Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Aster Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
An agency LPN administered another resident’s medications to a resident with dementia and dysphagia, including Amlodipine 10 mg, Aspirin, Divalproex Na, Zoloft, and Iron, in addition to the resident’s ordered Amlodipine 2.5 mg. The resident had moderately impaired cognition and was later sent to the ER for observation after a blood pressure drop was documented. The error occurred when the LPN failed to correctly identify the resident during med pass.
A resident with intact cognition alleged that an LPN screamed at them and used expletives, but the LNHA did not complete a full abuse investigation. He obtained statements from the two involved nurses and reviewed one behavior note, but did not gather written witness statements from other staff or residents, did not document a summary and conclusion, and did not suspend the accused staff as required by policy.
Failure to Investigate and Report Alleged Staff-to-Resident Abuse: The LNHA did not fully investigate a resident’s allegations that an LPN verbally abused and threatened them, and he did not report the allegations to the state agency because he did not think they were abuse and could not substantiate them. He also did not obtain witness statements or a written resident statement, and a separate allegation involving another LPN was handled similarly, despite the facility’s abuse policy requiring immediate protection of the resident, suspension of the accused staff, witness interviews, and timely reporting.
Failure to use an infection assessment tool for residents receiving antibiotics was identified for 14 of 14 months reviewed. Antibiotics were prescribed each month during the review period, but the IP stated she had not used a surveillance tool since taking the role, and the DON stated the facility had only just started implementing the McGeer Surveillance tool and did not know how antibiotic appropriateness had been determined. The facility’s Infection Surveillance Plan and Antibiotic Stewardship policy both referenced use of surveillance criteria and an antibiotic stewardship program.
A broken and disconnected hot water heater led to resident room and shower water being supplied from the building boiler, which cycled based on air temperature rather than water temperature. Surveyors found widely fluctuating water temperatures, including readings from 80 to 131 degrees Fahrenheit, and a resident reported the water was sometimes freezing cold, lukewarm, or burning hot. The MD confirmed the setup, and the Administrator stated the facility had known about the broken heater for about five years.
Failure to report alleged verbal abuse to NJDOH: A cognitively intact resident alleged that an LPN threatened and insulted them, including calling them an ugly cripple and using profanity. The LNHA and DON discussed the allegations and gathered some staff statements, but the LNHA said he did not report the matter because he did not think it was abuse or could be substantiated. The facility’s abuse policy required reporting suspected abuse to the state within two hours and obtaining written witness statements.
A facility failed to develop comprehensive care plans for a resident with PTSD, a resident with dementia, and a resident receiving continuous O2 therapy. Records showed the PTSD diagnosis was added to the chart but not reflected in the ICCP, the dementia diagnosis was present without related care plan interventions, and the oxygen order was active while the care plan lacked oxygen-related interventions. Staff confirmed the care plans were incomplete for these identified needs.
Failure to Investigate and Report Alleged Verbal Abuse: A cognitively intact resident alleged that an LPN used abusive language and threatened to set the resident on fire. The LNHA did not obtain full witness statements, did not report the allegation to the state, and relied on a progress note and staff statements instead of following the facility abuse policy requiring immediate reporting, written witness statements, and suspension of the accused staff pending investigation.
Failure to Maintain Consultant Follow-Up and Arrange Transportation: A resident with chronic venous insufficiency, bilateral leg ulcers, edema, and gout had weekly vascular visits with Unna boots left in place until the next consult, but the EMR lacked the consultant reports and staff described inconsistent follow-up on the outside recommendations. The facility also failed to provide transportation for a scheduled rheumatology appointment; staff gave conflicting accounts about who was responsible, no ride share was arranged, and the appointment was cancelled because transportation was not provided.
An LPN accidentally dropped a resident’s lorazepam tablet on the medication cart during a controlled substance count, then wasted it with another LPN, but the declining inventory sheet was not signed immediately by both nurses. Surveyors found the lorazepam count did not match the inventory record, and the LPN, LPN witness, LPN unit manager, and DON all confirmed the waste should have been documented right away.
