Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Park Place Llc during CMS and state inspections, most recent first.
Laundry staff failed to wear a protective gown while sorting soiled resident clothing and bed linens in the laundry room. An LA was observed handling soiled items with gloves only, and the LA stated the gown had been forgotten. The IP, DES, and DON all confirmed that gowns and gloves were expected when handling soiled linens, and the facility document on sorting soiled linens required proper PPE.
Sticky Floor and Soiled Table in Memory Care Dining/Activity Area: The memory care dining/activity room floor was repeatedly observed to be sticky while residents and staff were present, and a large rectangular table was visibly soiled with fingerprints, smudges, and a thick dried substance. The AA stated housekeeping typically cleaned the area, the DES said the floor was swept and washed each morning, and review of records showed the cleaning schedule did not document the memory unit dining/activity area. A later document confirmed the floor chemical dispenser was out of alignment and required replacement and calibration.
Inaccurate MDS Assessment for Resident with PTSD: A resident admitted with PTSD had an admission MDS that did not reflect the active diagnosis, even though the face sheet and hospital notes documented PTSD and the resident was cognitively intact with a BIMS of 15/15. The MDSC stated the diagnosis was missed because it was not entered into the EMR diagnosis tab until later, and the DON stated MDS assessments were expected to be completed accurately.
A resident admitted with ESRD had physician orders for PD every 4 hours with specific exchange volumes, dialysate, instill and drain times, and use of a cycler, but the baseline care plan did not include PD or related interventions. Staff interviews showed uncertainty about who completed the baseline care plan, and the DON stated it was unclear why the PD information was missed. The facility policy required the baseline care plan within 48 hours of admission and for orders to be reviewed and incorporated to meet immediate care needs.
The facility failed to develop complete, person-centered care plans for two residents. One resident had a CAA trigger for pressure ulcer risk, but no corresponding care plan was documented. Another resident with PTSD had a care plan noting the diagnosis, but it lacked interventions for staff to identify triggers or stressors, and staff acknowledged the omission.
A resident with a pureed diet and nectar thick liquids was observed having meals placed into a plastic cup and consumed by drinking from it, but there was no documented interdisciplinary assessment or order directing this method. CNA staff said the resident ate better this way, yet the RD, DOR, ST, and DON all confirmed there was no prior assessment or care plan direction for using a cup to ingest meals.
A resident with unspecified asthma had an order for PRN oxygen at 2 L/min via nasal cannula, but staff observed the concentrator set at 3 L/min and the MAR had no documentation of oxygen use. The tubing was also undated, and an LPN confirmed the oxygen setting, lack of MAR documentation, and uncertainty about when the tubing had been changed; the DON stated the flow should match the order or a revised order be obtained.
Bed Rail Use Without Required Assessment, Consent, or Alternative Measures: A resident with repeated falls and muscle weakness was observed in bed with a side rail up, but the EMR had no documentation that alternatives were tried, no documented risks-versus-benefits discussion, no signed informed consent, no care plan for bed rail use, and no physician order. An LPN said the rails were already on the beds and confirmed consent was not completed or signed, while the DON stated staff should discuss risks and benefits and complete informed consent.
Missing Hospice Recertification Documentation: The facility failed to maintain hospice recertification records for a resident receiving hospice services. The resident’s EMR showed hospice orders, severe functional dependence, and a terminal prognosis, but the clinical record and hospice communication book did not contain the recertification documents at the time of survey. The DON, SSD, and hospice DCS confirmed that recertification had been communicated verbally and the documents were not in the record before survey review.
A resident with obstructive sleep apnea and chronic respiratory failure did not receive a C-PAP machine as ordered by a physician. The facility failed to follow the physician's order, which required a respiratory consult and setup of the C-PAP machine. Staff interviews confirmed the oversight, and the facility's policy on PAP equipment was not adhered to.
Laundry Staff Failed to Wear Required PPE While Handling Soiled Linens
Penalty
Summary
The facility failed to ensure PPE was worn by laundry staff while sorting soiled resident clothing and bed linens in one of one laundry rooms. During an observation with the Infection Preventionist, the Laundry Aide was seen reaching into a soiled container of linens and loading them into the washing machine while wearing disposable gloves but not a protective gown. The Laundry Aide stated that a protective gown had been forgotten before handling the soiled items. The Director of Environmental Services entered the area and confirmed the Laundry Aide was required to don a protective gown because this was a potential infection control issue. The Infection Preventionist stated the Laundry Aide should have been wearing a gown while handling soiled linens and resident clothing, and the DON stated it was the expectation that laundry staff don gowns and gloves before handling soiled items because this could spread infection for workers and others. Review of the facility document titled Sorting Soiled Linens indicated the laundry room must have a process to effectively sort soiled linen without cross contaminating clean linen and that employees must use proper PPE.
