staff Member (SM) #35, a Registered Nurse with a date of hire of 1/30/26. The personnel file contained a License Verification Report dated 2/1/26, and there was no documented evidence that the RN's license was verified before the date of hire. During the entrance conference, the surveyor requested the personnel files for the facility's 36 new hire employees since the last recertification survey and identified this issue during review of the licensed staff file. During interview, the Business Office Manager stated that license verification was done on the website and was usually completed before the date of hire. She also stated that SM #35 had orientation on 1/30/26 and did not work on the unit until 2/3/26. However, the time card provided by the facility showed that the RN punched in at 9:00 AM and punched out at 3:00 PM on 1/30/26. The LNHA and DON were notified of the concern, and the LNHA stated that SM #35 attended a class on 1/30/26 and did not start on the unit that day, but no additional information was provided.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to the resident or resident representative for one resident who had an acute transfer to the hospital. The resident’s admission record showed diagnoses including personal history of TIA, cerebral infarction without residual deficits, unspecified atrial fibrillation, traumatic subdural hemorrhage without loss of consciousness, and unspecified dementia. The most recent discharge return anticipated MDS indicated an unplanned transfer to the hospital, and nursing documentation noted that the resident was admitted with an intracranial hematoma. Review of the medical record found no documented evidence that bed hold notifications were given to the resident or resident representative when the transfer occurred. The DSS stated that bed hold notices and Ombudsman notifications were sent the next day after discharge or transfer, or on Monday if the transfer occurred on a weekend, and that this process applied only to LTC residents. The LNHA stated that the facility did not give bed hold notices to subacute residents and that bed hold notices were given only to LTC residents; he also stated that the resident was at the facility for less than 24 hours and that the bed hold notice was only for Medicaid residents.
Inaccurate MDS Coding for Eating Assistance
Penalty
Summary
The facility failed to accurately complete a portion of the MDS for one resident, resulting in the resident’s eating status being coded as supervision or touching assistance when the supporting documentation reflected a higher level of assistance. The resident had diagnoses including metabolic encephalopathy, heart failure, dementia with severe cognitive impairment, and recurrent depressive disorders. The significant change MDS with an ARD of 1/12/26 included a BIMS score of 5 out of 15 and coded eating as supervision or touching assistance, while the care plan stated the resident required staff participation to eat and the RD note described the resident as dependent on staff for feeding. During survey observations, the resident was seen in a wheelchair with an untouched, uncovered lunch tray, and the CNA assignment sheet identified the resident as a feeder. The RN/UM stated the resident was a set up and not a feeder, but did not explain why the CNA assignment listed feeder. An LPN later stated the resident at times needs assistance with feeding. Review of the CNA task documentation for the 7-day look-back period showed the resident was documented as receiving substantial/maximal assistance for eating for a total of 10 meals. The MDSC stated that based on what was documented, eating should have been coded as substantial/maximal assistance and confirmed the MDS had been completed inaccurately.
Inadequate supervision of a high-elopement-risk resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment, a known history of wandering, and a high elopement risk was appropriately supervised and monitored for safety. The resident’s record showed diagnoses including delirium due to a known physiological condition, hypertension, and bipolar disorder. The most recent MDS reflected a BIMS score of 5 out of 15, indicating severely impaired cognition, and the care plan identified the resident as having potential for wandering related to dementia and being at risk for elopement/wandering due to disorientation to place and impaired safety awareness. The resident’s elopement risk evaluation identified the resident as high risk for elopement and included use of a wander guard as needed. The February 2026 eTAR included orders for a wander guard bracelet on the right ankle with every-shift checks for function and placement. During interviews, multiple staff members described checking the bracelet by bringing the resident near the elevator or door to see whether the alarm activated, rather than using the transmitter tester described in the manufacturer’s user guide. The LPN, RN, RN/UM, CNA, ADON, DON, and LNHA each described the resident being taken near the elevator or door as the method used to check function. The manufacturer’s user guide stated that the transmitter should be tested using the transmitter tester and specifically noted, “Never take a resident to a door to test their transmitter.” The facility’s own Wander Guard policy also stated that daily every-shift testing was required and described the elevator alarm system, with nearby personnel to redirect the resident if the alarm sounded or the doors held in place. The surveyor observed the resident asleep in bed, and later, while the RN showed the wander guard bracelet on the resident’s ankle, the resident stated that they wanted to get out of here. The facility’s staff were inconsistent about the existence and use of a testing device, with some stating they were unaware of one and the MD later showing the surveyor the testing device in a drawer in the third-floor RN/UM office.
