Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Complete Care At Barn Hill during CMS and state inspections, most recent first.
Medication orders were not followed for two residents. One resident with bladder cancer, gross hematuria, and CKD had a Macrobid order for 5 days, but the e-MAR showed the antibiotic as a standing order with no stop date and it was administered beyond the ordered duration. Another resident with PVD, CHF, and atherosclerotic heart disease had a metoprolol order with hold parameters for SBP and HR, but the e-MAR did not capture BP or HR and nurses documented the dose as given every day without holding it.
A resident with PVD, CHF, and ASHD had a daily Metoprolol ER order with hold parameters for low SBP and/or HR, but the e-MAR did not capture BP or pulse before administration and nurses documented only that the dose was given. The CP twice noted that the hold parameters were not being properly followed and that BP and pulse should be entered in the e-MAR, while the DON stated the unit manager was responsible for reviewing and signing CP recommendations.
Call Bells Not Kept Within Reach: Surveyors observed three residents in bed with call bells out of reach, including one with dementia, Parkinson's disease, and diabetes, one on oxygen with severe cognitive impairment, and one with Alzheimer's disease and severe cognitive impairment. The call bells were found on the floor, under the bed frame, or behind a privacy curtain on a roommate's table, and an LPN/UM and the Program Director confirmed that residents' call bells should be within reach.
A surveyor observed multiple resident rooms on one unit with discolored, soiled, and heavily stained floors, black smudge marks, chipped paint, cracked walls, missing molding, and exposed wallboard. An MNT tech acknowledged the floors needed cleaning, waxing, buffing, and/or replacement, and the DOM/H confirmed the conditions were not conducive to a clean, homelike environment.
A facility failed to administer O2 therapy according to physician orders for two residents. One resident with dementia, HTN, and CAD was observed on NC at 2.5 LPM despite an order for 3 LPM continuously, and an LPN confirmed the setting was incorrect. Another resident with CKD, chronic AFib, and cardiomyopathy was observed on NC at 3 LPM despite an order for 2 L/min for hypoxia; an LPN could not explain why the concentrator was set above the ordered rate. The care plan for the second resident did not include interventions for following the O2 order, and the DON stated all O2 settings should match the PO.
The facility failed to maintain kitchen equipment in a clean and sanitary manner, as observed by a surveyor. A microwave had food debris, and grill plates in an oven were dirty with grease. The FSD and RFSD acknowledged the need for cleaning to prevent contamination, as per facility policy.
A facility failed to accurately code the MDS for a resident, resulting in a deficiency. The MDS incorrectly indicated that a resident was discharged to the hospital, while progress notes showed the resident was discharged home with family. The MDS Coordinator confirmed the error, and the issue was reported to the DON and Administrator.
A medication error occurred when an LPN administered metformin to a resident without a physician's order, mistaking them for another resident. The resident, diagnosed with diabetes mellitus II with hyperglycemia, was monitored for blood sugar levels following the incident, with no negative outcomes reported. The facility's policy on medication administration was not followed, leading to this deficiency.
The facility did not notify CMS of a name change to include a DBA, as required by 42 CFR 424.516. The facility's documents showed the name as Complete Care at Barn Hill, but CMS records listed it as Barn Hill Care and Rehab Center. The LNHA admitted that the necessary 855B form had not been filed to update the DBA name.
The facility failed to develop and implement an NPO care plan for a resident with a PEG tube, despite the resident's severe cognitive impairment and multiple diagnoses. Staff interviews confirmed that an NPO care plan should have been initiated upon admission, but it was not present in the resident's care plan.
Medication Orders Not Followed and Required Vital Signs Not Documented
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and acceptable standards of practice for 2 of 27 residents reviewed. For one resident with diagnoses including bladder cancer, gross hematuria, and chronic kidney disease, a physician order dated 12/17/25 directed Macrobid 100 mg twice daily for 5 days, but the order summary and e-MAR reflected Macrobid 100 mg twice daily with no stop date and showed the medication plotted and administered from 12/17/25 through 1/5/26. During record review, both an LPN and the RN/unit manager acknowledged that the order should have been verified with the physician. For another resident with diagnoses including peripheral vascular disease, chronic diastolic CHF, and atherosclerotic heart disease, the physician ordered Metoprolol Succinate ER 25 mg daily with instructions to hold for SBP less than or equal to 90 and/or HR less than or equal to 60. The e-MAR showed the medication scheduled for 0800, but it did not provide a drop-down or other method to enter the resident’s HR or BP. The e-MAR also showed that from 10/2/25 through 12/30/25, nurses documented the medication as administered every day and never held it. The record review further showed that the resident’s BP and HR were not being monitored every day at 0800 in the electronic medical record. During review with the surveyor, the LPN acknowledged that the resident’s SBP and HR were not being documented and that the e-MAR should have had a drop-down so both values could be monitored. The facility policies stated that medications must be administered in accordance with orders and that vital signs must be obtained and recorded when applicable or per physician orders.
