Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allaire Rehab & Nursing during CMS and state inspections, most recent first.
Food storage, labeling, and sanitation practices were deficient when the FSD observed multiple opened or prepared food items in the walk-in refrigerator and prep areas without required dates, with some items mislabeled or past their use-by dates. Boxes of food were stacked on the floor in dry storage, dessert cups on the clean dishware rack had brown spots, staff moved deliveries through the kitchen without hair/beard nets, and a resident room refrigerator lacked a thermometer despite facility policy requiring one.
The facility failed to keep the outdoor refuse area sanitary when a surveyor observed two garbage containers outside, with one lid left open and cardboard boxes exposed to the elements. The FSD stated the lids should be closed, and the LNHA later confirmed both lids should be closed for infection prevention purposes. Facility policy stated that appropriate lids are provided for all containers.
Late Quarterly MDS Assessments for Six Residents: The facility failed to complete Quarterly MDS assessments on time for six residents with significant neurologic and mobility-related diagnoses, including subarachnoid hemorrhage, quadriplegia, cerebral palsy, intracranial injury, and traumatic subdural hemorrhage. The MDS Coordinator acknowledged the assessments were completed late and stated timely completion is important for regulatory compliance and proper care plan updates.
Medication Administration Errors Exceeded Allowed Rate: Surveyors observed an LPN administer multiple meds late for one resident and two meds late for another resident, resulting in an overall 44% med error rate. The LPN acknowledged the late administrations, and the DON confirmed the meds were given beyond the allowed time window and not in accordance with the physician’s orders and facility policy.
Unsafe and Unclean Resident Environment: A resident was observed in bed with an emptied, needleless saline syringe left on top of the blanket, and a soiled paper towel was found inside a drawer outside a room that contained PPE gowns. The LNHA stated that saline syringes should not be left in a resident’s bed. The facility policy requires a clean, sanitary, and orderly environment.
A resident with anxiety and depression, and a BIMS score of 14/15, was observed upset and speaking loudly about a breakfast tray while receiving alprazolam 0.5 mg PRN for anxiety. The order had no documented stop date, duration, or clinical rationale in the chart, and the DON stated PRN psychoactive meds should have a defined duration and documentation in the record.
A resident with neurofibromatosis and moderate protein calorie malnutrition complained of abdominal pain, refused VS and PRN meds, and called 911 for transfer to an acute care hospital. Survey review found the facility did not notify the LTCO of the unplanned hospital transfer/discharge, and the LNH administrator confirmed the notification was required under facility policy.
A resident with a thoracic spinal cord injury had an Annual MDS completed 8 days late. The MDS Coordinator acknowledged the delay and stated that timely completion is important so residents are assessed according to regulation and care plans are updated properly.
A resident with atrial fibrillation was ordered Eliquis, and the MDS reflected daily anticoagulant use, but the care plan did not address the anticoagulant therapy. During observation, the resident was upset about the breakfast tray and staff intervened immediately. The DON later stated the anticoagulant medication should have been included in the care plan.
Care Plan Not Updated for Indwelling Urinary Catheter: A resident with acute cystitis, urinary retention, and neuromuscular bladder dysfunction had physician orders for an indwelling catheter, but the resident-centered care plan still reflected only an external catheter at times and did not include the indwelling urinary catheter. The DON confirmed that care plans should be updated when a resident's condition changes and that residents with indwelling catheters should be care planned for that device.
Failure to follow the Consultant Pharmacist’s recommendation for a PRN alprazolam order. A resident with anxiety and depression, and a BIMS score of 14/15, was observed upset and speaking loudly about a breakfast tray while staff intervened. The pharmacist noted that a duration must be specified for PRN psychoactive meds, but the resident’s alprazolam 0.5 mg PRN order had no stop date or documented rationale in the EMR, and the DON stated monthly pharmacist recommendations should have been completed within 1 to 2 weeks.
Medication Administered Outside Ordered Hold Parameters: A resident with paraplegia, major depressive disorder, and hypotension had an order for Midodrine 5 mg BID with instructions to hold for SBP greater than 90. Review of the MAR showed the medication was given 16 times when BP readings were above the hold parameter. The DON stated nurses should follow physician orders, including medication hold parameters, and the facility policy required vital signs to be checked per physician order before medication administration.
Medication carts were not kept clean, orderly, or free of loose meds. On one cart, a surveyor found 13 loose, unidentified tablets and pills in the drawers and a med card behind the drawers out of reach. On another cart, inhalants, pain-relief patches, and nutritional formula were mixed together in the same drawer instead of being separated by route, and the top drawer handle was broken with jagged plastic exposed.
Infection control was not followed for two residents. A resident with chronic respiratory failure, pneumonia, and a trach had nebulizer tubing/T-piece stored behind the bedside table instead of in a dated bag between uses, despite an order to change the nebulizer set weekly. Another resident receiving IV vancomycin through a PICC had a dressing dated weeks earlier than the required 7-day change interval; the ADON and IP both confirmed the dressing should have been changed.
A corridor handrail on the first floor was not firmly secured to the wall, and a surveyor observed a section of wall adjacent to the elevator with the handrail missing and dry wall exposed where it had previously been attached. The LNHA stated the handrail had become dislodged, and the issue was identified on 1 of 4 floors during the initial tour.
Surveyors found that the nourishment room was not maintained in a sanitary condition, with misaligned cabinet doors, stained ice maker grates, an empty paper towel dispenser, and a dirty microwave. Staff interviews revealed unclear cleaning responsibilities and infrequent cleaning, despite facility policy requiring monthly cleaning and audits.
A deficiency was cited for not ensuring that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by anyone in the facility.
The facility did not manage its operations to ensure effective and efficient use of resources, as required by regulatory standards.
A nurse left oral medications unattended at the bedside of a cognitively intact resident with ALS and other conditions, contrary to facility policy and professional standards. The LPN stated she was waiting for pudding to administer the medications, but both the UM and DON confirmed that medications should not be left at the bedside and must be documented as refused if not taken.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
A resident with significant neurological impairment and pain management needs was discharged with unused Tramadol remaining in the facility. The required destruction of this controlled medication was not properly documented, as the signatures and dates confirming destruction and witnessing by two licensed staff were missing from the controlled drug record, contrary to facility policy and regulatory requirements.
