Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Christian Health Care Center during CMS and state inspections, most recent first.
Food storage and kitchen sanitation practices were deficient when surveyors found expired or past-use-date items in a refrigerator and freezer, including cottage cheese, cups labeled sb, clams, and clam sauce. Surveyors also observed a Chef with facial hair longer than a quarter inch transporting prepared food without a beard guard, and the SDoDNS confirmed the beard guard should have been worn. The facility’s DNS dress code policy did not address beard guards, while the food storage policy required refrigerated and frozen items to be covered, labeled, and dated.
Two residents were affected by failures in medication administration and documentation. A resident with moderate cognitive impairment reported being given an antacid and offered a thyroid pill they were not prescribed, and staff statements confirmed that a nurse administered omeprazole intended for another resident, contrary to the requirement to verify the right resident and right drug. Another resident with a traumatic brain injury, cancer, and a G-tube had a PRN order for ondansetron for nausea/vomiting; vomiting and nausea episodes were documented in progress notes, but there was no corresponding documentation that the PRN ondansetron was given or any explanation for not administering it, and when ondansetron was documented as given in progress notes, the MAR was not signed to reflect those administrations.
Survey results were not posted in a readily accessible location for residents, families, and the public. Staff at the reception desk and on the unit could not initially locate the survey binder, and the binder found in the lounge area contained only the most recent recertification survey and one FIC survey, with no 3-year survey history or complaint survey reports filed. The DON and LNHA stated they were unaware of the full posting requirement and that the facility had no policy on survey result posting.
The facility failed to include required bed-hold reserve payment information, LTCO information, and appeal rights in written transfer notices sent to the RR for two residents after hospital transfers. Both residents had intact cognition per MDS/BIMS, and the letters only stated the hospital transfer and attached a bed-hold policy notice. The DoAaCM said the price was not on the letter, and the LNHA later stated the notice had been changed to include the appeal process and reserve payment.
A resident with dementia, Parkinson's disease, osteoporosis, and a right hip fracture had a major decline after a fall and surgery, changing from independent walking and transfers to Hoyer transfers and non-ambulatory status. Therapy and MDS documentation showed declines in ambulation, transfers, and lower body dressing, and staff acknowledged the changes met criteria for a SCSA, but no SCSA MDS was completed within the required timeframe.
The facility failed to complete and transmit required MDS assessments on time for two residents. An MDSC/RN and MDS Manager/RN acknowledged late submissions, and the MDS Manager/RN stated the assessments appeared submitted but not transmitted or accepted by CMS, suggesting an electronic records glitch. Surveyor review confirmed the comprehensive and discharge MDSs were transmitted only after inquiry and well beyond required RAI timelines.
A resident with dementia and nicotine dependence had an MDS that incorrectly coded current tobacco use as no, even though staff confirmed the resident smoked and had a smoking care plan. Another resident’s MDS incorrectly coded the discharge as unplanned despite records showing a planned discharge home with discharge instructions, medication reconciliation, follow-up, and therapy notes documenting discharge to home.
A resident with a gastrostomy tube, dysphagia, and severe protein-calorie malnutrition had a physician order for continuous Jevity 1.5 tube feeding with a required total volume of 990 ml, but the RMAR showed incomplete or inconsistent documentation of the total volume delivered on multiple occasions. The DON stated staff should follow orders and clarify if needed, while the facility policy required verification of the physician’s order and documentation of the amount and type of feedings administered.
A resident with hypoxemia was observed with O2 tubing and humidifier dated, but the record showed weekly O2 equipment care orders that were documented as completed on separate dates. Another resident with COPD and chronic respiratory failure was observed on O2 at 2.5 lpm even though the order specified continuous 2 lpm. Staff stated that both RT and nursing were responsible for changing tubing and ensuring correct O2 settings, and the facility policy required weekly change of disposable O2 equipment.
Medication administration and documentation were not consistent with PO for several residents. One resident with a PEG tube and heart failure received PRN midodrine at a time that conflicted with the bedtime restriction, and daily C-metoprolol was given without documented BP checks at the required time. Two residents with diabetes also had sliding-scale insulin doses that were not documented on multiple shifts, even though the LPN and DON stated the dose should be recorded along with the BS result and injection details.
The facility failed to adequately monitor a resident receiving olanzapine, a psychoactive medication, because the RMAR and care plan did not document target behaviors for the drug. The facility also had duplicate and incomplete PRN polyethylene glycol orders for another resident; during med pass, an LPN administered the medication even though one order lacked a stated indication and another PRN order for the same medication was also present. The DON acknowledged the missing documentation and the order issues.
The facility's FWA failed to include necessary resources for water management and emergency food and water supply, affecting 277 residents. The oversight was identified during a survey when the LNHA and DON could not provide documentation including these elements. Despite receiving a CMS memo about regulatory changes, the facility did not update its assessment accordingly.
The facility failed to address residents' concerns about late supper delivery times, raised during resident council meetings. Despite requests for earlier meal times, no action was taken, and staffing issues during supper service affected 15 to 20 residents. The DFNS did not recall the issue being discussed, and facility policies requiring resolution of such concerns were not followed.
The facility did not provide mail and package delivery services on Saturdays, as the mail room was closed on weekends. Residents reported not receiving mail or packages on Saturdays, and some had to rely on representatives to receive deliveries. Interviews with staff confirmed the mail room's closure on weekends, and the facility's policy did not address weekend mail delivery.
