Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atrium At Navesink Harbor, The during CMS and state inspections, most recent first.
Surveyors found that dietary staff lacked the competency and oversight needed for safe food service. In the kitchen and pantry, staff were observed with incomplete hair and beard restraints, poor hand hygiene, improper glove use, reused thermometer wipes, and unsanitary food contact surfaces and storage areas. Foods were inconsistently labeled and dated, some items were past discard dates, raw foods were stored improperly, and temperature logs were blank or incomplete. Staff could not locate recipes for puree items and super cereal, and a cook stated he did not use recipes but instead eyeballed amounts.
Modified texture foods were not prepared with standardized recipes, proper portions, or appropriate temperatures. During a meal observation, a HCS and SRD were involved in serving puree items that were loose and runny, and a mechanical soft taco salad with hot beef was stored in a freezer drawer and later found at 57 degrees F. The ADD could not locate recipes for the puree items, and the cook stated he did not use recipes and instead eyeballed the amounts. The lunch temperature log was blank when requested, and temperatures had not been recorded at the time the meal was prepared.
Surveyors observed widespread food safety and sanitation failures in the kitchen and a remote pantry, including improper storage of raw and prepared foods, expired or missing labels, soiled equipment and surfaces, uncovered plates, and dirty sinks, carts, and racks. Staff were also observed without full beard or hair restraints, failing to perform hand hygiene before food handling and glove use, reusing an alcohol wipe for multiple temp checks, and documenting meal temps only after the meal was served.
Improper garbage and cardboard disposal was observed in the kitchen and dumpster area. Cardboard boxes were piled on the floor and against the walls near the exit, a bin was covered by broken-down cardboard, and dumpsters outside were overflowing with garbage bags and cardboard boxes. The DFM stated boxes should be tied and placed in recycling bins, and noted the conditions could lead to mice and a fire risk.
The facility failed to complete a facility-wide assessment that identified the staff competencies and skill sets needed to care for residents during routine operations and emergencies. The FA was a template and did not list specific competencies; the DON stated staff education was mainly done through a computer program, that Dietary was not included in training or competencies, and that only wound and respiratory competencies were completed. The LNHA confirmed Dietary was not included in the FA.
QAPI failed to identify and track multiple facility-wide concerns, including kitchen sanitation, pest control, garbage disposal, meal prep/service issues, and delays in clarifying wound care recommendations and orders. The LNHA stated the active QAPI topics focused on pharmacy, nursing education, pressure ulcers, incidents, infection prevention, social services reporting, and maintenance work orders, but there were no QAPI plans for the dietary issues, wound order concerns, or pest/garbage problems observed by surveyors.
IP Lacked Required Specialized IPC Training: The facility failed to show that the IP had completed CMS-required specialized IPC training. Surveyors were given only a Basic Course certificate, which was not designed to meet federal, state, and specialized industry requirements for IPs. The RCN said he was covering for the IP Nurse while she was out on leave, and the DON and VPHS stated the certificate was acceptable based on the IP’s 5 years of infection control experience and the facility’s job description, which was not reflective of the current CMS regulation.
An effective pest management program was not in place to control flies in the kitchen. Surveyors observed small black flies in the kitchen and on a microwave near the ice cream freezer, and the EC said the flies were due to a cracked pipe. The DFM stated there was no pest log, he had not been told about the cracked pipe, and although the facility knew flies were present and used fly traps and drain flushing, he was not notified that the flies continued. The pest service record also documented repeated fly issues in the kitchen area.
Failure to maintain resident dignity during meal service. A resident with dementia, dysphagia, and Parkinson's disease was observed eating breakfast in bed with bare hands while struggling to handle food, despite needing meal assistance. In the dayroom, another resident with severe cognitive impairment had an uncovered lunch tray left in front of them for more than 30 minutes before staff assisted and reheated the meal, while a CNA assisted another dependent resident with gloves on and conversed with another CNA during the meal. In a separate breakfast observation, a CNA placed a tray in front of a resident and left the meal setup incomplete.
Missing Pre-Employment Background Screening Documentation: The facility failed to ensure pre-hire screening was completed and documented for employees and contracted staff, including dietary personnel. Surveyors reviewed employee files and found multiple staff with no criminal background report in the file, and one employee whose background search was completed long after starting work. The facility’s policy required criminal background checks as part of pre-employment screening, and the contractor agreement also called for background screening of contractor personnel.
A dependent resident with Parkinson's disease and severe cognitive impairment was observed with long, jagged, discolored fingernails and black substance under the nails on multiple occasions. The resident was totally dependent for ADLs, and the record showed care planning for grooming assistance, but the facility could not provide documentation that nail care was offered and refused. Staff gave conflicting statements about who was responsible for nail care, and the DON stated CNAs were responsible.
A resident with Parkinson’s disease and a sacral pressure ulcer had a wound consultant recommend Dakin’s-soaked gauze, but the order lacked a specified strength and was not clarified promptly. Staff implemented 0.5% Dakin’s without documented physician clarification, and interviews confirmed the order was vague, the clarification was delayed, and the resident reported burning during wound care.
A facility failed to consistently monitor and verify significant weight loss and did not reliably carry out ordered nutrition interventions for two residents. One resident with Parkinson’s disease and dysphagia had a rapid, significant weight loss that was not reweighed or clearly escalated to the MD or RD. Another resident with dementia, dysphagia, and dependence for eating had ongoing weight loss, but was observed left without timely meal assistance or encouragement, and the fortified cereal provided was not prepared per recipe.
Wound Care Competency and Order Clarification Failures: The facility failed to ensure staff were competent in wound care and in verifying/clarifying treatment orders. For one resident, a wound care consult recommended Dakin's-soaked gauze but did not specify the strength or include physician signatures, yet the resident received Dakin's 0.5% without documented clarification. For another resident, an LPN was observed performing wound care with poor hand hygiene and without proper field setup, and the DON stated wound competencies did not include all staff or order clarification.