The facility conducted unauthorized searches of all residents' rooms for drugs without obtaining proper consent, violating their rights to dignity and respect. Two residents reported feeling harassed by the searches, which were conducted based on suspicion and probable cause. Despite claims of verbal consent, there was no signed documentation to support this, and law enforcement was not involved during the searches.
The facility failed to ensure cleanliness in medication and treatment carts, with observations revealing dust, debris, and sticky substances in various carts. Staff, including LPNs and RNs, were unclear about the cleaning schedule, and the Unit Manager and Administrator confirmed the carts were dirty. The facility's policy recommended monthly cleaning, but there was confusion about responsibilities between nursing and housekeeping staff.
The facility did not conduct annual performance reviews for several staff members, as required by its policy. Personnel records for a Unit Manager, Companion Aid, Housekeeping staff, Director of Rehabilitation, and a CNA showed no evidence of completed evaluations. The Director of Clinical Operations confirmed that performance reviews were halted, leading to staff dissatisfaction.
A resident's right to unrestricted visitation was violated when the facility enforced a policy limiting visiting hours from 8:00 AM to 8:00 PM, requiring prior permission for visits outside these hours. A family member was initially restricted from visiting before 8:00 AM, despite the resident's admission rights allowing visits at any time. The facility's administrator cited past disturbances as justification for the policy, but it did not align with the resident's rights.
The facility failed to provide complete and accurate SNF ABNs for two residents, omitting estimated costs and leaving options sections blank. The Social Services Director was unaware of the need to document costs and did not follow up with a resident's representative to ensure completion of the ABN.
A resident's privacy curtain was observed to be stained and unchanged over several days, contrary to the facility's cleaning policy. Staff interviews revealed confusion about responsibility for curtain maintenance, with the housekeeping director eventually confirming it was their duty, though he was unaware of the issue.
A resident's grievance regarding inadequate gastrostomy (g-tube) care was not promptly resolved by the facility. Despite family complaints and photographic evidence of improper care, including leaking and undated dressings, the facility failed to update care orders. Interviews revealed that the Social Services Director and an LPN did not ensure necessary changes were made, leaving the resident at risk for infection and diminished quality of life.
A resident with a history of substance abuse experienced an overdose at the facility. The facility failed to assess the resident's risk for substance abuse, develop a comprehensive care plan, or increase monitoring and supervision after the incident. Despite the overdose, there was no evidence of staff education on substance use signs or encouragement for the resident to attend NA meetings.
A resident with a gastrostomy tube did not receive appropriate care as per physician orders, leading to a build-up of matter on the tube and site. The LPN reported that care was provided by the previous shift, but observations showed otherwise. The DON confirmed the expectation to follow orders, indicating a deficiency in care practices.
A justice-involved individual in an LTC facility was denied autonomy and dignity, as they were secluded by correction officers, shackled, and restricted from participating in group activities or community dining. Despite being cognitively intact, the resident's care plan included minimal interactions and required CO approval for activities. Facility staff followed correctional facility protocols, leading to a violation of the resident's rights.
A Justice Involved Individual in a LTC facility was denied the right to retain personal possessions and live in a homelike environment. The resident was secluded by correction officers, restricted from participating in group activities, and served meals without dignity. Despite having intact cognition and requiring assistance with personal care, the resident's preferences for daily routines were not honored due to correctional restrictions.
A Justice Involved Individual in an LTC facility was denied the right to make choices about their care and participate in activities due to restrictions imposed by correction officers. Despite being cognitively intact, the resident was confined to their room, guarded, and not allowed to engage in social interactions or community dining. The facility failed to implement its policies on resident rights, leading to an Immediate Jeopardy situation.
A Justice Involved Individual in an LTC facility was involuntarily secluded by correction officers, restricting their autonomy and participation in activities. Despite having no cognitive impairments or behaviors requiring restraints, the resident was confined to their room, only leaving for showers and therapies under supervision. Facility staff followed correctional guidelines, limiting the resident's interaction and participation, contrary to facility policies on resident rights.
A resident, identified as a Justice Involved Individual, was admitted to the facility with metal ankle shackles applied daily by correction officers, leading to an Immediate Jeopardy situation. The facility's records lacked documentation or consent for the use of restraints, and care plans did not address the need for constant supervision or movement restrictions. Interviews with staff confirmed the routine use of shackles, and facility leadership agreed to follow correctional guidelines despite policies against such restraints.
A Justice Involved Individual admitted to the facility was subjected to seclusion and physical restraints by correction officers, violating resident rights. Despite being cognitively intact, the resident was shackled and unable to participate in activities or interact with others. Facility staff acknowledged that these restrictions were imposed by correctional officers, not the facility, leading to a deficiency in upholding resident rights.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner. During a kitchen observation with the Food Service Director (FSD), multiple food items in the walk-in refrigerator and food prep areas were found without required opened-on or use-by dates, including opened containers of chicken base, an opened bag of barley, an opened bag of dry pasta, and an opened bag of dry cereal. Other items were found with incorrect or expired labeling, including a container labeled as ketchup with an improper label, confectioner's sugar with a use-by date, and food items labeled as tuna and egg that were identified by the FSD as tuna salad and egg salad past their use-by dates. The FSD also observed cookies with a use-by date of 5/18/26 and removed expired items from the refrigerator. Additional observations showed several boxes of food stacked directly on the floor in the dry storage room, and a plastic container of clear tulip dessert cups on the clean dishware rack had brown spots on five cups. Two facility staff members were observed moving deliveries through the kitchen without hair nets, and one male staff member also had no beard net. During the facility tour, a personal refrigerator in a resident room was observed without a thermometer. The LNHA stated staff retrieving deliveries through the kitchen should have worn hair and/or beard nets, and the DON stated resident personal refrigerators should have a thermometer. Facility policies reviewed required opened food items to be dated, dry goods to be stored at least 6 inches above the floor, cold foods to be wrapped, labeled, and dated, and resident personal refrigerators to contain a manual thermometer.
