Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Bayshore Llc during CMS and state inspections, most recent first.
Staff responsible for food service lacked the demonstrated skills and oversight needed to keep the kitchen sanitary, operate the dish machine at the required wash temperature, and follow menus and recipes for proper portions and nutritional adequacy. Surveyors observed soiled kitchen areas, a dish machine running below the manufacturer’s minimum wash temperature, and meal service problems including cold hot foods, incomplete trays, incorrect portions, and puree items prepared without recipes. Residents reported that meals were disgusting, not what they selected, and often served cold.
Menus, recipes, and portion sizes were not followed. Two residents reported cold, poor-quality meals, and a resident council of 10 residents said they did not receive the foods they selected, did not get complete meals, and were served cold hot food. Tray observations showed missing menu items, inconsistent puree portions, and milk amounts that did not match the meal tickets. Kitchen staff and the FSD confirmed puree items were being prepared without recipes, while the menu company RD stated the menus were certified as nutritionally adequate and required to be followed as written.
The facility failed to use standardized recipes for puree foods and failed to serve meals at an appetizing temperature. Two residents reported cold, disgusting food, and a resident council of 10 residents said they did not receive selected or complete meals and that hot food arrived cold. During tray observations, residents received trays that did not match the menu, including incomplete items and puree foods with unclear consistency, while the cook stated puree items were made without recipes. The DM and FSD discussed temperature and portion standards, but observed milk and juice were warm and menu spreadsheets later showed portion sizes that did not match the portions staff described.
Food storage, kitchen sanitation, and dish machine temperature deficiencies were identified during a kitchen tour. The surveyor observed a dish machine running below the manufacturer’s required 160 F wash temperature while the FSD referenced a 150 F log and an empty clipboard. The surveyor also found soiled walk-in refrigerator gaskets, debris on vents, ceiling tiles, racks, sinks, and storage surfaces, rusted and peeled racks, raw cabbage stored in a dirty container without dates, dented cans mixed with regular stock, and icing stored without a use-by date.
The facility failed to maintain a comprehensive, documented QAPI program and did not show a process for tracking, trending, and measuring issues identified through daily meetings or grievances. The LNHA reported quarterly QAPI meetings with vendors and department heads, but had no QAPI plans for the new dietary management company or new systems, and could not explain grievance trending. Surveyors also found numerous QAPI initiatives that were not specific or measurable, including employee files, maintenance issues, dialysis forms, trayline accuracy, MDS coding, call bell response time, pressure wounds, medication hold parameters, and other facility concerns.
A facility failed to ensure that two residents had call lights that were accessible and working. One resident with cognitive impairment, blindness, and a history of falls had a call bell out of reach and later found not functioning when a CNA tested it. Another resident with severely impaired cognition, weakness, and mobility limitations could not reach the call light, which was later found tied to the bed frame outside the resident’s view; the resident also reported long delays in staff response to the call light.
A facility failed to maintain adequate linen supplies for resident care and comfort. Resident council minutes and resident interviews showed ongoing complaints about towel and linen shortages, especially on weekends, with staff unable to provide linens and change bed linens in a timely manner. The HD said there was no linen inventory or storage, and the LNHA could not provide a linen PAR or show how much linen was on hand versus what was needed; CNAs reported they often had to borrow linens from other floors or ask residents to wait for laundry.
A resident with respiratory failure, ventilator dependence, Alzheimer's disease, and major depression was receiving Seroquel plus multiple antidepressants for reported past combativeness, spitting, and restlessness. Staff observations and charting showed the resident was calm, nonverbal, and had no documented aggressive behaviors or refusal of care, while monthly psychotropic reviews repeatedly showed zero target behaviors and no documented nonpharmacologic interventions. The NP stated the meds were for prior behaviors but had not reviewed the monthly psychotropic evaluations.
Delayed Incontinence Care for Dependent Residents: Two residents reported that incontinence care was not provided timely, sometimes taking over an hour. Surveyors observed one resident saturated with urine and another heavily soiled with urine and feces, while CNAs stated they had not checked the residents before breakfast or during the morning despite being assigned to them. Records showed both residents required assistance with ADLs and incontinence care, and an LPN stated care was to be offered every 2 hours and during morning rounds.
A resident with diabetes, Parkinson’s disease, and spinal stenosis had a noticeable, oozing back abscess documented by an FNP, but nursing skin assessments and CNA skin observations did not identify it beforehand. Another resident with hemiplegia, dementia, and cataracts reported that an aide did not accompany them to eye surgery, and the LPN UM and DON acknowledged the escort was missed and not communicated well.
Inadequate fall supervision and ineffective call bell intervention: A resident with impaired cognition, visual deficits, and a history of falls was identified as high risk for falls, yet the call bell was repeatedly out of reach and was later found not to function when tested by a CNA. The resident’s care plan included general fall precautions, but after unwitnessed falls and a fall onto the floor mat, the fall investigations documented no new interventions tied to the causes of the falls. The DON stated the facility did not really document 2-hour rounding and was unaware of the resident’s visual deficits or need for a different call bell type.
Failure to Administer Ordered Oxygen Therapy: Two residents did not receive oxygen in accordance with physician orders. One resident with COPD, Parkinson’s disease, and a history of aspiration pneumonia was observed on 5 LPM via NC despite an order for 2 L PRN for low SpO2 or SOB, and the resident stated, “I cannot breathe.” Another resident with COPD and CHF was found with an empty portable O2 tank despite an order for 3 L/min via NC every shift; the LPN could not explain why the tank was empty.
Medication Parameter, Storage, and Controlled Substance Errors An LPN administered BP meds to two residents despite physician hold parameters being met, including one resident with ESRD and another with severe cognitive impairment. Surveyors also found unsecured midodrine left in a dialysis communication book and observed an LPN signing the narcotic log after giving clonazepam, contrary to facility policy for controlled substances.
Improper medication storage and expired supplies were found in medication carts and a medication room. Surveyors observed loose unidentified tablets, an expired nasal spray, an opened unused syringe, a tablet stored with IV supplies, a resident's Meropenem IV bag stored with NS bags, and multiple expired blood draw kits, vials, and other supplies. An LPN and RN acknowledged the items were outdated or improperly stored, and the unit manager stated expired medications should not be in drawers or cabinets.
