Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Arnold Walter Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with hypothyroidism and other serious conditions did not receive prescribed Liothyronine at multiple scheduled times due to medication unavailability. Staff failed to notify the physician or document reasons for missed doses as required by facility policy, and appropriate follow-up actions were not completed, as confirmed by the DON.
The facility failed to maintain proper kitchen sanitation, as observed during a survey. The FSD performed inadequate hand hygiene, and the trash receptacle was improperly positioned, risking contamination of clean supplies. Paper towels were stored incorrectly, and the exhaust hood had chipping paint. Cutting boards were discolored and pitted, and food in the freezer was improperly stored, leading to freezer burn. These issues indicate non-compliance with facility policies and CDC guidelines.
The facility failed to maintain a homelike environment on two nursing units. On the A Wing, issues included standing water in the shower room, discolored heaters, and inadequate window coverings. On the D Wing, there was ripped wallpaper and damaged baseboards. Staff acknowledged these concerns, but the facility did not adhere to its policy of providing a clean and comfortable environment.
The facility failed to manage respiratory equipment properly, leading to potential contamination. Oxygen tubing for two residents was left unbagged, and one resident used oxygen without a physician's order. Another resident's nebulizer tubing was undated and uncovered, with missing documentation for vital signs during treatments. Tracheostomy care for a resident was not performed with aseptic technique, as required by facility policy.
A facility failed to provide adequate pain management for a resident with a right below-knee amputation. The physician's order for acetaminophen lacked a specified pain level, and there was inconsistent documentation of pain assessment and medication effectiveness. Staff interviews revealed that the resident frequently complained of pain, but documentation was often missing due to nurses being busy. Facility policies required documentation of pain assessments, which were not consistently followed, leading to inadequate pain management.
A facility failed to maintain a resident's dignity during feeding assistance, as CNAs were observed standing over a resident while feeding them, contrary to the facility's policy. The resident, who was legally blind and required substantial assistance, confirmed that CNAs usually stood while assisting with meals. The DON acknowledged that the observed practices did not align with the facility's policy, which emphasized feeding residents with attention to safety, comfort, and dignity.
Two residents' care plans were not updated to include necessary interventions for oxygen use and fall prevention. One resident, receiving oxygen and at risk for falls, had no interventions for oxygen administration or floor mats in their care plan. Another resident using oxygen at night also lacked an intervention for oxygen in their care plan. Staff confirmed these omissions, which contradicted facility policies requiring care plans to be revised as conditions change.
Surveyors identified deficiencies in medication security and PICC line care at an LTC facility. An LPN left medications unsecured on a cart, posing a safety risk, while a resident with a PICC line had an outdated dressing that had not been changed according to facility policy. The facility's DON and other staff acknowledged these issues.
The facility failed to ensure proper accountability and documentation of narcotic medications. Reviews of medication carts revealed missing signatures on shift change logs and incomplete documentation of controlled substance administration. Interviews with staff confirmed that these logs should be completed and signed by both outgoing and incoming nurses, as per facility policy, but this was not consistently done.
The facility failed to properly label and secure medications, as observed during a survey. Opened multidose medications were not dated or labeled with resident information, and prefilled normal saline syringes were found unsecured at a resident's bedside. The facility's policy requires medications to be stored in labeled containers and secured in locked compartments, which was not followed.
The facility failed to properly store and label a resident's personal ice cream brought in by family, which was found in the freezer without a name label and past the discard date. The ice cream belonged to a resident no longer at the facility, violating the policy requiring labeling and timely disposal of uneaten portions.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including acute and chronic respiratory failure, congestive heart failure, and hypothyroidism did not receive their prescribed Liothyronine medication as ordered by the physician. The physician's order specified administration of Liothyronine 25 mcg orally four times daily, but the medication was not given at several scheduled times. Documentation in the Medication Administration Record (MAR) indicated missed doses with comments such as 'awaiting pharmacy delivery,' and in some instances, there was no comment or rationale provided for the omission. Interviews with facility staff revealed that the process for obtaining and administering medications involved the Unit Manager entering orders, pharmacy verification, and delivery to the facility. If a medication was unavailable, staff were expected to notify the physician and seek alternatives. However, in this case, there was no documentation that the physician was informed about the missed doses, and the required follow-up actions were not completed. The Director of Nursing confirmed that staff should have documented a rationale for any missed medication and notified the physician and Unit Manager. Facility policy required immediate notification of the nursing supervisor and physician if a medication was unavailable, contacting the pharmacy, and documenting the reason for any missed dose in the EMAR. These procedures were not followed, resulting in the resident not receiving their thyroid medication as ordered and the lack of appropriate documentation and communication regarding the omissions.