Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Prospect Heights Llc during CMS and state inspections, most recent first.
Food storage and kitchen sanitation deficiencies were identified when staff stored dented cans on the meal prep rack, left frozen and refrigerated foods unlabeled or past their use-by dates, and failed to maintain kitchen equipment in sanitary condition. The surveyor observed crusted residue on the stove, oven, and frying pans, bent ventilation hoods, and no trash bin at a hand washing station for paper towels.
The facility failed to revise its facility assessment to include the updated staffing contingency planning requirements. The LNHA confirmed the most recent FA was the one approved on 7/29/25, stated the facility did not use agency nursing staff and was not on a COVID outbreak, and did not respond when asked why the CMS staffing-related contingency plan update effective 8/28/24 was not reflected in the FA. The DON also did not respond during the QAPI discussion.
Surveyors found that the facility did not maintain required environmental standards in multiple resident-accessible areas. Dining/activity rooms on upper floors were documented at temperatures below the acceptable range, and a dining room that leadership described as decommissioned had no signage and remained accessible. In resident rooms, a loose pipe was found on the floor, privacy curtains were not properly hooked, and a ceiling vent had visible grayish buildup. A hallway linen cart was left partially uncovered with dried substances and stains on its cover. On two upper floors, hallways, rugs, walls, handrails, and dining rooms showed large dark stains, peeling wallpaper, and worn surfaces, with nursing and housekeeping leadership acknowledging that these conditions had persisted despite repeated cleaning and prior verbal reports. These findings conflicted with the facility’s own policy requiring a safe, clean, comfortable, and homelike environment in all resident areas.
Surveyors found multiple infection control failures, including an empty soap dispenser in a resident toilet room, uncovered and dirty linen carts on several floors, dust and debris in both clean and dirty laundry rooms, and improper PPE and hand hygiene practices during med pass. An LPN removed gown and gloves without hand hygiene, and another LPN changed gloves and disinfected a BP cuff without waiting the required contact time before using it on another resident.
The facility failed to provide sufficient CNA staffing to ensure timely and appropriate incontinence care for a resident who was cognitively intact, always incontinent of bladder and bowel, and dependent for toileting hygiene and transfers. On one unit, two CNAs were assigned to 28 residents, and a CNA reported having about 14 residents and not being finished with morning care. During an incontinence round, an RN/Unit Manager found the resident wearing double incontinence briefs that were saturated with urine, with wet pads and linens and a urine odor, despite no care plan entry or documentation that the resident had requested double briefs. Review of electronic CNA documentation showed toileting hygiene tasks were routinely signed off as completed, but on the day of observation only a single entry was recorded shortly after midnight, with no further documentation of incontinence care by the day shift, even though the resident was listed as incontinent and only two CNAs were scheduled on that floor.
A resident with dementia, hemiplegia, hemiparesis, and HTN had a PRN lorazepam order for anxiety and restlessness that was not limited to 14 days. The resident's record did not include documentation from the attending physician or prescribing practitioner with a rationale to extend the psychotropic medication, and an LPN was unsure whether the 14-day requirement applied while the SFUM stated the order should have had a stop date.
Late Completion of Admission MDS Assessments: Two residents had admission MDS assessments completed after the required 14-day timeframe. Record review and CMS validation reports showed one assessment was completed 3 days late and another 8 days late, with late completion tied to delayed Section F activities and Care Areas/Care Plan work. The MDSD and MDS Coordinator confirmed the timing requirements during interview, and the facility policy stated admission assessments must be completed within 14 days of admission.
A facility failed to accurately code the MDS for two residents. One resident’s MDS still showed an indwelling catheter even though the Foley had been removed and the resident was voiding and incontinent. Another resident’s MDS coded an unhealed stage 2 pressure ulcer despite records showing surgical wounds and no documented pressure ulcer; Section J was also completed after the ARD using auto-populated EMR data, and the DON acknowledged the MDS was inaccurate.
A resident with osteomyelitis and Rett's Syndrome had a Foley catheter removed, but the CCP did not reflect the catheter removal or current urinary incontinence. The MDS showed an indwelling catheter, while the RN stated the resident now voids and is incontinent. The care plan was not updated to match the resident's current bladder status.
