Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Autumn Lake Healthcare At Berkeley Heights during CMS and state inspections, most recent first.
A resident with schizophrenia, anxiety, depression, and gait/mobility issues, but intact cognition, left the facility through the lobby without notifying nursing staff or being signed out, contrary to usual practice and facility policy. An RN last saw the resident around midday and did not see or report their absence before shift end, and later an LPN and CNA noted an untouched dinner tray and absence from the room but initially assumed the resident was out smoking. The resident traveled by public transportation out of town, missed return buses, spent the night in a hospital lobby, and returned the next morning, demonstrating a failure to provide adequate supervision and to follow the facility’s elopement and sign-out protocols.
Inconsistent Wander Guard Function Checks: The facility failed to consistently verify the function of wander guards for residents at risk for wandering/elopement. A resident with a wander guard had diagnoses including depression, anxiety, CVA, and metabolic encephalopathy, while two other residents had dementia-related diagnoses and severe cognitive impairment; all were identified as wander/elopement risks with orders for placement and function checks every shift. Staff gave conflicting accounts of how the devices were checked, the handheld scanner was reported not to work after a system change, and documentation of the required checks could not be produced.
MDS Not Accurately Completed for Tube Feeding and Colostomy: Two residents had inaccurate MDS coding. One resident was observed receiving continuous tube feeding, with EMR orders and care plan documentation confirming the feeding and diagnoses of diabetes and dysphagia, but the MDS did not include the diagnoses or tube feeding. Another resident had a documented colostomy with ongoing orders, care plan focus, and TAR entries for colostomy care, but the MDS did not indicate the ostomy. The MDSC stated both omissions were her error.
A facility failed to follow CDC guidelines for pneumococcal vaccinations by not offering the Prevnar 20 vaccine to a resident over 65 who had previously received PCV13 and PPSV23. The facility's policy did not reflect current CDC recommendations, and staff interviews confirmed the oversight, which could increase the resident's risk of pneumonia.
A facility failed to protect residents from abuse, as evidenced by a dietary staff member speaking harshly to a resident, causing them to cry, and a wandering resident physically assaulting another, resulting in a lost tooth. The facility's investigation did not confirm the assault, and care plans were not updated to address the wandering behavior or the incident, highlighting a failure to follow abuse prevention policies.
The facility failed to provide an adequate supply of linens, including towels, to meet the needs of residents across four units. Despite the Housekeeping Director's claim of sufficient supply, resident feedback and a lack of documented linen distribution policy highlighted the deficiency. The DON confirmed the facility's census, but no additional information was provided to address the issue.
The facility failed to ensure that NAs received the required training and competencies before being assigned to provide direct resident care independently. Two NAs, enrolled in a training program, began providing care without completing necessary modules or having competencies verified. Facility staff were unclear about training requirements, leading to NAs providing care without adequate preparation, placing residents at risk.
The facility failed to maintain a clean and sanitary kitchen, risking foodborne illness. Observations included improper dishwashing practices, expired and unlabeled food, and unsanitary conditions throughout the kitchen and storage areas. The Food Service Supervisor and Human Resources Director acknowledged the lack of a cleaning schedule and the facility's failure to adhere to its Food Receiving and Storage Policy.
The facility failed to address resident concerns about staffing, staff training, and incontinence care through their QAPI program. Surveyors observed residents left soiled for extended periods and noted inadequate staff training and communication. Residents reported that agency CNAs were untrained and incontinence care was delayed, particularly by the 3:00 PM to 11:00 PM staff. The QAPI program did not address these issues, as confirmed by the LNHA.
The facility did not designate a full-time Infection Preventionist as required for facilities with 100 or more beds. The current Infection Preventionist has been performing dual roles as both the IP and ADON since 2019, despite completing CDC training and certification. The DON confirmed the facility's bed capacity and acknowledged the requirement for a full-time IP.
A LTC facility failed to follow its policies for abuse investigation and incident reporting, resulting in incomplete investigations for two incidents. One involved a resident alleging verbal abuse by staff, with an incomplete grievance form and no thorough investigation. The second incident involved a resident found unresponsive on the floor, with no comprehensive analysis or witness statements. The facility's policies require thorough documentation and investigation, which were not adhered to in these cases.
The facility failed to provide adequate incontinence and personal hygiene care, as residents were found in soiled conditions for extended periods, with some wearing multiple saturated briefs. Observations revealed strong odors and delayed care, with residents expressing concerns about staffing and response times. Care plans did not adequately address residents' needs, and staff inconsistencies were noted.