The facility failed to provide adequate respiratory care for several residents, including undated oxygen tubing, lack of documentation for oxygen therapy administration, and improper storage of equipment. Residents were observed with undated O2 tubing, and there were inconsistencies in monitoring and documenting SPO2 levels. Staff interviews revealed a lack of adherence to facility policies, contributing to these deficiencies.
A facility failed to accurately document a resident's advance directives, leading to conflicting information in their medical records. The resident's POLST form indicated a desire for resuscitation and a DNI status, but the EMR incorrectly included a DNR order. The discrepancy was confirmed by the RN/TL after consulting with the resident's representative.
The facility failed to accurately code the MDS for four residents, leading to deficiencies in care management. A resident's BIMS was not conducted despite being sometimes understood, another resident's fall incidents were inaccurately recorded, and a pressure injury was omitted from a resident's MDS. These errors were confirmed by facility staff.
A resident with moderate cognitive impairment and multiple health conditions experienced an unwitnessed fall, resulting in a head abrasion. Despite physician orders for frequent neuro-checks, the facility failed to document these assessments consistently. Interviews with staff confirmed the expected protocol, but the facility lacked a specific policy on neuro-checks, contributing to the deficiency.
A resident with Alzheimer's and a history of falls was found without a scoop mattress, a required intervention, and lacked documentation for other fall prevention measures. The ADON confirmed the absence of the scoop mattress, and the DON acknowledged the lack of documentation for toileting assistance. The CNA was unaware of the resident's fall history and interventions, relying on a kiosk and verbal instructions. The facility's fall prevention policy was not followed, as interventions were not timely documented in the CNA's tasks.
The facility failed to document supplemental intake and monitor weight for residents at risk for malnutrition. A resident's supplement intake was not consistently recorded, and another resident's daily weights were often refused or left blank without notifying the physician. The facility's policies on nutritional monitoring were not followed, leading to deficiencies in care.
The facility failed to monitor and administer enteral tube feeding according to physician's orders for two residents. One resident received incorrect volumes of feeding, while another had incomplete documentation of feeding completion. Staff interviews confirmed the discrepancies, and the facility's policy on enteral feeding was not followed.
A facility failed to document routine pain assessments for a resident with moderate cognitive impairment and pain management needs. Despite having PRN orders for pain medications, the resident's pain levels were inconsistently recorded, with only two entries noted for the month. The RN acknowledged the lack of documentation, and the DON confirmed the absence of routine pain assessments, contrary to the facility's policy.
A facility failed to provide appropriate dialysis care by not clarifying and following a physician's order for midodrine medication and not documenting fluid intake for a resident with fluid restrictions. The resident, diagnosed with end-stage renal disease, required hemodialysis and had specific orders for fluid restriction and midodrine administration. The facility did not consistently document fluid intake and there was confusion about midodrine administration, as it was given at the facility instead of the dialysis center. Interviews revealed a lack of clarity in following physician's orders.
A facility failed to identify an irregularity in a medication order for a resident, where Florastor was ordered as needed (PRN) but administered routinely. The resident, with diagnoses including Barrette's esophagus and GERD, was cognitively intact. The consultant pharmacist did not identify the issue during reviews, and staff interviews confirmed the order should have been clarified.
A medication administration error rate of 7.14% was observed in an LTC facility when an RN administered Carbidopa/Levodopa, Calcium, and a Multivitamin with Iron to a resident without checking for interactions. The facility's Consultant Pharmacist confirmed the interactions, and the facility's Medication Management Policy lacked information on drug interactions or errors.
A facility failed to ensure staff used appropriate PPE for a resident under Enhanced Barrier Precautions (EBP). A CNA provided care without a gown, unaware of the requirement. Interviews revealed staff confusion about EBP indicators, despite prior training. The facility's policy on PPE use during high-contact care was not effectively communicated, leading to non-compliance.
The facility failed to provide sufficient nursing staff and timely call bell responses for two residents, leading to significant delays. One resident experienced response times exceeding 15 minutes, with the longest being nearly 79 minutes, while another had delays up to 81 minutes. The facility also did not meet New Jersey's minimum staffing requirements for six out of seven day shifts.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness and in accordance with professional standards for food service safety. During an initial kitchen tour with the Senior Director of Dining Nutrition Services and the Manager of DNS, a container of cottage cheese was observed in refrigerator 3 with an open date of 2/9/26 and a use by date of 2/12/26. The Manager of DNS stated the facility policy was to discard opened items seven days after they were opened, and when asked to calculate the discard date from the open date, confirmed that the item should have been discarded on 2/16/26. In freezer 2, surveyors observed 8 cups labeled sb with an expiration date of 2/2/26, 5 cups labeled clams with a use by date of 2/16/26, and 1 cup labeled clam sauce with a use by date of 1/18/26. The surveyor also observed a Chef transporting a tray of prepared food from the preparation area to the refrigerator area while having facial hair longer than a quarter inch and not wearing a beard guard. The Senior Director of Dining Nutrition Services stated the Chef should have had a beard guard on. The facility’s Dining and Nutrition Services Dress Code Policy effective 1/26 did not include information on beard guards, and the Food Storage Standards policy effective 1/25 stated that items stored in refrigerators and freezers are to be covered, labeled, and dated.