A resident with Alzheimer’s disease, dysphagia, and myasthenia gravis was downgraded to a mechanical soft diet after difficulty swallowing eggs and sausage. Surveyors observed the resident’s tray contained cut-up sausage circles instead of the ground meat listed on the ticket, and the CNA, LPN, DDS, RD, and ST were unsure or inconsistent about the meaning of the meal notation and the correct diet item provided.
An LPN failed to maintain infection control during wound care by using improper hand hygiene, placing opened gauze on scrub pants instead of a clean barrier, and not changing gloves between heel treatments. Another LPN handled a resident’s Trelegy inhaler, a semicritical item, by placing it on a tray table and then on the med cart without cleaning it or the cart surface. During meal service, a CNA repeatedly changed gloves without performing hand hygiene while assisting residents with hand hygiene, soup, and beverages.
The facility failed to issue required SNFABN and NOMNC notices in the proper time frame for two residents reviewed for beneficiary protection notification. One resident’s notices were sent to the RP before the last covered day, while another resident’s notices were signed by the RP after the last covered day. The surveyor reviewed the facility’s Medicare discharge list, obtained the notices from the LNHA, and discussed the concerns with facility management.
A resident with Parkinson’s disease and an unhealed sacral pressure ulcer had wound orders for Dakin’s-soaked gauze, but the strength was not documented on the new order and was later shown on the TAR as 0.5% without evidence that the MD was contacted to clarify it. The CP stated he reviewed the TAR only every 6 to 12 months, and the monthly MRR for the resident’s chart did not identify any medication irregularity or make any recommendations.
Missing Current Hospice Agreement: A resident receiving hospice services had diagnoses including ASHD and a care plan noting hospice with H #1, but surveyors found the facility only had an older hospice contract with a different hospice name. The LNHA said the hospice had changed names, yet no current written agreement with the resident’s hospice was provided.
The facility failed to store food properly and maintain a sanitary kitchen environment. Observations included a wet food processor lid, debris on flour and sugar bins, and a dirty meat slicer. Additionally, unsanitary conditions were found in the server kitchen, with dried substances on soda dispensers and open ice cream container lids.
The facility failed to maintain AED kits and emergency supplies, with expired defibrillator pads found on two floors. An LPN confirmed the expired pads, and the Emergency Cart Daily Checklist was not properly followed. Additional expired items were found, and the facility's policy requiring monthly checks was not adhered to.
The facility failed to consistently offer pneumococcal vaccines to residents, as evidenced by two cases where documentation was missing or inaccurate. One resident's immunization status was not up to date, and the facility could not provide evidence of vaccination. Another resident, with respiratory issues, had no documentation of the pneumococcal vaccine being offered or declined, despite being cognitively intact and reporting prior vaccination. The facility's policy required assessment and offering of the vaccine upon admission, which was not followed.
The facility failed to maintain the dignity of a resident during a dining observation when a CNA ignored a request for pineapple chunks, refusing to communicate directly with the resident. Additionally, a resident with a urinary catheter was observed with an uncovered collection bag in contact with the floor, visible to others, compromising dignity and infection control. The LPN and Infection Preventionist confirmed the need for the bag to be covered and off the floor.
The facility failed to complete a criminal background check before an Activities Aide began working, resulting in the employee working 32 hours without clearance. Interviews with staff confirmed the oversight, and no email confirmation of clearance was provided, contrary to facility policy.
A facility failed to prevent potential contamination by allowing a urinary drainage bag and tubing to come into direct contact with the floor. A resident with a suprapubic catheter was observed with the drainage bag and tubing on the floor, contrary to facility policy. The LPN, CNA, and RN Infection Preventionist acknowledged the improper placement, which could lead to infection.
A resident with dementia and a hip fracture did not receive adequate pain management due to the facility's failure to create a comprehensive care plan and act on a physician's recommendation. The resident's pain was not consistently monitored, and a misunderstanding led to the discontinuation of shift-to-shift pain assessments. Despite having orders for pain medications, the facility did not address pain management in the care plan, resulting in insufficient pain control.
A resident with moderate cognitive impairment and a hip fracture was administered Midodrine outside the prescribed parameters for managing low blood pressure. The medication was given despite systolic blood pressure readings exceeding the hold threshold, and the resident's care plan lacked interventions for monitoring blood pressure. The facility had no policy for administering medications with parameters, and the Consultant Pharmacist missed the irregularities, with only two of three nurses receiving a graded medication pass observation.
Dietary Staff Lacked Competency in Food Safety, Sanitation, and Recipe Use
Penalty
Summary
The facility failed to provide sufficient support personnel with the skill sets and competencies needed to carry out food and nutrition services safely and effectively. During kitchen and pantry observations, surveyors found multiple sanitation, labeling, storage, temperature-monitoring, and infection-control problems involving dietary staff and food service processes. In the main kitchen, refrigerated and potentially hazardous foods were observed without consistent use-by dates, with some items already past their discard dates, and several foods were stored in a manner that did not match the documented labeling or expected handling practices. Surveyors observed multiple sanitation issues in the kitchen and storage areas, including debris on walls, ceilings, floors, racks, carts, gaskets, and equipment; rusted food storage racks; a heavily soiled oven; stained and grooved cutting boards; a soiled can opener with metal shavings; uncovered bread; and improperly stored raw foods. Staff were also observed with incomplete hair and facial hair restraints. In the 3rd floor pantry, a staff member identified as the Senior Director of Nutrition and Registered Dietitian had hair not fully covered and, after washing hands, used the same paper towel to wipe the sink area. The Healthcare Supervisor was observed handling food with bare hands, failing to perform hand hygiene before glove use, reusing an alcohol wipe to clean a thermometer probe, and using improper handwashing technique and timing. Meal service observations also showed food handling and recipe problems. The Healthcare Supervisor reported that crab cakes and rice had arrived at improper temperatures and were sent back to be reheated. Two taco salads containing ground beef, beans, cheese, tomato, lettuce, and sour cream were stored in the freezer, and the beef in one salad was later measured at 57 degrees Fahrenheit. Surveyors asked about recipes for puree items and super cereal, but the Assistant Director of Dining and the cook could not locate recipes, and the cook stated he did not use recipes and instead "eyeball[ed]" the amounts. The Assistant Director of Dining confirmed that recipes were important for consistency, portion sizes, and nutritional adequacy, but no recipes for the puree salmon, puree crab cake, puree rice, puree lima beans, or super cereal could be found. The food temperature log for lunch was blank when reviewed, and the cook began filling it in only after being questioned by the surveyor.
