Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Careone At Holmdel during CMS and state inspections, most recent first.
Exposed urinary drainage bag compromised resident dignity. A resident with an indwelling catheter and diagnoses including acute cystitis and CKD was repeatedly observed in a wheelchair, day room, dining area, and hallway wearing shorts with a leg drainage bag visible and without a privacy covering. Facility policy required staff to help keep urinary catheter bags covered, but a CNA confirmed the bag had no covering and the MGRN acknowledged the dignity concern.
A resident with dementia and severe cognitive impairment received Seroquel for psychosis, but the MAR lacked documentation of the specific target behaviors tied to the antipsychotic or routine behavior monitoring. The facility policy required monitoring for targeted behaviors and side effects, and the consultant pharmacist requested an update to the target behavior for Seroquel. An LPN said staff were unsure what behaviors to track, and the DON acknowledged the target behavior update had not been completed when requested.
A resident admitted with end stage renal disease and dialysis had an inaccurate MDS that did not document hemodialysis, even though physician orders showed the resident received HD on a regular schedule. The MDSC and another MDSC confirmed the assessment was not accurate because it omitted the resident’s dialysis status.
A resident with PTSD had an active diagnosis in the EMR and was receiving psychotherapy for symptoms including fatigue, insomnia, and psychomotor retardation, but the care plan did not identify PTSD or the resident’s triggers. The resident, a Vietnam veteran, reported ongoing flashbacks, night terrors, and difficulty sleeping, while RN and DON interviews confirmed the diagnosis should have been care planned and the AUM was unaware of it.
The facility failed to ensure alternatives were explored and required assessments were completed before using bedrails for two residents. One resident had moderate cognitive impairment, a care plan listing bilateral 1/4 bedrails, no bedrail order, and documentation showing no alternatives were explored. Another resident had severe cognitive impairment, bilateral one-half bedrails in use, and an incomplete informed consent form with missing required documentation and no facility representative signature. The DON confirmed alternatives had not been explored and that beds already had bedrails attached.
Failure to Follow Enhanced Barrier Precautions: Staff did not wear gowns as required for EBP when providing high-contact care to two residents with indwelling urinary catheters. One resident had MRSA wound infection and the other had acute cystitis and CKD; both were identified as being on EBP. Observations showed CNAs wearing gloves but no gown while repositioning, dressing, and handling urinary drainage bags, and staff acknowledged not following the EBP guidance.
The facility failed to maintain the required emergency water supply, initially having only 132 gallons instead of the needed 258 gallons for its residents. The FSD miscounted the water cases, and additional water was ordered during the survey. Facility policies and contracts required a three-day supply, but these were not met initially.
A resident admitted with a community-acquired pressure ulcer did not have their wounds measured or documented upon admission, and a physician's order for wound care was delayed. Facility staff interviews revealed that the protocol for wound assessment and treatment was not followed, leading to a delay in care.
A facility failed to obtain, record, and monitor weights for a resident on admission, readmission, and weekly as required. The resident, with diagnoses including dysphagia and GERD, had severely impaired cognition. Despite the care plan's focus on nutritional status, weights were not documented due to the resident's refusal and lack of follow-up by staff. Interviews revealed shared responsibility among staff for obtaining weights, but the facility's protocol was not followed.
A facility failed to obtain a physician order to maintain and discontinue a peripheral IV access after completing IV antibiotic treatment for a resident. The resident, admitted with multiple diagnoses, was observed with a heparin lock despite the completion of antibiotics. Records showed no physician order for flushing the line, and staff interviews revealed a lack of clarity on protocols for maintaining and removing peripheral lines. The facility's policy lacked guidance on peripheral line flushes and discontinuation, leading to the deficiency.
A resident with severe cognitive impairment was administered Midodrine despite physician's orders to hold the medication if systolic blood pressure (SBP) was above 100. The medication was given on four occasions when the SBP exceeded this threshold, as identified in the electronic Medication Administration Record (eMAR). The LPN acknowledged the error, which was contrary to the facility's medication administration policy.