Improper Garbage Disposal and Unsanitary Trash Area: Surveyors observed garbage disposal area #1 with cigarette butt receptacles, grills, gas cylinders, crates, cardboard, plastic pails, a bottle, and an IV pole stored in and around the area instead of being properly discarded or stored elsewhere. The FSD, HD, and LNHA all acknowledged that trash should be placed in designated containers and that the area should remain clean and sanitary; the facility policy also stated that no littering is allowed in or around the trash area.
Nonfunctional Handwashing Sink in Resident Room: A resident with intact cognition, bipolar disorder, and a history of TIA was observed with the room faucet taped off, and the resident said they used a wet cloth for hand hygiene. Staff reported washing hands in other locations because the sink was not working, while the DOM said the water had been shut off for about two months after the resident flooded the room several times. The LNHA stated the room should have a functional sink.
The facility was found to have multiple deficiencies in food storage and hygiene practices. Bread was improperly stored on the ground, and the Food Service Director failed to perform proper hand hygiene. Expired food items and unsanitary conditions were observed in the kitchen, including a bug trap with dead bugs, caked-on debris in the microwave, and pitted cutting boards. In the food storage room, items were stored directly on a soiled floor, and mold was found on breadcrumbs. The LNHA acknowledged these issues.
The facility failed to maintain a clean and safe environment, with issues such as disconnected handrails, peeling wallpaper, and uneven flooring on the 300 nursing unit. A resident's room had a buildup of brown substance and tripping hazards due to sunken tiles. The LNHA acknowledged these safety hazards, and the maintenance policy was not followed.
The facility failed to properly dispose of and maintain waste in the garbage dumpster areas. Observations revealed a lack of a lid on the cardboard dumpster, scattered garbage debris, and waste surrounding other dumpsters. Interviews with the FSD and HKD indicated that both housekeeping and kitchen staff were responsible for maintaining the area, but it was sometimes neglected. The facility's policy emphasized cleanliness, but the observed conditions did not align with this standard.
A resident with a history of falls and medical conditions such as depression and schizophrenia experienced a fall after tripping over shoes. Despite no injuries being observed, the facility failed to update the resident's comprehensive care plan to reflect this incident, contrary to their policy. The oversight was acknowledged by the facility's administration during a survey.
A resident with a history of smoking and intact cognition was not assessed for smoking safety in a timely manner, as required by the facility's policy. The Smoking Safety Screen was last completed in May, and the September assessment was missed due to a change in Activities Directors, only being completed in October after the oversight was identified.
A resident's oxygen tubing was not labeled or dated as required by the facility's policy, which mandates weekly changes and dating. Despite the resident's medical conditions requiring oxygen therapy, the tubing remained undated over several days of observation. The Unit Manager confirmed the policy but could not explain the oversight, and the issue was reported to the facility's administration.
A resident with multiple ulcers did not receive proper wound care due to an LPN's failure to perform hand hygiene between glove changes. The resident, admitted with conditions like acute respiratory failure and muscle weakness, had a care plan requiring specific wound care interventions. Despite initial hand hygiene, the LPN neglected to wash hands between glove changes, a lapse confirmed by the Unit Manager and ADON, violating the facility's infection control policy.
Significant Medication Error During Med Pass
Penalty
Summary
A significant medication error occurred when an agency LPN administered medications intended for one resident to another resident during medication pass. The medications given in error included Amlodipine 10 mg, Aspirin 81 mg, Divalproex Na 125 mg, Zoloft 50 mg, and Iron 325 mg, in addition to the resident’s prescribed Amlodipine 2.5 mg, resulting in a total Amlodipine dose of 12.5 mg. The facility’s report stated that the LPN believed the medications had been given to the wrong resident after being questioned by a CNA. The resident who received the medications in error had diagnoses including unspecified dementia and dysphagia. The resident’s MDS showed a BIMS score of 9 out of 15, indicating moderately impaired cognition. The care plan identified impaired cognitive function/dementia and included interventions to use the resident’s preferred name, identify staff at each interaction, face the resident when speaking, make eye contact, and provide cues as needed. The resident’s physician order for Amlodipine was 2.5 mg daily with instructions to hold if systolic blood pressure was less than 110. The resident’s vital signs showed a blood pressure of 137/60 at 12:10 PM and 99/47 at 12:37 PM before transport to the hospital. The resident was assessed and sent to the emergency room and admitted for observation, then returned to the facility two days later.