Open Garbage Container in Outdoor Refuse Area
Penalty
Summary
The facility failed to provide a sanitary environment by not keeping the designated outdoor garbage area free of trash and debris and by failing to keep a closed cover over the opening of 1 of 2 garbage containers. During observation with the Food Service Director, the surveyor saw two garbage containers outside the facility, and one container had an open lid with cardboard boxes exposed to the elements. When asked whether the lids should be open, the FSD stated they should be closed and said an employee was probably coming back to load more, although no additional employees were observed in the area. Later, the Licensed Nursing Home Administrator stated that both lids on the garbage containers should be closed and said this was necessary for infection prevention purposes. Review of the facility policy titled Dispose of Garbage and Refuse stated that appropriate lids are provided for all containers.
Late Quarterly MDS Assessments for Six Residents
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set assessments in a timely manner for 6 residents reviewed for resident assessment. Resident #45 had diagnoses including nontraumatic subarachnoid hemorrhage, and the Quarterly MDS showed an Assessment Reference Date of 04/03/2026, but the assessment was completed on 04/25/2026, 8 days late. Resident #81, who had quadriplegia, had an ARD of 04/05/2026 and the assessment was completed on 04/25/2026, 6 days late. Resident #139, diagnosed with spastic quadriplegic cerebral palsy, also had an ARD of 04/05/2026 and the assessment was completed 6 days late. Resident #141, with intracranial injury, had an ARD of 04/03/2026 and the assessment was completed 8 days late. Resident #142, diagnosed with traumatic subdural hemorrhage, had an ARD of 04/02/2026 and the assessment was completed on 04/25/2026, 9 days late. Resident #148, also diagnosed with traumatic subdural hemorrhage, had an ARD of 04/04/2026 and the assessment was completed 7 days late. During interview, the MDS Coordinator acknowledged that the Quarterly MDS assessments for these residents were completed late and stated that timely completion is important to ensure residents are assessed according to regulation and care plans are updated properly. The facility policy stated that the MDS Coordinator is responsible for ensuring timely resident assessments and review.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to administer medications with an error rate of less than 5%, with surveyors observing 11 errors out of 25 opportunities for error, resulting in a 44% error rate. During a medication pass observation, an LPN prepared 10 medications for Resident #109, including Vascepa, Keppra, Metformin, Metoprolol tartrate, Aspirin, Cholecalciferol, Colace, Cyanocobalamin, Escitalopram, and Furosemide. A review of the Medication Admin Audit Report showed all 10 medications were administered later than their scheduled times, with the medications given at 11:31 AM despite scheduled times ranging from 8:00 AM to 9:00 AM. The LPN acknowledged she should have followed the physician's orders and stated she believed medications could be given within one hour before or after the scheduled time. The DON also acknowledged the medications were administered late and more than one hour past the administration time. During another medication pass observation, an LPN prepared medications for Resident #37, including Calcium and Vitamin D, Sertraline, and Vitamin D. The Medication Admin Audit Report showed Sertraline and Vitamin D were administered later than their scheduled 9:00 AM times, at 10:56 AM and 10:57 AM respectively. The LPN acknowledged the two medications were given late. On reinterview, the DON stated medications should be given at their scheduled time and are allowed one hour before and one hour after the scheduled time. The facility policy reviewed in 12/2025 stated medications must be administered in accordance with orders and within one hour of the prescribed time unless otherwise specified.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for Resident #119 and for one of four floors observed during the environmental task. During the initial tour on 05/21/2026 at 10:28 AM, the surveyor observed Resident #119 in bed with an emptied, needleless saline syringe left on top of the resident’s blanket. Later that same tour, at 10:38 AM, the surveyor observed a plastic drawer outside of room [ROOM NUMBER] with a soiled paper towel inside the top drawer that contained personal protective gowns. During an interview on 05/28/2026 at 1:09 PM, the LNHA stated that saline syringes should not be left in a resident’s bed. The facility policy titled, Quality of Life - Homelike Environment, revised 01/2026, states that staff and management shall maximize characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Unnecessary PRN Psychotropic Medication Without Documented Duration
Penalty
Summary
A psychotropic medication regimen was not free from unnecessary use when a resident was ordered alprazolam 0.5 mg PRN for anxiety without a documented stop date, duration, or clinical rationale in the record. The resident had diagnoses of anxiety and depression and was cognitively intact, with a BIMS score of 14 out of 15 on the admission MDS dated 12/19/2025. During observation on 05/21/2026, the resident was speaking loudly and appeared upset about the breakfast tray, and staff intervened immediately. Review of physician orders showed alprazolam PRN orders dated 12/01/2025, 03/04/2026, and 03/12/2026, and the surveyor did not find a stop date or duration for the medication. Further review of the EMR did not reveal any documented rationale for the alprazolam order, and the DON stated that PRN psychoactive medications should be scheduled for 14 or 30 days and that the provider did not place a note in the resident's chart regarding the duration.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman when Resident #161 was transferred to an acute care hospital. Resident #161 had diagnoses including neurofibromatosis and moderate protein calorie malnutrition. On 04/02/2026, the resident complained of abdominal pain, refused all vital signs and all as-needed medications, and the provider was notified but did not prescribe any new orders. The resident called 911 and was transferred at approximately 8:45 AM. The resident’s MDS was updated with a discharge assessment on 4/2/2026 with return anticipated. During survey review, the facility was asked to provide evidence that the LTCO had been notified of the resident’s transfer and discharge, but the Senior Regional Nurse of Clinical Compliance stated that the notification had not been completed. The Licensed Nursing Home Administrator confirmed that when a resident is discharged to the hospital under a medical emergency and later discharged, the LTCO must be notified. The facility policy titled Transfer or Discharge Notice stated that notification of unplanned discharges will be sent to the Office of the State Long-Term Care Ombudsman.