A resident receiving hospice care had severe cognitive impairment and a care plan focused on coordination with the hospice team, but the facility failed to maintain consistent communication and documentation with the hospice provider. The hospice binder contained limited and partly incomplete records, and the UM and DON stated that hospice-related documentation should be kept in the binder and that the UM was responsible for ensuring it was completed.
The facility failed to ensure pre-hire screening was completed and documented for employees and contracted staff, including dietary, before they worked in the building. Surveyors found multiple files with background checks ordered or completed after hire, a pending check for a CNA, and inconsistent documentation in the HR files. The HRD stated new employees should not be in the building until the background check is completed, and the facility policy required screening for abuse, neglect, exploitation, and misappropriation with proof maintained in the file.
Dialysis Medication Times Not Adjusted: A resident with ESRD and HTN was scheduled for HD three times weekly, but the eMAR showed routine meds were administered at times when the resident was out of the facility for dialysis. Progress notes documented return times from dialysis around late morning to midday, and an LPN stated the med times should have been adjusted to match the resident’s return.
A resident with moderately impaired cognition, dependence on staff for ADLs and transfers, and a high fall risk had a call bell that did not function when tested by a CNA. The resident’s care plan directed that the call light be kept within reach and used for assistance, but the bell was found nonoperational during observation and interview.
A resident with multiple chronic conditions had an MDS assessment coded to show an indwelling urinary catheter, despite no documentation in physician orders, treatment records, or nursing notes indicating catheter use during the assessment period. A CNA had entered incorrect bladder-related information into the point of care system, and this data was used to complete the MDS without verification by the IDT, contrary to facility policy and RAI Manual requirements for multi-source, validated assessment data.
The facility's assessment failed to identify and address the specific services, procedures, and resources required for ventilator-dependent residents. The assessment did not specify the facility's ventilator care bed licensing, nor did it include ventilator-dependent residents in sections covering diseases, care needs, staff training, or equipment. Leadership confirmed the omission during interviews, stating that ventilator care was considered under general respiratory needs.
The facility failed to maintain kitchen equipment in a sanitary manner, with issues including a dirty ice machine, uncovered waste receptacles, and uncleaned cooking equipment. The FSD acknowledged non-compliance with cleaning policies, posing potential contamination risks.
A resident with severe impaired cognition was discharged from a facility without a prescription for clindamycin, an antibiotic needed for an ongoing infection treatment. The omission occurred due to a miscommunication, as the Nurse Practitioner mistakenly believed the antibiotic treatment was completed. The facility's Vice President Clinical acknowledged the error, confirming the resident did not receive their medication on time.
A facility failed to develop an individualized comprehensive care plan for a resident with chronic pain. Despite the resident's frequent pain and administration of pain medications, their care plan lacked a focus on pain management. The resident, who was cognitively intact, expressed the need for an appointment related to shoulder pain. The facility's leadership acknowledged the oversight, which violated their policy and regulatory requirements.
A resident with moderate cognitive impairment and multiple medical conditions experienced a fall in the facility. Despite the incident, the resident's care plan was not updated with new interventions as required by the facility's policy. The Vice President of Clinical confirmed that care plans should be reviewed and updated after a fall, indicating a deficiency in policy adherence.
A resident with a pressure ulcer did not receive a recommended low air-loss (LAL) mattress, as observed by surveyors. Despite a wound care consultant's recommendation and a physician's order for daily wound care, the facility's staff were unaware or unsure of the resident's use of a LAL mattress. The facility's Wound Care policy lacked guidance on implementing consultation recommendations, leading to this deficiency.
The facility failed to ensure proper accountability and documentation of narcotic shift count logs and controlled medication administration. Reviews revealed missing signatures and incomplete narcotic counts on shift-to-shift controlled substance count sheets for two medication carts. Additionally, a resident's clonazepam dose was not documented on the declining inventory log, although it was recorded in the electronic MAR. Staff interviews confirmed the lack of adherence to the facility's policy requiring two licensed nurses to account for controlled substances at each shift change.
A surveyor observed improper medication storage on an unattended medication cart in the Vent nursing unit. An LPN left the cart with unsecured medications, including Eliquis and midodrine HCl, visible on an unlockable tray. The DON confirmed that medications should always be secured, aligning with the facility's policy requiring locked storage accessible only to authorized personnel.
The facility failed to follow clinical practice standards by not consistently documenting medication and treatment administration in the MAR and TAR for two residents. This included missing documentation for tube flushes and wound care treatments, with no records to confirm that the care was provided. Interviews with staff confirmed the importance of proper documentation for accountability and continuity of care.
Food Service Oversight, Sanitation, and Menu Compliance Failures
Penalty
Summary
The facility failed to ensure staff responsible for food and nutrition services had the skills and competencies needed to maintain the kitchen in a clean and sanitary manner, operate the dish machine appropriately, follow menus and recipes for portioning and nutritional adequacy, and provide appetizing meals. During an initial kitchen tour, the surveyor observed debris and soiled areas in the walk-in refrigeration units, food storage areas, storage racks, on the ceiling, and on the exterior of equipment, tables, and the ice machine. The dish machine was also observed in use while the wash temperature was 146 to 147 degrees Fahrenheit, even though the Food Service Director stated the requirement was 150 degrees Fahrenheit and the machine plaque showed hot water sanitizing at 160 degrees Fahrenheit minimum wash tank temperature. Residents reported poor meal quality and incomplete service. Two residents stated the food was not good, the hot food was served cold, and the food was disgusting. During a resident council meeting, 10 of 10 residents stated they did not receive the foods they selected, did not receive complete meals, and all 10 stated the hot food was delivered cold. When the surveyor observed lunch trays in residents' rooms, one resident received cheese ravioli with meat sauce, a small hot dog, no vegetables, a small peanut butter and jelly sandwich wrapped in plastic, sliced apples, and 4 ounces of skim milk, while the meal ticket indicated a different meal. The resident stated the tray was disgusting and that they did not select those items. Another resident on a puree diet had an unclear puree meal on the tray and stated they did not know what was on it and asked why they never received coffee when they had no restriction. The surveyor also found that the cook did not use recipes for puree foods and stated the puree items were basically product, water, and thickener. The cook said the new menus had started the previous month, but he had not been provided the recipe book that the FSD later placed on the counter. During tray line observation, the surveyor saw modified consistency items portioned with scoops that did not match the FSD's stated portioning, and the FSD directed staff to change scoop sizes. The District Manager stated cold food should be 40 degrees Fahrenheit and hot food 135 degrees Fahrenheit in the kitchen, but did not state what temperatures food should reach at the resident. The Registered Dietitian associated with the menu company stated recipes were provided, the menus were certified as nutritionally adequate, and the facility was responsible for following the menus and recipes, including providing the correct milk portions.