The facility failed to ensure proper administration and monitoring of cardiac medications for residents, leading to deficiencies in care. A resident on Milrinone did not receive consistent blood pressure monitoring, and there was no policy for its administration. Another resident did not receive timely administration of cardiac medications upon admission, with no documentation of communication with the physician. A third resident's medication was not administered as ordered, with no evidence of physician notification.
A resident with severe cognitive impairment exhibited wandering and inappropriate urination behaviors, which were not adequately addressed by the facility. Despite documentation and reports from staff and other residents, the care plan lacked specific interventions for these behaviors. The facility's attempts, such as using stop signs, were ineffective, and there was no evidence of non-pharmacological interventions. The facility also failed to investigate incidents thoroughly, contributing to the deficiency.
A facility failed to provide appropriate restorative services for a resident with limited mobility, leading to a deficiency in maintaining or improving their range of motion (ROM). The resident was observed with contracted hands and no assistive devices, and the restorative program documentation was missing. Despite the resident's fall and diagnoses including Parkinson's disease, there was no referral to therapy services, and the facility's policy on ROM was not followed.
A resident with acute respiratory failure was not administered oxygen as ordered, with the concentrator set below the prescribed 3 LPM on multiple occasions. The resident's care plan required continuous oxygen to maintain saturation above 94%, but the facility failed to follow the physician's order. The issue was confirmed by an LPN and escalated to the RN/Unit Manager, but no further information was provided by the facility's administration.
The facility failed to post an up-to-date Nursing Home Staffing Report (NHSR), with surveyors finding the report outdated by several days. The HRD admitted the report was not printed over the weekend, and the Monday report was delayed. The facility's staffing policy lacked procedures to ensure timely posting.
A facility failed to acquire routine medications without delay for a resident, leading to a deficiency. An LPN was observed without the necessary medication in stock, despite a pharmacy order being created. The eMAR showed the medication was documented as administered on several dates, except one where delivery was awaited. The RN/UM and ADON confirmed procedures for out-of-stock medications, but the RN/UM was not informed of the issue. The deficiency was discussed with the survey team, corporate nurse, DON, and LNHA, but no further information was provided.
The facility failed to properly store and label medications, including a narcotic box that was not affixed in a refrigerator and intermingled prescription and OTC medications in a cart. An RN and LPN acknowledged these issues, which were observed during a survey.
Failure to Follow Elopement Protocol Resulting in Resident Leaving Facility Overnight
Penalty
Summary
The deficiency involves the facility’s failure to follow its elopement and supervision protocols, resulting in a resident leaving the building, traveling out of town, and remaining out overnight without staff knowledge. The resident had diagnoses including schizophrenia, anxiety disorder, depression, gait and mobility abnormalities, and other lack of coordination, but had an intact cognition with a BIMS score of 15/15. The facility’s policy on Elopements and Wandering Residents stated that residents at risk for elopement would receive adequate supervision to prevent accidents or elopements. On the day of the incident, the resident left the facility through the lobby without notifying nursing staff or being signed out, which differed from their usual practice of informing a nurse and signing out when going out. The resident later reported that they told a CNA they wanted to go out but did not inform a nurse or obtain a formal sign-out. RN staff last recalled seeing the resident around late morning to midday and did not see the resident again before the end of the shift, nor did they report the lack of contact in shift handoff. During the evening, the resident’s dinner tray was delivered and later found untouched, and the CNA reported this to the LPN, initially assuming the resident was out smoking. Progress notes showed that the resident was not seen in their room at multiple checks in the late afternoon and early evening, and a search was not escalated until it became clear later in the evening that the resident was not in the facility. By that time, the resident had already left, obtained a ride to a train station, traveled by public transportation to their hometown, missed return buses, and spent the night in a hospital lobby before returning the next morning. The facility’s failure to adequately monitor the resident’s whereabouts, recognize and act promptly on the missed meal and absence from the room, and ensure adherence to the sign-out process led to the resident’s elopement in violation of the facility’s policy requiring adequate supervision to prevent accidents or elopements.