Modified Texture Foods Not Prepared or Served Properly
Penalty
Summary
The facility failed to ensure that modified texture foods were prepared using standardized recipes, that appropriate portions were provided for texture-modified foods, and that foods were served at appropriate temperatures. During a meal observation in the 3rd floor food service pantry, the surveyor observed a Senior Director of Nutrition/Registered Dietitian with her hair not fully covered and a Healthcare Supervisor at the steam table. The Healthcare Supervisor stated that crab cakes and rice had not come up from the kitchen at the appropriate temperatures and had been sent back to be reheated. The surveyor also observed two taco salads stored in the lower freezer drawer on top of ice cream containers, including a mechanical soft salad and a regular consistency taco salad. The Healthcare Supervisor stated the salads had been placed in the freezer because the Senior Director of Nutrition thought they would not hold temperature, but also stated that was not how they should have been stored because the beef would be hot. When the Healthcare Supervisor checked the temperature of the beef in the mechanical soft taco salad, it was 57 degrees Fahrenheit. The surveyor also observed puree meals being plated for residents; the puree salmon, rice, and lima beans appeared loose and did not hold shape on the plate. For room service trays, the Healthcare Supervisor used a slotted spoon rather than a portion spoon to scoop puree salmon, and the food appeared runny and did not hold shape. During interviews, the Assistant Director of Dining could not locate recipes for the puree items in the recipe book, and the cook stated he did not use recipes and instead "eyeball[ed]" the puree items and thickener amounts. The Assistant Director later confirmed that recipes were important for consistency, portion sizes, and nutritional adequacy, but still could not locate recipes for puree salmon, puree crab cake, puree rice, or puree lima beans. The food temperature log for lunch was blank when requested, and the cook stated no temperatures had been written down and began filling in the log only after being asked. The menu and portion information reviewed by the survey team showed a portion size for puree shellfish, but puree salmon was not listed.
Unsafe Food Storage, Poor Sanitation, and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a sanitary manner, and surveyors observed multiple unsafe food handling and sanitation practices in the main kitchen and a remote service pantry. During the kitchen tour, the Executive Chef and other staff were observed without full facial hair restraints, and multiple food items were found improperly stored, including fresh food boxes on the floor, raw chicken and pork stored on shelves and in boxes without clear dating, and opened foods with missing, incorrect, or expired use-by labels. Surveyors also observed soiled equipment and surfaces throughout the kitchen, including debris on walls, ceilings, floors, racks, sinks, gaskets, carts, and the oven, as well as rusted shelving, stained cutting boards with deep grooves, metal shavings around a can opener blade, and uncovered plates stored in the kitchen entryway. In the dry storage and food service areas, surveyors observed dented cans, debris on bottles, soiled bins, uncovered bread, dirty juice dispenser nozzles, crumbs in cups and bowls, and flies affixed to a microwave. In the healthcare preparation area, the handwashing sink contained food debris, the garbage can lacked a liner, and the refrigeration gasket and nearby cart were visibly soiled. In the remote pantry, a staff member with hair not fully covered identified herself as the Senior Director of Nutrition/Registered Dietitian and then washed her hands and wiped the sink area with the same paper towel. Another staff member, the Healthcare Supervisor, stated that crab cakes and rice had not arrived at the proper temperatures and had been sent back to be reheated. During meal service, the Healthcare Supervisor handled food and temperature monitoring without performing hand hygiene, used bare hands to remove food containers, reused the same alcohol wipe for multiple temperature checks, and placed gloves on without washing hands first. She also washed her hands for less than 20 seconds after taking temperatures and later washed for 6 seconds before placing a meal plate in front of a resident. The surveyor also observed her put on a new pair of gloves without hand hygiene while setting up room service trays. The food temperature log for lunch was blank when first requested, and the staff member who prepared the meal stated no temperatures had been written down and that he was filling in the log at that time, saying the temperatures were kept "in his head."
Improper Garbage and Cardboard Disposal in Kitchen Dumpster Area
Penalty
Summary
Improper disposal and containment of garbage and cardboard were observed in the kitchen and dumpster area. During an initial tour with the Executive Chef, cardboard boxes were seen strewn about and piled on the floor and against the walls in an alcove near the exit to the dumpster area. The cardboard boxes were also covering a black bin that appeared to contain broken down cardboard boxes inside. Immediately outside the exit door, multiple large garbage bags were piled up in a garbage can, the blue dumpster was overflowing with cardboard boxes and clear bags that were lifting the lid, and adjacent dumpsters were overflowing with black garbage bags that were not exposed. The Executive Chef stated there had been no garbage pickup on Monday due to a holiday. The Director of Facility Management later stated garbage was picked up three days per week and recycling two days per week, that there had been missed pickups when trucks blocked access, and that the facility could call for additional pickup if needed. When shown the observed conditions, he stated the garbage and cardboard handling was not okay, that boxes should be tied and placed in recycling bins, and that the conditions could create a mouse issue and a fire risk.