Failure to Follow Medication Orders and Documentation Standards
Penalty
Summary
The deficiency involves failures in medication administration and documentation that did not meet professional standards or comply with facility policy. For one resident with hypertension, hyperlipidemia, and moderate cognitive impairment, the facility’s records included staff statements indicating that a nurse administered omeprazole, an antacid medication, to this resident even though it was intended for another resident. Another nurse documented that the resident reported being given an antacid pill and refusing a thyroid pill because they were not on that medication. These events show that the resident received a medication without a valid physician’s order and that the nurse did not correctly identify the resident before administering the drug, contrary to the facility’s policy requiring use of two identifiers and adherence to the six rights of medication administration, including right resident and right drug. A second deficiency involved another resident who was admitted with multiple serious diagnoses, including traumatic subdural hemorrhage, history of falling, protein-calorie malnutrition, lung cancer, and secondary malignant neoplasm of the cerebral meninges, and who was non-verbal. The physician’s order dated 2/14/26 directed that ondansetron 8 mg be given via G-tube every 8 hours as needed (PRN) for nausea or vomiting. This order was transcribed to the resident’s MAR as a PRN medication, and the MAR showed a PRN entry on 2/18/26. Progress notes documented that the resident vomited after a bolus feeding on one shift and had another vomiting episode at 6:20 AM on a later date. Further review of the medical record showed that there was no documentation that PRN ondansetron was administered at the times when vomiting or nausea were documented, nor was there documentation explaining why the medication was not given when the resident had nausea or vomiting. Additionally, progress notes recorded that ondansetron was administered on two separate occasions with positive effect, but there was no corresponding documentation on the MAR to show that the PRN medication had been signed out as given. These omissions conflicted with the facility’s medication administration policy, which requires that medications be administered as ordered by the physician and that the MAR be reviewed to identify the medication and signed after administration.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the State of New Jersey inspection results in an area readily accessible to residents, families, and the public, and failed to ensure reports of surveys, certifications, complaint investigations from the prior 3 years, and any available plan of correction were available for review. On 2/20/26, the surveyor asked staff at the reception desk and on the Heritage Manor unit where the survey results were located, and staff were unable to identify the location without asking others. The surveyor was directed to a white binder labeled Annual Long Term Care Survey in a bookshelf in the Hearth Area, but the binder contained only the most recent recertification survey dated 10/8/24 and a Focus Infection Control survey dated 1/17/24, with no other survey results filed. The DON confirmed that the binder contained only those two survey dates and stated she would get back to the surveyor regarding the facility policy. The LNHA later stated the facility had no policy regarding posting survey results and believed only the most recent recertification survey was required. The LNHA also stated she was not aware that the binder should include at least 3 years of surveys, including complaint surveys. The surveyor was informed that the survey results were not easily accessible at the reception desk or on the unit, and the facility history reviewed by the survey team showed additional surveys, including a recertification survey, an FIC survey, and complaint surveys, that were not filed in the survey binders.
Incomplete Transfer Notices for Bed-Hold and Appeal Information
Penalty
Summary
The facility failed to include required information in the written transfer notifications provided to the resident representatives for two residents who were transferred to the hospital. For one resident, the electronic medical record contained a letter dated 1/4/26 stating the resident was transferred to the hospital and admitted with a fever, with a copy of the Notice of Bed-Hold Policy-Secondary Notification attached. However, the letter did not include the bed hold reserve payment amount, the LTCO information, or the resident's appeal rights. For the second resident, the electronic medical record contained a letter dated 1/30/26 stating the resident was transferred to the hospital and admitted with DKA, with a copy of the Notice of Bed-Hold Policy-Secondary Notification attached. This letter also did not include the bed hold reserve payment amount, the LTCO information, or the resident's appeal rights. Both residents had intact cognition based on discharge MDS findings, with BIMS scores of 15 out of 15 and 14 out of 15, respectively. During interview, the DoAaCM stated that the bedhold information was sent the next morning after confirmation of hospital admission and that the price was not on the letter, noting it may be in the admission agreement. The LNHA later stated the notice had been changed to include the appeal process and reserve payment, and that admission staff had been in-serviced on the new process. The facility policy stated that, for emergency transfers to acute care, the resident and representative are to be provided a notice of transfer and the facility's bed hold notice policy.
Delayed Significant Change MDS After Major Functional Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) in a timely manner for a resident whose condition changed substantially after a fall and right hip fracture. Resident #85 had diagnoses including displaced intertrochanteric fracture of the right femur, history of falling, Alzheimer's disease, Parkinson's disease, osteoporosis, muscle weakness, and unsteadiness on feet. Before the fall, the resident's quarterly MDS showed independent transfers and walking 10 feet and 50 feet independently, with lower body dressing requiring supervision or touching assistance. After the resident fell in the hallway, an x-ray showed a right hip fracture, the resident was sent to the hospital and had surgery, and on return the resident required a Hoyer lift for transfers and was no longer able to stand or walk. Facility documentation showed the resident was re-admitted with a right hip ORIF, a surgical wound to the right upper leg, and a Hoyer transfer. Therapy evaluations documented a major decline from prior function, including transfers changing from minimal assistance or independent to total dependent, ambulation changing from 25 feet with contact guard assistance to non-ambulatory, and lower body dressing changing from maximum assistance to total dependence. Facility staff acknowledged that the resident had multiple areas of decline that triggered a Significant Change assessment. The MDS Manager/RN stated that a SCSA should be completed within 14 days of the determination of decline, and the MDS Coordinator/RN stated that multiple areas had triggered a Significant Change and that if baseline was not available, the assessment should be triggered. An email dated 10/17/25 from the MDS Coordinator to the ADON referenced a possible Significant Change, but there was no evidence that a SCSA MDS was completed for the resident after re-admission.
