Above 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 Complete Care At Green Knoll during CMS and state inspections, most recent first.
Improper Garbage and Dumpster Area Maintenance: The surveyor observed multiple cardboard boxes outside the dumpster and scattered around the garbage area during a kitchen tour with the FSD. The FSD said the area should have been cleaned by maintenance and dietary staff, and facility policy stated that trash or boxes left around the dumpster must be picked up and properly disposed of.
Call Bells Not Kept Within Reach: Surveyors observed multiple residents with call bells on the floor, behind furniture, under the bed, on a roommate’s table, or missing altogether, and one room’s call bell system was not working. Several affected residents had severe cognitive impairment, dependence on staff for ADLs, and fall-risk care plans that specifically required a reachable call light. Staff members confirmed the call bells should have been within reach.
The facility failed to complete and review a resident’s person-centered care plan through the IDC team on the required quarterly schedule, with several IDCP meetings missed despite MDS submissions showing the assessments were due. The facility also failed to update another resident’s care plan to reflect a new fluid restriction PO; the resident had ESRD, was on dialysis, and the care plan still showed an outdated fluid breakdown that did not match the current order.
Improper Disposal of Resident Records: Surveyors observed an open cardboard box in the dumpster area containing papers with resident names, room numbers, and a list of residents on EBP. The ADON confirmed the papers contained resident information and should have been placed in the designated shredding container, while the DON stated paper medical records must be disposed of to protect patient information but could not explain how the records were discarded incorrectly.
A surveyor observed multiple areas of disrepair in resident rooms on the 3rd floor, including a heavily rusted heater with a missing vent cover, cracked electrical outlet, pulled-off cove base molding, chipped paint, cracked molding, and a bathroom door with a large crack. The DOM stated he was not aware of the issues and confirmed they should have been repaired because they did not provide residents with a homelike environment.
Late MDS Transmissions: The facility failed to transmit multiple MDS assessments within the required timeframe for several residents. CMS validation reports showed late annual, quarterly, admission, and modification MDS submissions for five residents, and the MDSC/RN acknowledged that some assessments were late, including some from before she started. The DON stated that admission, quarterly, and annual MDS should be completed within 14 days of the ARD.
A facility failed to ensure specialty air mattresses were set and monitored according to resident weight and comfort for multiple residents. Surveyors observed mattresses set at incorrect weight ranges or with unclear indicator lights, while staff gave conflicting statements about whether nursing, maintenance, or hospice was responsible. Records showed orders for shift checks and nursing signatures on MARs/TARs, but staff interviews and documentation review showed the mattresses were not consistently verified as required.
Failure to Complete Post-Dialysis Assessments: A resident with dependence on renal dialysis, hypertension, and severe cognitive impairment received hemodialysis on a regular schedule, but the facility did not complete the required post-dialysis return assessments or document vital signs and access-site checks on multiple occasions. Review of the dialysis communication records and EMR showed missing nurse assessments after return from the dialysis center, and an LPN and the DON confirmed the post-dialysis assessment requirements.
Unlabeled and improperly stored medications were found in medication carts and a medication refrigerator, and an emergency crash cart was left open. Surveyors observed loose tablets, Velphoro bottles without pharmacy labels, a discontinued Enoxaparin injection without a label or resident name, and influenza vaccine stored in a refrigerator at 50 degrees with missing temperature logs; an RN/UM acknowledged the crash cart should have been locked.
The facility failed to inform residents about how to file anonymous grievances. During interviews, residents expressed their lack of knowledge about anonymous grievance filing, and staff confirmed that no explanation was provided. The facility's grievance policy did not address anonymous filing, and there was no method in place for it.
The facility failed to provide written notice of their bed hold policy and costs when residents were transferred to the hospital. This deficiency affected five residents, as there was no documented evidence of the required information being provided. Staff interviews revealed a lack of awareness and understanding of the official policy, leading to potential confusion or distress for residents and their representatives.
The facility failed to serve food at a palatable temperature, affecting several residents who reported the food was consistently cold and tasteless. Observations showed that food temperatures were not monitored throughout the meal service, resulting in significant temperature drops by the time meals were served. The facility's policy required hot foods to be served at a minimum of 135 degrees F, but the test tray showed temperatures well below this standard.
A resident was mistakenly dropped off at their personal residence instead of the facility after an appointment due to an address error. Additionally, two residents were transferred without gait belts, contrary to safe practices. Staff reported that gait belts were not commonly used unless approved by therapy, despite facility policy requiring safe handling evaluations.