Inconsistent Wander Guard Function Checks
Penalty
Summary
The facility failed to implement a system for staff to consistently check the function of wander guards used for residents at risk for wandering and elopement. This deficient practice was identified for 3 of 3 residents reviewed for wander guards: Resident #19, Resident #43, and Resident #79. The report states that the facility had orders for wander guard placement and function checks every shift, but staff interviews and observations showed that the process for confirming function was not being carried out consistently or in a reliable manner. Resident #79 was observed with a wander guard on the right ankle and had diagnoses including major depressive disorder, anxiety disorder, cerebral infarction, and metabolic encephalopathy. The resident’s MDS reflected moderate cognitive impairment, and the wandering/elopement assessment showed the resident was at risk to wander. The care plan identified the resident as an elopement risk/wanderer and noted confusion and impulsivity. The eTAR included an order to check the right ankle wander guard for function and placement every shift, but an LPN could not explain how the function was checked. The unit manager stated nurses checked placement, while the unit clerk on another wing said she was responsible for checking function with a handheld scanner and that it should be done every day on every shift, yet she could not produce documentation showing the checks had been completed. Resident #43 had diagnoses including metabolic encephalopathy and Alzheimer’s disease, with severe cognitive impairment on the MDS and a wandering/elopement assessment indicating high risk to wander. Resident #19 had diagnoses including metabolic encephalopathy and dementia, severe cognitive impairment on the MDS, and a wandering/elopement assessment indicating high risk to wander. The care plan and eTAR for Resident #19 reflected that the left ankle wander guard was to be checked for placement and function every shift. During interviews, staff gave inconsistent descriptions of how the function was checked, including taking residents to the front door, using a scanner, or relying on others to do it. The unit clerk stated the scanner was not working after a new system was installed, and the maintenance director confirmed the scanner on B-wing was not compatible with the new system. Staff were unable to provide the calendar or documentation that was supposed to show the wander guard function checks for the residents reviewed.
MDS Not Accurately Completed for Tube Feeding and Colostomy
Penalty
Summary
The facility failed to accurately complete the MDS for two residents. For Resident #7, the surveyor observed the resident lying in bed with tube feeding infusing via pump at 65 cc/hr. The EMR showed a physician order dated 9/2/25 for continuous Glucerna 1.5 at 65 ml/hr for a total volume of 1170 mls, and the ICCP included a focus area dated 9/2/25 stating the resident required tube feeding. The medical provider note dated 9/2/25 listed diagnoses of diabetes and dysphagia. However, the comprehensive admission MDS dated 9/5/25 showed a BIMS score of 7, did not indicate any diagnoses in section I, and did not indicate tube feeding in section K. When interviewed, the MDSC stated she was not sure what happened with Resident #7 and that it was her error. For Resident #93, the surveyor observed the resident in a wheelchair and staff indicated the presence of a colostomy. The EMR showed a physician order dated 5/30/25 to check the colostomy bag every shift and change it when 3/4 full. The ICCP included a focus area initiated 9/30/22 for the colostomy, and the July 2025 TAR showed colostomy checks and care were performed every shift, every day of the month. The most recent quarterly MDS showed a BIMS score of 9, diagnoses including atrial fibrillation, and section H did not indicate the presence of an ostomy. The MDSC stated the ostomy should have been checked and that it was her error.
Failure to Offer Prevnar 20 Vaccine to Resident
Penalty
Summary
The facility failed to adhere to the CDC guidelines for pneumococcal vaccinations, resulting in a deficiency related to the vaccination of a resident. The facility's policy, dated April 10, 2024, stated that pneumococcal vaccines should be administered in accordance with current CDC recommendations. However, the facility did not offer the Prevnar 20 vaccine to a resident over the age of 65, who had previously received the PPSV23 vaccine in April 2017 and the PCV13 vaccine in March 2016. The CDC guidelines indicate that adults who have received PCV13 and PPSV23 should be offered PCV20, but this opportunity was not provided to the resident or their representative. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that there were no updated pneumococcal policies reflecting the CDC's current recommendations. The Director of Nursing acknowledged that the resident should have been offered the Prevnar 20 vaccine, as it had been more than five years since the last pneumococcal vaccination. This oversight had the potential to increase the resident's risk of contracting pneumonia.