Incomplete Abuse Investigation After Verbal Abuse Allegation
Penalty
Summary
The facility failed to initiate a complete and thorough investigation after a cognitively intact resident made an allegation of staff-to-resident verbal abuse against an LPN. The resident, who had a BIMS score of 15 out of 15 and diagnoses including paraplegia, personality disorder, mood disorder, anxiety disorder, adjustment disorder, major depressive disorder, and PTSD, sent an email to the LNHA alleging that the LPN screamed at the resident, used expletives, and made derogatory remarks. The resident stated that the allegation had been reported to facility staff. The LNHA acknowledged receiving the email but did not complete a full investigation. He stated that he obtained statements from the two involved nurses and reviewed one behavior note, but he did not obtain written witness statements from other staff or residents, did not document a summary and conclusion, and did not interview all potential witnesses as required by the facility policy. The LNHA also stated that he did not think the allegation was a nature of abuse and did not report it to the state because he could not substantiate it and because the resident had a history of allegations that were unfounded. The facility’s abuse policy required a thorough investigation of suspected abuse, including interviews with the reporting person, the resident if able, staff members on all shifts, roommates, family, visitors, and other residents who may have witnessed the event, along with a documented conclusion. The policy also stated that when an allegation names a specific employee, the employee is suspended until completion of the investigation. Interviews showed that the accused staff were not suspended at the time of the allegation, and the LNHA later stated that he did not suspend them because he believed he had concluded the investigation before their next scheduled shift and needed the staff to care for other residents.
Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility’s LNHA failed to ensure staff implemented the abuse policies and procedures for allegations of staff-to-resident verbal abuse involving Resident #11, including failing to protect the resident from the alleged perpetrator pending a thorough investigation. Resident #11 told the surveyor that an LPN was nasty to them and allegedly said that if the resident kept ringing the call bell, she was going to light the resident on fire. The resident also reported being called an ugly cripple and being told, "Watch your mouth, you [expletive redacted] piece of shit." The resident was described by staff and the MD as difficult and boisterous, and the resident had a care plan for fabrication, but the resident was also described by the MD as awake, alert, and knowing what was going on. The LNHA acknowledged that he did not complete a full investigation for the verbal abuse allegation involving two LPNs. He stated that he obtained statements from the involved nurses, but he did not obtain witness statements from residents or other staff who may have observed the event, and he did not get a written statement from the resident. He also stated that he did not report the allegation to NJDOH because he did not think it was a nature of abuse and because he could not substantiate what the resident said. The DON stated she was aware of the resident’s allegations and that the LNHA had done the investigations, but she also indicated she did not learn of the resident’s concern with the nurses because the LNHA had told the resident to return to their room. The report also identified a separate allegation involving another LPN, where Resident #11 stated that the nurse screamed at them, threw her hands into the resident’s face, and asked, "what are you going to do about it." The LNHA stated that the resident called the police and that officers reviewed video footage, but he acknowledged that he had not done a complete and thorough investigation and that he had not been reporting the resident’s allegations. The DON similarly stated that the resident alleged the nurse was in their space, but the video showed only hand movements and no physical altercation. The facility’s abuse policy required immediate protection of the alleged victim, immediate suspension of suspected employees pending investigation, witness statements, interviews of the resident and staff, and reporting of alleged abuse to the state agency within 2 hours, but the LNHA acknowledged these steps were not completed for the resident’s allegations.
Failure to Use Infection Assessment Tool for Antibiotic Monitoring
Penalty
Summary
The facility failed to utilize an infection assessment tool for residents who were prescribed antibiotic medications for 14 of 14 months reviewed. A review of the facility’s Antibiotic Tracking from January 2025 through February 2026 showed antibiotics were prescribed each month, including 19 in January 2025, 8 in February 2025, 11 in March 2025, 12 in April 2025, 10 in May 2025, 12 in June 2025, 8 in July 2025, 9 in August 2025, 11 in September 2025, 3 in October 2025, 10 in November 2025, 8 in December 2025, 4 in January 2026, and 8 in February 2026. On 3/9/2026, the Infection Preventionist stated that she had been the IP for the past two years, worked part-time as the IP and as a UM, and had only just begun learning the McGeer Surveillance Criteria a few weeks earlier. She stated that since beginning her role as IP, she had not utilized a surveillance tool. The DON stated that the facility had just started implementing the McGeer Surveillance tool and that there was nothing in place for surveillance prior to that. When asked how the facility determined whether prescribed antibiotics were appropriate, the DON stated that she did not know. The facility’s Infection Surveillance Plan stated that a data collection tool and nationally recognized surveillance criteria would be used to conduct surveillance in a systematic fashion, and the Antibiotic Stewardship policy stated that the facility maintained an antibiotic stewardship program to promote appropriate antibiotic use and reduce possible adverse events associated with antibiotic use.