Delayed Response to CP Medication Review Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to the Consultant Pharmacist’s monthly medication regimen review recommendations for 1 of 27 residents reviewed, Resident #29. The resident was admitted with diagnoses including peripheral vascular disease, chronic diastolic heart failure, and atherosclerotic heart disease, and was cognitively intact with a score of 15 out of 15 on the admission MDS. During observation, the resident was seated on the bed, watching television, and stated that medications were received ყოველდღიურად. Record review showed a physician’s order for Metoprolol Succinate ER 25 mg daily with hold parameters for SBP less than or equal to 90 and/or HR less than or equal to 60. The e-MAR showed the medication was scheduled for 0800, but there was no drop-down field to enter BP or HR, and from 10/2/25 through 12/30/25 nurses documented only that the medication was administered, without recording BP or HR, and the medication was never held. The CP issued recommendations on 10/21/25 and again on 12/19/25 stating that the hold parameters were not being properly followed and that BP and pulse should be re-entered and documented in the e-MAR before administration; the response section was marked completed. The DON stated that the unit manager was responsible for reviewing and signing CP recommendations and that a completed notation meant the recommendation was being addressed. The facility’s pharmacy services policy did not include a section addressing the facility’s response to CP recommendations related to medication irregularities.
Call Bells Not Kept Within Reach
Penalty
Summary
The facility failed to maintain residents' call bells within reach for 3 of 27 residents reviewed for accommodation of needs: Resident #16, Resident #80, and Resident #101. On 12/29/2025, the surveyor observed Resident #101 in bed with the call bell on the floor and not within reach. Resident #101's record showed diagnoses including dementia, Parkinson's disease, and diabetes mellitus, a quarterly MDS with a BIMS score of 8 out of 15 indicating moderate cognitive impairment, and a care plan that included encouraging the resident to use the call bell for assistance. Also on 12/29/2025, the surveyor observed Resident #16 in bed on a specialty mattress with oxygen infusing at 2.5 liters per minute via nasal cannula, and the call bell was behind the privacy curtain on the roommate's table, not within reach. Resident #16's record showed diagnoses including dementia, hypertension, and coronary artery disease, a quarterly MDS with a BIMS score of 00 out of 15 indicating severe cognitive impairment, and dependence on staff for ADL care. The surveyor also observed Resident #80 in bed with the call bell on the floor under the bed frame and not within reach. Resident #80's record showed a diagnosis of Alzheimer's disease, an annual MDS with a BIMS score of 00 out of 15 indicating severe cognitive impairment, and dependence on staff for ADL care. During interviews, the LPN/UM confirmed that nurses and CNAs should make frequent rounds to ensure call bells are within reach when residents are in bed, and the Program Director confirmed that all residents should have their call bells within reach.
Unsafe and Unhomelike Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in resident rooms on one of five units, the [NAME] Unit. During a tour of the unit, the surveyor observed multiple rooms with discolored, soiled, or heavily stained floors, including black smudge marks throughout and brownish substances on the flooring. Several rooms also had damaged walls, including cracked areas exposing wallboard, chipped paint, missing molding, and exposed wallboard near the door, bed, or window. During interview, the maintenance floor technician acknowledged that the floors needed to be cleaned, waxed, buffed, and/or replaced. The DOM/H later confirmed that the observed conditions were not conducive to a clean, homelike environment and stated that the floors needed to be deep-cleaned, stripped, and waxed or replaced, and the walls needed to be repaired. The facility policy stated that residents will be provided a safe, clean, comfortable, and homelike environment.
Oxygen Therapy Not Administered Per Physician Orders
Penalty
Summary
The facility failed to administer oxygen therapy according to physician orders for 2 of 3 residents reviewed for respiratory therapy. Resident #16 was observed in bed with oxygen delivered via nasal cannula attached to an oxygen concentrator set at 2.5 LPM, although the physician’s order required oxygen at 3 LPM via nasal cannula continuously every shift. The resident’s record showed diagnoses including dementia, hypertension, and coronary artery disease, and the quarterly MDS indicated severe cognitive impairment, dependence on staff for ADL care, and receipt of special respiratory treatments including oxygen therapy. The care plan also indicated the resident used oxygen at 3 LPM via nasal cannula. Resident #53 was observed in bed receiving oxygen via nasal cannula running at 3 LPM, while the physician’s order in the record directed oxygen at 2 L/min via nasal cannula every shift for hypoxia. The resident’s record showed diagnoses including chronic kidney disease, chronic atrial fibrillation, and cardiomyopathy, and the admission MDS reflected moderate cognitive impairment and continuous oxygen therapy. The care plan addressed respiratory therapy for improvement in pulmonary function related to poor lung expansion, but did not include interventions for following the physician’s oxygen orders. The facility policy stated the nurse shall verify the physician’s orders for the rate of flow and route of oxygen administration, and the DON stated that all oxygen settings should match the physician’s order.