Failure to Protect Residents from Abuse and Inadequate Care Planning
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two incidents involving residents. In the first incident, a dietary staff member spoke to a resident in a harsh and abusive manner during a meal, causing the resident to cry. This behavior was witnessed by a surveyor and confirmed by an activity staff member, who noted that the dietary staff member had previously spoken to residents in a similar tone. The facility's Director of Nursing and Licensed Nursing Home Administrator were not aware of the incident until informed by the surveyor. In the second incident, a resident with a history of wandering entered another resident's room and physically assaulted them, resulting in the loss of a tooth. The assaulted resident reported the incident to staff, but the facility's investigation did not confirm the event through camera surveillance. Despite the resident's report and the presence of a history of wandering behavior, the care plan for the wandering resident was not updated to address the behavior or prevent future incidents. The facility's failure to follow its Abuse, Neglect, and Exploitation Policy and Procedure is further highlighted by the lack of appropriate interventions in the care plans of the involved residents. The wandering resident's care plan did not adequately address their behavior of entering other residents' rooms, and the assaulted resident's care plan was not updated to reflect the incident. This lack of action and oversight contributed to the continuation of abusive interactions and inadequate protection for the residents involved.
Inadequate Linen Supply for Residents
Penalty
Summary
The facility failed to ensure an adequate supply of linens, including sheets, pillowcases, towels, bed linens, wash cloths, bed pads, and gowns, to meet the needs and maintain the dignity and well-being of all residents across four resident units. This deficiency was identified through observation, interviews, and document reviews. During the entrance conference, the Director of Nursing confirmed the facility's census was 97 residents. However, feedback from residents indicated a shortage of towels, as noted in the Resident Council Meeting Minutes from March. Despite the Housekeeping Director's assertion that there was enough linen supply, the surveyor found discrepancies in the reported linen distribution schedule. The facility's linen distribution schedule indicated that each resident unit received a linen cart every shift, with specific quantities of linens and blankets. However, the facility failed to provide a policy regarding the linen process and distribution when requested by the surveyor. This lack of documentation and the residents' feedback about insufficient towels contributed to the determination of the deficiency. The Licensed Nursing Home Administrator and the Director of Nursing were informed of these concerns, but no additional information was provided to address the issue.
Inadequate Training and Competency Verification for Nurse Aides
Penalty
Summary
The facility failed to ensure that Nurse Aides (NAs) received the required training and competencies before being assigned to provide direct resident care independently. This deficiency was identified for two NAs who were enrolled in a Nurse Aide Training School but had not completed the necessary modules of the Nurse Aide Training and Competency Evaluation Program (NATCEP). Despite this, they were assigned to provide independent direct care, including tasks such as bathing, toileting, transferring, feeding, personal hygiene, and grooming. The NAs were enrolled in a training program on June 18, 2024, and completed Module 1 by July 12, 2024. However, they began providing independent care on July 5, 2024, without completing Module 2 or having their competencies verified by the facility. The facility lacked records of the NAs completing the required modules, and there was no evidence of a competency process beyond a checklist. Interviews with facility staff revealed confusion and miscommunication regarding the training requirements and oversight responsibilities for the NAs. The Human Resources Director (HRD) and other staff members were unclear about the training process and the requirements for NAs to work independently. The HRD believed that after two weeks of training, the NAs could be assigned independently, but this was not in line with the facility's policy or state regulations. The Assistant Director of Nursing (ADON) and other staff members were under the impression that the NAs had completed the necessary training, but this was not the case. The lack of proper oversight and verification of training completion led to the NAs providing care without adequate preparation, placing residents at risk.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, leading to potential foodborne illness risks. During a kitchen tour, a food service staff member was observed washing dishes with bare hands, handling both dirty and clean dishes without performing hand hygiene. The dish machine temperature log was outdated, and the Food Service Supervisor (FSS) was unaware of the required temperatures, relying on a weekly check by the dish machine company. Expired and unlabeled food items were found in the refrigerator and freezer, and various food items lacked proper labeling with use-by dates. The kitchen environment was unsanitary, with debris, a dead insect, and a malfunctioning prep sink. The FSS admitted to the absence of a cleaning schedule, and the Human Resources Director (HRD) confirmed that the kitchen was not clean. Additional observations included soiled food preparation tables, a can opener with debris, and a sticky metal table by the ice machine. The ice machine baffle had pinkish debris, and personal beverages were improperly stored. The facility's Food Receiving and Storage Policy required clean storage areas and proper labeling of dry foods, which was not adhered to. The HRD acknowledged that the dry storage room was not clean, contradicting the policy's requirements. The facility's failure to maintain cleanliness and adhere to food safety protocols was evident throughout the kitchen and storage areas.