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain kitchen sanitation standards, which was observed during a survey. The Food Service Director (FSD) was noted to perform hand hygiene for only 16 seconds, contrary to the facility's policy and CDC guidelines that require at least 20 seconds of lathering. Additionally, the trash receptacle was positioned such that it could come into contact with clean kitchen supplies, and paper towels were improperly stored on a shelf above the trash receptacle, with some appearing wet. The exhaust hood above the cooking area had chipping paint, and several cutting boards in the food preparation area were discolored, stained, and pitted, indicating they were not properly maintained or replaced. In the walk-in freezer, opened boxes of corn on the cob and croissants were found with their contents exposed to air, leading to freezer burn, which was acknowledged by the Regional Food Service Director (RFSD) as inappropriate. The facility's policies on hand washing, equipment maintenance, and food storage were not adhered to, as evidenced by the observations and interviews conducted with the FSD and Infection Preventionist (IP). These deficiencies highlight a failure to follow established procedures designed to prevent foodborne illness and ensure a safe food service environment.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on two nursing units, A Wing and D Wing. On the A Wing, the surveyor observed a shower room with standing water that had a white milky coloring, red/orange discoloration on metal wall heaters, and window coverings made of thin paper-like material with holes, compromising privacy. Additionally, a resident room had a damaged window screen that did not fit properly. The Licensed Practical Nurse/Unit Manager and the Director of Nursing acknowledged these issues, with the latter agreeing that the environment was not homelike. The Maintenance Staff indicated that there was an electronic maintenance system in place, but the issues persisted. On the D Wing, the surveyor noted that the wallpaper behind a resident's bed was ripped, exposing the wall, and the vinyl baseboard in the hallway and a resident room was either wrinkled, coming off, or missing, with the drywall showing rust-like discoloration. The Regional Maintenance Director and the Regional Nurse, along with other facility staff, acknowledged these environmental concerns. The facility's policy emphasized providing a safe, clean, and homelike environment, but the observations indicated a failure to adhere to this policy.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to properly manage and store respiratory equipment, leading to potential contamination and infection control issues. For Resident #85, the oxygen tubing was observed unbagged and exposed to air, contrary to the facility's policy requiring it to be stored in a bag when not in use. This was confirmed by multiple staff members, including the LPN/UM, DON, and IP, who acknowledged the importance of bagging the tubing to prevent contamination. Additionally, Resident #71 was using oxygen without a physician's order, and the tubing was similarly left unbagged and exposed. Resident #73's nebulizer tubing was found undated and uncovered, lying on personal belongings, which could lead to contamination. The facility's policy required the tubing to be labeled, dated, and stored in a designated respiratory bag. Furthermore, there was a lack of documentation for pre and post vital signs and lung sounds during nebulizer treatments, as required by the physician's order. The LPN acknowledged the oversight and the need for proper documentation and storage of the nebulizer equipment. For Resident #115, tracheostomy care was not performed with aseptic technique. The LPN failed to change gloves and perform hand hygiene after removing the resident's trach gauze, leading to potential contamination. The facility's policy required aseptic technique for tracheostomy care, which was not followed in this instance. The IP and DON acknowledged the concerns regarding infection control and the need for proper hand hygiene during trach care.
Inadequate Pain Management and Documentation
Penalty
Summary
The facility failed to ensure proper pain management for a resident with a right below-knee amputation, who frequently experienced pain in the surgical area. The physician's order for acetaminophen did not specify a pain level for administration, and there was no consistent documentation of pain assessment or reassessment after medication administration. The resident's medical records showed that pain medication was administered on multiple occasions without documented evidence of pain assessment, location, description, or effectiveness of the medication. Interviews with facility staff, including a CNA, PT, and LPN, revealed inconsistencies in pain management practices. The CNA reported that the resident often complained of severe pain and requested medication, while the PT noted that the resident experienced phantom pain and sometimes did not receive medication before therapy sessions. The LPN acknowledged that documentation of pain levels, location, and effectiveness was lacking, attributing it to nurses being busy and forgetting to document. The facility's policies on pain management and physician's orders required documentation of pain assessments and monitoring of medication effectiveness, which were not consistently followed. The Regional Director of Nursing confirmed that physician's orders should include a pain level and that all assessments should be documented in the MAR. The lack of documentation and adherence to policies resulted in inadequate pain management for the resident.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to maintain a resident's dignity while providing feeding assistance, as observed by a surveyor. During the initial tour, a Certified Nurses Aid (CNA) was seen standing over a resident in bed while feeding them, with the meal tray positioned behind the CNA. The resident later confirmed that CNAs typically stood while assisting with meals, although one CNA occasionally sat on the bed, requiring the resident to adjust their leg. The resident, who was legally blind and required substantial assistance with eating, was observed again being fed by a CNA standing over them. The Director of Nursing (DON) confirmed that the proper procedure for feeding assistance involved sitting next to the resident to ensure a dignified meal experience. The facility's policy on meal assistance emphasized feeding residents with attention to safety, comfort, and dignity, specifically advising against standing over residents during meals. The DON acknowledged that the observed practices by the CNAs did not align with the facility's policy, which was corroborated by the CNA's own understanding of the proper procedure.