A resident with a history of bipolar disorder and peripheral vascular disease sustained a serious laceration to the left lower leg, requiring hospital treatment. The incident was unwitnessed, and the resident, with moderately impaired cognition, could not explain the cause. The facility failed to report the injury to the NJ DOH within the required 2-hour timeframe, as the DON focused on patient care and staff interviews, delaying notification. The facility's policy mandates immediate reporting for serious injuries, which was not adhered to in this case.
A CNA failed to wear appropriate PPE, specifically eye protection, while exiting a resident's room under COVID-19 isolation precautions. Despite signage and training indicating the need for goggles or a face shield, the CNA wore regular eyeglasses, which do not provide adequate protection. The facility's IPN confirmed the deficiency, noting that the CNA had been trained and marked competent in PPE use.
The facility failed to maintain a designated qualified Infection Prevention and Control Nurse from December 2023 to February 2024. During this period, the DON assumed the responsibilities of the Infection Preventionist without the necessary certification, contrary to facility policy. The facility did not have a full-time IPN in the building after the previous IPN left, and the new IPN only completed training in February 2024. This gap in compliance occurred during a COVID-19 outbreak, underscoring the need for a qualified infection preventionist.
Exposed urinary drainage bag compromised resident dignity
Penalty
Summary
The facility failed to promote the dignity of one resident with an indwelling catheter when the resident was observed multiple times with a urinary leg drainage bag exposed and without a privacy covering. The resident was admitted with diagnoses that included acute cystitis without hematuria and chronic kidney disease, and physician orders for July 2025 showed an indwelling catheter. During observations, the resident was seen sitting in a wheelchair in the doorway of his room, in the day room with other residents watching television, returning from the dining room with others, and being pushed down the hallway in front of residents, visitors, and staff, each time wearing short pants with the leg drainage bag visible and containing yellow urine. The facility policy on dignity stated that demeaning practices and standards of care that compromise dignity are prohibited and that staff are expected to help residents keep urinary catheter bags covered. During interview, a CNA stated the resident wore the leg drainage bag during the day and confirmed it did not have a covering, while the MGRN stated she was aware the resident wore the bag on his thigh but was unaware that leg drainage bags came with privacy coverings. The MGRN admitted it could be a concern for the resident's dignity to be observed in public with a urinary drainage bag.
Failure to Monitor Target Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to ensure monitoring of target behaviors for the use of Seroquel for one resident with dementia and severe cognitive impairment. The resident’s significant change MDS showed a BIMS score of 4 out of 15, indicated no behavioral symptoms during the assessment period, and also showed the resident was receiving an antipsychotic medication. The physician order dated 07/09/25 directed Seroquel 0.25 mg, one tablet by mouth daily for psychosis. Review of the resident’s July 2025 MAR showed no documented evidence identifying the specific behaviors associated with the antipsychotic medication or routine monitoring of those behaviors. The facility’s psychopharmacologic medication policy required monitoring residents for targeted behaviors and medication side effects for antipsychotic medications. The consultant pharmacist’s medication regimen review dated 07/18/25 requested that the target behavior for Seroquel be updated. During interviews, an LPN stated she was unsure what specific behaviors should be tracked for Seroquel and agreed staff would be unsure whether the medication was effective. The DON stated nursing staff should monitor target behaviors each shift and acknowledged the pharmacy review request had not been completed until 07/31/25.
Inaccurate MDS Did Not Reflect Hemodialysis
Penalty
Summary
The facility failed to ensure that one sampled resident, admitted with end stage renal disease and dialysis, had an accurate MDS assessment. Review of the resident’s admission record showed a diagnosis including end stage renal disease with dialysis, and review of the physician orders for July 2025 showed the resident received hemodialysis on Tuesdays, Thursdays, and Saturdays. However, the resident’s admission MDS with an ARD of 03/18/25 did not document that the resident was receiving hemodialysis. During interview, the MDS Coordinator and another MDS Coordinator confirmed that the MDS was not accurate because it did not indicate the resident was receiving dialysis.