Late MDS Transmission for Two Residents
Penalty
Summary
The facility failed to complete and transmit required MDS assessments within the required timeframes for 2 of 38 residents reviewed. For Resident #132, the comprehensive MDS had an ARD of 4/17/25 with an admission date of 4/10/25, and the care plan completion date was 4/23/25; however, the assessment was not transmitted until 2/19/26, which was far beyond the required transmission deadline. For Resident #347, the discharge MDS return not anticipated had an ARD of 10/17/25 and was completed on 10/30/25, but it was not transmitted until 2/19/26, also well past the required deadline. During interview, the MDS Coordinator/RN and MDS Manager/RN stated the facility followed the RAI Manual timelines, but acknowledged there were late MDSs. When asked about the transmission reports for the two residents, the MDS Manager/RN stated the assessments had been submitted but did not show as transmitted or accepted by CMS and suggested there may have been a glitch in the electronic records system. The surveyor reviewed the records and confirmed both assessments were transmitted only after surveyor inquiry. The facility policy provided by the DON also reflected required timelines for entry, admission, and discharge assessments.
MDS Coding Errors for Tobacco Use and Discharge Status
Penalty
Summary
The facility failed to accurately complete portions of the MDS for 2 residents. For one resident with diagnoses including dementia, hypothyroidism, and nicotine dependence, the comprehensive MDS coded current tobacco use as no even though the resident had a smoking care plan, a BIMS score of 8 out of 15 indicating moderately impaired cognition, and staff confirmed the resident smoked one cigar a day and had smoked since admission. The MDS Manager stated the resident smoked, and the DON stated she would expect tobacco use to be reflected on the MDS because the resident had smoked since being at the facility. For another resident, the MDS Section A coded the discharge as unplanned even though the record showed the resident was discharged home with discharge instructions, medication reconciliation, physician follow-up, and therapy documentation describing the discharge as to home with family support. The nursing progress note, discharge summary, care plan, and therapy discharge summaries all reflected a planned discharge to home, and the MDS Coordinator acknowledged that the discharge should have been coded as planned and that the incorrect coding was due to human error.
Tube Feeding Order Not Followed as Written
Penalty
Summary
The facility failed to follow the physician’s order for enteral tube feeding administration for one resident who was admitted with unspecified severe protein-calorie malnutrition, dysphagia, a gastrostomy tube, and heart failure. The resident’s most recent MDS showed a BIMS score of 12 out of 15 and indicated that nutrition was being received through a feeding tube. A physician’s order dated 1/16/26 directed Jevity 1.5 continuous at 55 ml/hr for 18 hours or until 990 ml had been delivered, with a stop time of 1:00 PM, and the resident was also ordered NPO. Review of the RMAR showed the tube feeding order was transcribed and signed as administered, but the total volume was not documented as ordered on several dates, and when documented it did not match the ordered 990 ml. The recorded total volumes included 703 ml, 8 ml, and 112 ml on some dates, while other dates were left blank. When the DON was asked about the facility’s process for following physician orders in the RMAR, the response was to follow the orders and clarify if needed. The facility policy provided by the DON stated that staff should verify the physician’s order and document the amount and type of feedings administered.
Oxygen Therapy Not Provided and Documented as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided for residents receiving oxygen therapy. The facility was cited for failing to ensure the necessary respiratory care and services were delivered according to clinical practice and facility policy, specifically involving the correct oxygen flow rate for one resident and documentation of oxygen tubing changes for another resident. One resident was observed in bed sleeping with an O2 nasal cannula connected to an O2 concentrator set at 2 liters per minute. The resident had diagnoses including hypoxemia and chronic kidney disease, and the quarterly MDS showed severe cognitive impairment with a BIMS score of 5. The resident had physician orders for weekly monitoring of the O2 concentrator, including cleaning the filter and changing the tubing and humidifier, and the MAR showed this task as completed on 2/5/26 and 2/12/26. The tubing and humidifier were observed dated 2/6/26. Another resident was observed seated in a wheelchair with an O2 nasal cannula connected to a concentrator set at 2.5 liters per minute, although the physician order specified continuous O2 at 2 liters per minute. The resident stated that O2 was used all the time, day and night. The resident had diagnoses including COPD and chronic respiratory failure, and the MDS showed a BIMS score of 15 with O2 therapy in use. Facility staff, including the nurse educator and DON, stated that both respiratory therapists and nurses were responsible for changing tubing and ensuring appropriate settings. The facility policy for oxygen therapy required disposable equipment to be changed weekly or per infection control guidelines.