Medication monitoring orders were not followed consistently for two residents, including anticoagulant side effect documentation and unclear hypoglycemia instructions that were not clarified. Nurses used inconsistent charting for side effect monitoring, and progress notes did not identify the observed side effects when "N" was entered. In addition, a resident’s PPD/TB screening was documented as given twice, but the record lacked documentation explaining the duplicate entry or whether the second dose was actually administered.
A resident receiving hospice care had hospice recommendations for morphine for pain/dyspnea and lorazepam for muscle spasms, but the chart showed only one morphine order and no lorazepam order, with no PN documenting physician disagreement. Another resident with ESRD and diabetes had fluid restriction and hypoglycemia orders that were not followed as written: the chart lacked required documentation of fluid amounts, MD notification for low BS, administration/sign-off of PRN hypoglycemia treatments, and documentation that BS checks and change-in-condition notifications were completed.
An LPN failed to follow infection control practices during wound care for a resident with dementia and other diagnoses. During treatment of both heels and the right ankle, the LPN used a marker from her pocket without disinfecting it, repeatedly changed gloves without performing hand hygiene, washed hands for too short a time and turned off the faucet with wet hands, and touched the treatment cart after leaving the room without hand hygiene. The resident’s heels were also close to the bed linens during the procedure, and no clean surface was placed under the heels.
A resident with dysphagia, severe cognitive impairment, and PEG TF orders had physician orders entered incorrectly for PRN meds, and the nurse did not notify the MD after a 2.8-lb weight gain despite an order to report gains of 2 lbs or more within 24 hours or 5 lbs or more within one week.
A resident with ESRD and moderate cognitive impairment received dialysis on a Tue/Thu/Sat schedule, but ordered meds were not administered on multiple dialysis days because the resident was out to dialysis, and staff acknowledged the timing should have been adjusted. The resident also had a 1000 mL fluid restriction order that was exceeded on several days, with the DON stating the resident was noncompliant and no documented physician clarification found during review.
A facility failed to ensure the daily NHRCSR accurately reflected licensed nurse staffing, CNA staffing, and resident census at the beginning of the shift on multiple observed days. The posted census did not match the staffing sheet or the LNHA’s stated census, and interviews showed the SC was responsible for preparing and posting the report, sometimes with delays or by asking a Supervisor to post it. The LNHA acknowledged the report was not changed before 7 AM, and the facility’s staffing policy did not address the posting regulations.
A resident with dementia did not have a monthly CP medication regimen review documented in the chart, and another resident with severe cognitive impairment received duplicate docusate orders during med pass. The CP had recommended changing one docusate form and later flagged that Colace appeared twice on the eMAR, but the facility had no documented response to the recommendation.
Unclear Diclofenac Gel Dose Administration: A resident with no cognitive impairment and orders for diclofenac sodium topical gel to the hip and knee received the medication in a small cup, but the assigned RN could not state a specific dose and described it only as an estimated amount based on the area. The CP stated the gel should be measured as 2 g or 4 g on a dosing card depending on the site, and the PI specified exact dosing for upper and lower extremities.
Medication storage and labeling were deficient when an LPN left Aspirin and methylprednisolone unattended on top of a med cart during med pass, and surveyors later found an unlabeled Trelegy inhaler stored in a med cart drawer with only a resident name and date written on it. A second, properly pharmacy-labeled Trelegy inhaler for the same resident was also present, and the consultant pharmacist stated meds should not be left on top of the cart and should have proper labels or be stored elsewhere.
A leaking sink was observed in the food prep area, and the FSD could not turn it off with the faucet handles and said she was unaware of the leak. On a follow-up kitchen tour, the sink was still steadily leaking. The facility’s kitchen cleaning policy stated that staff shall maintain kitchen sanitation, and the issue was discussed with the LNHA and DON.
Three residents with significant medical conditions did not have their weights collected and documented as ordered by physicians, with only one weight recorded for each or none after admission, and no explanation documented in the medical record. Staff interviews and job descriptions confirmed that policies and responsibilities for weight monitoring were in place, but these were not followed.
The facility failed to screen two EMTs and ensure they wore PPE while transporting a resident on a COVID unit. The EMTs were not informed of the outbreak or required to wear masks, contrary to facility policy. The Receptionist admitted to not screening them, and the DON confirmed the expectation for screening all entrants.