Menus, recipes, and portion sizes were not followed
Penalty
Summary
The facility failed to ensure that menus and recipes were followed and that appropriate portion sizes were provided to residents. During interviews, two residents stated the food was not good, hot food was served cold, and the food was disgusting. One resident reported being on a puree diet and both residents stated they did not receive the foods they selected and did not have copies of the menu in their room. At a resident council meeting with 10 residents, all 10 stated they did not receive the foods they selected, did not receive complete meals, and that hot food was delivered cold. One resident stated they only received a bowl of broccoli as a dinner meal. During tray observations, one resident on a regular puree diet had a tray with a flat pancake-shaped reddish item and a white flat pancake-shaped item, while the diet ticket indicated regular puree with thin liquids and pureed peanut butter and jelly sandwiches. Another resident’s lunch tray contained cheese ravioli and meat sauce, a small hot dog, no vegetables, a small peanut butter and jelly sandwich, sliced apples, and 4 ounces of skim milk, although the meal ticket printed 8 ounces of milk. Kitchen staff and dietary leadership confirmed that recipes were not being used for puree foods. The cook stated he prepared puree items without recipes and described using product, water, and thickener. During tray line observation, dietary staff and the FSD discussed portion sizes for modified consistency items, and the FSD stated all protein should be 2 ounces, then directed staff to use 2-ounce scoops, although staff said they did not have enough of those scoops. The facility later provided menus and spreadsheets showing different portion sizes, including 3-ounce puree chicken, 4-ounce puree rice and broccoli, and 8 ounces of milk at breakfast and lunch, which did not match the portions observed or the portions described by the FSD. The menu company’s RD stated the menus were certified as nutritionally adequate, that recipes were provided, and that the facility was responsible for following the menus and recipes as written.
Food not prepared by standardized recipes and meals served at improper temperatures
Penalty
Summary
The facility failed to ensure that foods were prepared using standardized recipes and that meals were served at an appetizing temperature. The deficiency was identified during observation, interview, and document review and was reported to affect 10 of 10 residents who attended a resident council meeting, as well as two residents reviewed for food service concerns. The report states that the deficient practice affected the nutritional adequacy and consistency of all foods served and all residents in the facility. Two residents interviewed in their room stated that the food was not good, that hot food was served cold, and that the food was disgusting. One of the residents was on a puree diet and had a tumor in the cheek. During a resident council meeting, all 10 residents stated they did not receive the foods they selected, did not receive complete meals, and that hot food was delivered cold. One resident reported receiving only a bowl of broccoli for dinner. During lunch tray observations, the surveyor saw residents with trays that did not match the posted menu. One resident received cheese ravioli and meat sauce, a small hot dog, no vegetables, a peanut butter and jelly sandwich wrapped in plastic, sliced apples in a cup, and skim milk, while stating the items were disgusting and not selected. Another resident on a regular puree diet had unidentified puree items on the tray, and the resident stated they did not know what the food was and asked why coffee was not provided. The cook stated he prepared puree items without recipes and described using product, water, and thickener. During tray line observation, staff and the FSD discussed portion sizes for puree items, and the surveyor observed puree foods plated with items touching and a puree hot dog spread out on the plate. The DM stated cold food should be 40 degrees F in the kitchen and hot food 135 degrees F in the kitchen, while the surveyor measured milk and juice at 53 degrees F and observed puree rice with a spoon standing straight up in it. The facility later provided menu spreadsheets showing portion sizes that did not match the 2-ounce portions stated by the FSD, and the MRD stated that recipes existed for the menus and modified diets and that standardized recipes were important to maintain a standardized product and nutritional quality.
Food Storage, Kitchen Sanitation, and Dish Machine Temperature Deficiencies
Penalty
Summary
The facility failed to ensure that dishwashing equipment was used according to the manufacturer’s temperature specifications. During the kitchen tour, the surveyor observed the dish machine in use while dishware and food preparation items were being processed, and the wash temperature was repeatedly observed at 146 F to 147 F. The Food Service Director stated the wash cycle requirement was 150 F and pointed to an empty clipboard when asked for the temperature log. The surveyor then located the machine’s specification plaque, which identified the unit as requiring hot water sanitizing at 160 F minimum wash tank temperature, and the Food Service Director acknowledged that 150 F did not meet that requirement. The surveyor also observed multiple food storage and sanitation concerns throughout the kitchen and storage areas. In the first walk-in refrigerator, the gasket was blackened and soiled with embedded debris, ceiling vents and ceiling tiles had dark debris, the fan grate had visible debris, and the racks holding food had black embedded debris. The second walk-in refrigerator had racks with visibly peeled finish and rust, an elongated ceiling light with caked-on black debris, and a blue container of raw cabbage that was visibly soiled and had no dates. The floor under the food shelves had black splotched mold-like and yellow areas climbing up the back wall, the kitchen handwashing sink had debris inside and embedded by the foot pedals, and the rice bin, metal table, and floor had debris and darkened areas. Additional observations included splatters on ceiling tiles near the food preparation area, splatters and dust-like debris on the exterior and vent area of the ice machine, and visibly soiled dry storage racks. Three dented vanilla pudding cans were stored on a can rack, and a large container of vanilla icing had caked-on icing on the outside and no use-by date. During interview, the Food Service Director acknowledged several of the observed conditions, including that the gasket needed cleaning and replacement and that the dented cans were moved only after the surveyor questioned their storage. A chemical company representative later confirmed that the dish machine’s minimum wash temperature should have been 160 F and that the wash temperature was not functioning at the appropriate level.
