Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Canterbury At Cedar Grove during CMS and state inspections, most recent first.
Unsanitary dumpster and garbage area. The surveyor observed garbage debris outside the dumpster, including shower chairs, hospital bed frames, a dresser, wooden pallets, and cardboard boxes. The FSD stated maintenance should have cleaned the area, and the facility policy required waste storage areas and containers to be kept clean and sanitary.
Resident rooms and unit areas were not maintained in a clean, homelike condition. Surveyors observed holes in walls, stained privacy curtains, damaged flooring, a damaged bathroom door, removed water fountain area wall damage, missing AC/heater parts, peeling wallpaper and molding, stained and discolored bathroom fixtures, and soiled toilet seats and bathtub surfaces. The DHK acknowledged the housekeeping concerns and stated they did not provide residents with a clean, homelike environment.
Missing Physician Progress Notes in Resident Records: The facility did not have readily accessible PPN in the HMR for 14 of 14 residents reviewed. During observation and interview, several residents said they did not recall recent physician visits, while others had cognitive impairment or could not be interviewed. The unit manager stated the physician kept notes in a separate system that staff could not access, and the physician acknowledged being behind on uploading notes. The DON and DO stated notes should be uploaded within 48 hours, and the facility policy required a progress note for each visit in the clinical record.
A resident receiving enteral feedings was observed lying flat in bed while the feeding pump continued to run, despite orders and the care plan requiring the HOB to be elevated 30-45 degrees during tube feeding and after feeding. The resident had a gastrostomy tube, a tracheostomy tube, and severely impaired cognitive skills, and the CNA and LPN both acknowledged the feeding should have been stopped before the resident was placed flat.
A resident on continuous O2 had the machine set above the ordered LPM, and an LPN could not explain why the setting differed from the PO. Another resident receiving O2 via trach had nebulizer tubing left on the floor instead of being stored in a plastic bag as required for infection control. The DON confirmed the tubing should have been bagged when not in use.
A resident with severe cognitive impairment and on hospice care was found with a laceration on the lower leg, which was later determined to have occurred due to contact with a wheelchair footrest. Staff did not observe or report the injury during previous shifts, and the required notification to NJDOH and the Ombudsman was not made until 21 days after the incident, only following surveyor inquiry. The facility's policy and regulations required immediate reporting of such injuries of unknown origin.
A resident with multiple medical conditions experienced an incident outside the facility entrance after signing out and returning to the premises. The facility did not conduct a thorough investigation or complete required documentation, including staff statements and a comprehensive incident summary, as mandated by its own policy. Staff interviews revealed confusion about responsibility for follow-up, and the administrator confirmed that no additional documentation was available for the event.
Multiple rooms in the Gardenia Garden unit were found with temperatures below the regulatory standard, with some as low as 64.0°F. Several rooms were occupied, and radiators were either emitting low cool air or turned off. Staff confirmed ongoing heating issues, and the facility's emergency plan procedures were not effectively implemented, resulting in a failure to provide a safe and comfortable environment.
A facility failed to provide adequate incontinence care for a resident with severe cognitive impairment and a feeding tube, who was found in a soiled diaper. The CNA responsible had a high patient load, caring for 19 residents, and admitted to changing residents at least once per shift. The DON acknowledged staffing deficits and the lack of incontinence care, which did not comply with the facility's policy.
The facility failed to serve meals in a dignified manner, using Styrofoam plates and plastic utensils due to a broken dish machine. This practice was observed across three nursing units, and residents expressed dissatisfaction, preferring regular china and utensils. The Food Service Director confirmed the dish machine had been non-functional for weeks, and despite requests for repairs, the facility struggled to maintain non-disposable dining ware due to the resident population size.
A survey revealed that a facility failed to maintain proper kitchen sanitation and food storage practices. The dry storage area exceeded the temperature policy, and items in the walk-in freezer were improperly stored. Additionally, ovens were unclean, and open seasonings and bread lacked proper labeling, violating facility policies.