Late Annual MDS Completion
Penalty
Summary
The facility failed to complete the Annual Minimum Data Set (MDS) within the required time frame for one resident reviewed for assessment timing. Resident #91 was admitted with diagnoses including injury to the thoracic spinal cord. The surveyor reviewed the electronic medical record and found that the Annual MDS had an Assessment Reference Date of 04/02/2026, but the assessment was completed on 04/25/2026, which was 8 days late. During interview, the MDS Coordinator acknowledged that the Annual MDS was completed late and stated that timely completion was important to ensure residents were assessed according to regulation and care plans were updated properly. The facility policy identified the MDS Coordinator as responsible for ensuring timely resident assessments and review.
Failure to Care Plan Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan to address anticoagulant medication for one resident with a diagnosis that included atrial fibrillation. The resident’s physician orders showed Eliquis was started on 12/01/2025, and the admission MDS dated 12/19/2025 reflected that the resident received an anticoagulant daily. Review of the resident’s care plans showed no care plan was developed for the anticoagulant medication after it was initiated. During observation on 05/21/2026, the resident was speaking loudly and appeared upset regarding the breakfast tray, and staff intervened immediately. On 05/27/2026, the DON stated that the anticoagulant medication should have been included in the care plan. The facility policy titled Care Plans-Comprehensive, Person Centered stated that a comprehensive person-centered care plan with measurable objectives and timetables is developed and implemented for each resident.
Care Plan Not Updated for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan to include an indwelling urinary catheter. Resident #124 was observed lying in bed while family visited, and the family stated that the resident had recently had an indwelling catheter placed. The resident was later identified by the ADON as having been admitted to the hospital with diagnoses that included UTI. The resident's EMR showed diagnoses including acute cystitis, urinary retention, and neuromuscular dysfunction of the bladder, and physician orders included insertion of an indwelling catheter and a 16F indwelling catheter for urinary retention. A review of the resident-centered care plan showed that the resident was care planned for an external catheter at times related to assistance with personal needs, but use of an indwelling urinary catheter was not reflected. During interview, the DON stated that a resident's care plan should be updated with any change and during care plan meetings, and confirmed that residents with indwelling urinary catheters should be care planned for an indwelling urinary catheter. The facility policy on comprehensive person-centered care plans stated that assessments are ongoing and care plans are revised as information about residents and their conditions change.
Failure to Follow Pharmacist Recommendation for PRN Alprazolam
Penalty
Summary
The facility failed to follow the Consultant Pharmacist’s recommendation regarding Resident #1’s alprazolam regimen. Resident #1 had diagnoses including anxiety and depression, and the admission MDS dated 12/19/2025 showed a BIMS score of 14 out of 15, indicating the resident was cognitively intact. The surveyor observed the resident on 05/21/2026 speaking loudly and appearing upset about the breakfast tray, with staff intervening immediately. The Consultant Pharmacist’s monthly reports dated 02/01/2026 and 03/03/2026 stated that a duration must be specified for as-needed psychoactive medications and that the first order is limited to 14 days unless the prescriber documents a rationale to continue for a longer duration. Physician orders dated 12/01/2025, 03/04/2026, and 03/12/2026 showed alprazolam 0.5 mg as needed for anxiety, but the surveyor did not find a stop date or duration for the medication, and the EMR did not contain a documented rationale for the as-needed alprazolam order without a specified duration. On 05/28/2026, the DON stated that the monthly pharmacist recommendations should have been completed within one to two weeks, and also stated that the nurses could not get ahold of the providers.
Medication Administered Outside Ordered Hold Parameters
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications and that medications were administered in accordance with physician’s orders. Resident #7 was admitted with diagnoses including paraplegia, major depressive disorder, and hypotension. The resident had an order for Midodrine 5 mg by mouth twice daily at 8:00 AM and 5:00 PM for hypotension, with instructions to hold the medication for systolic blood pressure greater than 90. Review of the May 2026 MAR showed that Midodrine was administered outside the hold parameters on 16 of 49 scheduled administration times. The documented blood pressures at those times were above the ordered threshold, including readings such as 91/54, 97/60, 101/68, 112/64, 118/72, 123/72, 121/79, 100/66, 123/65, 112/78, 118/78, 107/67, 116/57, 118/68, and 118/70. The DON stated that nurses should follow physician orders, including medication hold parameters. The facility’s medication administration policy stated that vital signs, if necessary, must be checked per physician’s order before administering medications.
Medication Carts Not Kept Clean and Properly Organized
Penalty
Summary
The facility failed to ensure medication carts were kept clean, orderly, and free of loose medications. During observation of the 1 South medication cart, the surveyor found 13 loose, unidentified tablets and pills in the drawers, and also observed a medication card located behind the drawers and out of reach. These findings were identified during the Medication Storage task for 2 of 4 medication carts reviewed. During observation of the Annex medication cart, the surveyor found the bottom drawer contained prescription inhalants, pain-relief patches, and cartons of nutritional formula mixed together rather than separated by administration route. The surveyor also observed that the top drawer handle was broken and exposed jagged plastic. The facility administrator was informed of the medication cart findings, and the facility policy stated that medications must be stored to ensure proper sanitation, segregation, and security, including separate storage of external products and internal medications.
Infection Control Lapses With Respiratory Equipment and PICC Dressing Care
Penalty
Summary
Appropriate infection prevention and control practices were not followed for a resident receiving respiratory treatment. On 5/21/2026 during the initial tour, the surveyor observed the resident’s nebulizer on the bedside table with the tubing leading behind the table. The resident had diagnoses including chronic respiratory failure with hypoxia, pneumonia, and an encounter for attention to tracheostomy. The resident’s EMR showed an order to change the nebulizer set weekly on Wednesday night shift, and when the ADON retrieved the nebulizer administration T piece from behind the bedside table, she stated it should be stored in a dated plastic bag when not in use. The facility policy for nebulizer administration stated supplies should be dated and placed in a treatment bag. Appropriate central line dressing care was also not performed for a resident receiving IV antibiotics through a PICC line. On 5/21/2026, the resident was observed lying in bed receiving intravenous antibiotics and stated the PICC dressing had not been changed since returning from the hospital. The ADON later verified the dressing was dated 04/29/2026 and agreed it should have been changed. The resident had diagnoses including carbapenem-resistant Acinetobacter baumannii carrier status, a sacral pressure ulcer, and sepsis. The EMR showed orders for IV vancomycin, monitoring of the PICC site every shift, and PICC dressing changes every 7 days with labeling of the dressing date, time, and nurse initials. The IP stated PICC dressings should be changed every 7 days and confirmed the dressing should have been changed.