Incomplete QAPI Program and Failure to Track and Trend Facility Issues
Penalty
Summary
The facility failed to maintain a comprehensive and documented QAPI program and failed to demonstrate a process for identifying, prioritizing, tracking, and measuring performance issues through QAPI. During interview, the LNHA stated the facility held quarterly QAPI meetings with vendors, department heads, and the Medical Director, and provided sign-in sheets for the last three quarterly meetings, with the most recent meeting on 4/10/26. However, when asked about QAPI plans related to the new dietary management company and new systems, the LNHA stated there were none, despite the dietary operations having been taken over one month earlier in April 2026. The LNHA also stated that issues were identified during daily morning meetings and through the grievance process, but when asked about tracking and trending grievances, he did not understand the question and stated there was no QAPI related to grievance concerns. The surveyor reviewed multiple current QAPI initiatives and found many were not specific or measurable, including employee files, blocked areas in maintenance, dialysis form completion, trayline accuracy, MDS coding inaccuracy, activity staff recruitment, missing physician visits, call bell response time, therapy with inconsistent splints, medication hold parameters, lab reports, pharmacy reports, nurse aide assignments, GG coding, admissions, bed holds, activity assessments, Hoyer lifts in front of doors, in-house pressure wounds, air mattress settings, nurse aide reporting of skin breakdown, facility assessment, fire alarm education, nursing report communication, code/posting all residents, environmental concerns, elopement, wet nesting in the kitchen, and late meals. The LNHA stated there was no tracking and trending of significant events, and at the time of survey exit no actionable information had been provided regarding the identified concerns.
Call Lights Not Accessible or Functional for Two Residents
Penalty
Summary
The facility failed to ensure that residents had their call light easily accessible and functional. During observation, Resident #30 was seen sleeping in a low bed with the call bell not within reach, and later the call bell was again observed on the bed to the resident’s right side. When the CNA placed the call bell in the resident’s hand and asked the resident to press it, the resident attempted to do so and the call bell did not function. The resident’s record showed diagnoses including cognitive communication deficit, acute respiratory failure with hypoxia, and hydrocephalus, and the care plan directed staff to keep the call light within reach and encourage use for assistance. Resident #30’s responsible party reported that the resident was legally blind, could not see the call bell, and had a history of falls and a brain bleed. The responsible party also stated they had discussed purchasing a flat call bell with the facility because the resident could not advocate for themself. The resident’s care plan identified the resident as high risk for falls due to stroke/weakness, muscle weakness, history of falls, and lack of coordination, and included interventions to ensure the call light was within reach and to provide prompt response to requests for assistance. Resident #86 was observed in bed on the Sub-Acute unit and reported delays in staff answering the call light, stating that during the 3:00 PM to 11:00 PM shift it could take up to an hour for staff to respond. When asked to activate the call light, the resident could not reach it, and the roommate had to activate it. On a later observation, the resident stated they needed to be changed, but the call light was not accessible; the unit clerk and CNA could not locate it, and the surveyor observed it tied to the bed frame outside the resident’s view. The resident’s record showed diagnoses including fracture of the lower end of the right femur, cerebral infarction, difficulty walking, muscle weakness, and pain in the right knee, with an MDS indicating severely impaired cognition and need for assistance with all ADLs. The care plan identified decreased strength, functional activity intolerance, and falls related to gait and balance problems, with staff interventions to anticipate needs and educate caregivers about safety reminders.
Linen shortages affected resident comfort and timely linen availability
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment for residents with concerns about linen shortages. Resident Council minutes documented ongoing complaints over several months, including linen shortages, a need for more towels, and towel and linen shortages over the weekend, and the minutes did not reflect that these concerns were resolved. Three alert residents told the surveyor they had been complaining to staff about the shortage and said staff were unable to provide towels and change bed linens in a timely manner, with one resident stating the problem was worse on weekends. During the survey, laundry staff could not explain the linen PAR and referred the surveyor to the Housekeeping Director. The Housekeeping Director stated the facility did not have a linen inventory and did not have linen storage, and said, "I can tell you, what we had, we washed them and sent them to the unit." The facility was licensed for 250 beds and had a census of 145, but the Housekeeping Director could not provide the amount of linen sent to the floors on each shift. The Licensed Nursing Home Administrator stated he had completed a baseline inventory on 1/5/26 and was aware of the linen shortage. The inventory showed limited quantities of pads, gowns, sheets, blankets, pillowcases, washcloths, and towels, with some items in storage. The LNHA could not show the amount of linen the facility had in house or what was needed to satisfy the linen PAR based on the licensed beds or current census. The facility also could not provide the date received or location of linen ordered through invoices for towels and flat sheets. CNAs reported that linen was often not enough, that they changed bed linens every other day or when soiled, and that weekends were a "nightmare," with staff sometimes going to other floors for sheets and towels or asking residents to wait until laundry could provide more linen.
Unnecessary Psychotropic Medication Use Without Documented Behaviors
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, pneumonia, dependence on a ventilator, Alzheimer's disease, and major depressive disorder was free from unnecessary psychotropic medications and potential chemical restraints. The resident was observed lying in bed on the ventilator unit, nonverbal, attached to a mechanical ventilator, receiving tube feeding, and using a urinary catheter. During multiple observations, the resident appeared to be resting comfortably and did not engage visually with the surveyor, and staff described the resident as calm during care. The resident's physician orders included Seroquel 25 mg at bedtime and 12.5 mg in the morning for depression and mood disorder, Zoloft 75 mg daily for depression, Remeron 15 mg at bedtime for major depression and appetite stimulant, and Lexapro 5 mg daily for depression. The May 2026 MAR directed staff to monitor for psychoactive-related behaviors such as spitting on staff, restlessness, combativeness, aggression, outbursts, and refusal of care, and to document non-drug interventions and outcomes each shift. However, the progress notes from March, April, and May 2026 contained no documentation of aggressive behavior, outbursts, or refusal of care, and the documentation related only to ventilator care. Monthly psychotherapeutic drug evaluation forms from December 2025 through May 2026 showed target behaviors coded as zero, indicating no behaviors, and did not identify behavioral interventions or nonpharmacological approaches that had been used and failed. The nurse practitioner documented that the resident's mood symptoms were stable, there were no signs or symptoms of depression, anxiety, irritability, or agitation, and that a gradual dose reduction for Seroquel would be discussed with the resident representative. During interview, the nurse practitioner stated the medications had been ordered for prior combativeness, spitting, and restlessness, but also stated she had not reviewed the monthly psychotherapeutic drug evaluation forms and had not been able to discuss gradual dose reductions. The resident representative stated the resident had declined mentally and physically, no longer communicated or fed themselves, and that some medications needed to be discontinued in the absence of behavior.