The facility did not maintain and post the prior year's inspection results in an accessible area for residents, families, and the public. During a meeting, residents were unaware of the survey report's location, and no signs were observed on nursing units or elevators. Interviews revealed that the survey results were supposed to be available at the front desk and nursing stations, but there was no clear signage. The LNHA acknowledged the lack of signage and stated that signs were now posted.
The facility failed to report a resident-to-resident physical altercation to the NJDOH within the required 2-hour timeframe. The incident involved two residents with cognitive impairments, one with schizophrenia and the other with dementia. The altercation was provoked by an attempt to stop an alarm, and staff intervened immediately. However, the report was delayed until two days later, violating the facility's policy.
The facility failed to accurately complete MDS assessments for two residents, leading to deficiencies in care management. One resident's behavioral symptoms were not properly documented in the MDS, while another resident's cognitive and mood assessments were inaccurately conducted outside the required look-back period.
A facility failed to update a resident's care plan to include safe smoking practices, despite a smoking assessment indicating the need for supervision. The resident, with Bipolar and Seizure Disorders, was cognitively intact and required supervision for daily activities. Staff interviews confirmed the oversight, and the facility's policies emphasize the need for such documentation.
The facility failed to maintain professional standards by inaccurately documenting medication administration for a resident's hearing aids, not obtaining physician's orders for code status for two residents, and not verifying the correct medication administration route for another resident. These deficiencies were identified during a survey and involved issues with documentation and communication regarding residents' care plans.
Two residents experienced significant weight changes that were not addressed by their primary physicians. One resident had a significant weight loss, while another had a significant weight gain. The facility's records lacked clear physician progress notes addressing these changes, and attempts to contact the physicians were unsuccessful. Facility staff acknowledged the need for physicians to document significant weight changes.
The facility failed to ensure physicians conducted face-to-face visits and documented progress notes every 30 days for three residents. Additionally, two residents' monthly physician orders were unsigned for several months. The facility's policy requires regular physician visits and documentation, which was not adhered to, as evidenced by missing notes and signatures in medical records.
A resident with Type 2 Diabetes Mellitus and Bipolar Disorder was repeatedly served whole milk instead of the preferred skim milk, as specified in their care plan and meal ticket. Despite facility policies requiring checks to ensure dietary needs and preferences are met, errors were not caught by staff, resulting in a deficiency.
The facility failed to maintain complete and accessible medical records for three residents. One resident's hospice care documentation was incomplete, lacking recent nursing progress notes. Another resident's medical records contained illegible handwritten physician's notes, which staff could not read. A third resident's records also had illegible notes, with the physician confirming they were handwritten. Facility policies did not address the issue of illegible handwriting, contributing to the deficiency.
Unsanitary Dumpster and Garbage Area
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public by not keeping the dumpster and surrounding area free of garbage and debris. During a tour of the kitchen and dumpster area, the surveyor observed garbage debris outside the dumpster, including shower chairs, hospital bed frames, a dresser, wooden pallets, and cardboard boxes. The Food Service Director stated that the maintenance department should have cleaned the dumpster area. The facility policy titled "Dumpster/Garbage Area" stated that all waste storage areas and containers must be maintained in a clean and sanitary condition to prevent fire, health, or safety hazards and avoid attracting pests.
Resident Rooms and Unit Areas Not Maintained in Clean, Homelike Condition
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in resident rooms and on nursing unit common areas. During an initial tour of the 2nd floor nursing unit, the surveyor observed a hole in a wall, brownish staining on the walls, stained privacy curtains, damaged flooring tile, a damaged bathroom door, and a hallway water fountain that had been removed with the wall discolored and in need of repair. These observations were made on 2 of 3 units during the initial tour. On a later tour of the 2nd- and 3rd-floor nursing units, surveyors and the Maintenance Director observed additional room conditions including holes in walls, a closet in need of repair, missing top parts of an AC/heater, peeling paneling on a sink, stained brown privacy curtains, stained and discolored bathroom ceiling tiles, a discolored toilet seat, a stained and discolored bathtub, damaged wall area behind a bed, peeling wallpaper, peeling floor molding, and a toilet seat that was soiled and discolored with heavily soiled and stained bathtub surfaces. The Director of Housekeeping acknowledged these housekeeping concerns and confirmed that they did not provide residents with a clean, homelike environment. The facility policy stated that residents are to be provided with a safe, clean, comfortable, homelike environment.