Failure to Care Plan PTSD Diagnosis and Triggers
Penalty
Summary
The facility failed to develop a care plan with interventions for one resident with a diagnosis of PTSD. Review of the resident’s admission record and MDS showed an active PTSD diagnosis, and psychotherapy progress notes documented that the resident was receiving therapy for PTSD-related symptoms including fatigue, insomnia, and psychomotor retardation. The facility’s care plan, revised on 07/16/25, did not identify the resident’s PTSD diagnosis or include triggers related to the condition. During interview, the resident stated he was a Vietnam veteran with two tours and reported a PTSD diagnosis after service, with symptoms that had occurred as recently as that week. He described triggers including flashbacks to the war, night terrors with screaming, and difficulty sleeping. RN 1 reviewed the EMR and confirmed the PTSD diagnosis and that the resident was being seen by a psychiatrist, and stated a PTSD care plan should have been developed. The AUM stated she was unaware of the PTSD diagnosis and was not sure about developing a care plan for PTSD, while the DON stated a PTSD care plan should have been developed and should include the resident’s triggers.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure residents received alternative measures before bedrails were installed and failed to complete assessments for the risk of entrapment for two residents reviewed for side rails. The facility policy titled, Bed Safety and Bed Rails, stated bed rails or side rails are prohibited unless criteria for use have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. One resident was admitted with diagnoses including lack of coordination, dementia, and cognitive communication deficit. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment. The care plan identified the resident as at risk for ADL deficit related to physical limitations and listed bilateral 1/4 bedrails as an intervention. The physician orders showed no order for bedrail use, and the Resident Evaluation/Bedrail Assist Device indicated no alternatives were explored and that bedrails were not indicated for use. During interview, an LPN stated all residents sign consent forms for bedrails, that all beds have bedrails, and that alternatives were not being explored prior to bedrail use. The DON stated staff review bedrail consents on admission, but there was no time to explore alternatives because the beds already had bedrails attached. The second resident was admitted with diagnoses including cerebral infarction, right-sided hemiplegia, and hospice/palliative care. The resident’s significant change MDS showed a BIMS score of 3, indicating severe cognitive impairment. The admission evaluation documented that the resident wanted the bed rails raised for safety and/or comfort, and listed medical indications, security reasons, and reasons the rails would assist the resident; it also stated alternatives to bed rails were discussed and consent was obtained. However, the informed consent form had no documentation answering required questions about medical needs, benefits, risks, or alternatives, and there was no facility representative signature. Observations showed the resident in bed with bilateral one-half bedrails raised. During interview, the DON confirmed no alternatives to bedrails had been explored and stated the resident’s cognitive ability was limited to make an informed decision.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff followed enhanced barrier precautions (EBP) by wearing the required PPE for two residents who were on EBP. Review of CDC guidance stated that EBP uses targeted gown and glove use during high-contact resident care activities for residents with wounds, indwelling medical devices, or MDRO colonization or infection. The facility’s posted EBP signage directed staff to clean hands before entering and when leaving the room and to wear gloves and a gown for high-contact care activities, including dressing, bathing, transferring, changing linen, hygiene, toileting, device care, and wound care. One resident was admitted with MRSA infection of a wound and removal of internal fixation device, had a urinary catheter, and was identified in the care plan as having an indwelling catheter and being on EBP. During observation, two CNAs entered the room wearing gloves but no gown while repositioning the resident in bed, adjusting the gown, checking the urinary catheter, and preparing the resident for lunch. Another resident was admitted with acute cystitis and chronic kidney disease, had an indwelling catheter, and was also on EBP. During observation, a CNA assisted the resident to dress and sit in a wheelchair and emptied the urinary drainage bag while wearing gloves but not a gown. Both CNAs acknowledged not following the EBP guidelines, and the Infection Preventionist confirmed the staff were not donning appropriate PPE to provide resident care.