Improper Storage of Urinary Catheter Drainage Tubing
Penalty
Summary
The facility failed to ensure the indwelling urinary catheter drainage tubing for one resident was stored in a manner to prevent UTI. During observation, the resident was seated in a wheelchair in the room while a urinary catheter drainage bag and tubing were seen hanging on the side of the bed, not connected to the resident. The end of the tubing was not capped, and the drainage bag and tubing were not properly stored. The resident stated that staff had changed the drainage bag to a leg bag but was not sure what they did. The resident had diagnoses including cerebral infarction, neuromuscular dysfunction of the bladder, and hypertension. The most recent quarterly MDS showed a BIMS score of 13 out of 15, indicating intact cognition, and documented that the resident had an indwelling catheter. The February 2026 eTAR included an order to change urinary drainage bags every Tuesday night shift. Staff interviews reflected that when a drainage bag was changed to a leg bag for wheelchair use, the tubing should be wiped, capped, and placed in a bag in the bathroom. However, the surveyor observed that the tubing was left uncapped and not stored properly. The CNA and RN/UM stated that the tubing should have been capped and placed in a bag, and the DON stated that if the bag and tubing were disconnected, they should not be left in the room. The DON also stated that the bag and tubing should be recapped and, if the cap could not be found, thrown out. The facility policy addressed catheter care and weekly drainage bag changes, but it did not contain information on storing drainage bags.
Oxygen therapy and saturation monitoring were not documented as ordered
Penalty
Summary
The facility failed to ensure that Resident #9’s comprehensive care plan and nursing documentation reflected a physician’s order for oxygen therapy. Resident #9 was admitted with diagnoses including pneumonia, dysphagia, failure to thrive, dementia, and gastrostomy status. On observation, the resident was lying in bed with oxygen in place via nasal cannula at 2 LPM from a concentrator. The medical record showed an active physician order dated 1/29/26 for oxygen by nasal cannula at 2 LPM every shift for shortness of breath, along with an order to change the oxygen tubing weekly, and the eMAR showed these orders were transcribed and signed as administered. Despite the active oxygen order, the resident’s personalized care plan did not identify oxygen therapy, the monthly nursing summary did not reflect that the resident was on oxygen, and there were no progress notes documenting the resident’s oxygen therapy. The resident’s care plan had last been reviewed and completed on 1/22/26. The surveyor notified the LNHA and DON of these findings, and no additional information was provided at exit conference. The facility also failed to ensure that Resident #11, who was receiving oxygen therapy via a humidified trach collar, had oxygen saturation monitored as a standard of practice. Resident #11 had diagnoses including tracheostomy, anoxic brain damage, and hypertension, and the most recent quarterly MDS indicated a BIMS score of 00/15 with severely impaired cognition. The care plan stated the resident had a trach to maintain adequate airway and oxygen delivery related to respiratory failure and included monitoring oxygen saturation every shift, but there was no separate physician order for oxygen saturation monitoring. The February 2026 record contained oxygen saturation values documented in the vital signs section through 2/7/26, but there was no documentation of oxygen saturation results in the progress notes and no documented oxygen saturation results after that date. The DON stated that oxygen saturation was checked during trach care, but also acknowledged that if vital signs were done they should be documented and that if it was not done then it was not documented.