Delayed Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to ensure dependent residents received routine and appropriate incontinence care in a timely manner. During a tour of the 600 Unit, one resident stated that they had a UTI with burning and reported that incontinence care was not provided timely, sometimes taking up to one hour. Another resident stated that care was not received timely, mostly on the 3:00 PM to 11:00 PM shift, and that it could take over one hour to receive incontinence care. On observation, Resident #120 was found saturated with urine, and the CNA assigned to the resident stated she had been on another assignment and did not check the resident before breakfast. Later, Resident #120 was again observed in bed saturated in urine during an incontinence care observation. Resident #159 was observed in bed and stated they were soiled; shortly afterward, the resident was found heavily soiled with urine and feces. The CNA assigned to Resident #159 stated she had been told the resident received incontinence care earlier, did not check the resident that morning, and acknowledged that based on what was observed, she did not think the resident had been provided care. Record review showed Resident #120 had diagnoses including muscle weakness, difficulty walking, repeated falls, and urinary retention, required extensive assistance with most ADLs including incontinence care, and was incontinent of bowel and bladder. Resident #159 had diagnoses including muscle weakness, difficulty walking, unspecified dementia, and acute cystitis, was severely cognitively impaired, and had care plan interventions to change briefs or assist with toileting. The LPN Unit Manager stated incontinence care was to be offered every 2 hours and in the morning during rounds prior to breakfast, and the grievance book included a complaint that a resident waited more than 30 minutes for assistance with a bedpan and call light response.
Failure to identify a skin abscess and to ensure escort for a surgery appointment
Penalty
Summary
The facility failed to ensure that treatment and care were provided in accordance with professional standards for two residents. For one resident, who had diagnoses including spinal stenosis, Parkinson’s disease, and type 2 diabetes, the record showed a physician order for doxycycline for a cutaneous abscess on the left lower back after a family nurse practitioner documented a 3 x 5 cm fluctuant, erythematous abscess that was oozing and required incision and drainage. The nurse practitioner noted that the resident needed transfer to the hospital because appropriate supplies for incision and drainage were not available. However, the facility’s nursing documentation did not identify the abscess during the weekly skin assessments or CNA skin observations completed before the abscess was documented by the nurse practitioner. The resident stated that the lower back irritation had been present for several days before the nurse practitioner examined it. The CNA stated she completed skin checks but did not recall seeing an abscess, and the LPN stated the abscess should have been identified during the weekly skin assessment and CNA skin observation completed that day. The facility’s skin assessment policy required a full body skin assessment by an RN upon admission, daily for three days, weekly thereafter, and upon any change in condition or identification of a new wound. The facility’s acute condition changes policy also stated that direct care staff, including nursing assistants, would be trained to recognize subtle but significant changes in skin condition and communicate them to nursing. For the second resident, who had diagnoses including hemiplegia and hemiparesis, difficulty walking, muscle weakness, dementia, and cataract, the record showed that cataract surgery was scheduled and that the resident was picked up for right eye surgery and later returned stable with a follow-up appointment arranged. The resident stated that on one occasion an aide did not accompany them to the appointment and that they were not informed why. The LPN unit manager stated that an aide should have accompanied the resident for the surgery appointment, and the DON stated there was a lapse and that the appointment was not communicated well. The facility’s transportation policy stated that appointments would be scheduled in advance by nursing staff and that all residents and their needs would be considered for their appointments.
Inadequate fall supervision and ineffective call bell intervention
Penalty
Summary
The facility failed to provide adequate supervision and implement specific interventions for a resident identified as high risk for falls and cognitively impaired. The resident had diagnoses including cognitive communication deficit and hydrocephalus, and the record also reflected a history of stroke/weakness, muscle weakness, lack of coordination, and prior falls. The resident’s MDS showed moderately impaired cognition, dependence on staff for toileting, dressing, bathing, and transfers, and a fall risk assessment identified the resident as high risk for falls. Survey observations showed the resident in bed with the call bell not in reach on multiple occasions, including while sleeping in a low bed with a floor mat beside the bed. The resident’s responsible party stated the resident was legally blind, could not see the call bell, and had already discussed with the facility the need for a flat call bell because the resident had continued to fall and could not advocate for self. During another observation, the resident was again in bed with the call bell out of reach. When the CNA placed the call bell in the resident’s hand and asked the resident to press it, the resident tried but the call bell did not activate, and the CNA stated the call bell was not functioning. The resident’s care plan included interventions such as keeping the call light within reach, encouraging use of it for assistance, prompt response to requests, use of a floor mat, low bed, re-education to call for assistance, and a new PT screen. However, after the resident’s unwitnessed fall and later fall onto the floor mat, the fall investigations documented that no new interventions were added to the care plan specific to the causal factors of the falls or the effectiveness of current interventions. Therapy documentation also noted impaired executive function, impaired memory, poor auditory comprehension, poor orientation, and poor sustained attention, and the ST stated the resident had visual deficits and cognitive deficits that limited ability to use the call bell. The DON stated the facility did not really document 2-hour rounding, did not have a specific way to document it, and was unaware of the resident’s visual deficits or that a different call bell type might be needed.