Deficiency in Addressing Resident Concerns and Staff Training
Penalty
Summary
The facility failed to identify and implement interventions to address resident concerns regarding staffing issues, staff training, grievances, abuse, issues with medications, incontinence care, staff competency, and the use of uncertified nurse aides through their Quality Assurance and Performance Improvement (QAPI) program. This deficiency was observed across all four resident care units. During a care tour, surveyors noted that several residents were left soiled in their excrement for extended periods, with some wearing multiple soaked incontinent briefs. Residents also had long, jagged, and soiled fingernails. Interviews with alert residents revealed that the facility was understaffed, and staff were not adequately trained to care for the residents. One resident reported expressing concerns about the lack of training to the Licensed Nursing Home Administrator (LNHA), but no action was taken. During a Resident Council Meeting, eight out of eleven residents expressed concerns over staffing and staff incompetence. They reported that many Certified Nursing Assistants (CNAs) were agency staff who seemed untrained and lacked communication skills. Residents noted that incontinence care was not provided in a timely manner, particularly by the 3:00 PM to 11:00 PM staff, leading to malodorous odors in the hallways. The facility's QAPI program did not address these issues, as confirmed by the LNHA, who stated that there was no data-driven QAPI program for concerns identified with incontinence care, staff training, restorative care, and grievances. The facility's QAPI attendance logs and meeting notes did not reflect any actions taken to address these significant concerns.
Failure to Designate a Full-Time Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Prevention and Control Nurse solely responsible for the infection prevention and control program, as required by the State of New Jersey Department of Health Executive Directive No 20-026-1. During an interview, the facility's Infection Preventionist (IP) revealed that she has been performing dual roles as both the IP and the Assistant Director of Nursing (ADON) since 2019. Despite completing her CDC training and receiving certification as a Nursing Home Infection Preventionist in 2020, she continues to work full-time in both capacities. The Director of Nursing (DON) confirmed that the facility is licensed for 130 beds, which mandates a full-time IP with no other responsibilities. The DON acknowledged the requirement but did not provide further information to address the deficiency.
Incomplete Investigations and Documentation in LTC Facility
Penalty
Summary
The facility failed to follow its policy for Abuse Investigation and Incidents and Accidents, resulting in incomplete investigations and documentation for two separate incidents involving residents. In the first case, a resident alleged verbal abuse by staff, stating that staff made fun of them and ignored their needs. The grievance form filed by the resident was incomplete, lacking documentation of review, action taken, and resolution. The Director of Nursing (DON) admitted that no thorough investigation was conducted, and only a brief conversation with the resident was documented, without interviewing other potential witnesses or staff involved. In the second incident, a resident was found on the floor, unresponsive, and saturated with urine, requiring emergency transport to the hospital. The investigation into this incident was also incomplete, with no witness statements or a comprehensive analysis of the circumstances leading to the fall. The DON acknowledged the lack of documentation and stated dissatisfaction with the new investigation process, which contributed to the incomplete investigation. The facility's policies on incident reporting and abuse investigation require thorough documentation and investigation of all incidents, including interviewing all involved parties and providing complete documentation. However, in both cases, the facility failed to adhere to these policies, resulting in inadequate investigations and unresolved grievances.
Inadequate Incontinence and Hygiene Care in LTC Facility
Penalty
Summary
The facility failed to provide appropriate incontinence and personal hygiene care for several residents, as evidenced by multiple observations and interviews conducted by surveyors. Residents were found sitting or lying in soiled conditions for extended periods, with some residents wearing multiple incontinence briefs that were saturated with urine and feces. This was observed across different units and involved residents who were dependent on staff for care, including those with cognitive impairments and limited mobility. The surveyors noted strong malodorous odors in the hallways and rooms, indicating a lack of timely incontinence care. Specific incidents included a resident who had not been changed since the morning, resulting in soaked bedding and clothing, and another resident who was found with three saturated briefs. The care plans for these residents did not adequately address their needs for activities of daily living (ADLs) or incontinence care. Staff interviews revealed inconsistencies in care provision, with some staff members acknowledging the use of double briefs and others unable to confirm when residents were last changed. The facility's policy required incontinence care every two hours, but this was not consistently followed. Additionally, residents expressed concerns about inadequate staffing and delayed responses to call lights, which contributed to the deficiencies in care. A resident council meeting highlighted these issues, with residents reporting that incontinence care was often delayed until shift changes. The facility's management was reportedly unaware of the extent of the issues, despite the pervasive odors and resident complaints. The surveyors documented these deficiencies and discussed them with facility management during the survey process.