Facility Assessment Did Not Identify Required Staff Competencies
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the staff competencies and skill sets necessary to provide the level and types of care needed for the resident population during day-to-day operations and emergencies. A review of the Facility Assessment provided by the facility on 2/18/26 showed a section for staff training, education, and competencies, but it did not list any specific competencies and appeared to be a template that was not specific to the facility. The document referenced computer-based training, live training, competencies, and policy review, but did not identify the actual competencies required for the facility's staff. During interviews, the DON stated that staff education was handled through a computer education program and provided an education book used by the Infection Preventionist. When asked whether the contracted Dietary department was included in training or competencies, the DON stated they were not. The DON also stated that wound competencies were completed by an RN and that respiratory training competencies were completed, but no other competencies were completed by the facility. The LNHA stated that the purpose of the Facility Assessment was to make sure resources were available to care for residents, and confirmed that the Dietary department was not included in the assessment. The deficiency was cited under NJAC 8:39-33.4.
QAPI Program Failed to Address Multiple Facility-Wide Care and Sanitation Concerns
Penalty
Summary
The facility failed to self-identify areas of concern and develop comprehensive, data-driven QAPI plans related to sanitation, pest management, garbage disposal, appropriate meal preparation and meal service, and timely implementation and clarification of wound care recommendations and orders. The deficiency was identified through observation, interview, and document review and was stated to affect all residents who resided in the facility. The report cited related deficiencies at F550, F686, F802, F804, F805, F812, and F925. During interview, the LNHA stated the most recent QAPI meeting was the 4th quarter meeting held on 1/15/26 and that if the QAPI team believed a process had improved, it would not be included. The LNHA identified current QAPI topics as pharmacy, nursing online education completion and competencies, pressure ulcer averages, accidents and incidents, infection prevention activities, social services reporting, and maintenance work orders. The LNHA stated there were no QAPI plans related to wound recommendations or wound orders, and confirmed there were no QAPI plans related to kitchen sanitation concerns, the failure to use recipes for modified foods, lack of hand hygiene during meals, overflowing garbage, flies in the kitchen, garbage disposal concerns, or pest concerns. The Facility QAPI Plan 2025 stated that all departments and services would participate in QAA activities to promote ongoing performance improvement, and the Assistance with Meals policy required staff assisting with meals to be trained and demonstrate competency in prevention of foodborne illness, including personal hygiene and safe food handling.
IP Lacked Required Specialized IPC Training
Penalty
Summary
The facility failed to ensure that its Infection Preventionist (IP) had completed specialized training in infection prevention and control as required by CMS guidance. During the entrance conference, the surveyor was given a Certificate of Attendance for a Basic Course for Infection Prevention and Control, but the course was not designed to meet federal, state, and specialized industry requirements for infection preventionists. The surveyor then interviewed the Regional Corporate Nurse (RCN) and the Director of Nursing (DON), and the RCN stated he was covering for the IP Nurse while she was out on leave. When the surveyor requested documentation of the IP Nurse’s specialized infection prevention and control training, the DON said she would obtain and provide the certificate. The next day, the RCN provided the same Basic Course certificate that had already been reviewed, and confirmed that was all the facility had. At exit conference, the VPHS stated the certificate was acceptable because the IP Nurse had 5 years of infection control experience and that this was reflected in the IP job description. The job description dated 11/30/2023 stated the IP had to have primary professional training in a related field, be qualified by education, training, and at least 5 years of infection control experience or certification, and have completed specialized training in infection prevention and control, but it was not reflective of the current CMS regulation implemented on 08-08-24.
Pest Control Program Not Effective in Kitchen
Penalty
Summary
An effective pest management program was not in effect to control flies in the kitchen. During a kitchen tour with the Executive Chef and Director of Dining Services, the surveyor observed small black flies sporadically in the kitchen and black flies on the front and side of a white microwave oven in the area where the ice cream freezer was located. The Executive Chef stated the flies were due to a leak in a pipe that had a crack. The Director of Facility Management stated there was no pest log and that he had not been made aware of a cracked pipe. He acknowledged the facility was aware of flies in the kitchen and said the kitchen was supposed to flush the drains for the flies when the kitchen was cleaned. He also stated environmentally safe fly traps were used and the kitchen was supposed to notify him if the flies were still present, but he confirmed he was not notified of the continued presence of the flies. The pest service record showed prior entries for flies in the kitchen area, including recommendations to wash out pails with bleach, degrease and clean drain traps, replace fly vinegar traps, and have drains checked for a break with a camera.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to consistently treat residents in a dignified manner during meal service. During breakfast observation on the 300 Unit, a resident with Alzheimer's disease, dysphagia, Parkinson's disease, and severe cognitive impairment was observed in bed with the breakfast tray on the bedside table eating with bare hands. The resident had tremors in both hands and difficulty holding the pancake and bringing it to the mouth at the same time. The resident's record showed an order for a mechanical soft diet with thin liquids, a BIMS score of 2 out of 15, and a care plan that included assisting with meals and anticipating needs. During lunch observation in the dayroom, a resident with Alzheimer's disease, contractures, traumatic brain injury history, dysphagia, and severe cognitive impairment was seated in a recliner with an uncovered lunch tray placed on the table beside the resident while waiting for assistance. The tray remained there for more than 30 minutes while the resident watched others eat. A CNA later entered, washed hands, and assisted the resident after the tray had been sitting uncovered; the LPN prompted the CNA to reheat the meal. The CNA stated she had been busy providing care and was not aware the tray had been sitting there, and another CNA and a nurse stated the tray should not have been left in front of the resident without staff available to assist. During another lunch observation, a CNA assisted a resident who was totally dependent for all ADLs and had Parkinson's disease, unspecified dementia, dysphagia, and palliative care involvement while wearing gloves in the dayroom and conversing with another CNA. The Dietitian observed the CNA with gloves on and told her she could not have gloves on in the dayroom while assisting with meals. The CNA later continued assisting the resident with gloves on and stated she used them because the resident drooled and spat during mealtime, and that using gloves in the dining room was not facility policy and was a dignity issue. In a separate breakfast observation, a CNA placed a meal tray in front of a resident and did not open the milk or finish setting up the tray, while stating she was assigned to the roommate and knew the resident needed help but was not assigned to that resident.
