Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Careone At Wall during CMS and state inspections, most recent first.
A resident with dementia, a trach, feeding tube, and biliary drain was repeatedly observed uncovered or partially uncovered in bed, with exposed body parts, a twisted gown, sputum at the trach site, and a drainage bag visible from the hallway. The record showed the resident needed help with ADLs, hygiene, dressing, and dignity measures, and staff interviews confirmed that doors/curtains should be used and drainage bags covered, but these expectations were not consistently met.
A resident with RA, A-fib, and HTN repeatedly received scheduled meds late, including prednisone, enalapril, Eliquis, nifedipine ER, acetaminophen, and a lidocaine patch. The MAR showed multiple doses given outside the scheduled time, and staff interviews confirmed the meds were late and that physician notification/documentation was expected but not found in the record.
A resident with multiple chronic conditions, including type II DM, cerebral infarction, COPD, and HTN, developed new excoriation to the bilateral groins and scrotum that was documented by an RN, with the physician notified but no documentation that the resident’s representative was informed. In interviews, the RN acknowledged that the representative should have been notified and that such contact should be charted, while the DON and LNHA confirmed the expectation that representatives be notified of new conditions such as skin excoriation. Review of facility policy showed a requirement to promptly notify a resident’s representative of changes in condition within 24 hours, which was not met in this instance.
A resident with severe cognitive impairment, expressive aphasia, and neurologic deficits became frustrated during a verbal argument with a roommate and pushed a bedside table into the roommate’s abdomen. Facility documentation noted the altercation and added care plan interventions focused on emotional support and allowing time for the resident to express feelings. However, the care plan was not revised to include specific interventions to protect the roommate or other residents from future physical acting out when staff were not present, resulting in a cited deficiency in care planning.
A resident with hemiplegia, aphasia, apraxia, and speech disturbances, who was cognitively intact per MDS and required substantial assistance with toileting and bathing and was at risk for pressure ulcers, had multiple gaps in EMR documentation for bladder continence and toilet use, bowel movements and toilet use, and hygiene over several days and shifts, despite a care plan intervention directing daily skin observation during ADL care. A CNA, the DON, and the LNHA confirmed that CNAs are responsible for providing and documenting ADL care in the EMR and that nurses and unit managers must ensure care is provided and documented, while the facility’s charting policy requires complete and accurate documentation of all services rendered.
A survey revealed that the facility failed to store potentially hazardous foods properly and maintain kitchen equipment in a sanitary manner. Open and unsealed boxes of food in the freezer lacked proper labeling, and the ice machine had black mold. The Director of Culinary Management acknowledged these issues, which could affect all residents.
The facility did not secure narcotic medications under double lock in the Cove nursing unit's medication storage room. A surveyor found an unlocked medication refrigerator containing an unlocked narcotic medication lock box with 57 dronabinol capsules. The UM/LPN, DON, and LNHA confirmed that these medications should have been stored under two secured locks, as per the facility's policy.
Resident Left Exposed and Undignified During Care
Penalty
Summary
The facility failed to treat Resident #106 in a dignified manner that promotes quality of life. The resident was newly admitted with diagnoses including dementia, acute respiratory failure with hypoxia, severe sepsis with septic shock, acute cholecystitis, and aftercare following surgery on the digestive and respiratory systems. The resident had a tracheostomy, feeding tube, and biliary drain, and the record showed severe cognitive impairment on BIMS, poor verbal ability, and difficulty communicating related to the trach, cognitive impairment, and physical debility. During multiple observations, the resident was found uncovered or partially uncovered in bed with body parts exposed. On one occasion, the resident was observed from the open doorway lying in bed uncovered with the body exposed, the room door open, and the curtain not drawn; the resident wore an adult brief and a twisted hospital gown, with the biliary drain tubing under the right arm and sputum on the chest below the trach site. On another observation, the resident was again uncovered with the trach collar rotated to the right side and a small amount of sputum at the site, with the left arm out of the gown and only part of the upper body covered. Later, the resident was seen with exposed legs toward the edge of the bed, a sheet bundled around the thighs and midsection, bare legs, one sock on the right foot, and nothing on the left. A drainage bag was also observed hanging from the bed sheet and visible from the hallway. The care plan and orders reflected that the resident required assistance with ADLs, daily hygiene, dressing, grooming, and privacy measures related to the tracheostomy and biliary drain. The record also included interventions for the resident's tendency to remove clothing and sheets and for maintaining a neat and dignified appearance. Staff interviews confirmed expectations to keep residents covered, close doors or curtains during care, and cover drainage bags with privacy bags. The DON and LPN both stated that uncovered residents seen from the hallway should be immediately covered and that drainage bags should be covered to maintain privacy and dignity. The observations showed that these expectations were not consistently met for Resident #106.