Missing Corridor Handrail
Penalty
Summary
A corridor handrail on the first floor was not firmly secured to the wall, and the facility failed to maintain the physical environment in a safe condition. During the initial tour, the surveyor observed a portion of the wall adjacent to the elevator where a handrail was missing, with dry wall exposed where a previous handrail may have been secured. The deficient practice was identified on 1 of 4 floors. When informed of the finding, the LNHA stated that the handrail had become dislodged and that maintenance was working to install it. The facility policy titled Maintenance Services Policy stated that the building must be maintained in compliance with current federal, state, and local laws, regulations, and guidelines.
Failure to Maintain Sanitation and Cleanliness in Nourishment Room
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation in the nourishment room, which was found to be in disrepair. Specifically, the cabinet doors were misaligned and had not been reported to Maintenance, stains were present on the grates of the ice maker, and the paper towel dispenser was empty with a roll of paper towels placed on top of the refrigerator. The microwave contained brown debris on the bottom, and the Unit Manager was unsure of the cleaning frequency, stating that either a CNA or nurse would clean it if there was a mess. Additionally, paint chips and peeling paint were noted around the soap dispenser. Interviews with staff revealed that the nourishment room was scheduled to be cleaned once a month by the porter, and additional cleaning would occur if staff reported a need. The Director of Housekeeping confirmed that the ice maker grates should be cleaned during the monthly cleaning, and the cleaning log indicated the room was last cleaned at the beginning of the month. The Director of Nursing acknowledged that the microwave was not assigned to anyone's responsibility and should be cleaned if dirty. The facility's cleaning policy required monthly cleaning and completion of an audit sheet, but the observed conditions indicated these standards were not consistently met.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of its resources. This deficiency was identified based on observations and findings documented by surveyors, indicating that the facility did not meet the required standards for resource management as outlined in regulatory guidelines. No specific details regarding individual residents, staff actions, or particular events leading to this deficiency are provided in the report excerpt.
Medications Left Unattended at Bedside by LPN
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications according to professional standards and facility policy for a resident diagnosed with Amyotrophic Lateral Sclerosis (ALS), hypertension, mood disorder, and anxiety disorder. The resident, who was cognitively intact, had active physician orders for several oral medications, including a neuromuscular agent that required administration on an empty stomach. During a survey, the resident was observed in bed with six pills left in a medicine cup at the bedside while being fed lunch by a caretaker. The nurse responsible for the resident admitted to leaving the medications at the bedside, stating she was waiting for pudding to administer the medications, despite knowing this was against facility policy. Facility policy clearly states that medications must be administered in a safe and timely manner, as prescribed, and should not be left at the bedside. Both the Unit Manager and the Director of Nursing confirmed that leaving medications at the bedside is not permitted and that the expectation is to document medications as refused if not taken. The nurse's action of leaving the medications unattended at the bedside was not in accordance with the facility's medication administration policy and professional standards of nursing practice.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Document Destruction of Controlled Medication
Penalty
Summary
A deficiency was identified when a facility failed to ensure the proper destruction and documentation of a controlled medication for a resident who was no longer present at the facility. The resident, who had diagnoses including anoxic brain damage and required a gastrostomy tube, was on a scheduled pain management regimen that included Tramadol, a controlled substance. Upon review of the resident's records, it was found that although 30 tablets of Tramadol were received and only six were administered, the required documentation for the destruction of the remaining 24 tablets was incomplete. Specifically, the section of the Individual Patient's Controlled Drug Record (IPCDR) for documenting the destruction—'destroyed by,' 'witnessed by,' and 'date'—was left blank. Interviews with facility staff confirmed that the destruction of controlled substances should be witnessed by two licensed staff members and properly documented, as outlined in the facility's own policy. The DON acknowledged that although the medication was placed in the drug destruction system, the required signatures and documentation were not completed due to being called away for a rapid response. The Assistant DON also confirmed that the declining inventory sheet should have been signed after destruction. This failure to follow established procedures resulted in a lack of accountability for the controlled medication as required by state and federal regulations.
Facility Conducts Unauthorized Room Searches, Violating Resident Rights
Penalty
Summary
The facility failed to protect the residents' rights to be treated with respect and dignity by conducting searches of all 136 residents' rooms for drugs, including marijuana, without properly obtaining informed consent for two residents. The searches were conducted on multiple occasions, with the first full facility search occurring after a resident was found with a bottle of pills belonging to another resident. The facility's policy allowed for room searches based on suspicion and probable cause, but there was no documented evidence of consent from all residents, nor was law enforcement involved during the searches. Resident #105 reported feeling harassed by the weekly searches, which triggered flashbacks of living on the street. The resident had a fully intact cognition and was diagnosed with amyotrophic lateral sclerosis, anxiety disorder, and unspecified mood disorder. Despite the facility's claim that the resident verbally agreed to the searches, there was no signed documentation to support this consent. Resident #65 also expressed concerns about the searches, stating that their room had been searched multiple times without their consent. The resident, who was cognitively intact, had refused to sign the facility's policies related to forbidden items and drug possession. The facility claimed that the resident consented to the search when approached, but there was no signed documentation to confirm this. The searches resulted in the discovery of marijuana vapes and other contraband in the resident's room.
Removal Plan
- Room searches will not be conducted for any resident without suspicion or probable cause.
- The resident must be assessed, the care plan updated to reflect the findings of the assessment, and a written consent must be obtained from the resident.