Missing Physician Progress Notes in Resident Records
Penalty
Summary
The facility failed to have readily accessible physician progress notes (PPN) in the hybrid medical record for 14 of 14 residents reviewed. During observation, interview, and record review, the surveyor found that the HMR for each reviewed resident did not reflect any PPN, even though the residents had active diagnoses and were being followed by the physician. The residents reviewed included individuals with conditions such as altered mental status, pneumonia, anemia, dementia, hyperlipidemia, thyroid disorder, depression, anxiety, hypertension, COPD, bipolar disorder, sepsis, diabetes, cerebral infarction, Parkinson’s disease, schizophrenia, cerebral palsy, multiple sclerosis, aphasia, and Alzheimer’s disease. The surveyor observed and interviewed multiple residents in their rooms, dayrooms, or activities areas. Several residents stated they did not recall seeing the physician recently or could not remember when they last saw the physician. Some residents were unable to be interviewed due to confusion or cognitive impairment. The MDS assessments documented a range of cognitive status, including intact cognition for some residents and moderate to severe cognitive impairment for others, with one resident unable to complete a BIMS due to cognitive impairment. The unit manager stated the physician completes notes in the physician’s own charting system and facility staff do not have access to those notes, and that the physician is supposed to send the progress notes so they can be uploaded into the electronic chart or printed into the physical chart. The physician stated they write progress notes in their own system, the facility does not have access to that system, and they were behind on uploading resident notes. The DON and DO stated the physician should be uploading notes in a timely fashion within 48 hours. The facility policy titled Physician Documentation stated that a progress note must be entered into the clinical record for each visit, fully disclosing the kind and extent of services provided and the medical necessity for those services.
Enteral Feeding Administered While Resident Was Flat in Bed
Penalty
Summary
The facility failed to ensure appropriate care for a resident receiving enteral feedings when the enteral feeding pump was observed running while the resident was lying flat in bed with the head of bed not elevated. The resident was receiving Glucerna 1.5 at 80 mL per hour through a gastrostomy tube and had diagnoses including acute respiratory failure with hypoxia, a tracheostomy tube, and a gastrostomy tube. The resident's quarterly MDS indicated severely impaired cognitive skills for daily decision-making and that 51% or more of nutrition was received through an enteral feeding tube. The resident's physician orders required the head of bed to be elevated at least 30-45 degrees when enteral feeding was running and for 1-2 hours after the total volume was delivered, and another order required the head of bed to be elevated greater than 30 degrees every shift for aspiration precautions. The care plan also directed elevation of the head of bed during tube feeding. During the observation, the CNA was providing care while the feeding continued, and the CNA acknowledged she should have notified the nurse before placing the resident flat so the feeding could be stopped. The assigned LPN confirmed the CNA should have informed her before care was provided so the feeding could be stopped, and the DON later confirmed the resident's head of bed should have been elevated during tube feeding to prevent aspiration.