Late Medication Administration and Missing Physician Notification
Penalty
Summary
The facility failed to ensure medications were administered within the allotted timeframe for one resident who was cognitively intact and had diagnoses including rheumatoid arthritis, atrial fibrillation, and essential hypertension. The resident’s orders included enalapril maleate for hypertension, Eliquis for atrial fibrillation, prednisone for rashes, nifedipine ER for hypertension, acetaminophen for shoulder pain, and a lidocaine patch for pain management. During an initial tour, the resident told the surveyor they had returned from a doctor’s appointment and were waiting for their medications, and stated this was not the first time they had to wait for morning medications. Review of the medication administration audit report showed multiple instances in which scheduled medications were given late. Prednisone, scheduled for 8:00 AM, was administered as late as 12:41 PM on different days, and other scheduled 9:00 AM medications such as enalapril maleate, Eliquis, nifedipine ER, acetaminophen, and the lidocaine patch were also administered late, including times such as 10:53 AM, 11:02 AM, 10:35 AM, 12:41 PM, 12:42 PM, and 12:43 PM. The record review also found no progress note documentation indicating that the resident’s medications were not administered as scheduled according to the physician orders. During interviews, an RN stated medications could be administered one hour before and one hour after the scheduled time and acknowledged that the resident’s medications were given late. The RN stated she would notify the physician if medications were administered late, but also stated documentation would only be made if medications were not available and the physician was made aware. An RN/UM stated nurses should follow the five rights, including right time, and should notify the physician and document when medications were given late, either by obtaining a separate order or documenting that the physician was aware and approved. An LPN/UM stated she did not see documentation that the physician had been notified for the late medication administration. The DON stated the expectation was for medications to be given timely and that nurses should notify the physician if there was a true late medication administration.
Failure to Notify Resident Representative of New Skin Excoriation
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a change in the resident’s medical condition. A closed record review for a resident admitted with type II diabetes, cerebral infarction, COPD, and hypertension showed that on 1/11/26 at 11:39 PM, an RN documented newly identified excoriation (scraped skin) to the resident’s bilateral groins and scrotum and that the physician was notified. There was no documented evidence that the resident’s representative was informed of this new skin condition, despite the change being recorded in the progress notes. During an interview, the RN stated that a resident’s representative was to be notified of any change in a resident’s medical condition and that such notification should be documented, and acknowledged that if the family had been notified, it would have been charted. The RN further stated that the representative should have been informed. In a joint interview, the DON and LNHA confirmed that staff were expected to notify the resident’s representative of any new conditions, including skin excoriation, and that the RN should have informed the representative of the change. Review of the facility’s “Change in a Resident’s Condition or Status” policy dated February 2021 showed that the facility would promptly notify a resident’s representative of a change in medical condition within 24 hours, which did not occur in this case.
Failure to Revise Care Plan After Resident-to-Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to adequately revise the care plan for a resident after an incident of resident-to-resident physical aggression. Resident #3 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, apraxia, and speech disturbances, and had a BIMS score of 7/15, indicating severe cognitive impairment. On 1/10/26, a verbal argument occurred between Resident #3 and their roommate, Resident #1, related to the television remote control. RN #1 entered the room and observed Resident #3 waving the television remote, appearing frustrated, and pushing the bedside table toward Resident #1, bumping Resident #1 in the abdomen. Progress notes by UM #1 documented that Resident #3 had a verbal argument with the roommate and became frustrated, pushing the table at the roommate. Following this incident, the facility updated Resident #3’s care plan with a focus on difficulty expressing themselves due to expressive aphasia and added interventions such as providing emotional support and allowing time to express feelings. However, the care plan did not include any interventions addressing how the facility would protect the roommate or other residents when Resident #3 became frustrated in the absence of staff, nor did it include measures to address Resident #3’s risk of physically acting out toward others. During an interview, the DON and the Licensed Nursing Home Administrator confirmed that the updated interventions would not prevent Resident #3 from another altercation with another resident when staff were not present. This failure to include adequate, person-centered interventions to address the underlying source of the problem and to protect other residents constituted the cited deficiency.