A facility failed to disinfect a multi-use glucometer with an EPA-registered disinfectant, using alcohol wipes instead, which increased the risk of blood-borne pathogen transmission among residents. Additionally, improper disposal of PPE was observed, with used PPE being discarded in hallway trash receptacles instead of inside isolation rooms, contrary to facility policy. These practices were inconsistent with infection control protocols, as confirmed by the DON and housekeeping staff.
A facility failed to maintain appropriate physician orders and labeling for a resident's oxygen use. The resident was observed using oxygen without an active order, and the oxygen tubing was unlabeled and improperly handled. A nurse confirmed the lack of proper labeling and contamination of the tubing, and it was noted that the last active order for oxygen had expired over a month ago.
The facility did not post the Nursing Home Resident Care Staffing Report in areas accessible to residents, as required by policy. Observations showed no postings on resident floors, and interviews with the DON and Administrator confirmed the absence of postings where residents lived, potentially preventing residents from knowing staffing levels.
A facility did not effectively implement and revise care plan interventions for a resident experiencing significant pain, leading to a decline in condition. Despite having orders for pain medication and a care plan indicating pain management strategies, the resident reported high pain levels on multiple occasions without appropriate intervention. The lack of adequate pain management and care plan revision resulted in a decline in the resident's functional abilities and overall well-being, contrary to the facility's pain management policy.
The facility did not consistently follow the care plan, evaluate pain, or ensure proper administration of pain medications for a resident experiencing pain from various conditions. Pain assessments were not always conducted or documented appropriately, and medication records showed discrepancies where reported pain levels were not matched with the administration of prescribed pain medication. Occupational Therapy notes indicated continuous complaints of pain and a decline in interventions due to pain and fatigue. Communication gaps between the Occupational Therapy team and nursing staff were identified, highlighting challenges in managing pain with only PRN medication. The facility's policy emphasized the need for an interdisciplinary approach to pain management, including both pharmacological and non-pharmacological interventions.
The facility failed to accurately encode a resident's wound in the MDS assessment. A resident admitted with diagnoses including Difficulty in Walking and Protein Calorie Malnutrition was documented as not having a pressure ulcer in the MDS assessment. However, records showed the resident had a sacral pressure ulcer, and preventative skin care orders were in place. The MDS Coordinator confirmed the miscoding by previous staff.
A resident with multiple medical conditions was found in a neglected state, with a soaked incontinence brief and fecal matter on their back, due to the facility's failure to provide adequate toileting assistance. The CNA responsible did not check or change the resident since the beginning of the shift, citing staff shortages. Facility policies requiring regular checks and immediate changes were not followed.
The facility failed to provide adequate staffing, resulting in a resident with multiple health issues being left in a soiled and wet condition for several hours. The resident's care plan and MDS indicated the need for assistance with ADLs and incontinence care, which were not met due to staffing shortages.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility also failed to maintain kitchen equipment and utensils in a sanitary condition and in safe operating condition. The surveyor observed two of 14 ventilation hoods above the stove with small bends creating a 1/4 inch gap. The six-burner stove top had a black crusted substance that could be lifted with the tip of the surveyor's pen, and the oven had black crusted substances in the bottom corners that were also easily lifted. Two frying pans had crusted black substance lining the entire pan, and another frying pan later observed had crusted black substance around the perimeter and caked black substance where the handle met the pan. At the second hand washing station, there was no trash bin available for paper towels. The facility's dry food storage, food storage, and kitchen cleaning policies required unacceptable dented canned goods to be reported and discarded promptly, all foods to be securely covered, dated, and labeled, and staff to maintain kitchen sanitation.
Facility Assessment Missing Updated Staffing Contingency Plan
Penalty
Summary
The facility failed to ensure its facility-wide assessment was revised to include the contingency plan addressing staffing needs. During the entrance conference, the LNHA stated the facility census was 117 residents and confirmed the facility did not use agency staff for nursing staffing needs and was not on a COVID outbreak. The surveyor requested the most updated Facility Assessment, and the LNHA provided an assessment approved on 7/29/25. That assessment stated it would be reviewed and updated at least annually and whenever substantial changes required modification, and its contingency planning for staffing stated that if an event did not rise to the level of activating the emergency plan, the facility would refer to the COVID contingency staffing pattern/plan. During the QAPI meeting, the LNHA confirmed the 7/29/25 assessment was the most updated version and stated it was reviewed quarterly, annually, and as needed for global CMS changes. When asked about the updated CMS staffing requirements effective 8/28/24 and why the contingency plan requirement was not followed in the facility assessment, the LNHA and DON did not respond.