Respiratory Care and Equipment Storage Deficiencies
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents. One resident with diagnoses including hypertension, heart failure, and cerebral infarction had severe cognitive impairment with a BIMS score of 0 and was receiving continuous O2 therapy. The resident’s physician order dated 12/3/25 specified O2 inhalation at 2 LPM via nasal cannula every shift for shortness of breath and to maintain SpO2 at or greater than 92%, but the resident was observed with the O2 machine set at 3.5 LPM. An LPN confirmed the resident was on continuous O2 and could not state why the O2 was set above the ordered rate. A second resident with diagnoses including acute respiratory failure with hypoxia, a tracheostomy tube, and a gastrostomy tube had severe cognitive impairment and received special respiratory treatments including oxygen therapy and tracheostomy care. The resident had physician orders for albuterol nebulization via trach four times daily, Pulmicort via trach every 12 hours, and humidified oxygen at 5 LPM and 28% via trach every shift. During observation, the resident was receiving O2 via trach at 5 LPM and 28% via an EasyAir machine, and a nebulizer machine was present on the bedside table with the nebulizer tubing on the floor. During interview, the assigned LPN confirmed the nebulizer tubing should be stored in a plastic bag for infection control prevention and removed the tubing from the floor and discarded it. The DON later confirmed that the nebulizer tubing should have been stored in a plastic bag to prevent transmission of infection. The facility policy stated that oxygen tubing is to be single-use for a single resident, clean, properly stored, and dated, and that nebulizer tubing shall be dated, stored in a bag when not in use, and replaced every 7 days.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to notify the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman immediately or within two hours after identifying an injury of unknown origin, as required by federal and state regulations and the facility's own abuse policy. The incident involved a resident with severe cognitive impairment, multiple diagnoses including dementia, and who was receiving hospice services. The resident was found with a laceration on the inner left lower leg during morning rounds, which was not observed or reported by staff during the previous shifts, despite documentation indicating that ace wraps were to be applied and removed on a regular schedule. Upon investigation, it was determined that the injury occurred when the resident, who had recently received a new wheelchair with leg rests, made contact with a bolt on the footrest while habitually standing up and moving away from a table. Blood and tissue were found on the wheelchair footrest, supporting this conclusion. Staff interviews revealed that the injury was not noticed or reported by those responsible for the resident's care during the night and evening shifts, and there was uncertainty about whether required care tasks, such as donning and doffing ace wraps, were actually performed as documented. Despite the clear requirement to report injuries of unknown origin immediately or within two hours, the facility did not notify the NJDOH and Ombudsman until 21 days after the incident, and only after being prompted by a surveyor during an onsite complaint investigation. Both the DON and the Administrator acknowledged that the injury should have been reported immediately, regardless of the subsequent determination of its cause. The facility's policy and state regulations require prompt reporting to ensure proper oversight and investigation of potential abuse, neglect, or mistreatment.
Failure to Investigate and Document Resident Accident per Facility Policy
Penalty
Summary
A deficiency was identified when the facility failed to conduct a thorough investigation and follow its own policy regarding incident and accident reporting after an event involving a resident. The resident, who had multiple medical diagnoses and required assistance with activities of daily living, was involved in an incident outside the facility premises. The resident had signed out of the facility and, upon returning, remained outside the entrance while an accompanying individual went inside to speak with staff. During this time, the resident experienced an incident that required medical attention and was subsequently transported to the hospital by ambulance. The facility's documentation and staff interviews revealed that the required procedures for investigating and reporting the incident were not fully followed. The facility's policy mandates that the licensed nurse who first witnesses an incident must complete an incident/accident report in its entirety, with input from staff present at the time. Additionally, all employees assigned to the resident are required to fill out employee statement forms, and the unit manager is responsible for investigating, summarizing, and concluding all incidents. In this case, the facility did not complete all necessary documentation, including employee statements and a comprehensive summary or conclusion of the incident. Interviews with staff indicated confusion regarding responsibility for follow-up and documentation. One nurse stated that she would have completed the necessary follow-up if the incident had occurred during her shift, but was told by another staff member that they would handle it. The facility administrator confirmed that the policy would have been followed if the incident had occurred on the premises, but no additional documentation or summary was available for the incident. This lack of thorough investigation and incomplete documentation constituted a failure to meet the regulatory requirements for accident investigation and reporting.