Deficiency in Emergency Water Supply Maintenance
Penalty
Summary
The facility failed to maintain the required emergency water supply for its residents in the event of a loss of normal water supply. During a survey, it was observed that the facility, which was licensed for 120 beds and had a census of 86 residents, only had 22 cases of water, each containing six one-gallon bottles, totaling 132 gallons. This was insufficient to meet the requirement of one gallon per person per day for three days, which would require 258 gallons. The Food Service Director (FSD) initially miscounted the number of cases, stating there were 22 cases when there were actually 36 cases, totaling 216 gallons. Additional water was ordered during the survey, but the initial deficiency was acknowledged by the Licensed Nursing Home Administrator (LNHA). The facility's policies and contracts indicated that a three-day supply of water should be maintained, with specific guidelines for emergency situations. However, the facility did not have the required amount of water on hand initially, and there was confusion regarding the responsibility for ordering and maintaining the emergency water supply. The Director of Maintenance (DM) stated that he did not order the water and that it was the FSD's responsibility. The facility's contract with a food service vendor also outlined the need for maintaining an inventory of bottled water, but the facility did not meet these requirements at the time of the survey.
Failure to Document and Treat Pressure Ulcer on Admission
Penalty
Summary
The facility failed to document the measurement of a pressure ulcer and obtain a physician's order for wound care for a resident admitted with a community-acquired pressure ulcer. This deficiency was identified for a resident who was admitted with diagnoses including venous insufficiency, an unstageable pressure ulcer on the right heel, and peripheral vascular disease. Upon admission, the resident's evaluation indicated a stage 3 pressure ulcer on the sacrum and right buttock, but no measurements were documented. The care plan included interventions for skin breakdown, but a physician's order for wound treatment was not obtained until several days after admission. Interviews with facility staff, including the wound care LPN, LPN/Unit Manager, and Director of Nursing, revealed that the protocol for wounds identified on admission was not followed. The protocol required a full-body assessment, measurement, and documentation of wounds, and obtaining physician orders for treatment immediately. The facility's policies also outlined these steps, but they were not adhered to in this case, resulting in a delay in wound care treatment for the resident.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to obtain, record, and monitor weights for a resident on admission, readmission, and weekly as per professional standards of practice. This deficiency was identified for a resident who was admitted with diagnoses including dysphagia, depression, and GERD. The resident's comprehensive admission MDS indicated severely impaired cognition, and the care plan included a focus on nutritional status with interventions such as obtaining weights. However, the physician's orders for January and February did not include an order to obtain weights, and the resident's most recent weight was not documented in the resident evaluations completed by nursing on admission. The facility's protocol required weights to be obtained on admission, readmission, and weekly for four weeks, but this was not followed. Interviews with the LPN/UM, RD, and DON revealed that the responsibility for obtaining weights was shared among staff, but the resident's weight was not obtained due to the resident's refusal and lack of documentation. The RD attempted to address missing weights by contacting the family and using hospital weights, but the facility's policy on monitoring and documenting weights was not adhered to, leading to the deficiency.
Failure to Discontinue Peripheral IV Access After Antibiotic Treatment
Penalty
Summary
The facility failed to obtain a physician order to maintain peripheral intravenous (IV) access and to discontinue the peripheral IV access after the completion of an IV antibiotic treatment for a resident. This deficiency was identified for a resident who was observed with a heparin lock in the left antecubital space, despite the completion of IV antibiotic treatment. The resident was admitted with multiple diagnoses, including sepsis, cellulitis, urinary tract infection, and pneumonia, and had received IV medications during their stay. The review of the resident's records revealed that there was no physician order to flush the heparin lock, and the peripheral line remained in place even after the completion of the IV antibiotics. The care plan indicated a focus on potential complications at the IV insertion site, but the interventions included flushing IV lines per physician orders, which were not present. Progress notes documented that the peripheral line was intact and easy to flush, but there was no documentation of a physician order for maintaining the line or for its removal after the antibiotics were completed. Interviews with facility staff, including an LPN, LPN/Unit Manager, and the Director of Nursing, revealed a lack of clarity and adherence to protocols regarding the maintenance and removal of peripheral lines. The LPN was unsure of how long a peripheral line should remain in place, and the LPN/UM acknowledged that the heparin lock should not remain at the same site for more than 72 hours. The DON confirmed that the peripheral line should have been removed after the completion of IV antibiotics and that there should have been a physician order for flushes. The facility's policy did not include protocols for peripheral line flushes and discontinuation, contributing to the deficiency.