Inconsistent Hot Water Temperatures Due to Broken Water Heater
Penalty
Summary
The facility failed to ensure that hot water supplied to resident rooms and showers was provided by proper equipment capable of maintaining safe and comfortable temperatures. During observation in the boiler room, the hot water heater was found broken and disconnected, and the Maintenance Director confirmed that the hot water for rooms and showers had been piped from the boiler used to heat the building. He stated that the boiler comes on and off based on air temperature at the thermostat rather than water temperature, and that the hot water heater needed to be replaced. Facility observations showed inconsistent hot water temperatures throughout the building, including readings of 100, 85, 75, 70, 88, 110, 100, and 105 degrees Fahrenheit, and later 18 temperatures in resident room sinks and shower rooms ranging from 80 to 131 degrees Fahrenheit. One resident stated the water temperatures were not comfortable and described them as sometimes freezing cold, sometimes lukewarm, and sometimes burning hot. The Administrator stated the facility was aware the hot water heater was broken and planned to replace it, and said it had been like that for about five years.
Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report within two hours to the NJDOH an allegation of staff-to-resident verbal abuse involving a cognitively intact resident. Resident #11, who had diagnoses including paraplegia, personality disorder, mood disorder, anxiety disorder, adjustment disorder, major depressive disorder, and PTSD, had a BIMS score of 15/15 and was documented as fully cognitively intact. The resident alleged that an LPN was nasty, threatened to light the resident on fire if the call bell was used again, and later made additional allegations that staff called the resident an ugly cripple and used profanity toward the resident. Surveyor interviews and record review showed that the LNHA and DON were aware of the resident’s allegations and discussed them with staff, but the LNHA stated he did not report the matter because he did not think it was abuse and believed the allegations could not be substantiated. He also stated that he obtained statements from the involved nurses, but did not obtain written witness statements from residents who may have observed the event. The facility’s own abuse policy required immediate notification of the state agency within two hours after identification of alleged or suspected abuse and required witness reports to be written or typed and signed. The record also showed that the resident had a history of making accusations and was care planned for false accusatory statements and fabrication, and staff described the resident as challenging and accusatory. Even so, the LNHA later acknowledged that if a resident accused a nurse of threatening to set the resident on fire or calling the resident a cripple, it was important to report the allegation to the DOH. The LNHA further stated that neither involved nurse was suspended because he concluded his investigation before their next scheduled shift and believed there was no reason to punish them. A second allegation involving another LPN was also not reported, and the LNHA stated that he had not been reporting the resident’s allegations.