Failure in Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, specifically in the administration and monitoring of cardiac medications. For Resident #88, the facility did not have a procedure in place for administering Milrinone, an intravenous medication for heart failure, which required specific monitoring. The resident's blood pressure was not consistently monitored every four hours as ordered, with only 28 out of 84 required readings documented. Additionally, there was no policy in place for the administration of Milrinone, and the staff were not adequately trained to monitor and administer the medication according to the physician's order. For Resident #296, the facility failed to provide timely administration of physician-ordered cardiac medications upon admission. The resident was admitted with several diagnoses, including paroxysmal atrial fibrillation and COPD, and required medications such as Amiodarone and Advair. However, these medications were not administered on the ordered date, and there was no documentation of communication with the physician regarding the missed doses. The facility's process for acquiring medications from the pharmacy was not effective in ensuring timely administration. Similarly, for Resident #297, the facility did not administer Magnesium Oxide as ordered on the date of admission. The medication was not documented as administered, unavailable, or refused, and there was no evidence of communication with the physician regarding the missed dose. The facility's failure to acquire and administer routine medications without delay was a recurring issue, as evidenced by the lack of documentation and timely action for multiple residents.
Failure to Address Wandering and Inappropriate Urination Behaviors
Penalty
Summary
The facility failed to accurately assess and address the behavior management needs of a resident, identified as Resident #74, who exhibited wandering and inappropriate urination behaviors since December 2023. Despite these behaviors being documented in the resident's clinical records and reported by other residents and staff, the care plan was not revised to include meaningful interventions to manage these behaviors. The care plan focused on cognitive function and elopement risk but did not address the specific behaviors of wandering into other residents' rooms and urinating in inappropriate places. The resident, who has diagnoses including vascular dementia and major depressive disorder, was noted to have a severely impaired cognitive status with a BIMS score of 00 out of 15. Despite this, the Minimum Data Set (MDS) did not reflect the wandering behavior, and the care plan lacked specific interventions for the resident's nighttime wandering and urination issues. The facility's interventions, such as placing stop signs at door entrances, were ineffective, and there was no evidence of non-pharmacological interventions being implemented. Interviews with staff and residents confirmed the ongoing issues, with reports of the resident entering other rooms, displacing belongings, and urinating in trash cans. The facility did not provide adequate supervision or scheduled activities at night to address these behaviors. Additionally, the facility failed to investigate incidents thoroughly, such as when the resident was found on the floor in another resident's room, which could have indicated potential abuse. The lack of a comprehensive behavior management plan and appropriate interventions contributed to the deficiency.
Failure to Provide Restorative Services for Resident with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate services for a resident with limited mobility, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, identified as having contracted hands and no assistive devices, was observed without splints or hand rolls. The Temporary Nurse Aide confirmed the absence of assistive devices, and the Assistant Director of Nursing (ADON) was unable to open the resident's hands fully. The Licensed Practical Nurse/Unit Manager (LPN/UM) admitted that the restorative book, which documents services provided, had been missing for two months, indicating a lack of proof that the restorative program was functional. The resident's electronic medical record lacked orders for ambulation or assistive devices to prevent further decline in ROM. The LPN/UM confirmed the absence of hand rolls for the past two years and was unable to provide documentation for Passive Range of Motion (PROM) or Active Range of Motion (AROM) exercises. Despite the resident's fall, there was no referral to therapy services for skilled interventions, as indicated in the care plan. The resident's diagnoses included arthropathy, Parkinson's disease, mood disturbance, and hypotension, with a moderately impaired cognition score. The Physical Therapy Director (DPT) confirmed that restorative nursing was recommended post-discharge from physical therapy to prevent decline, but the nursing department was responsible for its implementation. The PT discharge summary indicated that the resident had achieved maximum potential and was to continue with a restorative ambulation program. However, the facility's policy on resident mobility and ROM, which was undated, stated that residents should not experience an avoidable reduction in ROM and should receive appropriate services and equipment to maintain or improve mobility. The lack of documentation and implementation of the restorative program contributed to the deficiency.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that a resident received oxygen as ordered, which was identified during a survey. The deficiency involved a resident who was admitted with acute respiratory failure and hypoxia, requiring continuous oxygen administration at 3 liters per minute (LPM) via nasal cannula to maintain oxygen saturation above 94%. However, observations by the surveyor revealed that the oxygen concentrator was set between 2 and 2.5 LPM on multiple occasions, contrary to the physician's order. The resident was cognitively intact and had a care plan in place that included providing oxygen as ordered. Further review of the electronic Treatment Administration Record (eTAR) showed that the order for oxygen was not consistently signed off by nurses on certain shifts. During a follow-up observation, the Licensed Practical Nurse (LPN) confirmed the oxygen was set to 2 LPM, which was not in accordance with the physician's order. The issue was escalated to the Registered Nurse/Unit Manager, who instructed the LPN to check the resident's blood oxygen level and contact the physician. Despite discussions with the survey team, the facility's corporate nurse, Director of Nursing (DON), and Licensed Nursing Home Administrator (LNHA) did not provide additional information to address the concerns raised.