Failure to Maintain Sanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary manner, as observed by a surveyor on two separate occasions. On the first occasion, the surveyor, accompanied by the Food Service Director (FSD) and the Regional FSD (RFSD), noted that the interior of a microwave unit had multi-colored splattered food debris stuck to its upper wall. Additionally, the surveyor found three cast iron grill plates inside an oven that were visibly used and dirty with solidified grease. The FSD confirmed that these grill plates had been used the previous night and should have been cleaned afterward. During interviews, both the FSD and RFSD acknowledged that the cooking equipment should have been cleaned and maintained in a sanitary manner to prevent foodborne illness and contamination, as per facility policy and regulations. A review of the facility's General Kitchen Cleaning Policy and Food Borne Illness Policy revealed that all equipment used in food handling must be cleaned and sanitized to prevent contamination. The policies emphasize the importance of maintaining sanitation through a comprehensive cleaning schedule and following food safety practices throughout the food handling process.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency. The surveyor found that the MDS for a resident, who was discharged from the facility, incorrectly indicated that the resident was discharged to the hospital. However, a review of the resident's progress notes revealed that the resident was actually discharged home with family. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged that the MDS should have indicated discharge to home or lesser care and that the error was made in coding the discharge destination. The issue was brought to the attention of the Director of Nursing and the Administrator during the surveyor's visit.
Medication Error: Unordered Metformin Administered
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services by administering a medication not ordered by the physician to a resident. Specifically, metformin, a medication used to lower blood sugar levels in individuals with type 2 diabetes, was given to a resident without a valid physician order. This incident involved a resident with a diagnosis of diabetes mellitus II with hyperglycemia, who was not present in the facility at the time of the survey. The resident's electronic health records indicated orders for other diabetes medications, but not for metformin. The error occurred when an agency LPN mistakenly administered metformin to the wrong resident, confusing them with another resident. The incident was documented as a medication error, and the resident's blood sugar levels were monitored following the administration, showing no negative outcomes. Interviews with facility staff, including the unit manager and the DON, confirmed the error and the subsequent monitoring of the resident. The facility's policy on medication administration emphasizes the importance of following the rights of medication administration, which were not adhered to in this case.
Failure to Notify CMS of Name Change
Penalty
Summary
The facility failed to notify CMS and apply for a change in name to include Doing Business As (DBA) in accordance with 42 CFR 424.516. This deficiency was identified through interviews and a review of facility documentation. The facility's admission agreement, census report, and business cards all reflected the name as Complete Care at Barn Hill. However, the CMS Novitas documentation listed the Legal Business Name as COMPLETE CARE AT BARN HILL LLC with a DBA name of Barn Hill Care and Rehab Center. The Licensed Nursing Home Administrator (LNHA) confirmed that the facility had not filed the necessary 855B form to change the DBA name to Complete Care at Barn Hill. Further review revealed that the facility's license, issued by the New Jersey Department of Health, was under the name Barn Hill Care and Rehab Center, not Complete Care at Barn Hill. This discrepancy between the facility's operational name and the name registered with CMS and the state licensing authority led to the deficiency. The LNHA acknowledged the oversight and indicated that the appropriate form had not been submitted to rectify the name change with CMS.
Failure to Implement NPO Care Plan for Resident with PEG Tube
Penalty
Summary
The facility failed to develop and implement a Nothing by Mouth (NPO) care plan for a resident with a PEG tube, despite the resident's severe cognitive impairment and multiple diagnoses, including dysphagia and pneumonia. The resident's electronic medical record and care plan did not include an NPO care plan, even though the resident was admitted with a feeding tube and had documented NPO status in progress notes. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), confirmed that an NPO care plan should have been initiated upon admission but was not present in the resident's care plan. The facility's policy on comprehensive, person-centered care plans, which was revised in October 2022, mandates the development and implementation of a care plan that includes measurable objectives and timetables to meet the resident's needs. Despite this policy, the resident's care plan lacked the necessary NPO care plan, which was acknowledged by both the LPN and ADON during interviews. The Certified Nursing Aide (CNA) assigned to the resident was aware of the NPO status through shift reports and visual indicators, but this information was not formally documented in the care plan.
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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 Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Rehabilitation And Healthcare Ctr | 0.1 mi | ★★★★★ | 0 | 0 |
| United Methodist Communities At Bristol Glen | 0.8 mi | ★★★★★ | 10 | 0 |
| Mohawk Meadows | 3.4 mi | ★★★★★ | 3 | 0 |
| Homestead Rehabilitation & Health Care Center | 4.6 mi | ★★★★★ | 5 | 2 |
| Forest Manor Hcc | 12.7 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.