Failure to Maintain Safe Temperatures and Clean, Homelike Environment in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident-accessible areas. Surveyors observed that thermostats in the 3rd and 4th floor dining/activity rooms showed temperatures of approximately 67°F and 66.7°F, and a later temperature check in the 3rd floor dining room showed 64°F, below the facility’s own policy definition of comfortable and safe temperature levels and below the CMS temperature range referenced in state guidance. The 3rd floor dining room, which the LNHA stated was decommissioned and not in use, had no signage or notifications indicating it was closed, and the doors could be opened by surveyors, visitors, residents, and staff. Facility environmental temperature and safety rounds documentation did not include temperature measurements for any dining/activity areas on any floor. Additional environmental deficiencies were observed in resident rooms and common areas. In one resident room, a white pipe was found on the floor, which a CNA stated was likely from the metal cover under the sink. On a 6th floor hallway near a resident room, a linen cart was observed not fully covered, with whitish and blackish dried substances and a brownish stain on the cover; the Director of Recreation and a CNA acknowledged the cart should not be left open and that the white stain was from soap that had burst. In two separate resident rooms on the 4th floor, privacy curtains were hanging and not properly hooked on the rods, and in one of those rooms, a ceiling vent was observed with an accumulation of grayish substances upon entry. Surveyors also documented widespread issues with cleanliness and maintenance of floors, walls, and dining areas on the 5th and 6th floors. On the 5th floor, between specific rooms, the hallway rug was stained with a large dark brownish substance, handrails were scuffed and worn, and walls were stained with brown substances; wallpaper was peeling in at least one hallway area, and rugs throughout the 5th floor, including around the nursing station and near several rooms, had dark stains. The 5th floor dining room area had peeling wallpaper. The 5th floor RN/UM reported she had repeatedly raised these concerns with the LNHA, Maintenance Director, and DON for over a year and that shampooing every two weeks did not remove the stains. On the 6th floor, the main dining room had peeling wallpaper on the ceiling near the television and on the walls, and the rug area by the windows was stained with a brownish substance. These conditions were inconsistent with the facility’s Safe and Homelike Environment Policy, which requires a safe, clean, comfortable, and homelike environment in all resident-frequented areas, including hallways and dining/activity rooms.
Infection Control Failures in Hand Hygiene, Linen Handling, Laundry Cleanliness, and PPE Use
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program in several areas observed by surveyors, including hand hygiene supplies, linen storage and laundry cleanliness, disinfecting wipe use, and PPE practices during medication administration. The deficiency was based on observations, interviews, and review of facility policies and CDC guidance. The report identified issues with an empty soap dispenser in a resident toilet room, uncovered and improperly maintained linen carts on multiple floors, dust and debris in both the clean and dirty laundry rooms, and staff not following required hand hygiene and equipment disinfection procedures during med pass. In one resident room, surveyors observed an empty soap dispenser in the toilet room on two separate observations. An RN acknowledged that staff use the sink for handwashing and that soap should be in the dispenser, while a housekeeper stated he was responsible for putting soap in the resident's room. The concern remained that the soap dispenser was empty for two days of observation. The report did not describe the resident's condition beyond the resident being present in the room during one of the observations. Surveyors also observed linen carts on the 6th floor, 4th floor, and in the laundry area that were not properly maintained. One linen cart was not fully covered and had whitish, blackish dried substances and a brownish stain on the cover; another cart had a whitish substance on top of the cover; and a cart in the laundry area contained papers and plastics on the bottom shelf with clean linen supplies inside. In the laundry room, a large stand fan was blowing air toward clean linen supplies and the folding table, and both the clean and dirty laundry rooms had visible dust accumulation on the fan, floor, walls, and washers. The laundry staff stated the dust should have been cleaned and that there was no accountability log for cleaning the laundry rooms. During medication pass, surveyors observed two LPNs fail to follow infection control practices while caring for residents with Enhanced Barrier Precautions. One LPN removed gown and gloves after entering a resident's room and did not perform hand hygiene afterward. Another LPN changed gloves multiple times, cleaned the cuff of a facility blood pressure machine with a purple-top wipe, and did not wait the required two-minute contact time before using the equipment on the next resident. The infection preventionist stated staff should sanitize hands before and after room entry, perform hand hygiene after removing gloves, and wait at least two minutes after using the purple-top wipes before reusing the equipment. Facility policies reviewed by surveyors also stated that hand hygiene is required before donning gloves and immediately after removing them, and that equipment must be cleaned and disinfected after each use before being used for another resident.