- If the resident/representative does not consent, a room search cannot be completed.
- All staff were educated on the updated facility's drug policy.
Medication and Treatment Cart Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in four medication storage carts and three treatment supply carts, as observed during a survey. The carts were found to have dust, debris, and residue, which could potentially contaminate resident medications and treatment supplies. The facility's policy recommended cleaning the carts at least once a month and as needed, but there was a lack of clarity among staff regarding the frequency of cleaning. During interviews, several staff members, including LPNs and RNs, were unsure about the cleaning schedule, and some carts were found to be dirty despite recent checks. Observations revealed that the medication carts in various areas of the facility, including the annex, first floor North and South Halls, and the third floor, had significant dust, debris, and sticky substances. The treatment carts also had similar issues, with dust, paper, and loose screws found inside the drawers. The Unit Manager and Administrator confirmed the carts were dirty and acknowledged that there was confusion about the cleaning responsibilities, with nurses expected to clean the carts and housekeeping responsible for cleaning them once emptied.
Failure to Conduct Annual Performance Reviews
Penalty
Summary
The facility failed to conduct performance reviews every 12 months for five out of seven employees whose personnel records were reviewed. The facility's policy, revised in November 2023, mandates annual performance appraisals to discuss, plan, and review employee performance. However, the personnel records of several staff members, including a Unit Manager, Companion Aid, Housekeeping staff, Director of Rehabilitation, and a Certified Nursing Aide, showed no documented evidence of performance evaluations being completed. These evaluations are crucial for assessing employee performance and contributions. During an interview, the Director of Clinical Operations acknowledged the absence of performance reviews, stating that this has led to dissatisfaction among staff, with some quitting or requesting raises. The Director mentioned that performance evaluations were officially stopped in July 2024, and this issue is scheduled for discussion in the next corporate meeting. The lack of performance reviews is a violation of the facility's policy and the New Jersey Administrative Code (NJAC 8:39-43.17(b)).
Violation of Resident's Right to Unrestricted Visitation
Penalty
Summary
The facility failed to uphold a resident's right to receive visitors of their choosing at any time, as evidenced by the case of a resident who was restricted from having family visits before 8:00 AM. The facility's policy, which limited visiting hours from 8:00 AM to 8:00 PM, required visitors seeking access outside these hours to obtain prior permission and restricted them to designated supervised areas. This policy was not aligned with the resident's rights as outlined in the New Jersey Admission Packet, which allowed for visits at any time, provided they did not interfere with care or the privacy of other residents. The deficiency was highlighted when a family member of the resident attempted to visit before 8:00 AM and was initially informed by a security officer that staff had complained about early visits. Despite this, the security officer allowed the visit, as there was no direct instruction from the administration to deny access. The resident's roommate expressed no concerns about the family member's visits and appreciated their presence, indicating that the visits did not disturb them. The facility's administrator acknowledged the existence of a visiting hours policy and stated that 24-hour visits were still possible but required scheduling and supervision if they occurred outside the designated hours. The administrator cited past disturbances caused by visitors as a reason for the policy, aiming to ensure a safe and restful environment for all residents. However, the policy's implementation did not adequately consider the individual rights of residents to have unrestricted access to visitors, as guaranteed by their admission rights.
Incomplete SNF ABN Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was complete and accurate for two residents prior to their discharge from Medicare Part A skilled services. For Resident #12, the ABN indicated that skilled care was no longer required as of 04/02/24, but the estimated cost section was left blank. This omission meant that the resident was not fully informed about potential out-of-pocket expenses for continued care. Similarly, for Resident #57, the ABN indicated that skilled care was no longer required as of 09/17/24, and the estimated cost section was also left blank. Additionally, the options section, which allows the resident or their representative to choose how to proceed with care and billing, was not completed. During an interview, the Social Services Director (SSD) admitted to not being aware of the requirement to document the estimated cost on the ABN form. Furthermore, the SSD acknowledged that although a note was sent to Resident #57's representative, there was no follow-up to ensure the representative completed the options section of the ABN. This lack of follow-up and incomplete documentation placed the residents and their representatives at risk of not being fully informed about their potential financial liabilities.
Failure to Maintain Clean Privacy Curtains
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident by not ensuring that the privacy curtain in the resident's room was clean and unstained. The facility's policy on cleaning and disinfection of environmental surfaces, revised in January 2021, states that window/privacy curtains in resident areas should be cleaned when visibly contaminated or soiled. However, during a facility tour, the privacy curtain for a resident was observed to have multiple large, dried, brown stains along the bottom edge, which remained unchanged over several days. Interviews with staff revealed a lack of clarity regarding responsibility for changing soiled privacy curtains. A housekeeping aide indicated that the maintenance department was responsible, while a licensed practical nurse assumed it was housekeeping's responsibility but was unsure. The housekeeping director, upon being informed, confirmed that it was indeed the housekeeping department's responsibility to change soiled curtains, but he was not previously aware of the issue with the resident's curtain.
Failure to Resolve G-Tube Care Grievance
Penalty
Summary
The facility failed to promptly resolve a grievance related to the care of a gastrostomy (g-tube) for a resident, identified as Resident#126. The resident was admitted with diagnoses including spastic hemiplegia and injury of the oculomotor nerve. The care plan required specific interventions for the g-tube, including daily cleansing and dressing changes. However, the resident's family reported issues with the g-tube care, including leaking and improper dressing, which were not addressed in a timely manner. The family member of Resident#126 communicated concerns about the g-tube care through emails to the Social Services Director Assistant (SSDA), highlighting issues such as the tube not being flushed daily and dressings not being dated. Despite these communications, the facility did not make the necessary changes to the resident's care orders. The family provided photographic evidence of the inadequate care, showing dressings soaked with yellowish to dark gray matter, indicating potential infection and neglect. Interviews with the Social Services Director (SSD) and LPN#1 revealed a lack of follow-through on the grievance. Although the SSD acknowledged receiving the grievance and intended to change the care orders, no verification was done to ensure the changes were implemented. LPN#1 admitted to not obtaining the necessary orders for twice-daily dressing changes, resulting in the grievance being unresolved and the resident at risk for infection and diminished quality of life.