Sticky Floor and Soiled Table in Memory Care Dining/Activity Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the memory care unit. During multiple observations of the unit’s main dining/activity room, the floor was repeatedly observed to be sticky, and a large rectangular table facing the back wall and cabinets was visibly dirty with fingerprints, smudges, and a thick, dry, raised substance on its surface. The condition of the floor and table was observed while residents and staff were present in the area participating in activities, waiting for meals, and sitting near the table. During interview and document review, the Activity Aide stated that housekeeping typically cleaned the area, and the Director of Environmental Services stated that the housekeeper swept and washed the dining/activity floor each morning. The facility provided a cleaning schedule document that did not show evidence of the memory unit dining/activity area cleaning schedule. The floor technician later cleaned the table, and the Regional District Manager stated the chemical used to wash the floor needed re-calibration. A facility document confirmed the floor chemical dispenser was out of alignment and required replacement and calibration, and the document also confirmed that the floor was sticky.
Inaccurate MDS Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a comprehensive MDS assessment was completed accurately for one resident with PTSD. Review of the resident’s face sheet showed a diagnosis of PTSD on admission, and hospital notes also documented PTSD as an active diagnosis. However, the admission MDS with an ARD of 01/28/26 showed a BIMS score of 15 out of 15 and did not indicate an active PTSD diagnosis on the assessment. Further review of the resident’s EMR showed that PTSD was not entered into the diagnosis tab until 02/05/26. During interview, the MDSC stated the PTSD diagnosis should have appeared on the diagnosis list but was missed because it was not entered into the EMR diagnosis tab until later, and it should have been indicated on the admission MDS. The DON stated that MDS assessments were expected to be completed accurately. The RAI Manual states that specific documentation, such as physician or hospital discharge summary documentation, may assist assessors in determining whether a diagnosis should be coded as active in the MDS.
Baseline care plan omitted peritoneal dialysis needs
Penalty
Summary
The facility failed to ensure that the baseline care plan included information needed to meet the immediate care needs of one resident admitted with end stage renal disease. Review of the resident’s face sheet showed admission to the facility with ESRD, and physician orders dated 02/27/26 included peritoneal dialysis every 4 hours with a 2L exchange volume, 2.5% Dianeal, 20-minute instill time, 20-minute drain time, and continuation of the home prescription with a cycler. The resident also used a combination of 2.5% and 1.5% bags, usually 2 green and 1 yellow bag, every evening shift for PD. The baseline care plan dated 02/27/26 did not include the presence of peritoneal dialysis or interventions to implement for care. During interviews, an LPN stated the admission baseline care plan is completed by the nurse responsible for admission or sometimes the unit manager, while another LPN stated the supervisor or unit manager likely completes it and agreed PD should be included. The DON stated the supervisor or nurse writes the baseline care plan and it is reviewed the next morning, and said it was uncertain why the PD information was missed. The facility policy required a baseline care plan within 48 hours of admission and directed the interdisciplinary team to review practitioner orders and implement a plan to meet the resident’s immediate care needs.
Incomplete Care Plans for Pressure Ulcer Risk and PTSD
Penalty
Summary
The facility failed to develop person-centered, comprehensive care plans with measurable goals and interventions for two residents. For R13, the record showed admission on 09/01/23 and an annual MDS with an ARD of 12/13/25 indicating the resident could not be scored with BIMS and was at risk for pressure ulcers. The CAA triggered for pressure ulcers and directed staff to develop a care plan, but the Care Plan section contained no evidence that a pressure ulcer care plan had been developed. During interview, the MDSC confirmed there was no care plan for R13 related to pressure ulcer risk, and the DON stated that when a CAA triggers a care area and directs staff to develop a care plan, it should be done. For R87, the admission record showed a diagnosis of PTSD, and the admission MDS with an ARD of 01/28/26 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The Care Plan identified the resident as at risk for PTSD, but it did not include interventions for staff to recognize potential stressors or triggers. The SSD stated PTSD was discussed in clinical meetings and morning support, but was unsure why it was missed in care planning. The DON stated there was no documentation that staff attempted to discuss PTSD with the resident, and the resident stated no staff had asked about potential triggers or stressors, although the resident said there were no issues discussing past trauma and that psych providers were seen regularly.
Unassessed change in meal delivery method
Penalty
Summary
The facility failed to ensure that Resident 19 received services to maintain or improve activities of daily living when staff altered the resident’s meal consumption method without a documented interdisciplinary assessment. The resident was admitted on 12/13/24, had a care plan dated 05/27/25 indicating the need for verbal cues during mealtimes from one staff member, and had physician orders dated 07/29/25 for a pureed diet with nectar thick liquids. The quarterly MDS with an ARD of 01/02/26 showed the resident had no impairment of bilateral upper extremity function and required supervision or touch assistance with eating. Dietary progress notes dated 01/06/26 noted weight loss expected with hospice services, but there was no documentation directing staff to place the resident’s meals into a plastic cup. During observation on 03/10/26, CNA 3, a hospice staff member assigned to the resident, placed pureed food into a plastic cup, poured thickened liquids into the cup, stirred the contents, and the resident drank from the cup. CNA 3 stated the resident consumed meals better this way. A meal ticket reviewed during the interview did not direct staff to pour the meal into a cup. During a later observation, CNA 3 confirmed the same practice for breakfast. The Regional RD stated there was no note indicating the resident had been assessed to have meals poured into a plastic cup. The DOR and ST stated there was no prior assessment in place for the resident to use a plastic cup to ingest meals, and the DON stated that an assessment should be in place and the practice care planned.