Dialysis Medication Times Not Adjusted
Penalty
Summary
The facility failed to provide dialysis-related medication care and services in accordance with professional standards for a resident with end stage renal disease, essential hypertension, and severe cognitive impairment. The resident’s care plan included giving hypertensive medications as ordered, and the physician orders showed dialysis every Tuesday, Thursday, and Saturday with a 6:00 AM chair time. The electronic record also showed carvedilol ordered for both dialysis and non-dialysis days at 8:00 AM and 8:00 PM. The eMAR documented that the carvedilol ordered for dialysis days was given during the 8:00 AM medication time interval, even though the resident’s dialysis schedule required an early morning chair time and the resident typically returned to the facility around 11:30 AM to 12:00 noon. During interview, the DON confirmed the dialysis schedule and stated the resident could not receive 8:00 AM medications on dialysis days unless the resident refused to go to dialysis. The DON also stated that medication times should be adjusted to accommodate dialysis. The consultant pharmacist progress notes reflected medication regimen reviews with no recommendations made, and the facility’s consultant pharmacy reports policy required irregularities to be documented and reported. The regional consultant pharmacist stated that the CP should be reviewing eMARs for medication times that do not conflict with dialysis and acknowledged that the carvedilol orders should have been reviewed as a valid concern. The facility’s medication administration policy required medications to be administered in accordance with the orders, including the required time frame.
Insufficient staffing led to missed feeding assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure residents received feeding assistance in accordance with their care plans. Surveyors observed that the Nursing Home Resident Care Staffing Report for the 7 AM to 3 PM shift showed a CNA-to-resident ratio of 1:9.3 on a unit with a census of 111, and the CNA assignment sheets showed multiple CNAs each responsible for 10 to 11 residents, including several residents who needed help with feeding. The facility’s staffing and ADL policies stated that adequate staffing would be maintained and that residents would receive assistance with ADLs, including eating, each shift as appropriate. One resident had diagnoses including metabolic encephalopathy, heart failure, diabetes, severe dementia with agitation, dysphagia, and hearing loss. The resident’s MDS showed severely impaired cognition, and the care plan required 1:1 feeding assistance with all meals and staff participation to eat. The dietitian documented that the resident was dependent on staff for feeding and that intake should continue to be observed. During lunch observation, the resident was served a tray, the meal was uncovered, and the resident was left alone without anyone feeding them. The food was later confirmed to be untouched. Although the RN/UM initially stated the resident was a set-up only, other staff, including an LPN, stated the resident at times required feeding assistance. The DON later stated the resident could feed self after set-up but also acknowledged that the resident sometimes required physical assistance because of behavior. A second resident had diagnoses including failure to thrive, protein-calorie malnutrition, and hypertension. The resident’s MDS showed severe cognitive impairment, eating dependence, and that more than half of calories came from tube feeding. The care plan included interventions to encourage oral intake and addressed refusal to eat. Surveyors observed the resident twice seated with a lunch tray and eating only small amounts without staff assistance or encouragement. The DON stated the resident could eat by themselves but might need assistance, redirection, or other aid because of confusion and dementia, and the RD stated the resident did much better when assisted with feeding or fed with total assistance. The facility’s assignment sheet also listed this resident as needing help with eating, yet surveyors observed no staff assisting during the meal observations.
Improper Documentation of Controlled Substance Inventory
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring proper documentation of controlled dangerous substances for three residents. During observation of the side 2 medication cart on the 4th floor, the surveyor saw the RN still had to sign the declining inventory documents for Unsampled Resident #1’s Suboxone, Resident #44’s alprazolam, and Resident #89’s lacosamide. The RN then signed and dated the declining inventory sheets in the surveyor’s presence and stated that they had been running late and forgot to sign the declining inventory. When questioned, the RN stated the usual process was to sign for the medications when they were given and said the medications had been administered around 8:30 AM. The DON later stated that the declining inventory should be signed immediately upon removal of the medication. Review of the facility’s Storage of Medications Policy and Medication Administration Policy did not include guidance about signing out CDS medications on a declining inventory, while the Inventory of Controlled Substances Policy stated that controlled drugs are inventoried and documented under proper conditions in compliance with state and federal requirements.