Incomplete Care Plans for PTSD, Dementia, and Continuous Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents with identified needs. One resident had diagnoses including PTSD, paraplegia, mood and anxiety disorders, and depression. Although the resident’s record and MDS reflected PTSD as an active diagnosis, the individualized comprehensive care plan did not include a focus area or interventions related to PTSD or related triggers. Staff interviews confirmed that the diagnosis had been added to the record, but the care plan had not been updated to reflect it. A second resident had diagnoses including unspecified dementia, depression, diabetes, and bipolar disorder. The resident’s MDS listed non-Alzheimer’s dementia as an active diagnosis, but the individualized comprehensive care plan did not include a focus area or interventions addressing dementia care. Staff who reviewed the care plan confirmed that the diagnosis was present and that the care plan did not reflect interventions related to dementia. A third resident was receiving continuous oxygen therapy via nasal cannula at 2 L/min per physician’s order. The resident was observed multiple times receiving oxygen therapy, and the order summary confirmed continuous oxygen use. However, the individualized comprehensive care plan did not include a focus area or interventions addressing the resident’s continuous oxygen therapy. Staff confirmed that a care plan should have been developed for the oxygen order and that the resident’s care plan did not include it.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse policy after a cognitively intact resident made an allegation of staff-to-resident verbal abuse. The resident alleged that an LPN was nasty, called the resident an ugly cripple, and threatened to light the resident on fire if the call bell was kept ringing. The resident also reported that the allegation had been shared with facility staff. The resident had diagnoses including cervical spinal cord injury with paraplegia, personality disorder, mood disorder, anxiety disorder, adjustment disorder, major depressive disorder, and PTSD, and the quarterly MDS documented a BIMS score of 15 out of 15, indicating intact cognition. During the investigation, the LNHA stated he obtained statements from the two involved nurses and reviewed a progress note, but he did not obtain written witness statements from other staff or residents and did not know whether any residents had witnessed the event. He also stated that nothing was reported to the NJDOH because the allegation could not be substantiated and he did not think it was abuse. The DON stated the LNHA had done the investigations and indicated she had not learned of the concern because the LNHA had told the resident to return to the room. The facility’s abuse policy required immediate protection of the resident, immediate suspension of suspected employees pending investigation, witness statements in writing, and reporting to the state agency within 2 hours of identification of suspected abuse. The record also showed conflicting accounts of the interaction between the resident and staff. A behavior note documented the resident using vulgar language toward an LPN and making mocking noises, while the resident’s email alleged that the LPN screamed at the resident and used abusive language. Interviews with staff reflected that the resident was described as challenging and accusatory, but staff also acknowledged that verbal abuse allegations required immediate reporting and written statements. The MD stated that an investigation should be done in response to an allegation of abuse and that calling the resident an ugly cripple or threatening to set the resident on fire would be verbal abuse if true. The facility was unable to produce the daily assignment sheet for the shift in question, and personnel files for the involved LPNs contained no documented evidence of prior abuse allegations.
Failure to Maintain Consultant Follow-Up and Arrange Transportation
Penalty
Summary
The facility failed to ensure continuity of care for a resident admitted with chronic venous hypertension with bilateral lower extremity ulcers, edema, peripheral vascular disease, polyneuropathy, and gout. The resident had bilateral Unna boots ordered for wound care, with instructions that they were not to be removed until the resident was seen by vascular. The resident reported that an outside vascular specialist recommended bilateral leg elevation to improve circulation and edema, and the record reflected weekly outpatient vascular visits for chronic venous insufficiency and lower leg edema. Survey review and staff interviews showed that the facility did not have the consultant’s recommendations available in the medical record after the vascular appointments. The RN stated that the unit manager prepared a consultation packet for appointments and that staff usually reviewed paperwork after the resident returned, but if paperwork was missing the office would be contacted. The unit manager stated that she provided the consultation form for the resident to take to the appointment and would call the consulting office if the form was not returned. The DON also stated that nurses should follow up with consultants and call the office if the report was not returned. The surveyor reviewed the EMR and could not locate the report of consultation from the weekly vascular appointments. The facility also failed to provide transportation for a rheumatology appointment that had been scheduled by the facility. The resident’s record showed a referral to rheumatology and a note that the resident was scheduled to see a rheumatologist for positive ANA, elevated ESR, and positive anti-Ro (SSA), but was unable to arrange transportation. The resident stated that the appointment was cancelled because the facility did not provide transportation and the resident was only told about the appointment the day before. The unit manager stated she made transportation arrangements but could not recall the entity used and confirmed that no ride share was arranged. The RN stated she believed the resident had to arrange their own transportation because they did not have Medicaid or Medicare, while the social worker stated the facility should have arranged transportation and assumed the cost. The LNHA stated the facility was responsible for ensuring residents were transported to physician appointments and that he had covered the resident’s transportation cost in the past.