A facility failed to ensure a resident received alternative measures and informed consent before installing bed rails. The resident, with intact cognition, had no documented alternatives or consent for bed rail use. Interviews revealed staff did not adhere to protocols, with unfilled consent forms and uncertainty about alternatives. The DON acknowledged incomplete QAPI efforts and inconsistent consent practices.
The facility failed to properly label medication containers, leading to a risk of residents receiving incorrect medications. Observations revealed that medication carts contained boxes of slow-release iron pills and Alaway eye drops labeled only with room numbers, lacking specific resident names. Staff confirmed that all medications, including OTCs, should be labeled with the resident's name, as per facility policy.
Improper Garbage and Dumpster Area Maintenance
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public by not keeping the dumpster and surrounding garbage area free of garbage and debris. During a kitchen and garbage area tour with the Food Service Director, the surveyor observed multiple cardboard boxes outside the dumpster on the ground and in the surrounding area. The Food Service Director stated the area should have been cleaned by the maintenance and dietary departments. The facility policy titled, Garbage and dumpster area policy, stated that if trash blows out or is dropped on the ground around the dumpster, it must be picked up, and that everyone is responsible for breaking down and disposing of their own boxes in the proper recycling bin. During a later meeting, the LNHA stated that all boxes need to be broken down and put into the dumpster and not left on the ground.
Call Bells Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to keep residents’ call bells within reach for multiple residents reviewed for accommodations of needs. Surveyors observed several residents in bed with call bells on the floor, behind furniture, under the bed, or otherwise not accessible, and one resident was observed without a call bell in the room. The deficient practice was identified for 8 of 30 residents reviewed, including residents with cognitive impairment, dependence on staff for ADL care, and fall-risk care plan interventions that specifically directed staff to keep the call light within reach. Resident #139 was observed in bed with floor mats on both sides of the bed and the call bell on the floor, not within reach, on two separate observations. The resident’s record reflected dementia, diabetes mellitus, a BIMS score of 7 indicating severe cognitive impairment, and dependence on staff for ADL care. The care plan identified fall risk and included an intervention to ensure the call light was within reach and that requests for assistance received prompt response. Resident #37 was observed in bed with the call bell on the floor behind the dresser on multiple occasions. The resident’s record reflected Alzheimer’s Disease, chronic kidney disease stage 3, a BIMS score of 3 indicating severe cognitive impairment, and substantial to maximum assistance needed for ADLs. The care plan identified fall risk and required a safe environment with a working and reachable call light. When shown the call bell on the floor, CNA #3 confirmed it should have been placed within reach, and an LPN also confirmed that call lights should be within residents’ reach. Other residents were found with similar issues. Resident #55 had the call bell on the roommate’s end table behind the privacy curtain, Resident #152 had the call bell on the floor, Resident #44 was observed without a call bell, Resident #15 had the call light under the bed, Resident #155 had a tap bell on the bedside table not within reach, and Resident #6 had a call bell next to the resident but the room’s call bell system was not working; the tap bell was later found on the roommate’s nightstand and not within reach of either resident. The records for these residents reflected diagnoses including dementia, Alzheimer’s Disease, hypertension, diabetes mellitus, cerebral infarction, gastrostomy status, multiple sclerosis, restless leg syndrome, chronic pain syndrome, and venous insufficiency, with several residents assessed as severely cognitively impaired and dependent on staff for ADL care. The facility policy stated that a call bell would be available within reach and operational for each resident.
Care Plans Not Timely Reviewed or Updated to Match Orders
Penalty
Summary
The facility failed to ensure that each resident’s person-centered comprehensive care plan was completed and reviewed by the interdisciplinary care team in a timely manner, and failed to update a care plan to match a new physician order. For one resident with diagnoses including hemiplegia, CVA, and COPD, the record showed a BIMS score of 15/15 and MDS submissions indicating quarterly and annual assessments, but several corresponding IDCP meetings were not completed on the quarterly schedule. The record reflected missed IDCP meetings for multiple assessment periods, and the social worker stated that quarterly meetings should occur but were sometimes canceled and not documented in the electronic record. The DON stated that resident care plans are revised as needed and quarterly, and that the care plan is officially reviewed with residents during IDCP meetings. However, the facility’s own policy stated that the comprehensive care plan is to be prepared by an IDC team and reviewed and revised after each comprehensive and quarterly MDS assessment. The DON acknowledged the survey findings when the issue was discussed with facility leadership. For another resident with ESRD, dependence on renal dialysis, and protein-calorie malnutrition, the surveyor observed that the resident reported dialysis three times per week and a specialized diet with fluid restriction. The medical record showed a physician order for a 1500 mL fluid restriction with a specific breakdown for dietary and nursing allotments, but the care plan still reflected an older fluid restriction breakdown that did not match the updated order. The RD stated there had been miscommunication between her and nursing staff, and the DON stated the care plans should match the physician orders for fluid restriction.