Insufficient CNA Staffing Leads to Untimely Incontinence Care and Undocumented Double Brief Use
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to ensure timely and appropriate incontinence care, as evidenced by staffing levels and the condition of an incontinent resident. On one morning, the Nursing Home Resident Care Staffing Report showed a census of 118 residents on the 7 AM–3 PM shift with a CNA-to-resident ratio of 1:14.8. On the 5th floor, there were 28 residents and only two CNAs assigned. When interviewed, a CNA on that unit stated she had about 14 residents, described the assignment as hard, and reported she was not finished with morning care. On another day, the posted staffing report showed a census of 117 with 10 CNAs on the 7 AM–3 PM shift, for a ratio of 1 CNA to 11.7 residents. The facility’s own leadership later acknowledged that staffing concerns and at times not meeting New Jersey minimum staffing ratios were known issues. During an incontinence round on the 5th floor, the RN/Unit Manager confirmed that a resident was incontinent of both bladder and bowel and obtained the resident’s permission to check the incontinence brief. The RN/Unit Manager and surveyor observed that the resident was wearing double incontinence briefs that were wet with urine. The RN/Unit Manager also found that the resident’s pads, folded linen, and cloth-type chuck under the resident were wet beyond the pads, and there was a noticeable urine odor. The RN/Unit Manager stated she was unaware that the resident had requested double briefs and indicated that double briefs were not allowed unless specifically requested by the resident and included in the care plan. She further stated she was unsure whether this preference was in the care plan. The surveyor was unable to interview the CNA assigned to the resident at that time. Record review for this resident showed diagnoses including type 2 diabetes mellitus without complications, COPD unspecified, need for assistance with personal care, and difficulty in walking. The care plan identified a focus on potential impairment to skin integrity with an intervention to assist with toileting needs, but there was no care plan entry documenting a preference for double incontinence briefs or any documented evidence that the resident had requested them. The most recent quarterly MDS showed the resident was cognitively intact (BIMS 15/15), always incontinent of bladder and bowel, and dependent for toileting hygiene and toilet transfer, with no documented skin impairment. Review of CNA electronic documentation for toileting hygiene from 1/10/26 to 1/22/26 showed the task was checked off every shift as completed with the resident dependent and requiring assistance of two or more helpers. However, on 1/23/26, only one shift at 12:17 AM documented toileting hygiene, and there was no documentation by the 7 AM–3 PM shift or any evidence of incontinence care after 12:17 AM that day, despite the resident being listed on the facility’s list of incontinent residents and only two CNAs being scheduled on the 5th floor for that shift.
PRN Lorazepam Order Not Limited to 14 Days
Penalty
Summary
The facility failed to ensure that an as needed psychotropic medication order was limited to 14 days unless the attending physician or prescribing practitioner documented a rationale to extend it for Resident #12. Resident #12 was admitted with diagnoses including dementia, hemiplegia, hemiparesis, and hypertension, and the most recent MDS showed a BIMS score of 10 out of 15, indicating moderately impaired cognition. On 1/21/26, the resident was observed lying asleep in bed. A review of the January eMAR and eTAR showed an order for Lorazepam Oral Concentrate 2 mg/mL, give 0.25 mL by mouth every 4 hours as needed for anxiety and restlessness, with an order date of 1/16/26. The order was not limited to 14 days, and the resident's progress notes did not include documentation from the attending physician or prescribing practitioner with a rationale to extend the medication. During interviews, an LPN stated that hospice residents had lorazepam PRN orders but was unsure whether a 14-day stop and reevaluation was required, and the SFUM stated the lorazepam order should have had a stop date.