Failure to Administer Oxygen According to Physician Orders
Penalty
Summary
The facility failed to provide appropriate oxygen therapy for two residents by not administering oxygen according to physician orders. One resident had diagnoses including Parkinson’s disease with dyskinesia, COPD, hemiplegia affecting the left side, and depression, along with a history of aspiration pneumonia, dysphagia, and acute hypoxic respiratory failure. During observation, the resident was found in bed wearing a nasal cannula with oxygen running at 5 LPM, and when the surveyor entered the room the resident stated, “I cannot breathe.” The charge nurse later confirmed the resident was on 5 LPM, obtained a pulse oximeter reading of 93% to 94%, and attempted to feed the resident, who stated, “It is hard to swallow.” Record review for this resident showed a physician order for oxygen at 2 L if SpO2 was below 90% or if shortness of breath occurred every 8 hours as needed, with head of bed elevated. The care plan addressed COPD and ineffective gas exchange and included oxygen therapy at 2 L as needed for shortness of breath, but there were no care plans related to the resident being on 5 L oxygen or to the behavior described by staff. The MAR showed the PRN oxygen order for 2 L was left blank on the dates reviewed while oxygen was observed running at 5 L via nasal cannula. The regional clinical supervisor stated the charge nurse was suspended pending investigation related to failure to follow procedures after being notified of the resident’s breathing difficulty, and the source of the 5 L oxygen not matching the physician order was unknown. A second resident was observed in a wheelchair with a portable oxygen concentrator, and the surveyor found the needle in the red area indicating the tank was empty. Facility staff also acknowledged the tank was empty. The resident was alert and oriented, and the assigned LPN stated she had just changed the oxygen tank and that the resident would tell staff if it needed to be changed. The LPN said the facility checked oxygen every morning but could not explain why the tank was empty. The resident’s record showed diagnoses including COPD, CHF, hypertension, and peripheral vascular disease, a BIMS score of 15 out of 15, and a physician order for oxygen at 3 L/min via nasal cannula every shift. The care plan noted the resident had behavior problems and was non-compliant with oxygen use, with an intervention to ensure portable oxygen was functioning and accessible at all times.
Medication Parameter, Storage, and Controlled Substance Documentation Failures
Penalty
Summary
The facility failed to follow physician orders for medications with blood pressure parameters for two residents. One resident with chronic kidney disease, ESRD, dependence on renal dialysis, and essential hypertension had an order for fludrocortisone 0.1 mg daily to be held if systolic blood pressure was greater than 140, but the medication was documented as administered when the resident’s systolic blood pressure was 148. A licensed practical nurse later acknowledged that the medication should have been held based on the recorded blood pressure. A second resident with chronic kidney disease, essential hypertension, peripheral vascular disease, and severe cognitive impairment had an order for amlodipine 5 mg daily to be held if systolic blood pressure was less than 110. The e-MAR showed the medication was administered on two occasions when the resident’s systolic blood pressure was 105 and 106. The LPN reviewing the record acknowledged that the medication should have been held on those occasions based on the physician’s parameters. The facility also failed to properly secure medication and to accurately reconcile and document a controlled substance. Three tablets of midodrine 5 mg were found inside a dialysis communication book on the A-unit, and the unit manager stated the medication should have been removed and destroyed. In addition, during a narcotic count on Unit B, an LPN was observed signing the narcotic inventory logbook after administering clonazepam 1 mg, and the LPN stated that controlled substances must be signed out of the narcotic inventory logbook once removed from the medication card.
Improper Medication Storage and Expired Supplies
Penalty
Summary
The facility failed to properly label, dispose of, and store medications and medical supplies in 2 of 6 medication carts and 1 of 3 medication rooms. During inspection of B-Wing medication cart #2, the surveyor found 2 unidentifiable loose tablets inside the cart and a Fluticasone propionate nasal spray with a used-by date of 2/6/26. The LPN present stated that loose pills should have been discarded immediately in a pill buster and that medications past their used-by date should be removed from the cart. In the subacute unit medication room, the surveyor observed a tablet in a medication package stored in a bin of normal saline IV bags, a resident's Meropenem IV bag stored on top of IV normal saline bags, an opened and unused syringe, and multiple expired blood collection sets and vials with expiration dates ranging from 7/31/22 through 2/28/25, along with a bag of 10% dextrose 1000 ml with an expiration date of 9/2025. The LPN acknowledged the items were outdated and stated the loose tablet and syringe should have been discarded and the Meropenem IV bag should have been stored separately. The unit manager stated it was the responsibility of the overnight supervisor and herself to check expiration dates and that there should be no expired medications in drawers or cabinets. In the ventilator unit medication cart, the surveyor also found an expired blood draw kit with an expiration date of 2/28/25, which an RN acknowledged should have been removed.
Incomplete Hospice Communication and Documentation
Penalty
Summary
The facility failed to maintain a process to ensure consistent communication between the facility and the hospice provider for coordination of resident care for one resident receiving hospice services. The resident had diagnoses including idiopathic normal pressure hydrocephalus and palliative care, an order for hospice care dated 04/01/2026, and a significant change MDS showing a BIMS score of 4, indicating severe cognitive impairment. The resident’s care plan included an intervention to work with the hospice team to meet the resident’s spiritual, emotional, intellectual, physical, and social needs. During observation, the resident was lying in bed watching television and stated they were in no pain and comfortable. Review of the resident’s hospice communication binder showed a hospice visit note report, patient information sheet, hospice aide care plan sheet, an incomplete hospice aide weekly visit record, a medication profile, and an NJ universal transfer form, with several items undated. The Unit Manager stated that hospice aide care is provided once a week and that communication documentation should be in the hospice binder, while the DON stated that when the hospice aide provides care, it should be documented in the resident’s hospice binder and that the UM was responsible for ensuring the documentation was completed. The facility policy stated that the facility will communicate with hospice and identify, follow, and document all interventions put into place by hospice and the facility, and will maintain communication with hospice regarding the resident’s plan of care.
Incomplete Pre-Hire Screening and Documentation for Employees and Contract Staff
Penalty
Summary
The facility failed to have a system in place to ensure that, prior to hire, all employees were pre-screened to confirm they had not been found guilty in court of abuse, neglect, or misappropriation, and that no findings had been entered into the state nurse aide registry or against a professional license. The facility also failed to maintain documentation showing that appropriate pre-screening had occurred for all contracted employees, including dietary staff. This deficient practice was identified in 4 of 73 employee files reviewed by surveyors from the facility-provided records. During the survey, the Licensed Nursing Home Administrator provided a list of employees hired since the last survey, along with their files. Review of the files showed that a Social Worker hired on 7/14/25 had a criminal background check ordered and completed on 9/5/25; a CNA hired on 1/15/25 had a criminal background check ordered on 5/7/26 with results still pending; another CNA hired on 3/19/25 had a criminal background check ordered on 6/20/24 with results dated 6/21/24; and a contracted District Manager for the food service company hired on 3/23/26 had a criminal background check ordered and completed on 5/6/26. The HRD stated that she prints the criminal background check when it is ordered and again when results are received, and that a new employee should not be in the building until the background check is completed. The facility’s policy stated that all final candidates are contingent upon clear background checks and that the facility will maintain documentation of proof that screening occurred.