Unnecessary Primidone Without Documented Indication
Penalty
Summary
The facility failed to ensure that Resident #6’s drug regimen was free from unnecessary drugs because Primidone was ordered without documentation of a diagnosis, indication, or benefit-versus-risk rationale. The resident’s admission record listed diagnoses including type 2 diabetes and COPD, but did not include seizures or essential tremors. The medication order summary showed Primidone 50 mg, 0.5 tablet by mouth at bedtime for “overactive nerves,” a description that did not identify a clear clinical indication for the medication. Review of the resident’s progress notes, psychiatrist consult, and consultant pharmacist medication regimen review notes did not reveal documentation supporting the use of Primidone or any associated diagnosis. The physician progress note and NP note also did not reflect the medication’s use or indication. During the survey, the LNHA, DON, and regional consultant pharmacist were informed that there was no documentation for Primidone’s use or effectiveness, and the regional consultant pharmacist acknowledged that the medication should have been reviewed for appropriate diagnosis and indication. The neurologist consult reviewed by the surveyor also did not provide any contributory information, diagnosis, or indication for Primidone.
Meal Slip and Food Preference Failures During Observed Meals
Penalty
Summary
The facility failed to ensure that the menu or diet slip was followed and failed to ensure that residents received food and beverages in accordance with their preferences. During a lunch observation in the 4th floor dining room, Resident #92 was being fed by an LPN, but the resident did not receive the 4 fluid ounces of whole milk listed on the dietary slip placed on the resident’s table. The surveyor also observed that the resident did not receive the two oatmeal raisin cookies and ice cream listed on the diet slip. The LPN confirmed the resident did not receive the milk, and later confirmed the resident was not given the ice cream and cookies. The IPN did not respond when the concern was raised, and the Dietician stated the resident probably did not want milk for lunch, while also stating there was no way to remove milk from the diet slip and being unsure whether that preference was in the care plan. Resident #92’s record showed diagnoses including epileptic seizures related to external causes, unspecified cataract, and dementia with agitation. The most recent MDS showed a BIMS score of 00 out of 15, indicating severely impaired cognition. The active care plan identified a nutritional risk related to psychosis, depression, dementia, variable appetite, and history of non-significant weight loss, and included interventions to encourage PO and fluid intake, honor food preferences such as vanilla ice cream and sandwiches, and provide ordered oral nutrition supplements. Despite these documented preferences and interventions, the resident did not receive items listed on the meal slip during the observed meal. During another meal observation, Resident #3 was being fed in the room by a CNA, and the resident did not receive sherbet listed on the diet slip in the tray. The CNA acknowledged the sherbet was not given, and the RN stated she would call the kitchen to send it because the resident likes it. Resident #3’s record showed diagnoses including end stage renal disease and unspecified protein-calorie malnutrition, with a quarterly MDS BIMS score of 5 out of 15 indicating severely impaired cognition. The active care plan identified nutritional risk related to dysphagia, mechanically altered diet, and MNA score, with interventions to encourage PO and fluid intake and honor food preferences.
Hand Hygiene and PPE Failures During Meals and Medication Pass
Penalty
Summary
The facility failed to follow appropriate hand hygiene practices for four residents during meal observation and failed to follow appropriate hand hygiene and PPE practices for an RN during medication administration. Surveyors observed Resident #70 self-propel their wheelchair into the dining room and join other residents for lunch without being offered hand hygiene before the meal, and no disinfecting wipes or hand wipes were available in the dining room at that time. Resident #104 was also brought into the dining room and was not offered or assisted with hand hygiene before the meal was served. During the same meal observation, Resident #70, Resident #39, and Resident #52 left the dining area without staff offering hand hygiene after the meal. Resident #52 later stated that hand hygiene was not offered before or after the meal that day. When the Infection Preventionist Nurse checked the dining room, there was no container of hand wipes present. The LNHA stated that he did not find hand hygiene guidelines indicating residents should be offered or assisted with hand hygiene after meals, and both the LNHA and DON stated that hand hygiene should be provided prior to meals. Surveyors also observed an RN preparing and administering medications to Resident #29 while wearing gloves but without performing hand hygiene before entering the room or after removing the gloves. The RN administered eye drops and other due medications, then returned to the med cart and removed the gloves without observed hand hygiene. The DON later stated that handwashing should be performed both before and after glove use, and that ABHR would be appropriate if hands were not soiled after glove removal. The facility policy reviewed by surveyors stated that hand hygiene should be performed before and after contact with residents, before gloving and after gloves are removed, and before and after eating.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in the 3rd floor tub room, two resident room privacy curtain areas, and the 4th floor nourishment area. During an environmental tour, the surveyor and the RN/UM observed grayish dust accumulation on the ceiling vent in the middle of the tub room, dust on the ceiling vents in the first and second shower cubicles, and dust on the ceiling vent in the toilet room inside the tub room. The RN/UM confirmed the dust accumulation and stated housekeeping would be notified. The third shower cubicle had no privacy curtain and no posted sign indicating whether it was in use, and a shower chair was present inside the cubicle; the RN/UM stated the cubicle was not being used and acknowledged the missing curtain and dust on the vent. The surveyor also observed privacy curtain rods in rooms R343 and R342 that were not properly hooked. In the 4th floor nourishment area, the wooden cover under the sink was uneven, and the cabinet below the ice machine had chipped wood with a piece sticking out. The Regional Maintenance staff member acknowledged the concerns and stated the condition could be a safety issue for residents, staff, and visitors because the area was open and part of the common resident area. The facility policy stated that housekeeping and maintenance shall maintain a sanitary, orderly, and comfortable environment, but these conditions were observed during the tour.