Plan Of Correction
1. How the corrective action will be accomplished for those residents found to be affected by this practice? [R] Resident #2. The Regional Nurse alongside the Director of Nursing conducted a new thorough investigation into the incident regarding Resident #2, following the facility policy carefully. The Director of Nursing reviewed the incident report, re-interviewed the resident, as well as staff involved. The Director of Nursing reviewed the Police report as a part of her investigation. After review of those items, it was concluded by the Regional Nurse and the Director of Nursing that the outcome of the re-investigation was the same as the initial investigation. The interventions put in place remained and staff continued to monitor. There were NJ Ex Order 26.4(b)(1) on Resident #2 by the facility's failure to thoroughly investigate and follow the facility policy on investigating incidents and accidents. 2. How the Facility will identify other residents having the potential to be affected by the same deficient practice? (a) All residents have the potential to be affected by the facility's failure to thoroughly investigate and follow the facility's policy on investigating incidents and accidents. 3. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice will not recur? (a) The U.S. FOIA (b) (6) was re-inserviced by the Regional Nurse on the Facility's policy for investigating incidents and accidents. (b) All Nurses were re-inserviced by the Director of Nursing on the facility's policy for investigating incidents and accidents. (c) The Director of Nursing or designee will audit all incidents and accidents to ensure they are thoroughly investigated and following the company's policy, monthly x 3 and quarterly thereafter. 4. How the facility will monitor its corrective actions to ensure that the deficient practice will not recur; (e.g., what quality assurance program will be put into place?) (a) The Director of Nursing or designee will bring the results of the following audit to the members of the QAPI team to determine the frequency of future audits.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable room temperature levels for residents in one of the two nursing units on the third floor, specifically the Gardenia Garden unit. During observations, multiple resident rooms were found to have temperatures ranging from 64.0 to 70.0 degrees Fahrenheit, with several rooms occupied and radiators either emitting low cool air or being turned off. Some residents were present in their rooms, dressed warmly with blankets, but were not noted to be in distress at the time of observation. Hallway and common area temperatures were also recorded, with the Gardenia Garden hallway at 67.2 degrees Fahrenheit, which is below the recommended range. The deficiency was identified through direct temperature measurements and interviews with staff, including the maintenance person and the LNHA, who confirmed ongoing issues with the heating system. The facility's Cold Stress Emergency Plan requires maintenance to ensure proper room temperatures and prompt repairs, but the observed temperatures indicated that these procedures were not effectively implemented. The LNHA acknowledged receiving complaints about low heat and stated that maintenance and corporate staff had been working to address the problem, including bleeding the boiler system. Despite these efforts, the room temperatures remained below the regulatory standard of 71-81 degrees Fahrenheit at the time of the survey, resulting in a failure to provide a safe, clean, and comfortable environment as required by regulation.
Inadequate Staffing Leads to Insufficient Incontinence Care
Penalty
Summary
The facility failed to ensure sufficient and competent staff were available to provide timely and appropriate incontinence care for a resident who was dependent on staff for their Activities of Daily Living (ADLs). During an observation, the surveyor noted that the resident, who had severe cognitive impairment and was non-verbal with a feeding tube, was found in a soiled diaper that was saturated with urine and feces. The Certified Nursing Assistant (CNA) responsible for the resident admitted to having a high patient load and stated that she typically changed dependent residents at least once per shift. The Unit Manager confirmed this practice. The facility's staffing levels were inadequate, with three CNAs assigned to care for 55 residents on the third floor nursing unit. Each CNA was responsible for 17 to 19 residents, which contributed to the insufficient incontinence care observed. The Director of Nursing (DON) acknowledged the staffing deficits and the lack of incontinence care, indicating that the facility was aware of these issues. The facility's policy on incontinence care required appropriate treatment and services for incontinent residents, but this was not adhered to in practice.