Improper Disposal of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of resident information and properly dispose of paperwork containing resident data. During observation of the garbage and dumpster area near the building, the surveyor found an open cardboard box with multiple papers. Further review of the papers showed printed documents dated 8/12/25 and 8/18/25 that contained resident names, room numbers, and a list of residents under enhanced barrier precautions, which are infection control measures requiring staff to wear gowns and gloves during high-contact care activities for residents at risk of or colonized with multidrug-resistant organisms. The ADON confirmed that the papers in the cardboard box contained resident information and stated they should have been disposed of in the designated disposable box for later shredding by an outside company. The DON later stated that all paper medical records should be placed in the designated area and shredded to protect patient information, but was unable to explain how or why the resident paperwork had been incorrectly discarded. The facility policy provided by the LNHA stated that paper notes or reminders with residents' personal or medical information shall not be left unattended or viewable by unauthorized persons and must be disposed of in a way that does not compromise resident information.
Resident Room Disrepair on 3rd Floor
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in resident rooms on the 3rd floor nursing unit. During a tour, the surveyor observed in one room that the heater was heavily rusted, the heating vent cover was missing, and the cove base molding was pulled away from the wall. In another room, an electrical outlet was cracked. In a third room, the cove base molding under the sink was pulled off. In another room, the wall behind the bed by the door had chipped paint, the molding along the wall was cracked, and the bathroom door had a large crack at the bottom. The Director of Maintenance stated he was not aware of the areas in disrepair and confirmed they should have been repaired because they did not provide residents with a homelike environment.
Late MDS Transmissions
Penalty
Summary
The facility failed to complete and transmit Minimum Data Set (MDS) assessments within the required timeframe for 5 of 30 residents reviewed: Resident #9, #39, #111, #131, and #134. The surveyor reviewed the CMS final validation reports and found multiple MDS assessments for these residents were transmitted well beyond 14 days after the assessment reference date (ARD), including annual, quarterly, admission, and modification assessments. Examples included Resident #39’s annual MDS with an ARD of 1/1/26 transmitted on 1/30/26, Resident #111’s quarterly MDS with an ARD of 12/30/25 transmitted on 1/30/26, and Resident #131’s annual MDS with an ARD of 1/3/26 transmitted on 1/31/26. During the survey, the MDS Coordinator/RN stated she began working at the facility in November 2025 and was aware that some MDS assessments were late, including some that were late before she started. The facility’s VPQPI provided the MDS 3.0 Completion policy, which stated that all assessments shall be transmitted to the designated CMS system within 14 days of completion. The DON also stated that admission, quarterly, and annual MDS should be completed within 14 days of the ARD. Despite this, the record review showed repeated late transmissions for the identified residents across several assessment types.
Specialty air mattresses were not accurately set or consistently monitored
Penalty
Summary
The facility failed to ensure that low air loss and specialty air mattresses were accurately set and monitored according to resident weight and comfort for multiple residents. Surveyors observed several residents on specialty mattresses with settings that did not match the residents’ reported or documented weights, and staff interviews showed confusion about who was responsible for checking and maintaining the mattresses. The deficiency was identified for four residents reviewed: one resident reported the mattress was very stiff and causing back pain, while the mattress was observed set at 380 lbs even though the resident stated they weighed about 130 lbs. For another resident with Alzheimer’s disease and severe cognitive impairment, the air mattress pump was observed set to 180-250 lbs on two separate observations. The resident had an active order for the mattress to be checked for placement and functioning every shift, and the MAR showed nursing staff signed off each shift. However, an LPN stated the resident did not appear to weigh 190 lbs and said maintenance was responsible for setting and monitoring the mattress, while a unit manager stated nursing was not responsible and that maintenance and hospice handled it unless the mattress beeped. A third resident with Alzheimer’s disease and severe cognitive impairment had an active order for an air mattress to be checked every shift, and the TAR was signed by nurses each shift, but the mattress was observed with different light settings on separate days. The resident’s care plan did not include a specialty air mattress intervention, and a CNA stated she did not know anything about the mattress because maintenance checked it. A fourth resident with dementia and severe cognitive impairment had a low-air-loss mattress order and care plan intervention, and the mattress was observed with all lights on. Staff again stated that maintenance and hospice were responsible for setting and monitoring the mattress, while the maintenance director confirmed specialty mattresses should be set according to resident weight and acknowledged there was no documentation for weekly monitoring of the air mattresses.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide assessments of a resident's condition and to monitor for complications after dialysis treatments for a resident who received hemodialysis at a certified dialysis facility. The resident had diagnoses that included dependence on renal dialysis and hypertension, and the quarterly MDS reflected a BIMS score of 5 out of 15, indicating severe cognitive impairment. The physician's orders included dialysis every Tuesday, Thursday, and Saturday at 9:40 AM, along with monitoring of the right chest permacath site every shift for placement, bleeding, and signs or symptoms of infection. Review of the hybrid Nursing Facility/Dialysis Communication Record forms from October 2025 through February 2026 showed that on three dates the facility nurse did not complete the post-dialysis return assessment section. The surveyor also found no documentation in the electronic medical record showing that the resident was assessed upon return from dialysis on those dates. During interview, an LPN confirmed that the facility nurse should have completed the post-dialysis assessment, including vital signs and checking the dialysis access site, and the DON confirmed that facility nurses should have completed the post-dialysis sections of the Dialysis Communication Record.