Medication Administration and Documentation Errors
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician's orders for multiple residents. For one resident with severe protein-calorie malnutrition, dysphagia, a PEG tube, and heart failure, the record showed orders for midodrine PRN for orthostatic hypotension and C-metoprolol daily with parameters for blood pressure and pulse monitoring. The midodrine was documented as given at 7:05 PM on one occasion even though the order stated it should not be administered 4 hours prior to bedtime, and the facility's DON acknowledged that bedtime was 9:00 PM. The C-metoprolol was documented as administered on multiple days without evidence that the required blood pressure was obtained and documented at the time of administration or within the ordered time window. For another resident with type 2 diabetes and intact cognition, the February RMAR showed a sliding-scale insulin lispro order, but the nurse did not document how many units were given at multiple 4:30 PM and 9:00 PM medication times across several days. The LPN stated that the blood sugar result, insulin dose, site, and initials should be documented, and the ADON stated that the units given should have been documented because the dose depended on the blood sugar result. The record therefore did not show the actual insulin dose administered on those occasions. A third resident with metabolic encephalopathy, type 1 diabetes, and congestive heart failure had a January RMAR with a sliding-scale insulin lispro order, but the nurse again failed to document how many units were given at multiple 4:30 PM and 9:00 PM medication times over several days. The DON confirmed that the units given were not documented on some shifts and stated that the expectation was for nurses to document the units given, the site, the blood sugar result, and the nurse's initials. The facility's policy required documentation of the time and location of insulin injections, but the records reviewed did not include the insulin dose for the affected administrations.
Inadequate psychotropic monitoring and duplicate PRN medication orders
Penalty
Summary
The facility failed to provide adequate monitoring for a psychoactive medication for one resident who was admitted with traumatic subdural hemorrhage, a history of falling, malnutrition, lung cancer, and secondary malignant neoplasm of the cerebral meninges. The resident was awake and non-verbal during observation, and the record showed an order for olanzapine 5 mg via g-tube at bedtime for anorexia nervosa that was later changed to olanzapine 5 mg at bedtime for depression. Although the medication was transcribed to the RMAR with a directive to monitor target behavior, the RMAR contained no documented target behavior entries, and the care plan did not include documented target behaviors for olanzapine. The facility’s psychotropic medication policy stated that residents receiving antipsychotic, anti-anxiety agents, and antidepressants for specific behavioral disturbances would be monitored for effectiveness and potential side effects. The facility also failed to ensure that another resident did not receive an unnecessary medication due to duplicate and incomplete medication orders. During a med pass observation, an LPN prepared polyethylene glycol 3350 for a cognitively intact resident with chronic kidney disease and anemia. The order being used was a PRN order for constipation, but the LPN stated it was needed routinely and that the order should be scheduled. The resident’s EMR showed multiple polyethylene glycol orders: one PRN order without a stated indication, another PRN order with constipation listed as the reason, and a later order entered after the observation that discontinued the original PRN order and added a new PRN order with the indication for constipation. Surveyors identified that the original PRN order lacked the required condition for use, while a duplicate PRN order for the same medication existed in the record. The LPN changed the order after the observation and inquiry, and the new order was documented as given. The facility’s medication orders policy stated that PRN orders should specify the condition for which they are administered, but the policy did not address duplicate medication orders.
Deficiency in Facility Wide Assessment for Emergency Preparedness
Penalty
Summary
The facility failed to ensure that its Facility Wide Assessment (FWA) included necessary resources for water management and emergency food and water supply, which are critical for resident care during both routine operations and emergencies. This oversight was identified during a survey when the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were unable to provide documentation that included these elements in the FWA. The assessment, dated July 2024, lacked information on measures to prevent the growth of Legionella and other waterborne pathogens, as well as plans for emergency food and water supply for the facility's 277 residents. Upon further investigation, it was revealed that the FWA process involved input from the Interdisciplinary Team (IDT) and was reviewed during the Quality Assurance Performance Improvement (QAPI) meetings. However, the DON acknowledged that the emergency water and food supply and water management were not included in the FWA, attributing this to an oversight. Despite receiving a CMS memo about regulatory changes, the facility did not update its assessment to reflect these requirements. The survey team confirmed these deficiencies with the facility management, who did not provide additional information or refute the findings.
Failure to Address Resident Meal Delivery Concerns
Penalty
Summary
The facility failed to consistently address issues and concerns raised during resident council meetings and through resident questionnaires. Specifically, the facility did not respond to requests from residents to have supper served earlier than the current delivery time of 6:00 PM. This issue was raised during the resident council meetings held in July and September 2024, but no action was taken to address the concern. The Director of Food and Nutrition Services (DFNS) was present at these meetings but did not recall the issue being discussed, and no changes were made to the meal delivery schedule. During a surveyor-conducted resident council meeting, several residents reported that the late delivery of supper and insufficient staffing during meal times affected 15 to 20 residents in the dining room. The Activity Person (AP) confirmed that she often worked alone during supper, which delayed meal service. Despite the residents' repeated requests for an earlier supper time, the facility management did not take action to resolve the issue, and the DFNS did not receive or act upon the meeting minutes indicating the residents' concerns. The facility's policies on diet ordering and resident council meetings require that concerns be addressed and resolved, but these procedures were not followed. The Licensed Nursing Home Administrator (LNHA) acknowledged that the residents' concerns should have been treated as grievances and resolved accordingly. However, the facility management did not provide a resolution or timeline for addressing the residents' requests for earlier meal delivery, leading to the deficiency noted by the surveyors.