Failure to Address Substance Abuse Risk Leads to Resident Overdose
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident#125, who was at risk for substance abuse and overdose. The resident was admitted with a history of alcohol abuse, opioid abuse, psychoactive substance abuse, and major depression disorder. Despite this, the facility did not assess the risk of substance abuse while the resident was in the facility, nor did they develop a comprehensive care plan with interventions to help prevent an overdose. The care plan lacked specific interventions to monitor for signs and symptoms of substance use and did not encourage the resident to attend Narcotics Anonymous (NA) or Alcoholics Anonymous (AA) meetings. The deficiency was highlighted when Resident#125 experienced an overdose while at the facility. The resident was found unresponsive and hypoxic, requiring Narcan administration, and later tested positive for fentanyl. Despite the overdose incident, there was no documented evidence that the facility increased monitoring and supervision of the resident or visitors, assessed the resident's risk for substance abuse, or educated staff on signs and symptoms of possible substance use. Additionally, the facility did not encourage the resident's participation in NA meetings following the overdose. Interviews with facility staff revealed a lack of proactive measures to address the resident's substance abuse risk. The Social Services Director admitted to not encouraging the resident to attend NA meetings, relying on the resident's self-advocacy. The Licensed Practical Nurse confirmed there was no increased monitoring or supervision provided for the resident. The facility administrator acknowledged the presence of a large population of residents with substance abuse problems but did not indicate any specific interventions implemented for Resident#125 following the overdose.
Failure to Provide Appropriate G-Tube Care
Penalty
Summary
The facility failed to provide appropriate gastrostomy tube (g-tube) care for a resident, identified as Resident#126, which increased the risk of g-tube complications. Resident#126 was admitted with diagnoses including spastic hemiplegia and injury of the oculomotor nerve. The care plan indicated the need for g-tube care to prevent aspiration, with specific physician orders to cleanse the site with normal saline, cover it with split gauze, and secure it with paper tape daily. However, on the day of the survey, the Licensed Practical Nurse (LPN#1) reported that the care had been provided by the previous shift, but upon observation, the resident was found holding a piece of gauze with dried yellowish-brown matter and no date, indicating the care had not been performed as documented. Further observation revealed a build-up of dark brown matter on the underside of the retention ring and small amounts on the tube itself, confirming that the site and tubing had not been cleaned. The Director of Nursing (DON) stated that the facility's policy was to follow physician orders for cleaning gastrostomy sites and tubes, and she expected staff to complete the care. The failure to adhere to these orders and policies was confirmed through interviews and observations, highlighting a deficiency in the facility's care practices.
Violation of Resident Rights for Justice-Involved Individual
Penalty
Summary
The facility failed to ensure that a justice-involved individual (JII), identified as Resident #6, was afforded the autonomy to participate in group activities, community dining, and to freely communicate with visitors. Upon admission, Resident #6 was secluded each day by correction officers (COs) from the Middlesex County Correctional Facility (MCCF), which restricted the resident from leaving the room at will and participating in activities outside the room. The resident was observed shackled in their room, with COs present, and was not allowed to intermingle with other residents or visitors. Resident #6 was admitted with diagnoses including cerebrovascular disease and abnormalities of gait and mobility. The Minimum Data Set (MDS) indicated that the resident was cognitively intact with no behaviors and did not utilize physical or chemical restraints. Despite this, the resident's care plan included restrictions such as minimal and supervised interactions with staff, and all activities and items had to be approved by the COs. The resident reported feeling like dirt due to the conditions, including being served meals on disposable plates without proper utensils, which forced them to eat with their hands. Interviews with facility staff revealed that the facility was following MCCF protocols, which included shackling the resident and restricting their rights. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that the resident's rights were not being followed, as they considered the resident to be under the jurisdiction of the MCCF. The facility's failure to treat Resident #6 with dignity and respect, as required by federal regulations, resulted in an immediate jeopardy situation.
Removal Plan
- The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care.
Failure to Respect Resident Rights and Dignity for Justice Involved Individual
Penalty
Summary
The facility failed to ensure that a Justice Involved Individual (JII), identified as Resident #6, was afforded the right to retain personal possessions and to have a homelike environment. Upon admission, Resident #6 was secluded daily by correction officers from the Middlesex County Correctional Facility, which led to an Immediate Jeopardy situation. The resident was not allowed to participate in group activities, community dining, or interact with other residents, and was served meals in a manner that lacked dignity. This seclusion and restriction of personal freedoms were observed by surveyors on 8/15/2024. Resident #6 was admitted with several diagnoses, including disease of the pericardium, auditory hallucinations, hypertension, anemia, personal muscle weakness, and shortness of breath, requiring assistance with personal care. The Minimum Data Set (MDS) assessment indicated intact cognition and a need for assistance in Activities of Daily Living (ADL). Despite expressing preferences for daily routines and activities, the resident reported being unable to exercise these choices due to restrictions imposed by the correction officers, such as needing approval to use a phone or receive personal items. The facility's care plan for Resident #6 included interventions that limited interactions and required correction officer approval for any activities or personal items. During a tour, Resident #6 was found shackled in their room, with limited access to personal belongings, such as a cell phone. Interviews with facility staff revealed that the facility followed a correctional agreement with the correctional facility, which dictated the restrictions placed on Resident #6, undermining the resident's rights and dignity.
Removal Plan
- The facility implemented a corrective action plan to remediate the deficient practice.
- The facility provided education to all administrative facility personnel on CMS guidance in reference to federal requirements for providing services to JIIs' and to ensure that the rights of JIIs can be respected if the individuals is admitted into the facility care.
