Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Careone At East Brunswick during CMS and state inspections, most recent first.
Two residents experienced deficiencies related to medication management: one received duplicate diabetes medications without physician clarification despite pharmacist recommendation, and another did not receive a prescribed diuretic due to unavailability, with no documentation that the physician was notified as required by policy.
A resident with a pressure ulcer and physician orders for a low-air-loss air mattress did not have this intervention added to their comprehensive care plan. Nursing staff confirmed that the care plan should have been updated to reflect the new order, but this was not done, despite facility policy requiring such updates.
A facility did not report an allegation of staff-to-resident abuse to the NJDOH within the required two-hour window after a family member alleged inappropriate touching by a CNA during a skin assessment. The resident, who was cognitively intact and required significant assistance, denied the allegation, and the facility's internal investigation found it unsubstantiated. However, the DON and LNHA confirmed the event was not reported as required by regulation.
A resident with multiple medical conditions and moderate cognitive impairment was admitted with a pressure ulcer, but staff failed to consistently document the wound's condition, measurements, and location as required. Physician orders for wound care and pressure-relieving interventions were not fully implemented or reflected in the care plan, and required skin assessments were missing or incomplete. Nursing staff and leadership confirmed that documentation and assessment practices were not followed according to facility policy.
Failure to Clarify Medication Orders and Ensure Timely Administration
Penalty
Summary
The facility failed to clarify physician's admitting medication orders for a resident admitted for hospice respite care, who had diagnoses including multiple sclerosis, heart failure, and chronic kidney disease. Upon admission, the resident had active orders for both Farxiga and Jardiance, which are considered potential duplicate therapies for diabetes mellitus. The consultant pharmacist identified this duplication and recommended clarification, but there was no documentation that the physician was notified or that the orders were clarified. The resident received both medications for several days, and facility leadership was unable to provide evidence of physician notification or a clinical rationale for the concurrent use of both drugs. Additionally, the facility did not ensure that another resident received their prescribed medication, acetazolamide, as ordered for diuretic therapy. The medication was not available on multiple occasions, and nursing staff documented the unavailability in the medical record. However, there was no documentation that the attending physician was notified about the missed doses, as required by facility policy. The DON confirmed that the nurse should have contacted the physician and that the medication could have been delivered stat, but this was not done. Both deficiencies were identified through record review, interviews, and policy review. The facility's failure to clarify medication orders and ensure timely administration of prescribed medications, as well as to notify the physician when medications were unavailable, were not in accordance with professional standards of practice and facility policy.
Failure to Update Care Plan with Pressure-Relieving Device Intervention
Penalty
Summary
The facility failed to revise the comprehensive care plan (CP) interventions for one resident who was admitted with multiple diagnoses, including a displaced bimalleolar fracture and dementia. The resident was assessed as having moderately impaired cognition and was found to have an unstageable pressure ulcer on the coccyx, with wound care recommendations that included the use of a low-air-loss mattress and turning and positioning measures. Physician orders for an air mattress were documented and initiated, and nursing staff recorded the use of the air mattress in the treatment administration record. However, a review of the resident's comprehensive care plan revealed that there were no interventions or tasks associated with the pressure-relieving air mattress included in the plan. Interviews with nursing staff, including an LPN, unit manager, and clinical nurse, confirmed that the care plan should have been updated to reflect the new physician order for the pressure-relieving device, but this was not done. The facility's policy requires that a comprehensive, person-centered care plan be developed and implemented for each resident, including measurable objectives and timetables to meet their needs. Despite this policy, the care plan was not revised to include the air mattress intervention, as required.
Failure to Timely Report Allegation of Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the New Jersey Department of Health (NJDOH) within the required two-hour timeframe after becoming aware of the allegation. The incident involved a certified nursing assistant (CNA) who was alleged by a resident's family member to have inappropriately touched the resident during an initial skin evaluation. The family member reported the concern to the Assistant Director of Nursing (ADON) on the day of the resident's discharge, several days after the alleged incident. The resident, who had diagnoses including acute cystitis, sepsis, diabetes, and muscle weakness, was cognitively intact and required significant assistance with mobility and toileting at the time of the incident. Upon receiving the allegation, the Director of Nursing (DON) and ADON immediately interviewed the resident, who denied any inappropriate touching, and subsequently interviewed the CNA and the nurse present during the assessment, both of whom denied the allegation. The facility's investigation concluded that the allegation was unsubstantiated. However, the facility did not report the allegation to the NJDOH within two hours as required by regulation, regardless of the outcome of the internal investigation. Interviews with facility leadership confirmed that all staff are responsible for reporting abuse allegations and that such allegations should be reported to the NJDOH within two hours. The Licensed Nursing Home Administrator (LNHA) acknowledged that the event was not reported, mistakenly believing that if the facility could unsubstantiated the allegation within two hours, reporting was not necessary. This failure to report was contrary to both facility policy and state regulations.
Failure to Document and Manage Pressure Ulcer Care
Penalty
Summary
The facility failed to consistently document and assess a resident's pressure ulcer upon admission and during their stay. Upon review, it was found that the resident was admitted with multiple diagnoses, including a right lower leg fracture and dementia, and was assessed as having a moderate risk for developing pressure ulcers. However, there was no documentation of the site and description of the existing pressure ulcer on the coccyx/buttocks at admission, and subsequent progress notes lacked detailed wound assessments, including measurements and descriptions as required by facility policy. Further review revealed that physician orders for wound care and pressure-relieving interventions, such as the use of a low-air-loss mattress and regular turning and positioning, were not consistently documented as being implemented. The care plan did not include interventions or tasks related to the use of a pressure-relieving mattress, despite recommendations from the wound care provider. Additionally, required bi-weekly skin observations and Braden scale assessments were either missing or inconsistently documented in the medical record for the three weeks following admission. Interviews with nursing staff and facility leadership confirmed lapses in documentation and assessment practices. Staff acknowledged that wounds were not always measured or described, and that documentation was sometimes missed. The facility's own policy required full assessment and documentation of pressure ulcers, including location, stage, and measurements, as well as examination of newly admitted residents for existing skin conditions, but these standards were not met in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Brunswick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Old Bridge | 3.4 mi | ★★★★★ | 15 | 0 |
| Village Point | 4.2 mi | ★★★★★ | 1 | 1 |
| Reformed Church Home | 4.8 mi | ★★★★★ | 0 | 0 |
| Preferred Care At Old Bridge, Llc | 5.1 mi | ★★★★★ | 2 | 0 |
| Rose Mountain Care Center | 5.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.