Failure to Post Accurate and Timely Nursing Home Staffing Report
Penalty
Summary
The facility failed to ensure that the posted Nursing Home Staffing Report (NHSR) was up to date and accurate. On multiple occasions, surveyors observed that the NHSR was outdated, with the report dated 7/12/24 still posted on 7/14/24 and 7/15/24. The report was supposed to reflect the current resident census and the number of nursing staff on duty, but it was not updated for several days. The Director of Nursing confirmed that the resident census was 97, differing from the outdated report which showed a census of 101. The Human Resources Director (HRD) acknowledged that the receptionist was responsible for posting the NHSR daily, but the report was not printed over the weekend, and the Monday report was delayed. The HRD admitted that the NHSR should have been up to date for the benefit of residents and their families. During discussions with the survey team, the corporate nurse, the Director of Nursing, and the Licensed Nursing Home Administrator did not provide further information to address the concerns. Additionally, the facility's staffing policy did not include procedures to ensure the NHSR was posted accurately and timely.
Failure to Acquire Routine Medications Timely
Penalty
Summary
The facility failed to acquire routine medications without delay for timely administration to a resident. On a specific date, a surveyor observed an LPN preparing medications for a resident, which included a physician's order for Cholecalciferol. The LPN stated that the medication was not in stock for administration, and a review of the order audit report revealed that a pharmacy supply order was created but not received. The electronic Medication Administration Record (eMAR) indicated that the medication was documented as administered on several dates, except for one date where it was noted that the facility was awaiting delivery. The RN/UM stated that when a medication is out of stock, the nurse can order it through the electronic Medication Record, call, or fax the pharmacy. The ADON confirmed that the expectation was for the nurse to inform the supervisor, check with the pharmacy, and inform the doctor if there was an issue. However, the RN/UM was not informed that the medication was not received since the order date. The ADON also confirmed that a stat immediate order was a service provided by the pharmacy, and a call should have been made to inform the prescriber. The deficiency was discussed with the survey team, corporate nurse, DON, and LNHA, but no further information was provided regarding the concerns.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of controlled substances and other medications, as observed during a survey. In one of the medication rooms, a narcotic box containing a resident's sealed Lorazepam medication was found to be not permanently affixed within the refrigerator. The box was easily removable, which was acknowledged by a Registered Nurse (RN) as a safety concern to prevent theft or misuse. This issue was identified during an inspection conducted in the presence of the RN, who stated that the narcotic box should have been bolted for security. Additionally, during an inspection of a medication cart, it was observed that prescription ointments, creams, and over-the-counter (OTC) medications were intermingled in the drawers. An LPN confirmed that the OTC medications were house stocked and used for any resident, and that prescription ointments should have been separated by resident and indication to avoid cross-contamination. An unlabeled Mupirocin Ointment with white creamy seepage was found among the medications, and the LPN could not explain its presence. The LPN/Unit Manager confirmed that prescription medications should have labels and be stored separately, acknowledging the failure to maintain the pharmacy's provided separation of medications.
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 1,065 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 Berkeley Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Runnells Center For Rehabilitation & Healthcare | 1.3 mi | ★★★★★ | 11 | 1 |
| Continuing Care At Lantern Hill | 2.1 mi | ★★★★★ | 4 | 1 |
| Spring Grove Rehabilitation And Healthcare Center | 2.4 mi | ★★★★★ | 18 | 0 |
| Mcauley Hall Health Care Cente | 2.9 mi | ★★★★★ | 14 | 0 |
| Chatham Hills Subacute Care Center | 4 mi | ★★★★★ | 17 | 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.