Controlled Medication Waste Not Immediately Documented
Penalty
Summary
The facility failed to accurately document the wasting of a controlled medication for Resident #28, whose lorazepam 1 mg tablets were stored on Unit 3-A’s medication cart. During inspection of the secured narcotic box, the surveyor and an LPN compared the resident’s lorazepam blister packs to the declining inventory sheet and found a mismatch: two blister packs were present, one containing 30 tablets and the other 27 tablets, while the inventory sheet indicated 58 tablets should have remained. The LPN stated she had administered the medication earlier and then accidentally dropped one lorazepam tablet on top of the medication cart while double-checking the controlled substance count. The LPN stated the dropped tablet was contaminated and had to be wasted, and that she and another nurse witness were required to sign the declining inventory sheet after wasting it. She reported that she and another LPN disposed of the tablet in the medication disposal container, but the witness had been called away before co-signing the declining inventory sheet. The second LPN confirmed she had wasted the tablet but had not signed the sheet because she was distracted by assisting a resident. The LPN unit manager and the DON both stated the nurses should have signed the declining inventory sheet immediately after wasting the medication, and the DON said this was important to ensure there was no miscount and no thought of diversion.
Improper Garbage Disposal and Unsanitary Trash Area
Penalty
Summary
The facility failed to provide a sanitary environment by not properly disposing of garbage and refuse in 1 of 2 garbage disposal areas. On 3/3/26 at 8:49 AM, the surveyor observed garbage disposal area #1 with cigarette butt receptacles, three grills, two gas cylinders, seven red and green crates, a flattened cardboard box, multiple plastic pails, a plastic bottle, and an IV pole stored in and around the area rather than being properly discarded or stored elsewhere. On 3/4/26 at 10:14 AM, the surveyor and the FSD toured the area and observed that garbage disposal area #1 was not maintained in a clean and sanitary condition, with garbage exposed to the environment. During interviews, the FSD stated that maintaining the garbage disposal areas was a shared responsibility between dietary and housekeeping and that trash and discarded items were expected to be placed inside designated containers rather than on the ground. The FSD acknowledged the refuse observed in the area posed a safety hazard and could contribute to pest control issues. On 3/5/26, the HD stated garbage should only be brought outside on the day it was scheduled for pickup and should not be stored in the garbage disposal area, explaining that doing so could create a fire and safety hazard and attract pests. The LNHA confirmed that garbage should be disposed of properly to prevent attracting pests and unwelcomed visitors and to maintain a safe and sanitary environment. The facility policy titled Housekeeping - Outdoor Trash Area, revised 5/2025, stated the nursing home is committed to maintaining a clean, safe, and hygienic environment and that no littering is allowed in or around the trash area.
Nonfunctional Handwashing Sink in Resident Room
Penalty
Summary
The facility failed to ensure that a handwashing sink in a resident's room was functional. On 3/9/26, the surveyor observed Resident #3 sitting upright in bed and eating lunch while the room faucet was wrapped with clear tape. The resident stated they were very particular about keeping their hands clean and said that when they needed to perform hand hygiene, they would call staff for a wet cloth. Resident #3 had diagnoses including bipolar disorder and a history of transient ischemic attack, and the quarterly MDS dated 2/3/20 indicated a BIMS score of 15 out of 15, showing intact cognition. The MDS also showed the resident was occasionally incontinent of bladder and frequently incontinent of bowel. During interviews, CNA #1 stated she provided care for Resident #3 earlier that morning after the resident voided in their brief, and that she wiped the resident's perineal area and trimmed their fingernails. She said she washed her hands in the unit pantry because the resident's sink was not working, although she usually washed her hands in the resident's room after care. RN #3 stated she had to wash her hands in another resident's bathroom because Resident #3 did not have a functional handwashing sink, and said there should be running water in the room for good hygiene to prevent infection. The DOM stated the water had been shut off for about two months because the resident flooded the room several times and caused too much damage to the building, and that the resident could not have access because they could not be trusted. The LNHA stated the room should be equipped with a functional sink and later said the sink was operational and the tape had been removed, but he was not sure why it had not been in service for so long.