Failure to Follow Oxygen Orders and Document Oxygen Use
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident with a diagnosis of unspecified asthma. The resident’s EMR showed a physician order dated 01/29/26 for oxygen to be administered via nasal cannula as needed for shortness of breath or low oxygen at 2 liters per minute. The resident’s care plan dated 01/28/26 did not include any interventions for oxygen use, and the MAR for March 2026 contained no documentation that oxygen had been administered to the resident. During observations on 03/11/26 and 03/12/26, the resident was lying in bed with the oxygen concentrator positioned approximately two feet from the left side of the bed and oxygen being delivered via nasal cannula at 3 liters per minute. The tubing was undated. An LPN confirmed the concentrator was set at 3 liters per minute and stated oxygen use had not been documented on the MAR. The LPN also confirmed the tubing was undated and was unsure whether it had been changed. The DON stated the oxygen flow should have been set at the ordered amount or a revised order obtained for 3 liters per minute, and that PRN oxygen use should be documented on the MAR and tubing should be changed and dated.
Bed Rail Use Without Required Assessment, Consent, or Alternative Measures
Penalty
Summary
The facility failed to ensure that, before bed rails were installed or used for one resident, alternative measures were attempted, the risks and benefits were discussed with the resident or representative, and signed informed consent was obtained. The resident was admitted with diagnoses of repeated falls and muscle weakness, and the 5-day MDS showed a BIMS score of 15 out of 15, indicating intact cognition. The EMR contained a side rail assessment dated 03/04/26 with no indication whether bed or side rails would be used, and there was no documentation of risk versus benefit discussion or signed consent. The resident’s care plan contained no bed or side rail use plan, and there was no physician order for bed or side rail use. Observations on 03/10/26 and 03/11/26 showed the resident in bed with a side rail up on the right side. During interview, an LPN stated residents use bed or side rails for repositioning and turning, was unsure whether alternatives had been explored, and said the rails were already on the beds. The LPN also stated the bed rail assessment should indicate whether the resident would use bed rails and verified that consent was not completed or signed. The DON stated staff should discuss risks and benefits and complete informed consent, but was unaware that alternatives were supposed to be explored before bed or side rail use.
Missing Hospice Recertification Documentation
Penalty
Summary
The facility failed to obtain documentation of hospice recertification for one resident who was receiving hospice services. The resident was admitted on 02/22/17 and had a physician order for hospice services dated 12/16/24. The annual MDS with an ARD of 12/27/25 indicated the resident’s BIMS score could not be determined, that the resident was dependent on staff for all activities of daily living, and that the resident had a diagnosis of having six months or less to live. Review of the resident’s EMR and hospice communication book did not show that the facility maintained hospice recertification in the clinical record at the time of survey. During interviews, the DON stated he/she would need to contact the SSD to locate the documents, and the SSD confirmed the hospice book did not contain the recertification documents. The hospice Director of Clinical Services stated hospice had only provided verbal notification of recertification and had never provided the recertification documents to the facility. The DON later brought in the resident’s recertification documents for the past year and confirmed they were received on that date, but they were not available in the clinical record before the request.
Failure to Provide C-PAP Machine for Resident
Penalty
Summary
The facility failed to adhere to a physician's order for a resident requiring a continuous positive airway pressure (C-PAP) machine at night. During an initial tour, a surveyor observed an oxygen concentrator near the resident's bed but did not see a C-PAP machine. The resident, who was admitted with diagnoses including obstructive sleep apnea and chronic respiratory failure, confirmed that they used a C-PAP machine at home but was uncertain about its use in the facility. The physician's order, dated several months prior, specified the need for assistance with the C-PAP machine at night and required a respiratory consult to ensure proper setup. Interviews with facility staff revealed a lack of compliance with the physician's order. The Registered Nurse/Unit Manager acknowledged the existence of the order and confirmed that the resident should have had the C-PAP machine. The Director of Nursing admitted that a respiratory consult was not completed, and the agency providing respiratory services was not contacted. The physician reiterated the necessity of the C-PAP or BiPAP machine for the resident, emphasizing that a respiratory therapist should have been involved in the setup. The facility's policy on PAP equipment, which includes verifying medical orders and gathering necessary equipment, was not followed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monmouth Junction
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carnegie Post Acute Care At Princeton Llc | 2.1 mi | ★★★★★ | 1 | 0 |
| Merwick Care & Rehab Center, Llc | 3.3 mi | ★★★★★ | 4 | 0 |
| Stonebridge At Montgomery Health Care Center | 3.9 mi | ★★★★★ | 0 | 0 |
| The Elms Rehab And Healthcare Center Of Cranbury | 5.7 mi | ★★★★★ | 15 | 1 |
| Cranbury Center | 7.4 mi | ★★★★★ | 10 | 2 |
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