Unlabeled medications, improper refrigerator storage, and unsecured crash cart
Penalty
Summary
Drugs and biologicals were not properly labeled, stored, or disposed of in 2 medication carts and 1 medication room refrigerator. On the 2nd floor medication cart, the surveyor found two loose tablets in the 2nd drawer and one loose tablet in the 3rd drawer that were not in pharmaceutical packaging. The same cart also contained two bottles of Velphoro 500 mg chewable tablets that had no pharmacy label and were identified only with the resident's name written on the bottles. An LPN stated the loose medication should have been destroyed per facility policy and confirmed the Velphoro was not supplied by the pharmacy and did not have a pharmacy label. On the 1st floor medication cart, the surveyor found one Enoxaparin 40 mg/0.4 mL injection with no pharmacy label or resident name, and an LPN stated it was a discontinued medication that should have been removed from the cart. In the 1st floor medication room refrigerator, the temperature was 50 degrees and a vial of influenza vaccine was stored inside. The refrigerator temperature log showed no documented temperatures for 2/3/26 and 2/4/26, and an LPN confirmed the temperature was outside the 36-to-46-degree range and that the last 2 days had not been documented. The facility also failed to secure 1 of 3 emergency crash carts observed, as the crash cart on the first-floor nursing unit was open when the surveyor inspected it and the RN/UM acknowledged it should have been locked.
Failure to Inform Residents About Anonymous Grievance Filing
Penalty
Summary
The facility failed to provide information on how to file an anonymous grievance for six residents reviewed for the grievance process. During a resident group interview, all six residents expressed that they were unaware of how to file an anonymous grievance, stating that they were only informed about filing grievances through the social worker, but not anonymously. The review of Resident Council meeting minutes from January to September revealed no mention of anonymous grievance filing. Interviews with the Social Services staff and the Administrator confirmed that residents were not informed about the process for filing anonymous grievances. The Social Services staff mentioned that she regularly checked in with residents about grievances but did not explain the anonymous filing process. The Administrator also acknowledged the lack of explanation and stated that there was no existing method for filing anonymous grievances in the facility. The facility's grievance policy emphasized the right to voice grievances without interference or reprisal but did not address anonymous grievance filing.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written notice of their bed hold policy and the cost of a bed hold when residents were transferred to the hospital. This deficiency was identified for five residents who were hospitalized, as there was no documented evidence that the facility provided the required information to the residents or their representatives. The absence of this information had the potential to cause confusion or distress regarding the cost to hold a room and whether or not a resident would be able to return to the facility after hospitalization. For Resident 119, the facility did not provide a bed hold letter for two hospitalizations, and the letters that were found did not include the cost after the ten-day hold period or confirm the resident's ability to return. Similarly, for Residents 87, 83, 29, and 67, there was no documented evidence of written information regarding the facility's bed hold policy being provided at the time of transfer. Interviews with staff revealed a lack of awareness and understanding of the official policy, with the Administrative Receptionist admitting to sending out notices without being familiar with the policy details. The facility's policy, updated in January 2024, required that written information be provided to residents or their representatives before a transfer to the hospital or therapeutic leave, specifying the duration of the bed-hold policy, the reserve bed payment policy, and conditions for returning to the facility. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation and communication with the residents' representatives regarding the bed hold policy and associated costs.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was at a palatable temperature, affecting five of six residents reviewed for palatability. Residents reported that the food was consistently cold and tasteless, and these concerns had been raised in monthly council meetings without any observed changes. Observations revealed that food temperatures were not monitored throughout the meal service, leading to significant temperature drops by the time meals were served to residents. During the meal service, the food temperatures on a test tray were significantly below the facility's policy requirements, with chicken at 130.3 degrees F, potatoes at 113.3 degrees F, and broccoli at 112.8 degrees F. The facility's policy required hot foods to be held and served at a temperature of at least 135 degrees F. The Dietary Manager acknowledged the significant temperature drops and stated that the facility used heated pellets intended to maintain temperatures for up to 20 minutes. However, the food temperatures did not meet the desired range, indicating a failure in maintaining the required standards.