Dialysis Medication Times Not Adjusted
Penalty
Summary
The facility failed to provide safe, appropriate dialysis-related medication administration for a resident with chronic kidney disease, ESRD, dependence on renal dialysis, and essential hypertension. The resident’s significant change MDS dated 3/5/26 indicated a brief interview for mental status score of 13 out of 15, showing the resident was cognitively intact. The physician’s order specified hemodialysis on Monday, Wednesday, and Friday at 5:30 AM, and the record showed that the resident returned to the facility after dialysis around 11:30 AM on multiple occasions, including notes documenting return times of 11:10 AM, about 12:30 PM, 12:30 PM, and 11:30 AM. The May 2026 eMAR showed that medications were administered at times that occurred while the resident was out at dialysis, including cholecalciferol at 10:00 AM, fenofibrate at 8:00 AM, folic acid at 8:00 AM, and sucralfate at 10:00 AM. During interview, the LPN who was the resident’s medication nurse stated that the resident returned from dialysis around 11:30 AM and that medications would be given then, and after reviewing the eMAR she stated the medication times should have been adjusted to the time the resident returned from dialysis. The facility’s administrative team was informed of the concern, and no additional information was provided.
Nonfunctioning Call Bell for Resident at High Fall Risk
Penalty
Summary
The facility failed to ensure a resident call bell was operational for one resident who was reviewed for accidents. During observation, the resident was in bed while a CNA was at the bedside setting up the meal. In a follow-up interview, the CNA stated the resident got out of bed every other day with a mechanical lift and 2-person assist. When the CNA placed the call bell in the resident’s hand and instructed the resident to press it, the resident attempted to do so and the call bell did not function; the CNA then confirmed it was not working. The resident’s record showed a care plan identifying the resident as high risk for falls due to a history of stroke/weakness, muscle weakness, history of falls, and lack of coordination. The care plan included interventions to keep the call light within reach and encourage use for assistance, along with prompt response to requests for help. The resident’s MDS indicated moderately impaired cognition, dependence on staff for toileting, dressing, bathing, and transfers, and a fall risk assessment identified the resident as high risk for falls.
Inaccurate MDS Coding of Bladder Function Due to Unverified CNA Documentation
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was accurately coded to reflect a resident's bladder function. A resident admitted with type 2 diabetes mellitus, chronic obstructive pulmonary disease, and stage 3A chronic kidney disease had an MDS with an Assessment Reference Date of 01/06/26 coded to indicate the presence of an indwelling urinary catheter. Review of the resident's physician orders, treatment records, and nursing documentation in the electronic medical record showed no evidence that the resident had an indwelling urinary catheter during the assessment period. During an interview, the Regional Nurse Clinical Supervisor reported that a CNA had entered incorrect information into the point of care system, and this inaccurate information was then used to complete the MDS without verification. Facility policy on MDS 3.0 Completion required that all disciplines follow the RAI Manual guidelines, which state that accurate assessments must be based on information collected from multiple sources covering the same observation period and validated for accuracy by the interdisciplinary team. These steps were not followed, resulting in the inaccurate coding of the resident's bladder function on the MDS.
Facility Assessment Lacks Ventilator-Dependent Resident Planning
Penalty
Summary
The facility failed to ensure that its facility-wide assessment (FA) adequately identified and addressed the required services and procedures necessary for ventilator-dependent residents. Upon review, the FA did not specify that the facility was licensed for 12 ventilator care beds in addition to 220 long-term care beds, nor did it include ventilator-dependent residents under the sections for diseases/conditions, resident support/care needs, staff training/education and competencies, or physical environment and equipment needs. The FA only referenced general respiratory conditions such as COPD, pneumonia, asthma, and respiratory failure, but did not specifically mention ventilator dependency or related requirements. During interviews, facility leadership confirmed that the FA was current but could not identify any vent-specific or related assessments within the document. When asked, the Vice President of Clinical stated that ventilator care was covered under the general respiratory category, and the President of Operations asserted that federal regulations do not require specific mention of ventilator care in the FA. The surveyor noted that the omission of ventilator-specific planning, licensing, and resources in the FA constituted a deficiency, as the facility did not comprehensively address the needs of ventilator-dependent residents as required.
Deficient Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary manner, as observed during a survey. The ice machine was found with stains and debris, and the Food Service Director (FSD) admitted it should be cleaned daily but was not. Two waste receptacles were uncovered, exposing food preparation stations to potential contamination. The eight-burner stove had accumulated burnt food and sludge, indicating non-compliance with cleaning policies. Additionally, a slicer marked as clean was found with crusted debris, and the can opener base had wipeable debris, both acknowledged by the FSD as not cleaned according to policy. The steam tables contained dirty water with floating debris, which the FSD admitted had not been cleaned as required. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) acknowledged these concerns. The facility's Equipment Cleaning Policy outlined specific cleaning procedures for each piece of equipment, which were not followed, leading to potential cross-contamination and foodborne illness risks. The Ice Machines Sanitation policy also required daily cleaning of the ice machine's exterior, which was not adhered to.
Failure to Provide Antibiotic Prescription at Discharge
Penalty
Summary
The facility failed to ensure a resident was adequately prepared for discharge by not providing a prescription for an active antibiotic treatment. The resident, who had severe impaired cognition and was being treated for an infection related to a hip prosthesis, was discharged to an assisted living facility without a prescription for clindamycin, an antibiotic that was supposed to continue post-discharge. The resident's medical record indicated that clindamycin was administered regularly until the day before discharge, but the prescription was not included in the discharge documents. The deficiency occurred due to a miscommunication between the Nurse Practitioner and the facility staff, leading to the omission of the clindamycin prescription. The Nurse Practitioner mistakenly believed that both antibiotics prescribed to the resident had been completed, resulting in the failure to provide the necessary prescription upon discharge. This oversight was acknowledged by the facility's Vice President Clinical, who confirmed that the resident did not receive their medication on time, and there should have been no missed doses of clindamycin.