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to a physician's orders for the administration of blood pressure medication for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including peripheral vascular disease and heart failure, had a physician's order for Midodrine to be administered three times a day, with specific instructions to hold the medication if the systolic blood pressure (SBP) was greater than 100. However, the medication was administered on four occasions when the resident's SBP exceeded this threshold. The deficiency was identified through a review of the electronic Medication Administration Record (eMAR) for February and March 2024, which showed that the medication was given despite the SBP being above 100 on specific dates. The Licensed Practical Nurse (LPN) acknowledged the error upon review of the records in the presence of the surveyor. The facility's policy for administering medications, which requires adherence to prescriber orders and verification of vital signs, was not followed in this instance.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin that resulted in serious bodily injury to the New Jersey Department of Health (NJ DOH) within the required 2-hour timeframe. This incident involved a resident with a history of bipolar disorder, peripheral vascular disease, recurrent depressive disorder, anxiety disorder, and a laceration to the left lower leg. The resident was found bleeding profusely from a large laceration on the left lower leg, which required immediate medical attention and resulted in the resident being sent to the hospital for treatment, including 20 stitches. The incident was unwitnessed, and the resident, who had moderately impaired cognition, was unable to explain how the injury occurred. The facility's Director of Nursing (DON) reported the incident to the NJ DOH and the Ombudsman's office, but not within the required 2-hour timeframe. The DON acknowledged that the focus was on patient care and staff interviews to ensure accurate reporting, which delayed the notification to the authorities. The facility's policy on reporting abuse, neglect, exploitation, or injury of unknown source requires immediate reporting to the administrator and state officials, defined as within two hours for incidents involving serious bodily injury. The DON admitted to not being familiar with the specific reporting timeframes and recognized that the incident should have been reported sooner. The Licensed Nursing Home Administrator (LNHA) also confirmed that the incident should have been reported within 2 hours, as per the facility's policy.
Failure to Adhere to PPE Protocols for COVID-19 Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) to prevent the potential spread of COVID-19 on the North unit. This deficiency was observed when a Certified Nursing Assistant (CNA) exited a resident's room without wearing goggles or a face shield, despite the presence of a sign indicating the need for droplet/contact precautions, which included eye protection. The CNA was wearing regular eyeglasses, which do not provide adequate protection against exposure to respiratory secretions. The resident in question was on isolation for COVID-19, as indicated by the sign on the door and confirmed by the CNA. The facility's Infection Preventionist Nurse (IPN) confirmed that the CNA was not following the required precautions, as eyeglasses are not sufficient for eye protection. The CNA had previously been marked as competent in donning PPE, including goggles or a face shield, and had received in-service training on COVID-19 infection control and PPE. The facility's policy on droplet precautions also specified the need for gloves, gown, and goggles if there is a risk of spraying respiratory secretions. Despite these measures, the CNA did not adhere to the required PPE protocols, leading to the deficiency.
Failure to Maintain Qualified Infection Preventionist
Penalty
Summary
The facility failed to maintain a designated qualified Infection Prevention and Control Nurse from December 1, 2023, to February 18, 2024. During this period, the Director of Nursing (DON) assumed the responsibilities of the Infection Preventionist (IP) without having the necessary certification in infection control. The facility's policy requires that the infection prevention control program be coordinated by a certified infection preventionist, which was not adhered to during the transition period. The DON was performing dual roles, managing both the duties of the DON and the IP, which is against the facility's policy that mandates a full-time IPN with no other responsibilities. The deficiency was further evidenced by the fact that the facility did not have a designated full-time IPN in the building after the previous IPN left on November 30, 2023, until a new IPN assumed the role on February 18, 2024. The new IPN had only completed the necessary training on February 19, 2024, indicating a gap in compliance with the state directive requiring facilities to have trained individuals in infection prevention and control. During this period, the facility experienced a COVID-19 outbreak, which the DON managed without the required infection control certification, highlighting the critical need for a qualified infection preventionist in the facility.
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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 Holmdel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Bayshore Llc | 2.7 mi | ★★★★★ | 2 | 0 |
| Meadowbrook Respiratory And Nursing Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Anchor Care And Rehabilitation Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Complete Care At Madison, Llc | 4.1 mi | ★★★★★ | 14 | 0 |
| De La Salle Hall | 4.1 mi | ★★★★★ | 1 | 0 |
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