Failure to Provide Weekend Mail Services
Penalty
Summary
The facility failed to provide Saturday mail and package delivery services to its residents, as identified during a resident council group meeting. Seven residents reported that they did not receive mail or packages on Saturdays because the mail room was closed. One resident mentioned that a delivery from an outside vendor was returned because the mail room was closed on weekends, and another resident had to rely on their representative to receive packages. The facility's policy and practice confirmed that the mail room was only open Monday through Friday, and no mail or packages were delivered on weekends. Interviews with the Unit Clerk and the Shipping, Receiving & Inventory Manager corroborated the residents' statements. The Unit Clerk explained that mail and packages were delivered to the unit from the mail room during weekdays, and the Shipping, Receiving & Inventory Manager confirmed that the mail room was closed on weekends. The facility's policy on requisition ordering and inventory control did not address weekend mail delivery, and the facility management did not provide additional information or refute the findings during the exit conference.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies observed during the survey. For Resident #9, the oxygen (O2) tubing was not dated, and there was no documented evidence that the O2 therapy was administered as ordered. The resident's saturation of peripheral oxygen (SPO2) was not monitored every shift as required, with only sporadic checks documented. Interviews with nursing staff revealed inconsistencies in the understanding and execution of the facility's policy regarding O2 therapy, including the dating and changing of O2 tubing. Resident #38 was observed receiving O2 therapy with undated tubing and a humidifier bottle that had not been changed since 9/25. The resident's O2 tank was also found to be empty, indicating a lack of proper monitoring and maintenance. The Assistant Director of Nursing (ADON) confirmed that the responsibility for changing and dating the tubing and humidifier bottles lay with the nursing staff, yet these tasks were not being performed as per the facility's policy. For Resident #124, there was a failure to document the administration of PRN O2 therapy and to monitor SPO2 levels every shift, as ordered. The resident's medical records showed gaps in documentation, with missing entries for SPO2 checks and PRN O2 administration. Additionally, Resident #157's O2 tubing was improperly stored, hanging on a feeding pump pole instead of being placed in a plastic bag, which posed an infection control risk. The facility's policy did not adequately address the proper storage of O2 equipment when not in use, contributing to this deficiency.
Inaccurate Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation and review of a resident's advance directives (AD) for one of the residents reviewed. The resident, who had diagnoses including dementia, spondylosis, and type 2 diabetes mellitus, was assessed to have moderate cognitive impairment. The resident's medical records contained conflicting information regarding their AD. A physician's order indicated a Do Not Intubate (DNI) and Do Not Resuscitate (DNR) status, while the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, signed by the resident's representative and an advance practice nurse, indicated the resident desired resuscitation and a DNI status. There was no documentation in the progress notes indicating the resident desired a DNR status. During interviews, a Registered Nurse (RN) and a Registered Nurse/Team Leader (RN/TL) explained the facility's protocol for AD, which included ensuring that AD information in the electronic medical record (EMR) matched the provided documentation. However, upon review, the RN/TL confirmed with the resident's representative that the POLST was correct and the DNR order should not have been entered in the resident's EMR. The Director of Nursing (DON) acknowledged the concern with the resident's AD during a meeting with the survey team.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to deficiencies in the management of their care. For Resident #15, the MDS was inaccurately coded in Section C, Cognitive Patterns, as the Brief Interview for Mental Status (BIMS) was not conducted despite the resident being sometimes understood. This oversight was identified during a review of the resident's significant change in status MDS, which incorrectly indicated that the BIMS should not be conducted. Resident #194 also experienced a similar issue with the MDS coding. The resident was coded as sometimes understood in Section B, yet the BIMS was not conducted, contrary to the coding instructions. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged that a BIMS should have been attempted for residents coded as sometimes understood. For Resident #153, the MDS inaccurately reflected the resident's fall incidents. Despite having multiple unwitnessed falls, one of which resulted in a complaint of pain, the MDS was coded as having no injury. This was contrary to the facility's practice of coding any fall-related pain as a minor injury. Similarly, Resident #253's MDS failed to document a stage I pressure injury, despite evidence of non-blanchable redness during the assessment period. This omission was later confirmed by the Director of Nursing, who acknowledged the error in coding.
Failure to Complete Neuro-Checks After Resident Fall
Penalty
Summary
The facility failed to consistently follow professional standards of clinical practice by not ensuring the completion of neurological checks after a resident experienced a fall. This deficiency was identified during a survey, which included observation, interviews, and record reviews. The incident involved a resident who had an unwitnessed fall and was found on the floor with an abrasion to the right side of their head. Although neuro-checks were initiated as per the physician's order, the documentation did not reflect that these checks were completed at the specified intervals. The resident involved had a history of colon cancer, chronic obstructive pulmonary disease, muscle weakness, and atrial fibrillation, and was assessed to have moderate cognitive impairment. The physician's order required neuro-checks every 30 minutes for an hour, then every hour for 2 hours, and then every 4 hours for 24 hours. However, the progress notes did not consistently document the neuro-check assessments at each required time, indicating a lapse in following the prescribed medical regimen. Interviews with the nursing staff, including the RN and ADON, confirmed that neuro-checks should be performed following unwitnessed falls, and the frequency should be documented as per the physician's order. Despite this understanding, the facility lacked a specific policy on neuro-check assessments, and the existing fall prevention policy did not address neuro-check protocols. This gap in policy and documentation contributed to the deficiency identified by the surveyor.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to provide appropriate interventions and ensure that interventions to prevent further falls were documented and monitored for a resident with a history of falls and cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, dementia, muscle weakness, and repeated falls, was observed without a scoop mattress, which was an intervention listed in the care plan. The resident's care plan also lacked documentation for other interventions such as a low bed, bed alarm, and pad sensor, which were not included despite being relevant to the resident's fall risk. The Assistant Director of Nursing (ADON) confirmed that the resident did not have a scoop mattress as required by the care plan, and there was no documented evidence that the resident was offered toileting assistance before and after breakfast as part of the fall prevention interventions. The Director of Nursing (DON) acknowledged that the facility's process was to update the care plan with new interventions after each fall, but there was no option in the electronic records to add actual falls as a focus. The Certified Nursing Aide (CNA) responsible for the resident was unaware of the resident's fall history and the specific interventions required, relying instead on information from a kiosk and verbal instructions. The facility's Resident Safety Program-Fall Prevention Policy required that all residents at risk for falls be identified through a comprehensive assessment process and that interventions be implemented based on identified risk areas. However, the surveyor found that the interventions for offering toileting assistance were not entered into the CNA's monitoring tasks until after the surveyor's inquiry, indicating a lack of timely documentation and implementation of fall prevention measures. The facility management did not provide additional information or refute the findings during the exit conference.