Failure to Honor Resident Food Reheating Preferences
Penalty
Summary
The facility failed to honor the residents' choices regarding having their food warmed by staff members after 7:00 PM, affecting 99 out of 107 residents who received meals. During a group meeting, residents expressed concerns that they were unable to have their food reheated after 7:00 PM because the dietary staff, who were the only ones trained and allowed to reheat food, were not present. This policy was confirmed by the facility's Administrator, who stated that only dietary staff were trained to prevent unsafe food temperatures, and the kitchen operated from 5:30 AM to 7:00 PM. Interviews with various staff members, including CNAs and the Regional Dietician, confirmed that only dietary staff were permitted to reheat food, and this service was unavailable after 7:00 PM. The facility's policy on food reheating, dated 01/24/24, stated that only dietary staff could reheat food, and this service was available only during kitchen hours. The facility's undated policy on Resident Rights emphasized the importance of respecting residents' choices, yet the restriction on reheating food after 7:00 PM contradicted this policy, leading to the deficiency.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as R69, which could lead to unmet care needs. R69 was admitted with diagnoses including heart failure, osteoarthritis, osteoporosis, and a history of falls. The resident's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment, but no upper or lower extremity impairment, requiring partial assistance to move from lying to sitting. The care plan included an intervention to ensure the call light was within reach, as R69 was at risk for falls. However, during multiple observations, the call light was found out of reach, either on the bed, tied to the bedside rail, or on the floor, and R69 was unaware of its location. Interviews with staff, including an LPN and an RN, confirmed that all staff were responsible for ensuring call lights were accessible to residents. The LPN acknowledged the improper placement of the call light and corrected it during the observation. Despite the facility's policy and physician orders to keep the call light within reach every shift, the repeated failure to do so was observed, indicating a deficiency in accommodating the resident's needs and preferences.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R105, who was receiving an anticoagulant medication, apixaban, for atrial fibrillation. Upon review of R105's Comprehensive Care Plan in the electronic medical record, it was found that there were no focus areas, measurable goals, or interventions documented for the use of the anticoagulant. This oversight was identified during a review of the resident's Medication Administration Record, which confirmed the administration of apixaban at a dosage of five milligrams twice daily. The Director of Nurses acknowledged that residents on blood thinners should have a care plan that includes monitoring for abnormal bleeding. The facility's policy mandates an individualized, interdisciplinary plan of care with measurable objectives and timeframes, which was not adhered to in this case.
Failure to Provide Adequate Showering Assistance
Penalty
Summary
The facility failed to provide adequate assistance with showering for a resident, identified as R14, who was reviewed for activities of daily living (ADLs). R14, who had moderate cognitive impairment and required substantial assistance for showering, was documented to have received only four showers out of 16 scheduled opportunities over a two-month period. The resident's care plan indicated a need for total assistance with most ADLs, yet there was no documentation of reoffering showers after refusals, nor were refusals consistently documented in the progress notes. Observations and interviews revealed that R14's hair was greasy and dandruff was present, indicating unmet hygiene needs. Despite the facility's policy requiring documentation of shower refusals and reoffering showers, there was a lack of consistent documentation and follow-up. Interviews with staff, including CNAs and the DON, indicated that R14 often answered 'no' to questions, which may have contributed to the lack of showers. However, the facility's documentation did not reflect attempts to reoffer showers or adequately document refusals. The facility's policies on shower documentation and ADL performance were not adhered to, as evidenced by the lack of documentation in the Point of Care kiosks and progress notes. The failure to provide consistent showering assistance and documentation increased the potential for R14 to have unmet hygiene needs, as observed by the surveyors. The facility's non-compliance with its own policies and procedures regarding showering and documentation contributed to the deficiency identified in the report.