Missing Pre-Employment Background Screening Documentation
Penalty
Summary
The facility failed to have a system in place to ensure that, prior to hire, all employees were pre-screened to confirm they had not been found guilty in a court of law of abuse, neglect, or misappropriation, and that no findings had been entered into the state nurse aide registry or against a professional license. The facility also failed to maintain documentation showing that appropriate pre-screening had occurred for all contracted facility employees, including dietary staff. This deficient practice was identified in 3 of 56 employee files reviewed that were provided by the facility. A review of the facility’s Hiring Policy: Employment Application & Pre-Employment Checks, revised April 2025, stated that the facility would hire only those individuals who successfully completed pre-employment assessment criteria, including a criminal background check. During the survey, the HRD provided a list of employees and contracted employees hired since the last recertification survey. File review showed Employee #8 had no criminal background report in the file, Employee #22 had no criminal background report in the file, and Employee #44 had a criminal background search dated 264 days after beginning work. Employee #56, hired later, also had no criminal background report in the file. The LNHA later provided a Dining Service Agreement showing the contractor was responsible for employee pre-employment background screening for its personnel, but no further information was provided at exit conference.
Failure to Provide Timely Nail Care
Penalty
Summary
The facility failed to ensure a dependent resident received routine and appropriate nail care in a timely manner. Resident #18 had diagnoses including Parkinson's disease, unspecified dementia, dysphagia, and encounter for palliative care, and the MDS reflected a BIMS score of 2 out of 15 with total dependence on staff for all ADLs. On observation, the resident's fingernails were long, jagged, and discolored with a black substance underneath them, and the resident was unable to answer questions about nail care. The same condition was observed again several days later while the resident was being assisted with a meal. Record review showed the care plan identified a self-care deficit related to dementia and Parkinson's disease and included staff assistance with grooming, but the TAR did not show a documented shower on one scheduled date and the resident's nails remained unchanged on later observation. During interviews, the CNA stated the resident's nails needed to be trimmed and cleaned and said nurses were responsible for nail care, while the LPN stated CNAs should provide nail care during morning care. The DON stated CNAs were responsible for nail care, but the facility could not provide documentation that nail care had been offered and refused by the resident.
Delayed Clarification of Wound Treatment Order
Penalty
Summary
The facility failed to ensure a system was in place to clarify and implement wound treatment recommendations in a timely manner for a resident with a sacral pressure ulcer. The resident was admitted with Parkinson’s disease and an unstageable sacral pressure ulcer, and the comprehensive assessment documented impaired skin integrity with an unhealed pressure ulcer on admission. The resident’s care plan identified skin breakdown related to deconditioning, weakness, fragile skin, and a pressure wound to the gluteal/sacral region. The wound consultant documented multiple wound assessments and treatment recommendations over time, including debridement and wound care orders. On 1/13/26, the consultant documented a recommendation for cleansing with Vashe, applying Santyl to slough, packing with Dakin’s-soaked gauze twice daily, and covering with a foam dressing. However, the consultation form did not specify the Dakin’s strength, the attending and consulting physician names were left blank, and there was no physician signature on the document. The resident was started on 0.5% Dakin’s solution on 1/21/26, but the strength was not clarified by the physician until 2/19/26, and the record did not show a physician order clarifying the dose during that interval. Facility staff confirmed during interviews that the Dakin’s order should have been clarified and implemented when the recommendation was received, but they were unable to produce documentation showing that the physician was contacted to clarify the strength. The wound consultant later stated that 0.125% Dakin’s is typically used in his practice and that 0.5% could cause burning. The resident stated that wound treatments burned when the liquid was applied. The DON acknowledged that the order was not clarified and not implemented at the time the recommendation was received, and that the consultation documentation was vague.
Failure to Monitor Weights and Provide Consistent Meal Assistance
Penalty
Summary
The facility failed to have a system in place to ensure resident weights were consistently and accurately monitored, that a significant weight loss was verified with a reweight, and that the interdisciplinary team responded to the loss. One resident with Parkinson’s disease, dysphagia, and a sacral pressure ulcer was admitted on a pureed diet with thickened liquids and was identified by the RD as needing assistance with meals, fluid encouragement, supplements, and weight monitoring. The resident’s documented weight dropped from 128.0 pounds to 115.8 pounds in 10 days, which was noted as a significant loss, and later a weight of 115.0 pounds was documented by the DON. The record did not show that the weight loss was verified with a reweight or that the physician or RD was notified when the loss was identified. The RD’s assessment for this resident documented altered nutrition risk, moderate decrease in food intake, and the need for nutritional supplements and monitoring, but the record did not show documented follow-up after the significant weight loss was recorded. The RD later stated that the resident had not been reweighed and that she could not confirm the accuracy of the admission weight because no reweight had been obtained. The RD also stated that staff should have alerted her when the weight discrepancy was recorded and that she would have made additional dietary recommendations if informed. The facility also failed to consistently implement identified nutritional interventions for another resident with Alzheimer’s disease, dysphagia, and myasthenia gravis who had documented cognitive impairment, dependence for eating, and ongoing weight loss. The resident’s record showed repeated weight loss over several months, with RD notes describing refusal to eat most foods, poor intake, and the need for multiple supplements, fortified cereal, encouragement, and assistance at meals. During observation, the resident was left in front of a meal tray without staff present to assist or encourage eating, and a CNA who was not assigned to the resident did not remain to help. Another CNA later set up the tray and placed the utensil in the resident’s hand, but did not provide the meal assistance or encouragement described in the care plan. The meal tray also did not match the ticket in several respects, and the fortified cereal observed appeared watery; the Executive Chef stated there was no recipe being used at the time, while the RD stated that following a recipe was important to ensure the appropriate calories and protein were provided.