Deficiencies in Nutritional Documentation and Monitoring
Penalty
Summary
The facility failed to ensure complete documentation of supplemental intake for residents identified as at risk for malnutrition, as evidenced by the case of Resident #90. The resident, who had a history of significant weight loss and was prescribed Ensure Plus as a supplement, had numerous instances where the amount of supplement consumed was not recorded in the Medication Administration Record (MAR). Despite the resident's varying appetite and occasional refusal of the supplement, the nursing staff did not document the intake or lack thereof, as required by the physician's order and care plan interventions. In the case of Resident #124, the facility failed to monitor weight according to the physician's order. The resident, who had experienced significant weight loss, was supposed to have daily weights recorded, but the records showed numerous refusals and blank entries. Additionally, there was no documented evidence that the physician was notified of the resident's refusal for daily weight and supplements, nor was there documentation explaining the refusals or any follow-up by the clinical team. The facility's policies on high-calorie/high-protein supplements and weight monitoring were not adhered to, as evidenced by the lack of documentation and follow-up on the residents' intake and weight monitoring. The Registered Dietician (RD) also indicated a lack of awareness of where to check the records for supplement intake, further highlighting the deficiencies in the facility's processes for monitoring and documenting nutritional interventions.
Failure to Monitor and Document Enteral Feeding
Penalty
Summary
The facility failed to monitor and administer enteral tube feeding according to physician's orders for two residents. Resident #157, who had a history of acute respiratory failure, pneumonia, anemia, gastrostomy, and dysphagia, was observed not receiving tube feeding during multiple visits by surveyors. A review of the resident's medical records revealed discrepancies between the physician's orders and the actual volume of tube feeding administered. The orders specified certain volumes to be delivered, but the resident received significantly more or less than prescribed on several occasions. Interviews with nursing staff confirmed the oversight, and the staff acknowledged the error in administering the incorrect total volume of tube feeding. Resident #230, diagnosed with metabolic encephalopathy, dysphagia, acute respiratory failure, and epilepsy, was observed receiving enteral feeding at a specified rate. However, the facility failed to document the completion of the feeding and the total volume received daily, as required by the physician's orders. The medical records lacked documentation of the total volume of feeding administered, and interviews with nursing staff revealed inconsistencies in the documentation process. The Assistant Director of Nursing acknowledged the absence of proper documentation and stated that the nurses could document the completion of feeding in progress notes, but this was not consistently done. The facility's policy on enteral feeding and documentation was not followed, leading to the deficiencies identified by the surveyors. The Director of Nursing and other administrative staff were informed of the issues, and the facility did not refute the findings. The lack of adherence to physician's orders and inadequate documentation of enteral feeding administration contributed to the deficiencies observed during the survey.
Failure to Document Routine Pain Assessments
Penalty
Summary
The facility failed to ensure routine pain level assessments were completed and documented for a resident, as required by their policy and standards of practice. This deficiency was identified for a resident who was observed to be alert and verbally responsive, reporting pain from a wound on their backside. The resident had a history of moderate cognitive impairment and was prescribed PRN pain medications, including acetaminophen, tramadol, and a lidocaine patch, but often refused stronger medications and the air mattress provided for comfort. The Registered Nurse (RN) caring for the resident acknowledged that the resident occasionally complained of pain, typically at a level of 2 to 3 out of 10, and had orders for PRN pain medications. However, the RN admitted that the resident's pain assessments were not consistently documented, as required by the facility's protocol. The resident's medical records showed only two documented pain level entries for the month, and the resident had refused the lidocaine patch for 12 out of 22 days when it was routinely ordered. The Director of Nursing (DON) confirmed that there was no routine pain assessment documented for the resident, despite the facility's policy requiring weekly pain assessments for residents with pain medication orders. The facility's policy on pain management stated that pain should be assessed at regular intervals, but this was not adhered to in the case of the resident, leading to the identified deficiency.