Failure to Serve Meals in a Dignified Manner
Penalty
Summary
The facility failed to ensure that residents were served their meals in a dignified manner, as observed by surveyors on multiple occasions across three nursing units. During these observations, residents were served meals on Styrofoam plates and cups with plastic utensils, both in the main dining room and in their rooms. This practice was confirmed by a Certified Nursing Assistant, who stated that the use of disposable dining ware had been ongoing for the past six weeks. Residents expressed their dissatisfaction during a resident council meeting, indicating a preference for regular china and utensils. They were informed by the dietary department that the dish machine was broken, which was corroborated by the Food Service Director. The Food Service Director confirmed that the dish machine had been non-functional for five to six weeks and had made frequent requests to management for repairs. Despite the availability of a three-compartment sink for manual cleaning and sanitizing, the dietary department struggled to maintain meal preparation with non-disposable items due to the size of the resident population. The Licensed Nursing Home Administrator acknowledged the issue and had sent multiple emails to corporate regarding the dish machine repair. The facility's Resident Rights policy emphasizes the right to a dignified existence and reasonable accommodation of resident needs and preferences, which was not upheld in this situation.
Improper Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and store potentially hazardous foods correctly, as observed during a survey. The surveyor, accompanied by the Food Service Director (FSD), noted several deficiencies during a kitchen tour. The dry storage area was found to have a temperature of 80 degrees Fahrenheit, exceeding the facility's policy range of 50-70 degrees Fahrenheit. The FSD attributed this to a recent heatwave and stated that maintenance was aware of the issue. In the walk-in freezer, boxed items were improperly stored on the floor and stacked to the ceiling, violating the policy of keeping items at least 6 inches off the ground and 18 inches from the ceiling. Additional observations included dual ovens in the cooking area with black-colored baked-on debris, indicating a lack of cleanliness. In the chef preparatory area, multiple open seasonings were found without open or use-by dates, and the FSD could not confirm when they were opened. Similarly, in the bread storage area, several open bags of sliced white bread, hamburger buns, and hotdog buns lacked open/use-by labels, with the FSD unable to provide opening dates. These practices were inconsistent with the facility's policies on food storage and labeling, which require items to be dated upon opening and stored properly to prevent foodborne illness.
Failure to Post Survey Results Accessibly
Penalty
Summary
The facility failed to maintain and post the prior year's state of New Jersey inspection results in an area that was readily accessible to residents, families, and the general public. During a group meeting with seven residents, none of them were aware of the location of the previous year's survey inspection report. The surveyor also noted the absence of any signs regarding the survey results on the nursing units or in the elevators. Interviews with the Director of Recreation, the Unit Manager of the third floor, and the Licensed Nursing Home Administrator (LNHA) revealed that the survey results were supposed to be available at the front desk and at each nursing station, but there was no clear signage to inform residents of their location. The LNHA stated that the location of the survey results was discussed with residents upon admission, but there was no policy in place regarding the survey results. The surveyor observed a binder labeled 'Survey Book Vol.11' at the front desk, but it was not easily identifiable due to the spine facing outward and the original item/brand sticker on it. The surveyor informed the facility's leadership team about the concern of the survey inspection report not being easily accessible, and the LNHA acknowledged the lack of signage and stated that signs were now posted at the front reception, in the elevators, and at each nurse's station.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report an allegation of a resident-to-resident physical altercation to the New Jersey Department of Health (NJDOH) within the required 2-hour timeframe. The incident involved two residents, one of whom was observed holding and hurting the other. The altercation was provoked by one resident attempting to stop the other from setting off an alarm while trying to open an exit door. The staff intervened immediately, separating the residents, and subsequently transferred one resident to the hospital and the other to a different unit. Despite the immediate response to the incident, the facility did not report the event to the NJDOH until two days later, which was beyond the mandated reporting period. The residents involved had significant medical histories, with one diagnosed with schizophrenia and the other with unspecified psychosis and dementia with behavioral disturbances. The resident with schizophrenia had moderately impaired cognition, while the other resident had severely impaired cognition. The facility's policy required that such incidents be reported immediately, but not later than 2 hours if they involved abuse or resulted in serious bodily injury. The Licensed Nursing Home Administrator confirmed the delay in reporting, acknowledging that the incident occurred over the weekend and was not reported until the following Monday.