Failure to Develop Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan for a resident with chronic pain, which was identified during a survey. The resident, who was admitted with medical diagnoses including diabetes, depressive disorder, and chronic pain syndrome, was observed by the surveyor in bed with eyes closed and later in a wheelchair speaking with the Unit Manager/LPN about needing an appointment for shoulder pain. The resident's medical records indicated frequent pain and the administration of pain medications, including oxycodone, as prescribed by a physician. However, the resident's comprehensive care plan did not include a focus area for pain management, despite the resident being cognitively intact and experiencing frequent pain. The surveyor's review of the facility's policies revealed that a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's needs. The Unit Manager/LPN confirmed that a resident with pain should have a pain management plan included in their care plan. During a meeting with the survey team, the facility's leadership acknowledged that the care plan should have been initiated when the resident began experiencing pain. This oversight was a violation of the facility's policy and regulatory requirements.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with a history of falls, which was identified during a survey. The resident, who had moderate cognitive impairment and multiple medical diagnoses including heart failure and muscle weakness, experienced a fall on December 4, 2023. The fall occurred when the resident slid off their wheelchair in the bathroom, although no injuries were sustained. Despite the incident, the resident's individualized comprehensive care plan was not updated to include new interventions post-fall, which is a requirement according to the facility's policy. The facility's policy on managing falls and fall risks mandates that if falls recur despite initial interventions, staff should implement additional or different interventions or justify why the current approach remains relevant. However, the interdisciplinary team note dated December 5, 2024, indicated that a new intervention of frequent bathroom rounds was added, but this was not reflected in the resident's care plan. During an interview, the Vice President of Clinical confirmed that the care plan should be reviewed and updated with new interventions after a fall, highlighting the deficiency in the facility's adherence to its own policy.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to implement the wound care consultant's recommendations for a resident with a pressure ulcer, leading to a deficiency. The resident, who was cognitively intact and had a history of major depressive disorder, chronic pain, kidney stones, and cerebral infarction, was admitted with an unstageable pressure ulcer. The wound care consultant recommended the use of a low air-loss (LAL) mattress to offload pressure and prevent the worsening of the ulcer. However, during multiple observations by the surveyor, the resident was not provided with the recommended LAL mattress, and the care plan did not include this intervention. Despite the physician's order for daily wound care and the wound nurse practitioner's recommendation, the facility's staff, including the LPN and Unit Manager, were unaware or unsure of the resident's use of a LAL mattress. The facility's Wound Care policy did not address the process for implementing wound care consultation recommendations, contributing to the oversight. The Vice President of Clinical acknowledged the oversight and the need for staff education to follow wound care consultant recommendations.
Deficiency in Narcotic Accountability and Documentation
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs and accurately document the administration of controlled medications. During a review of medication storage, it was found that the shift-to-shift controlled substance count sheets for two medication carts had numerous missing signatures from both incoming and outgoing nurses. Additionally, the narcotic counts were not recorded for several shifts, indicating a lack of proper documentation and accountability for controlled substances. Further investigation revealed that a resident's Controlled Drug Administration Record log was incomplete, as the 9:00 AM dose of clonazepam was not signed out on the declining inventory log. An LPN admitted to administering the medication but failing to document it on the log, although it was recorded in the electronic Medication Administration Record. This oversight was acknowledged by the LPN, who confirmed that the declining inventory logs should be completed upon dispensing medication to maintain accurate narcotic counts. Interviews with facility staff, including the Director of Nursing and the Vice President of Clinical, confirmed that the shift-to-shift narcotic count logs were not completed as required. The facility's policy mandates that two licensed nurses account for all controlled substances at the end of each shift, but this procedure was not consistently followed, leading to missing documentation and signatures on the narcotic count logs.
Improper Medication Storage on Unattended Cart
Penalty
Summary
The facility failed to properly store medications, as observed by a surveyor on the Vent nursing unit's medication cart A. The cart was left unattended by an LPN while administering medication to an unsampled resident. On the cart's unlockable pull-out tray, several packets of individually wrapped medications were visible and unsecured. These included medications such as Eliquis, midodrine HCl, memantine HCl, pravastatin sodium, oxybutynin chloride, levofloxacin, baclofen, metoprolol tartrate, and amiodarone HCl. Upon questioning, the LPN acknowledged that medications should not be left unsecured on the tray, as there was a risk of them being taken. The DON confirmed that medications should always be secured and locked, regardless of the residents' mobility status. The facility's Medication Storage policy, reviewed in November 2022, mandates that all medications be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. The VPC, along with the survey team, LNHA, and DON, confirmed that the medications should not have been stored unsecured on the cart.
Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to follow acceptable standards of clinical practice by not consistently documenting the administration of medications and treatments in the electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR). This deficiency was identified for two residents. Resident #2 had multiple instances where tube flushes were not documented in the MAR, despite having orders to flush the tube with water every six hours. The review of the MAR and progress notes for various months showed blanks on specific dates, and there was no documentation to confirm that the flushes were administered. The nursing staff responsible for these dates were not available for interview during the survey. Resident #3 had severe cognitive impairment and was at risk for pressure ulcers. The facility discovered a Stage II open wound on the resident's sacrum, and there were orders for wound care treatments, including the application of Santyl and Metrogel. However, the MAR and TAR revealed multiple instances where these treatments were not documented as completed. The review of the progress notes also did not show any documentation that the treatments were performed on the specified dates. The nursing staff responsible for these dates were not available for interview during the survey. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that it is the responsibility of the nurses to document the completion of care in the MAR and TAR. The DON emphasized the importance of signing the MAR and TAR for accountability and continuity of care. The facility's policy on charting and documentation also required that all services provided to residents be documented in their medical records. The failure to document the administration of medications and treatments led to the deficiency identified in the report.
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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.
Illustrative
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Nursing homes near Holmdel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anchor Care And Rehabilitation Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Respiratory And Nursing Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Careone At Holmdel | 2.7 mi | ★★★★★ | 0 | 0 |
| Arnold Walter Nursing & Rehabilitation Center | 2.9 mi | ★★★★★ | 20 | 0 |
| Complete Care At Madison, Llc | 2.9 mi | ★★★★★ | 14 | 0 |
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