Deficient Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, specifically in clarifying and following a physician's order for midodrine medication and documenting fluid intake for a resident with fluid restrictions. The resident, who was cognitively intact and diagnosed with end-stage renal disease, required hemodialysis three times a week. The physician's order included a fluid restriction of 1000 ml per day and the administration of midodrine for low blood pressure, with specific instructions for documentation and administration. The surveyor found that the facility did not consistently document the resident's fluid intake as required by the physician's order. There were several instances where the fluid intake was not recorded in the Medication Administration Record (MAR) across different shifts. Additionally, there was confusion regarding the administration of midodrine, as the medication was documented as being given at the facility prior to hemodialysis, contrary to the expectation that it would be administered at the dialysis center as needed. Interviews with the registered nurse, Assistant Director of Nursing (ADON), and Director of Nursing (DON) revealed a lack of clarity and consistency in following the physician's orders for midodrine administration and fluid intake documentation. The facility's policy on dialysis care was not adhered to, as evidenced by the missing documentation and unclear communication regarding the administration of midodrine. The deficiency was identified through observations, interviews, and a review of the resident's medical records and facility documentation.
Failure to Identify Medication Order Irregularity
Penalty
Summary
The facility failed to identify an irregularity in the physician's order for a resident's medication, specifically Florastor, which was ordered as needed (PRN) for loose stool but was administered routinely at 9:00 AM and 9:00 PM. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had diagnoses including Barrette's esophagus, gastro-esophageal reflux disease, and heartburn. The consultant pharmacist did not identify the irregularity in the medication order during reviews in August and September 2024, and the medication was incorrectly transcribed and administered as a routine medication rather than PRN. Interviews with facility staff, including a Licensed Practical Nurse and a consultant pharmacist, revealed that the order should have been clarified, as Florastor is not typically given PRN. The facility's Medication Management Policy outlines the need for safe and effective medication management, including the correct transcription and processing of physician orders. Despite this policy, the irregularity was not addressed, leading to the deficiency noted by the surveyors.
Medication Administration Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure that all medications were administered with an error rate of less than 5%, resulting in a medication error rate of 7.14%. During a medication administration observation, a Registered Nurse (RN) was observed administering medications to a resident without checking for cautionary or informational warnings on the medication packaging. The medications included Carbidopa/Levodopa, Calcium with Vitamin D, and a Multivitamin with minerals containing Iron. The RN was unaware of the interactions between these medications, specifically that Iron should not be administered at the same time as Carbidopa/Levodopa and Calcium, as it may reduce the absorption of these medications. The facility's Consultant Pharmacist confirmed the interactions between Carbidopa/Levodopa and Iron, as well as between Calcium and Iron, stating that they should be administered separately by at least two hours. The resident involved was a new admission, and the Consultant Pharmacist had not yet reviewed the chart. The Director of Nursing (DON) and the Licensed Nursing Home Administrator were informed of the medication error rate and the specific errors observed. The facility's Medication Management Policy did not include information regarding drug interactions or medication errors, and no additional pertinent documentation was provided by the facility.
Inadequate PPE Use and EBP Knowledge Among Staff
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) before providing care to a resident requiring Enhanced Barrier Precautions (EBP). During an initial tour, a surveyor observed that a resident with a pressure ulcer, who was supposed to be under EBP, did not have the necessary PPE bin with gloves and gowns outside their room. A Certified Nursing Assistant (CNA) was found providing care to this resident without wearing a gown, and upon interview, the CNA admitted to not knowing the requirement to wear a gown for this resident. Further investigation revealed that the facility's staff, including CNAs, were not adequately knowledgeable about the EBP requirements. Interviews with multiple CNAs showed a lack of understanding of the significance of the orange sticker indicating EBP, with varying interpretations of its meaning. The Director of Infection Control acknowledged that EBP education was provided earlier in the year, but some staff, including a newly hired CNA, had not received adequate training or reinforcement on the EBP protocols. The facility's policy on Isolation Precautions required the use of gloves and gowns during high-contact care activities for residents with indwelling medical devices or wounds. However, the policy was not effectively communicated or enforced among the staff, leading to non-compliance with infection control practices. The facility management, including the Director of Nursing, acknowledged the oversight and the need for staff to adhere to PPE protocols to prevent the spread of infections.
Deficient Staffing and Call Bell Response Times
Penalty
Summary
The facility failed to ensure sufficient nursing staff and timely response to call bells for two residents. For one resident, the Alarm Average Response Time Report showed multiple instances where the response time exceeded 15 minutes, with the longest being 78 minutes and 59 seconds. This resident had a moderate cognitive impairment and multiple health issues, including pleural effusion, non-Hodgkin lymphoma, and squamous cell carcinoma. The survey team informed the facility management of these concerns, but no additional information was provided by the facility. Another resident's call bell response times also exceeded acceptable limits, with delays ranging from 16 minutes to over 81 minutes. This resident had a displaced intertrochanteric fracture, hypertension, and depression. The DON acknowledged the issue but did not provide documentation to support the resolution of these delays. Additionally, the facility was found to be non-compliant with New Jersey's minimum staffing requirements for six out of seven day shifts during a specified week, with fewer CNAs than required for the number of residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,405 citations issued within 25 miles in the last 12 months — including the 17 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wyckoff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windmere | 1.2 mi | ★★★★★ | 7 | 0 |
| Excel Care At Wayne | 3.1 mi | ★★★★★ | 3 | 1 |
| Family Of Caring Healthcare At Ridgewood | 3.6 mi | ★★★★★ | 0 | 0 |
| Preakness Healthcare Center | 3.7 mi | ★★★★★ | 1 | 0 |
| Ridgewood Center | 3.7 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.