Violation of Resident Rights for Justice Involved Individual
Penalty
Summary
The facility failed to ensure that a Justice Involved Individual (JII), identified as Resident #6, was afforded the right to make their own choices regarding aspects of life and care, participate in activities, and interact with other residents. Upon admission, Resident #6 was secluded each day by correction officers (COs) from the Middlesex County Correctional Facility (MCCF), which led to an Immediate Jeopardy (IJ) situation. The resident was observed being confined to their room, guarded by COs, and not permitted to participate in group activities or community dining. This seclusion was in direct violation of the resident's rights as outlined by the Centers for Medicare and Medicaid Services (CMS) guidelines. Resident #6 was admitted with diagnoses including cerebrovascular disease and abnormalities of gait and mobility. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, the resident was subjected to restrictions that prevented them from engaging in normal social interactions and activities. The care plan for Resident #6 included minimal and supervised interactions with recreation staff, and any leisure materials had to be approved by the COs. The resident was not allowed to use electronics or receive salon services without approval from the correctional institution. Interviews with facility staff and COs revealed that the facility was following MCCF's protocol for inmates, which included restricting Resident #6's movement and interactions. The resident was served meals on disposable plates with plastic utensils, and their cell phone was kept out of reach. The facility's policies on resident rights, abuse prevention, dining room services, and activities were not implemented for Resident #6, as the facility adhered to MCCF's instructions. This failure to uphold the resident's rights and provide a dignified existence was identified as an isolated incident that jeopardized the health and safety of the resident.
Removal Plan
- The JII was discharged from the facility.
- The facility's referral team will review all future JII referrals to ensure that the rights can be fully respected if the individual is admitted into the facility's care.
Involuntary Seclusion of Justice Involved Individual
Penalty
Summary
The facility failed to ensure that a Justice Involved Individual (JII), identified as Resident #6, was free from involuntary seclusion, leading to an Immediate Jeopardy (IJ) situation. Upon admission, Resident #6 was secluded daily by correction officers from the Middlesex County Correctional Facility (MCCF), restricting their autonomy and choice in daily activities. The resident was not allowed to participate in group activities, community dining, or interact with other residents, which posed a likelihood of psychological harm. Resident #6 was admitted with diagnoses including cerebrovascular disease and abnormalities of gait and mobility. Despite having a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, and no behaviors or restraints noted, the facility did not initiate care plans addressing the need for constant supervision by correction officers. The resident was only permitted to leave their room for showers and physical or occupational therapies, always accompanied by correction officers, and was not allowed to leave the room at will. Interviews with facility staff, including the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and other personnel, revealed that the facility agreed to follow the guidelines of the MCCF, which included restrictions on the resident's participation in activities and visitation. The facility's policies on resident rights and activities were not adhered to, as the resident was not offered activities outside the room and meals were provided in-room without the option to dine with other residents. The correction officers confirmed the use of metal ankle restraints and restricted movement and interaction for Resident #6.
Removal Plan
- The JII was discharged from the facility.
- The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a Justice Involved Individual (JII), identified as Resident #6, was free from physical restraints, which led to an Immediate Jeopardy (IJ) situation. Upon admission, Resident #6, who had diagnoses including cerebrovascular disease and abnormalities of gait and mobility, was shackled by the ankles daily by correction officers from the Middlesex County Correctional Facility. The resident was observed by surveyors with metal ankle shackles and was guarded by correction officers, indicating a lack of autonomy and choice in their care. The facility's records, including the Electronic Medical Record (EMR) and Individualized Care Plans, did not document the use of restraints or provide any consents for their use. The care plans failed to address the need for constant supervision by correction officers or the restrictions on the resident's movement, such as being confined to their room except for showering and therapy sessions. This oversight violated the resident's rights to be free from physical restraints not required for medical treatment. Interviews with facility staff, including the Licensed Practical Nurse (LPN) and correction officers, confirmed the routine use of shackles on Resident #6. The facility's leadership, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), acknowledged that they had agreed to follow the correctional facility's guidelines, which included the use of restraints. This decision was made despite the facility's policies that restraints should only be used for the safety and well-being of residents and with proper consent and documentation.
Removal Plan
- The JII was discharged from the facility.
- The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care.
Failure to Uphold Resident Rights for Justice Involved Individual
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of policies and procedures regarding Resident Rights and Self Determination, as well as the prevention of physical restraints and seclusion. This deficiency was identified during a survey conducted on 8/15/2024, which revealed that a Justice Involved Individual (JII), referred to as Resident #6, was admitted to the facility and subjected to seclusion and physical restraints by correction officers from the Middlesex County Correctional Facility (MCCF). The resident was observed to be shackled and secluded in their room, unable to participate in group activities, community dining, or freely communicate with visitors. Resident #6 was admitted with diagnoses including cerebrovascular disease and abnormalities of gait and mobility. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, the resident was not afforded the autonomy to engage in activities or interact with other residents. The care plan for Resident #6 included interventions that restricted interactions and activities, requiring approval from correction officers for any leisure materials or services. The facility's policies did not include any physician's orders for restraints, yet the resident was subjected to such measures by the correctional officers. Interviews with facility staff, including the LNHA, Director of Nursing (DON), and other personnel, revealed that the decision to accept Resident #6 was made collectively with MCCF administrative staff, who insisted on maintaining the use of restraints. The facility staff acknowledged that the interventions and restrictions were imposed by the correctional officers and not by the facility itself. This situation resulted in a violation of federal and state regulations regarding resident rights, as the facility failed to ensure that Resident #6 could exercise their rights and live in a dignified environment.
Removal Plan
- The JII was discharged from the facility.
- The facility's referral team will review all future JII referrals to ensure that the rights of JII residents can be fully respected if the individual is admitted into the facility's care.
- The facility will review, and update policies annually and as needed.
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 644 citations issued within 25 miles in the last 12 months — including the 14 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 Freehold
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wedgwood Gardens Care Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Applewood Village, Inc | 3.3 mi | ★★★★★ | 4 | 0 |
| Manor, The | 3.4 mi | ★★★★★ | 0 | 0 |
| Jewish Home For Rehabilitation And Nursing, The | 3.6 mi | ★★★★★ | 0 | 0 |
| Accela Rehab And Care Center At Manalapan | 5.7 mi | ★★★★★ | 5 | 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 October 2026) and official state health department websites.