Inaccurate MDS Completion for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the management of their care. For one resident, the Quarterly MDS did not accurately reflect observed behaviors such as hitting, striking out, and flipping furniture, which were documented in the electronic Medication Administration Record (eMAR) during the look-back period. These behaviors were not coded in the MDS, indicating a failure to accurately capture the resident's behavioral symptoms as required by federal guidelines. For another resident, the Annual MDS inaccurately reflected the resident's cognitive status and mood assessment. The Social Worker responsible for completing the MDS sections conducted interviews before the Assessment Reference Date (ARD), contrary to the required 14-day look-back period. This resulted in an inaccurate representation of the resident's mood and cognitive status. The MDS Coordinator confirmed that the assessments should have adhered to the guidelines outlined in the Resident Assessment Instrument (RAI) Manual, which was not followed in these instances.
Failure to Revise Care Plan for Safe Smoking
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan to include safe smoking practices. This deficiency was identified for a resident who was admitted with diagnoses including Bipolar Disorder and Seizure Disorder. The resident was cognitively intact and required supervision with activities of daily living. Despite a smoking assessment being completed upon admission, which indicated the need for supervision during smoking, the care plan did not reflect this requirement. Interviews with various staff members, including LPNs, CNAs, and unit managers, revealed that the smoking assessment was completed, and the resident was deemed a safe smoker with supervision. However, the care plan was not updated to include the necessary interventions for safe smoking, such as the use of protective equipment like a smoking apron. The staff confirmed that a care plan should have been implemented to ensure the resident's safety during smoking times. The facility's policies on smoking and comprehensive care plans emphasize the importance of documenting resident wishes, functional and cognitive assessments, and compliance with smoking policies. Despite these guidelines, the care plan for the resident in question did not include the necessary interventions for safe smoking, as confirmed by the staff and the surveyor's review of the resident's care plan.
Deficiencies in Documentation and Code Status Orders
Penalty
Summary
The facility failed to maintain professional standards of clinical practice for three residents, as identified during a survey. For one resident, the facility did not accurately document in the electronic Medication Administration Record (eMAR) according to the physician's order regarding the use of hearing aids. The resident, who was cognitively intact, reported a missing left hearing aid, which had been missing for about two months. Despite the facility's attempts to locate the hearing aid and notify the resident's family and insurance, the eMAR continued to show that both hearing aids were administered and removed as per the physician's order, without proper documentation of the missing device or a change in the physician's order. The facility also failed to obtain a physician's order for the code status of two residents. One resident, who was moderately impaired cognitively, had no documented code status in their medical records, and staff assumed the resident was a full code. The lack of documentation was confirmed by the nursing staff and administration, who acknowledged that a Practitioner Orders for Life-Sustaining Treatment (POLST) was not present. Another resident, who was a ward of the state, also lacked a documented code status in their medical records, with only a social service progress note indicating a full code status. The nursing staff confirmed that there was no physician's order for the code status, which is crucial for timely decision-making in emergencies. Additionally, the facility did not verify the correct route of administration for a medication order for another resident. The resident's gastrostomy tube was removed, yet the eMAR showed that a medication was administered via the G-tube route, which was no longer applicable. The nursing staff acknowledged the error and the need for verification of the physician's order. These deficiencies highlight the facility's failure to adhere to professional standards of documentation and communication regarding residents' care and treatment plans.
Failure to Address Significant Weight Changes in Residents
Penalty
Summary
The facility failed to ensure that the primary physicians addressed and evaluated significant weight changes in a timely manner for two residents. Resident #131 experienced a significant weight loss of 14.7 pounds, or 5.8%, over 30 days, which was not part of a prescribed weight-loss regimen. Despite the resident's alertness and responsiveness, they could not recall the last time they saw their primary physician. The surveyor's review of the resident's medical records revealed no physician's progress notes addressing the weight loss, and attempts to contact the primary physician were unsuccessful. Resident #95 experienced a significant weight gain of 26.2 pounds, or 19.7%, over 180 days. The resident's family confirmed the weight gain but had not communicated with the primary physician. The surveyor found that the physician's progress notes were illegible, and the unit manager could not confirm if the weight gain was addressed. Interviews with facility staff, including the Director of Nursing and Licensed Nursing Home Administrator, acknowledged the need for physicians to address significant weight changes in their notes, but no further information was provided.