Wound Care Competency and Order Clarification Failures
Penalty
Summary
The facility failed to assure nursing staff had the competency and skill set to provide appropriate wound care and to verify and clarify physician recommendations for wound treatment for two residents. For one resident, a wound care consultation on 1/13/26 documented a debrided wound measuring 13.5 cm x 8.5 cm x 2 cm and recommended cleansing with Vashe, applying Santyl to slough, packing with Dakin's-soaked gauze twice daily, and covering with a foam dressing. The consultation form did not identify the attending or consulting physician, was not signed by either physician, and did not specify the Dakin's strength. The resident was later given Dakin's 0.5% without clarification of the recommendation, and the record reviewed did not show any physician order or documentation that the strength had been clarified. The DON stated the order should have been clarified and implemented the same day it was obtained, and the consulting wound care physician stated he had not been made aware the resident had been ordered Dakin's 0.5% and that he should have been contacted to clarify the recommendation. For another resident, a surveyor observed an LPN perform wound care and noted the LPN washed her hands for six seconds, did not cleanse the bedside table or use a barrier for wound care supplies, and used her lap to set up the field. During interview, the DON stated wound competencies were completed by an RN, but the competencies reviewed did not include all staff and were not related to order clarification. The DON also stated the dietary department was not included in any training or competencies. These observations and record reviews showed the facility did not ensure staff were competent in wound care practices or in verifying and clarifying wound treatment orders.
Mechanical Soft Diet Not Followed for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident who required a mechanically altered diet received appropriate meal items. Resident #5 had diagnoses including Alzheimer's disease, dysphagia, and myasthenia gravis, and had been downgraded to a mechanical soft diet after being observed spitting out food and being unable to swallow eggs and sausage during breakfast. The resident also had weight loss and increasing confusion, and the RD stated interventions had been added in response to the weight loss. During observation, the resident’s meal tray contained cut-up sausage circles, French toast, unopened milk, hot cereal, and a beverage, while the meal ticket indicated a mechanical soft texture and listed ground Canadian bacon. CNA #1 moved the tray to the resident but did not further assist or encourage feeding. The CNA stated she was not assigned to the resident and was unsure what the meal ticket notation meant. The LPN also did not know what the notation meant and stated dietary checked trays before they were sent and CNAs checked trays before giving them to residents. The DDS later stated the resident should have had Canadian bacon instead of sausage, and the RD and ST stated that the notation meant ground meat and that the resident should have received ground meat.
Infection Control Failures During Wound Care, Medication Handling, and Meal Service
Penalty
Summary
The facility failed to maintain proper infection control practices during wound treatment, medication administration, and resident meal service. During a wound treatment for one resident, an LPN performed hand hygiene but did not wash for the required 20 seconds, turned off the faucet with wet hands, and placed opened gauze on her scrub pants instead of using a clean barrier. The LPN then cleansed the resident’s left heel, did not perform hand hygiene or change gloves before treating the right heel, and used the same gloves for both treatments. The LPN later acknowledged that the gauze should have remained in the packet and that hand hygiene and glove changes should have occurred between the treatments. During medication administration, an LPN prepared and administered Trelegy Ellipta, a semicritical inhalation device, to a resident with asthma/chronic obstructive pulmonary disease. After the resident self-administered the inhaler, the device was placed on the resident’s tray table, which was identified as a high-touch surface, and then placed on the medication cart where medications for other residents were prepared. The inhaler was then being returned to its carton without cleaning the device or the top of the medication cart. The LPN acknowledged that the inhaler should have been cleaned and should not have been placed on the medication cart. During lunch service in the dining room, a CNA assisted residents with hand hygiene and food service while repeatedly changing gloves without performing hand hygiene between tasks. The CNA assisted one resident with a hand towelette, removed gloves, put on a clean pair without hand hygiene, poured soup for another resident, removed gloves again without hand hygiene, assisted a third resident with a can of soda using bare hands, then put on another clean pair of gloves without hand hygiene. The CNA continued this pattern while assisting additional residents with hand hygiene and beverages. The CNA stated she did not think hand hygiene was needed after assisting residents with hand towelettes, then acknowledged she probably should have performed hand hygiene. The DON later confirmed that hand hygiene was needed between different pairs of gloves.
Late Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue the required Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) within the proper time frame for 2 of 3 residents reviewed for Beneficiary Protection Notification. Resident #12 had a Medicare Part A episode that began on 8/28/25 with a last covered day of 9/26/25, but the facility email showed both the SNF ABN and NOMNC were sent to the resident’s responsible party on 9/25/25 at 4:06 PM. Resident #46 had a Medicare Part A episode that began on 9/25/25 with a last covered day of 10/5/26, but the SNF ABN and NOMNC provided by the facility were both signed by the resident’s responsible party and dated 10/6/25. The surveyor reviewed the facility’s list of residents discharged from Medicare-covered Part A in the last six months, selected three residents, and requested the beneficiary notices from the LNHA, then later met with facility management to discuss the concerns.