Failure to Provide Adequate Nutrition for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident, who was undergoing dialysis, was provided with adequate nutrition and hydration on dialysis days. The resident, identified as R51, was not offered a snack or fluids when away from the facility during mealtimes, which could potentially lead to hypoglycemic incidents. The facility's policy required that the dietary department be notified to provide a snack on dialysis days, but this was not adhered to. The resident reported leaving the facility at 9:00 AM and returning around 3:36 PM without any food provided by the facility, despite having diabetes and being at nutritional risk. The resident's care plan was not updated to reflect the new dialysis center location after a physician order change, and there was a lack of communication between the facility and the dialysis center regarding the resident's nutritional needs. The facility staff, including RN1 and the Director of Nursing, were under the impression that the resident could not take food or drink to the dialysis center due to infection control concerns. However, the dialysis center confirmed that residents could bring snacks and drinks to consume before or after the procedure, especially for diabetic patients. Additionally, there were inaccuracies in documenting the resident's nutritional intake. The Point of Care system recorded meal intakes at times when the resident was not present at the facility, indicating a delay in meal intake documentation. This inaccurate documentation could lead to incorrect nutritional assessments for the resident. The facility staff, including CNAs, were responsible for capturing meal intakes, but the documentation did not accurately reflect the resident's actual meal consumption.
Failure to Follow Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure that staff adhered to physician-ordered parameters for administering blood pressure medications to a resident diagnosed with hypertension. The resident, identified as R105, was prescribed Entresto and metoprolol, with specific instructions to withhold these medications if the systolic blood pressure (SBP) was below 110. However, the Medication Administration Record (MAR) indicated that the resident received these medications on multiple occasions when the SBP was below the prescribed threshold, specifically on four consecutive days. Registered Nurse (RN) 3, who was responsible for administering the medications during the specified times, acknowledged awareness of the SBP parameters and claimed not to have administered the medications when the SBP was below 110. Despite this assertion, the MAR documented that the medications were given, and there was no documentation to indicate that the medications were held. The facility's policy on medication administration requires verification of vital signs before administering medications, which was not adhered to in this instance.
Failure to Maintain Bed Rail Safety
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to a deficiency in ensuring the safety of a resident's bed. Specifically, the bed rails of a resident, who was admitted with spinal stenosis and encephalopathy, were not properly maintained. The resident had a physician's order for two half side rails to assist with repositioning due to muscle weakness and decreased balance. However, observations revealed that the left bed rail was loose and had a significant gap between the rail and the mattress, posing a potential risk of entrapment. Interviews with facility staff, including a registered nurse and the Director of Nursing, indicated that while nurses were responsible for assessing the need for bed rails, they did not monitor the condition or placement of the rails. The maintenance department was tasked with ensuring the bed rails were secure, but the process for reporting and addressing maintenance needs was ineffective. The communication book used by nursing staff to report repairs did not include the resident's bed rail issue, and the Regional Maintenance Director acknowledged the inadequacy of the current system in tracking and completing necessary repairs.
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What surveyors actually found near you
We read the 1,536 citations issued within 25 miles in the last 12 months — including the 25 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kearny
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alaris Health At Belgrove | 0.4 mi | ★★★★★ | 16 | 0 |
| Broadway House For Continuing Care | 1.1 mi | ★★★★★ | 1 | 0 |
| New Vista Nursing & Rehabilitation Ctr | 1.1 mi | ★★★★★ | 2 | 0 |
| Forest Hills Center For Rehabilitation And Healing | 1.3 mi | ★★★★★ | 0 | 0 |
| Sinai Post-acute Nursing & Rehab Center | 1.9 mi | ★★★★★ | 1 | 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.