Failure to Revise Care Plans for Oxygen and Fall Prevention
Penalty
Summary
The facility failed to revise the individual comprehensive care plans (ICCP) for two residents, leading to deficiencies in their care. Resident #85 was observed receiving oxygen via nasal cannula at 2 liters per minute, with floor mats folded up in their room. Despite being at risk for falls, the ICCP did not include floor mats as an intervention. Additionally, the ICCP lacked an intervention for oxygen administration, even though a physician's order was in place for oxygen use when the resident's oxygen saturation was below 92%. The Licensed Practical Nurse/Unit Manager acknowledged these omissions and confirmed that the care plan should have been updated to include these interventions. Resident #71, who had a diagnosis of chronic obstructive pulmonary disorder and used oxygen at night, also had an incomplete ICCP. The care plan did not include an intervention for oxygen administration, despite the resident's use of an oxygen concentrator. The resident reported that the facility did not provide a bag to store the oxygen tubing, which was observed lying on the bed. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed that oxygen should have been included as an intervention in the care plan. The facility's policies on comprehensive person-centered care plans and fall prevention emphasize the need for care plans to be revised as residents' conditions change and to include specific interventions for identified risks. However, the care plans for both residents failed to incorporate necessary interventions for oxygen use and fall prevention, as confirmed by the Regional Nurse and other staff members during the survey.
Medication Security and PICC Line Care Deficiencies
Penalty
Summary
The facility failed to properly secure medications during administration, as observed by surveyors. An LPN prepared medications for a resident, including a lidocaine patch and Miralax, and left them unsecured on a medication cart while attending to the resident in their room. This was acknowledged as a safety hazard by the LPN, the Unit Manager, and the Director of Nursing, as residents who wander could potentially access the unsecured medications. The resident involved had a history of spinal stenosis, spondylosis, difficulty walking, and muscle weakness, and was cognitively intact. In another instance, the facility did not ensure proper care for a resident with a peripherally inserted central catheter (PICC) line. The resident, who had chronic respiratory failure and a MRSA infection, showed the surveyor an IV access site with an outdated dressing that had not been changed since insertion. The facility's policy required dressing changes within 24 hours of insertion and weekly thereafter, but there were no records of such changes being made. The RN responsible for the resident confirmed the oversight, and the Infection Preventionist stated that physician's orders were necessary for PICC line dressing changes. The survey team, along with the facility's Regional Nurse, Assistant Administrator, and DON, acknowledged the deficiencies in both medication security and PICC line care. The facility's policies on medication administration and catheter dressing changes were not adhered to, leading to these deficiencies.
Deficiency in Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs and accurately document the administration of controlled medications. During a review of medication storage, it was found that the Change of Shift Controlled Medication Accountability Records for two medication carts had missing signatures from both outgoing and incoming nurses across multiple shifts. This included missing signatures for day, evening, and overnight shifts over several months. Additionally, the Individual Patient Controlled Substance Administration Record log showed that a dose of oxycodone for a resident was not signed out by the administering nurse. Interviews with LPNs and the Director of Nursing confirmed that the change of shift accountability sheets and narcotic inventory logs should have been completed and signed by both outgoing and incoming nurses to ensure accurate counts. The facility's policy required that these logs be completed at each shift change and that the administration of controlled substances be documented immediately. However, the review revealed that these procedures were not consistently followed, leading to incomplete documentation and accountability issues.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label and secure medications, as observed during a survey. In two of the four medication carts reviewed, opened multidose medications such as ipratropium bromide/albuterol sulfate inhalation solutions and prescription artificial tears were not dated with an opened date or labeled with the resident's identifying information. This was confirmed by the LPNs present during the observations, who acknowledged that the medications should have been dated and labeled correctly. The facility's Medication Storage policy requires that medications be stored in their original, labeled containers and dated when opened, which was not adhered to in these instances. Additionally, during an initial tour of the facility, unsecured prefilled normal saline syringes were found at a resident's bedside, stored in a plastic cup on the nightstand. The DON confirmed that these syringes should have been secured in a medication storage compartment accessible only to nurses. The facility's policy mandates that all medications, except emergency drug kits, be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. This failure to secure medications properly was a deviation from the facility's established guidelines.
Improper Storage of Resident's Personal Food
Penalty
Summary
The facility failed to ensure that food brought in by family and visitors for residents was stored and handled in a safe and sanitary manner. During a kitchen tour, a surveyor observed a container of black raspberry ice cream, which was approximately three-quarters empty and dated as opened on 9/23/24, stored in the facility's ice cream freezer. The ice cream was identified as belonging to a specific resident who was no longer at the facility, and it was not labeled with the resident's name. The facility's policy, last reviewed in November 2023, requires that food and beverages from outside sources be labeled with the resident's name and date, and any uneaten portion should be discarded after 72 hours. The Regional Nurse, along with the Director of Nursing, Assistant Administrator, and survey team, acknowledged that the ice cream should have been disposed of.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hazlet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurel Bay Health & Rehabilitation Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Anchor Care And Rehabilitation Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Complete Care At Bayshore Llc | 2.9 mi | ★★★★★ | 2 | 0 |
| Careone At Holmdel | 4.7 mi | ★★★★★ | 0 | 0 |
| Careone At Middletown | 5.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.