Pharmacist Failed to Identify Missing Dakin’s Strength During MRR
Penalty
Summary
The facility failed to identify a medication irregularity during the Consultant Pharmacist’s monthly Medication Record Review for one resident with Parkinson’s disease and an unhealed sacral pressure ulcer. The resident’s admission record, MDS, and wound documentation showed the resident was cognitively intact, had an unstageable pressure ulcer on admission, and was receiving wound care that included Vashe, Santyl, and Dakin’s-soaked gauze twice daily with foam dressing. The wound consultant note dated 1/13/26 included the wound treatment plan, and the corresponding RN order entry also directed packing the wound with Dakin’s-soaked gauze, but the strength of the Dakin’s solution was not documented on the new wound order. On 2/19/26, the active February 2026 TAR showed the Dakin’s order had been started on 1/21/26 at 0.5%, and the LPN reviewing the record could not show that the physician had been contacted to clarify the strength, despite the wound consultant’s recommendation. The Consultant Pharmacist stated that he reviewed the TAR every 6 to 12 months, and the facility’s MRR for 1/1/26 to 1/25/26 showed the resident’s chart was reviewed with no recommendations made. During the survey discussion, facility leadership stated the expectation was that all medication be reviewed monthly, and the facility policy described MRR as a thorough evaluation of the medication regimen.
Missing Current Hospice Agreement
Penalty
Summary
The facility failed to have a current written agreement between the Medicare-certified hospice and the facility for one resident receiving hospice services. Resident #28 had diagnoses including arteriosclerotic heart disease, and the physician’s orders included hospice services from H #1. The resident’s quarterly MDS dated 2/25/26 showed a BIMS score of 13, indicating intact cognition, and the comprehensive care plan documented that the resident was receiving hospice services with H #1 for overall decline and per the resident’s wishes for heart disease. During record review, the hospice communication book behind the nursing station showed that Resident #28 was admitted to H #1 in August 2025 for arteriosclerotic heart disease. The facility provided a hospice contract effective 7/8/20 between the facility and H #2, but the LNHA stated the hospice had changed names and did not provide a current written agreement with H #1. The survey team notified facility management of the concern, and the LNHA later provided a social service note showing the resident’s responsible party had given permission for a hospice referral to H #1.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to store food in a manner that prevents food-borne illness and did not maintain the kitchen environment and equipment in a sanitary manner. During an initial tour of the kitchen, the surveyor observed several issues, including a large commercial food processor stored with a wet lid, which the Food Service Director (FSD) acknowledged should not have been left wet. Additionally, crumb debris was found on bins storing bulk flour and sugar, and debris was noted on the base of a can opener affixed to a stainless steel table. A large meat slicer, identified as clean by the FSD, was covered in plastic but had debris by the slicer blade and on its base, with a blue-handled food scoop stored on the base. In a follow-up observation, further unsanitary conditions were noted in the server kitchen area. The surveyor found a dried brown substance on two of the four dispensing tubes from the soda drink dispensers and a brown substance on the floor beneath the drink dispenser boxes. Inside the box ice cream freezer, six out of ten lids on the ice cream containers were found open. The FSD confirmed that the server kitchen area should have been clean and that the ice cream lids should have been closed.
Expired AED Kits and Emergency Supplies
Penalty
Summary
The facility failed to maintain Automated External Defibrillator (AED) kits and other emergency items prior to their expiration date, as observed by surveyors. Two expired AED kits were identified on the second and third floors, each containing defibrillator pads that had expired. During an inspection, a Licensed Practical Nurse (LPN) confirmed the presence of an expired AED pad on the third floor and acknowledged that it was the only AED machine available on that floor. The Emergency Cart Daily Checklist, which was supposed to ensure that all emergency supplies were available and not expired, was reviewed and found to have been checked daily, except for one instance where oxygen was not marked as checked. The LPN stated that the shift nurse was responsible for checking the emergency supplies. Further inspection revealed additional expired items in the AED room, including test strips, glucose, and resuscitator bags. The Registered Nurse/Infection Preventionist (RN/IP) and the Registered Nurse/Charge Nurse (RN/CN) were informed of the expired items and confirmed the oversight. The RN/CN stated that the AED pads should not have been expired as the AED machine would not function properly with expired pads. The Licensed Nursing Home Administrator later stated that the AED pads were not part of the checklist, and it was uncertain if the nurses checked the expiration dates on the AED pads. The facility's policy required monthly checks of the AED units, including the pad expiration date, but this was not adhered to, leading to the deficiency.
Failure to Consistently Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to consistently offer pneumococcal vaccines to residents, as evidenced by the cases of two residents. For one resident, the surveyor could not locate documentation supporting the administration of the pneumococcal vaccine in either the paper or electronic medical records. The resident's immunization status was not up to date according to the Comprehensive Minimum Data Set (MDS) assessment, and no reason was provided for the lack of vaccination. The facility's administration was unable to provide evidence of the resident's pneumococcal vaccination. In the case of another resident, the surveyor observed the resident using a nasal cannula for supplemental oxygen due to acute and chronic respiratory failure. The resident's immunization record did not include information about the pneumococcal vaccination. Although the resident was cognitively intact and had informed staff of receiving the vaccine upon admission four years ago, there was no documentation of the type or date of vaccination. The Quarterly Minimum Data Set (qMDS) inaccurately reflected that the resident's pneumococcal vaccination was up to date, and there was no documentation of the vaccine being offered, declined, or any education provided. The RN/Infection Preventionist acknowledged the lack of documentation and stated that the resident's pneumococcal vaccination status was not up to date. The facility's policy required residents to be assessed for vaccine eligibility upon admission and offered the vaccine within thirty days unless contraindicated or previously vaccinated. However, the facility failed to adhere to this policy, as evidenced by the missing documentation and inaccurate records in the cases reviewed.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of an unsampled resident during a dining observation. A Certified Nursing Aide (CNA) was observed ignoring a resident's request for pineapple chunks with their meal. The CNA, present during the request, did not address the resident directly and instead informed the surveyor that the resident was aware that dessert is served after the meal. The CNA refused to communicate directly with the resident and walked away without addressing the resident's request, which was later deemed unacceptable by the Director of Nursing. Additionally, the facility failed to ensure the dignity of a resident with a urinary catheter. The resident was observed with an uncovered urinary catheter collection bag in direct contact with the floor, visible from the hallway and to the roommate due to an open privacy curtain. The resident, who had severe cognitive impairment, was also seen in a wheelchair with the catheter bag partially covered and still in contact with the floor. The LPN and the Infection Preventionist confirmed the importance of keeping the catheter bag covered and off the floor to prevent contamination and maintain the resident's dignity.