Deficiencies in Resident Safety and Transfer Practices
Penalty
Summary
The facility failed to ensure the safety of a resident during transport to an outside appointment. A resident with severe cognitive impairment and mobility issues was mistakenly dropped off at their personal residence instead of being returned to the facility. This error occurred because the transportation company was provided with the resident's personal address instead of the facility address. The incident was not immediately noticed, and the facility only contacted the transportation company after realizing the resident had not returned. Additionally, the facility did not ensure safe resident transfers for two residents who required assistance. One resident, who had hemiplegia and moderately impaired cognition, was transferred by two CNAs without the use of a gait belt, which is contrary to safe transfer practices. The CNAs used their arms and the resident's clothing to assist with the transfer, and it was noted that gait belts were not available on the floor. Another resident, with severely impaired cognition, was transferred by a CNA without locking the wheelchair brakes and without using a gait belt. The facility's staff, including CNAs and LPNs, reported that gait belts were not commonly used unless approved by therapy. The facility's policy on safe resident handling was not adhered to, as the interdisciplinary team is supposed to evaluate and assess each resident's mobility needs and perform lifting and transferring according to the resident's care plan. The Rehabilitation Director indicated that gait belts should be used unless a resident can transfer with minimal assistance and respond well to verbal cues. However, this practice was not followed, leading to unsafe transfer methods being used for residents.
Failure to Obtain Informed Consent and Explore Alternatives for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident received alternative measures and informed consent with explained risks and benefits prior to the installation of bed rails. The resident, identified as R30, was admitted with diagnoses including vascular dementia, depression, bipolar disease, muscle weakness, and anxiety. The resident's Minimum Data Set (MDS) assessment indicated intact cognition with a BIMS score of 13 out of 15. Despite this, the facility did not document any alternative measures before installing the bed rails, nor did they obtain informed consent for their use. Interviews with facility staff revealed a lack of adherence to protocols regarding bed rail use. An LPN admitted that alternatives were not tried before using side rails for the resident, and informed consent forms were found unfilled and unsigned. Another LPN was unsure about what alternatives could have been used and stated that the decision to use side rails was binary. The Director of Nursing acknowledged that informed consent was not consistently obtained and that a Quality Assurance and Performance Improvement (QAPI) initiative had been implemented but was incomplete. The QAPI did not address the lack of exploring alternatives prior to bed rail use.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of medication containers, which led to a potential risk of residents receiving incorrect medications. During an observation, it was found that medication cart one on the second floor contained boxes of slow-release iron pills labeled only with room numbers 223 and 224, without specifying whether they were for bed A or B. This lack of specific labeling could result in the wrong resident receiving the medication. A registered nurse confirmed that the boxes should have included the resident's name, not just the room number. Additionally, medication cart two on the second floor was found to have a bottle of Alaway eye drops labeled only with a room number and no resident name. An LPN was unsure if the eye drops required a name since they were over-the-counter (OTC) medication. However, the Director of Nursing confirmed that all medications, including OTCs, should be labeled with the specific resident's name. The facility's policy on labeling medication containers, updated in January 2024, requires that labels for OTC drugs include the resident's name, indicating a failure to adhere to this policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 676 citations issued within 25 miles in the last 12 months — including the 15 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bridgewater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waterfront Rehabilitation And Healthcare Center | 1.2 mi | ★★★★★ | 13 | 0 |
| Bridgeway Care And Rehab Center At Bridgewater | 1.2 mi | ★★★★★ | 3 | 1 |
| The Arbor At Laurel Circle | 1.9 mi | ★★★★★ | 8 | 0 |
| N J Eastern Star Home | 2.9 mi | ★★★★★ | 16 | 0 |
| Skilled Nursing At Fellowship Village | 4.7 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Complete Care At Green Knoll.
100% money-back within 48 hours.
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.