Deficiency in Physician Documentation and Order Signing
Penalty
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every 30 days. This deficiency was identified for three residents. For Resident #131, the surveyor observed that there were no monthly physician progress notes in the electronic or paper chart, despite the Unit Manager's assertion that the physician visited frequently. The Director of Nursing confirmed the requirement for monthly progress notes but could not explain the absence of documentation. For Resident #7, the physician had not signed the monthly physician orders from December 2023 through June 2024, and there were no progress notes for February and April 2024. The physician stated that he was present in the facility but was not informed by the staff to sign the orders. Similarly, for Resident #77, the physician had not signed the monthly physician orders for the same period. The Unit Manager was unaware of the requirement for the physician to sign the orders, and the physician could not provide further information on the missing signatures. The facility's policy requires that residents be seen by a physician at least once every 30 days for the first 90 days after admission and every 60 days thereafter. The policy also mandates that the physician review the resident's care program, write and sign a progress note for each visit, and sign all orders. The surveyor's findings indicate a failure to adhere to these policies, as evidenced by the lack of documentation and signatures in the residents' medical records.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, as evidenced by repeated observations of incorrect meal items being provided. On two consecutive days, a surveyor observed that a resident's lunch tray contained 8 ounces of whole milk instead of the 16 ounces of skim milk specified on the meal ticket. Despite the meal ticket clearly indicating the resident's preference for skim milk, the dietary staff and unit manager did not ensure the correct item was provided. The unit manager initially confirmed the tray was correct but later acknowledged the error upon rechecking. The resident involved had a medical history that included Type 2 Diabetes Mellitus and Bipolar Disorder, and was on a carbohydrate-controlled diet with no added salt. The resident's care plan specifically included an intervention to provide food and beverage preferences as available. The facility's policy on tray accuracy required that all trays be set up according to the resident's dietary needs and preferences, with checks by both dietary staff and healthcare professionals before serving. However, these procedures were not followed, leading to the deficiency.
Deficient Medical Record Maintenance
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for three residents, as observed during a survey. For one resident, the hospice care documentation was incomplete, with the last hospice nursing progress note dated several months prior to the survey. Despite the resident being under hospice care, there were no recent nursing progress notes in the hospice care binder or the hybrid medical record. Interviews with facility staff and hospice personnel revealed that the hospice nurse was supposed to visit weekly and document each visit, but this was not reflected in the records. Another resident's medical records were found to have illegible handwritten physician's progress notes. The resident's family had not been in contact with the physician regarding the resident's care, and the facility staff, including the Unit Manager, were unable to read the physician's notes. The physician confirmed that all notes were handwritten and stated they were available to clarify any notes if needed. However, the facility's policy did not address the issue of illegible handwriting, leaving staff unable to access necessary information about the resident's care. A third resident's medical records also contained illegible handwritten physician's progress notes spanning several months. Despite the resident having intact cognition, the facility staff, including the Licensed Nursing Home Administrator and Director of Nursing, were unable to read the notes. The physician confirmed that they wrote all notes by hand and could be contacted for clarification. The facility's policy on physician visits did not specify requirements for legible handwriting, contributing to the deficiency in maintaining accessible medical records.
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 1,467 citations issued within 25 miles in the last 12 months — including the 24 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 Cedar Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alaris Health At Cedar Grove | 0.4 mi | ★★★★★ | 28 | 0 |
| Complete Care At Cedar Grove | 0.8 mi | ★★★★★ | 1 | 0 |
| Complete Care At St Vincents Llc | 1.7 mi | ★★★★★ | 0 | 0 |
| Family Of Caring Healthcare At Montclair | 1.8 mi | ★★★★★ | 0 | 0 |
| Arbor Glen Center | 2 mi | ★★★★★ | 29 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Canterbury At Cedar Grove.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.