Failure to Complete Pre-Employment Background Check
Penalty
Summary
The facility failed to implement its abuse policy by not ensuring that criminal background checks were completed before the start date of employment for new hires. This deficiency was identified in the case of an Activities Aide, who was hired and began working before the completion of their background check. The employee was hired on 5/13/24, but the background check was not completed until 5/17/24. Despite this, the employee worked a total of 32 hours from 5/13/24 to 5/17/24, as evidenced by their timecard and the signed Employee Acknowledgement Form. Interviews with facility staff, including the Human Resource and Information System home office staff, the Director of Activities, the Director of Nursing, and the Licensed Nursing Home Administrator, confirmed the oversight. The HRIS staff acknowledged the missing documents, and the Director of Activities and Director of Nursing both stated that an email from HR should confirm when an employee is cleared to start work. However, no such email was provided for this employee. The facility's policy requires a criminal background check as a condition of employment, but this was not adhered to in this instance.
Improper Placement of Urinary Drainage Bag and Tubing
Penalty
Summary
The facility failed to ensure that a urinary drainage collection bag and drainage tubing were not in direct contact with the floor, which could lead to potential contamination. This deficiency was observed in a resident who was using a urinary catheter. The facility's policy on Indwelling Urinary Catheter Insertion/Maintenance clearly stated that both the drainage tubing and bag must be kept from touching the floor. However, during observations, the surveyor noted that the urinary drainage tube and bag were lying directly on the floor while the resident was in bed and later in a wheelchair in the activity day room. The resident involved had a medical history that included chronic kidney disease, unspecified mood disorder, and urinary retention, and had a suprapubic catheter insertion. Despite the facility's policy and the resident's care plan goal to prevent cross-contamination, the urinary drainage bag was not maintained properly. The LPN and CNA responsible for the resident's care acknowledged the improper placement of the urine collection bag and tubing, which was confirmed by the RN Infection Preventionist, who stated that the bag and tubing must be off the floor to prevent infection.
Inadequate Pain Management and Care Planning
Penalty
Summary
The facility failed to provide a comprehensive patient-centered care plan for a resident requiring pain management, and did not act upon a pain management physician's recommendation in a timely manner. The resident, who had a history of unspecified dementia, generalized muscle weakness, and a nondisplaced intertrochanteric fracture of the left femur, was observed complaining of pain. Despite having orders for various pain medications, the resident's care plan lacked goals or interventions for pain management, including preferences, triggers, and non-pharmacological interventions. The facility's documentation practices were inadequate, as the resident's pain was charted by exception, and there was no shift-to-shift pain monitoring after a certain date. The RN/CN confirmed that the resident should have had a care plan for pain, especially given the resident's cognitive impairment and history of pain during movement. The discontinuation of shift-to-shift pain assessment was based on a consultant pharmacist's recommendation, which was misunderstood to mean stopping pain assessment altogether, rather than just removing documentation from electronic records. Additionally, a pain management consultant's report recommended adjusting the resident's pain medication for better control, but this recommendation was not acted upon within the expected 24-hour timeframe. The RN/UM was unable to explain how the consult was missed, and there was no evidence that the attending physician was notified. The facility's policy required that pain management be addressed in the resident care plan, but this was not done, leading to inadequate pain management for the resident.
Failure to Administer Midodrine According to Physician Orders
Penalty
Summary
The facility failed to administer medications used to manage low blood pressure in accordance with physician orders for a resident with moderate cognitive impairment and a history of a hip fracture. The resident was prescribed Midodrine with specific parameters to hold the medication if the systolic blood pressure (SBP) exceeded 120. However, the medication was administered outside these parameters on multiple occasions in August and September 2024, with recorded SBP readings of 132, 136, 122, and 137, among others. The resident's comprehensive care plan did not include interventions to monitor blood pressure, contributing to the oversight. The deficiency was further compounded by the lack of a facility policy on administering medications with parameters and the failure of the Consultant Pharmacist to identify and address the irregularities in medication administration. Additionally, only two out of the three nurses who administered Midodrine outside the prescribed parameters received a graded medication pass observation, indicating a lapse in monitoring and evaluation of nursing staff performance in medication administration.
What surveyors are citing around you — mapped
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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 601 citations issued within 25 miles in the last 12 months — including the 19 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 Red Bank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Shrewsbury Llc | 0.5 mi | ★★★★★ | 15 | 0 |
| Redbank Center For Rehabilitation And Healing | 1.2 mi | ★★★★★ | 0 | 0 |
| De La Salle Hall | 3.7 mi | ★★★★★ | 1 | 0 |
| Shore Pointe Care Center | 4.1 mi | ★★★★★ | 1 | 1 |
| Careone At Middletown | 4.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.