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food storage and hygiene practices, as observed by the surveyor. Upon arrival, the surveyor noted that boxes of bread were delivered and placed directly on the ground in the parking lot, which was confirmed by the Acting Director of Nursing (ADON) as inappropriate. The Food Service Director (FSD) admitted that the bread company routinely delivered bread in this manner and mistakenly believed it was acceptable since the bread was in boxes. Additionally, the FSD failed to perform proper hand hygiene after returning to the kitchen from the stock room, acknowledging the oversight only after being prompted by the surveyor. During a tour of the kitchen, several deficiencies were noted. A bug trap with over twenty dead bugs was found open, exposing the kitchen area. Expired food items, including egg salad and macaroni salad, were found in the refrigerator, along with an opened container of cottage cheese without a proper use-by date. The microwave was observed to have caked-on debris, and several cutting boards were deeply pitted and discolored, posing a risk of cross-contamination. Dented cans were found in dry storage, and the walk-in freezer was missing vinyl strip curtains, which are essential for maintaining temperature and cleanliness. Further inspection revealed additional issues in the food storage room, where the floor was soiled and tiles were coming up due to condensation from the air conditioner. Food items, including a box of cereal and a bag of breadcrumbs, were stored directly on the floor, with the breadcrumbs showing signs of mold and insect activity. A condiment bottle pump was also found caked with a brownish/black substance. The Licensed Nursing Home Administrator (LNHA) acknowledged these concerns in the presence of the survey team.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents, as evidenced by several observations made by the surveyor. On the 300 nursing unit, the handrail on the ramp was found to be disconnected in three areas, exposing metal framing and posing a safety hazard. Additionally, the wallpaper was peeling and bubbling, and the threshold connecting the ramp to the corridor had missing tiles and uneven elevations, creating a tripping hazard. A hole in the wall by the doorframe of the unit's entrance was also noted, with crumbling debris around it. Further observations on the 300 nursing unit revealed a split in the wallpaper along a corner seam, exposing black and white dust debris. A soffit enclosure had a cutout hole, exposing its interior. In a resident's room, the doorway threshold had cracked and sunken tiles, creating an uneven entryway. The Licensed Nursing Home Administrator acknowledged these issues and confirmed that they posed safety hazards, such as potential cuts from the handrail and tripping hazards from the flooring. In another resident's room, a thick buildup of a brown substance was observed on the floor, along with a sunken tile creating a tripping hazard. The bathroom in this room had a missing tile corner, a loose tile, and a dark brown substance around the toilet base. The Housekeeping Director stated that the worst rooms were cleaned first, but a room checklist marked the room as unsatisfactory. A maintenance request for a water leak was noted, but the maintenance log indicated no leaks, only a dirty floor. The facility's maintenance policy requires maintaining the building in good repair and free from hazards, which was not adhered to in these instances.
Improper Waste Disposal and Maintenance in Garbage Area
Penalty
Summary
The facility failed to properly dispose of and maintain waste in the garbage dumpster areas, as observed by a surveyor. During a tour of the facility's outside garbage disposal area, it was noted that the cardboard dumpster lacked a lid, and garbage debris was scattered around it. The Food Service Director (FSD) acknowledged the issue, stating that the facility was attempting to have the lid replaced. Additionally, three other dumpsters had paper and food waste surrounding them, and a storage container in the area was surrounded by food and paper debris, wooden boards, and an unidentifiable large object. The wooded area adjacent to the dumpster area contained trash, including food products, paper waste, broken wooden boards, and a mattress. Furthermore, the fence along the garbage area was cluttered with pallets and other debris, and the fence itself was dirty and falling down. Interviews with the FSD and the Housekeeping Director (HKD) revealed that both housekeeping and kitchen staff were responsible for maintaining the garbage area. The HKD admitted that while they aimed to clean the area daily, it was sometimes forgotten, and the pallets had been left by delivery personnel for at least two to three months. The HKD acknowledged the importance of maintaining the garbage area to prevent injuries and rodent attraction and admitted that the condition observed by the surveyor was unacceptable. The facility's policy on maintaining the outdoor trash area emphasized the importance of keeping the area clean and free of debris, but the observations indicated a failure to adhere to this policy.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a history of falls, which was identified during a survey. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had a history of medical conditions including depression, schizophrenia, hypertension, and low back pain. Despite being independent with toileting and hygiene, the resident experienced a fall on August 19, 2024, after tripping over their shoes. Although no injuries were observed, and neurological checks were initiated, the incident was not reflected in the resident's individualized comprehensive care plan (ICCP). The ICCP, which was last revised on May 14, 2024, did not include the fall from August 19, 2024, and was not updated following the incident. The facility's policy requires care plan revisions based on resident assessments when a problem, goal, or approach changes. However, the Unit Manager/LPN confirmed that the ICCP was not updated post-fall until the surveyor's inquiry. The Licensed Nursing Home Administrator, along with the Acting Director of Nursing, acknowledged the oversight during the survey.