Failure to Maintain Complete and Accurate ADL Documentation in EMR
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident when required ADL documentation was missing from the electronic medical record (EMR) over multiple days and shifts. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, apraxia, and speech disturbances. A comprehensive MDS dated 1/12/26 showed a BIMS score of 14/15, indicating the resident was cognitively intact, and documented that the resident required substantial assistance with toileting and bathing and was at risk for pressure ulcers/injuries. The resident’s care plan included a focus on risk for alteration in skin integrity, with an intervention initiated on 1/6/26 directing that the resident’s skin be observed during daily ADL care and abnormalities reported. A review of the resident’s January 2026 task list, which the facility stated should be documented each shift, revealed no evidence of documentation for bladder continence and toilet use, bowel movement and toilet use, and hygiene on multiple specified dates and shifts. Corresponding progress notes for those dates also did not contain documentation related to these tasks. During interviews, a CNA stated that CNAs were primarily responsible for providing ADL care and were required to document all care provided in the EMR, and emphasized that documentation verified monitoring and care. The DON and LNHA confirmed that CNAs were responsible for ADL care and documentation, and that nurses and unit managers were responsible for ensuring both that appropriate care was provided and that CNAs documented the care. The facility’s Charting and Documentation policy dated July 2017 required that all services provided to residents be documented and that documentation be complete and accurate, including treatments or services performed.
Improper Food Storage and Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to store potentially hazardous foods properly and maintain kitchen equipment in a sanitary manner, as observed during a survey. In the walk-in freezer, boxes of chocolate chip premade dough cookies, beef patties, and vegetable burgers were found open, with no dates indicating when they should be used by. The bags inside these boxes were unsealed, and the products were covered in ice crystals. The Director of Culinary Management (DCM) was unable to provide information on when the boxes were opened. This lack of proper labeling and sealing could lead to contamination and foodborne illness. Additionally, the ice machine in the kitchen was found to have black sediment on the output flap, which the DCM identified as black mold. The facility's policies on refrigerator and freezer maintenance, as well as ice machine sanitation, were not followed, as evidenced by the lack of proper labeling and cleaning. The Licensed Nursing Home Administrator (LNHA) acknowledged these concerns but did not provide additional information. These deficiencies have the potential to affect all residents in the facility.
Failure to Secure Narcotic Medications Under Double Lock
Penalty
Summary
The facility failed to ensure that narcotic medications were secured under double lock in one of the two medication storage rooms observed, specifically in the Cove nursing unit. During an observation by the surveyor, it was found that the medication refrigerator was unlocked, and inside it, the narcotic medication lock box was also unlocked. This lock box contained 57 dronabinol 5 milligram capsules, a controlled medication. The Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed that these controlled medications should have been stored under two secured locks. Further interviews with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) confirmed that the narcotic medications were not stored according to the facility's policy, which requires Schedule II-V medications to be stored in a permanently affixed, double-locked compartment separate from other medications. The facility's Controlled Substance Storage policy, effective since February 2019, mandates that controlled substances requiring refrigeration must be stored within a locked box attached to the refrigerator to prevent removal. The failure to adhere to this policy was acknowledged by both the DON and the LNHA.
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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 Wall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Wall Llc | 0.5 mi | ★★★★★ | 2 | 1 |
| Tower Lodge Care Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Sunnyside Manor | 2.3 mi | ★★★★★ | 3 | 0 |
| Jersey Shore Post Acute Rehabilitation And Nursing | 2.7 mi | ★★★★★ | 0 | 0 |
| Coral Harbor Rehabilitation And Healthcare Center | 2.8 mi | ★★★★★ | 2 | 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.