Failure to Conduct Timely Smoking Safety Assessment
Penalty
Summary
The facility failed to ensure that a resident who smoked cigarettes was assessed for safety, which was identified for one of the residents reviewed for accidents. The resident, who had diagnoses including hypertension, depression, and hyperlipidemia, was observed to have a fully intact cognition and was a current tobacco user. The resident's comprehensive care plan included interventions for smoking safety, such as requiring supervision while smoking and being assessed quarterly for smoking safety. However, the most recent Smoking Safety Screen was completed on 5/31/24, and there was no assessment completed in September as required. The Activities Director acknowledged that a smoking assessment should have been completed in the first week of September, but it was missed due to a change in Activities Directors. The Licensed Nursing Home Administrator confirmed that the Smoking Safety Screening was due in September and was not completed until 10/7/24, after the issue was brought to their attention. The facility's Resident Smoking Policy required evaluations upon admission, re-admission, quarterly, or upon any significant change to a resident's physical or cognitive status, which was not adhered to in this case.
Failure to Date and Label Oxygen Tubing
Penalty
Summary
The facility failed to properly label, date, and initial a resident's oxygen tubing, which was identified during a survey. The deficiency was observed in a resident who was using a portable oxygen tank and an oxygen concentrator. The surveyor noted that the oxygen tubing connected to both the portable tank and the concentrator was not dated, despite the facility's policy requiring weekly changes and dating of the tubing. The resident, who was cognitively intact, had medical diagnoses including chronic obstructive pulmonary disease and respiratory failure, and was observed using oxygen at three liters per minute. The surveyor's observations spanned several days, during which the resident's oxygen tubing remained undated. The Unit Manager/LPN confirmed that the tubing should be changed and dated every Sunday night, but could not explain why the tubing was not dated during the surveyor's observations. The Licensed Nursing Home Administrator and Acting Director of Nursing were informed of the issue, but no additional information was provided to address the deficiency. The facility's Oxygen Administration policy, revised in July 2023, mandates that staff date and initial tubing and humidifiers weekly, which was not adhered to in this case.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during wound care for a resident with multiple ulcers. The resident, who was admitted with conditions including acute respiratory failure, metabolic encephalopathy, and muscle weakness, had a history of skin integrity issues and was at risk for pressure injuries. The resident's care plan included specific interventions for wound care, such as the use of Betadine and Dakins solutions for cleansing and dressing wounds on the feet and heel. On the day of the observation, a Licensed Practical Nurse (LPN) was seen performing wound care on the resident's left and right foot without following proper hand hygiene procedures. The LPN initially performed hand hygiene before donning gloves and a gown but failed to wash hands or use an alcohol-based hand rub between glove changes while treating the wounds. This lapse in protocol was acknowledged by both the LPN and the Unit Manager, who confirmed that hand hygiene should have been performed between each glove change. The Acting Director of Nursing (ADON) and the Licensed Nursing Home Administrator (LNHA) were interviewed and confirmed that the facility's expectations for hand hygiene were not met during the wound care process. The facility's Infection Control Policy emphasizes the importance of hand hygiene as a critical step in preventing healthcare-associated infections, highlighting the deficiency in the LPN's actions during the observed wound care session.
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 509 citations issued within 25 miles in the last 12 months — including the 11 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 Tinton Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Care At Seabrook | 0.6 mi | ★★★★★ | 10 | 0 |
| Imperial Care Center | 1.5 mi | ★★★★★ | 17 | 0 |
| Tower Lodge Care Center | 2.6 mi | ★★★★★ | 20 | 0 |
| Jersey Shore Post Acute Rehabilitation And Nursing | 2.9 mi | ★★★★★ | 0 | 0 |
| King Manor Care And Rehabilitation Center | 3.1 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Aster Creek Nursing And Rehabilitation Center.
100% money-back within 48 hours.
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.