Late Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) admission assessments within 14 days for 2 of 31 residents reviewed for MDS compliance, identified as Residents #51 and #94. Resident #51 had a comprehensive admission MDS that was completed 3 days late, and Resident #94 had a comprehensive admission MDS that was completed 8 days late. Both residents had Entry MDSs completed before the comprehensive admission assessments, and the late completion was confirmed through review of the records and CMS validation reports. During interview, the MDS Director stated that she was responsible for MDS assessments and that the facility tries to complete assessments as they are due, following the Resident Assessment Instrument process. When asked about the timing for admission MDS completion, the MDS Coordinator stated that the assessment and Care Areas need to be completed on the 14th day from admission. Review of Resident #51's record showed Section F activities were completed late, and review of Resident #94's record showed the Care Areas/Care Plan were not completed timely. The facility's MDS 3.0 Completion Policy stated that admission assessments are to be completed within 14 days of admission, counting the day of admission as day 1.
Inaccurate MDS Coding for Catheter Status and Skin Condition
Penalty
Summary
The facility failed to accurately reflect resident status in the MDS for 2 of 31 residents reviewed for MDS coding accuracy. For one resident, the quarterly MDS with an ARD of 11/21/25 coded the resident as having an indwelling catheter and urinary continence not rated because of the catheter. However, the medical record showed the Foley catheter had been removed on 10/31/25, the resident was voiding freely, and nursing documentation stated the catheter was removed without complications. The resident’s care plan did not reflect a catheter, catheter removal, or urinary incontinence at that time, although the RN later stated the resident voided and was incontinent after the catheter was removed. For another resident, the most recent comprehensive MDS with an ARD of 8/27/25 coded Section M as having an unhealed stage 2 pressure ulcer. The record instead showed surgical wounds to the midchest, epigastric area, and left medial shin, and the weekly skin review did not document an unhealed pressure ulcer. The August 2025 eMAR and eTAR showed the sacrum stage 2 wound treatment had been discontinued on 8/22/25, and the active care plan did not reflect an unhealed pressure ulcer. The MDS Director stated that the resident’s current condition should be reflected at the time of assessment and acknowledged that the MDS was inaccurate. The record also showed that Section J for the second resident was electronically signed after the ARD and was based on auto-populated responses from an earlier pain assessment. The MDS Coordinator stated she used auto-populated responses from the EMR and did not interview the resident or staff because she worked remotely. The DON confirmed that the resident had no pressure ulcer because it was resolved and acknowledged that the MDS was inaccurate because the resident had no unhealed pressure ulcer.
Care Plan Not Updated for Bladder Incontinence
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident reviewed for bladder incontinence. The resident was admitted with diagnoses including osteomyelitis and Rett's Syndrome, and the quarterly MDS with an ARD of 11/21/25 showed the resident could not complete the BIMS interview and had an indwelling catheter noted in Section H. A physician note dated 10/31/25 documented that the Foley catheter was removed and the resident urinated comfortably, and a general note the same day stated the resident was voiding freely after catheter removal with no complications noted. The resident's comprehensive care plan dated 11/22/25 did not reflect that the resident had a catheter, that the catheter had been removed, or that the resident was incontinent of urine. During interview, the RN stated the Foley catheter had been removed about two months earlier due to leaking and that the resident now voids and is incontinent. When the survey team raised the concern with the LNHA and DON, the facility later provided a revised care plan focus reflecting bowel and bladder incontinence dated 1/28/26 after the surveyor's inquiry.
Failure to Follow Medication Monitoring, Clarify Orders, and Document TB Testing
Penalty
Summary
The facility failed to follow physician orders for medication side effect monitoring and failed to clarify a hypoglycemia order for two residents. One resident was admitted with diagnoses including left femur fracture, dementia, and hypertension, and had severely impaired cognitive skills. The resident’s January eMAR/eTAR included an anticoagulant monitoring order requiring documentation of specific side effects every shift, but nurses sometimes signed "N" without documenting in the progress note what side effect was observed, as required by the order. The same resident also had an order stating that if the resident was not alert or not able to swallow during a hypoglycemic episode, a meal or snack should be given within 1 hour, and the order was not clarified even though the instruction did not match the resident’s condition. A second resident, admitted with diagnoses including dementia, hemiplegia and hemiparesis, and hypertension, had a BIMS score of 10 out of 15 indicating moderate cognitive impairment. The resident’s January eMAR/eTAR included multiple medication monitoring orders, including anticoagulant, anticonvulsant, antidepressant, and antipsychotic monitoring. For the anticoagulant order, the record showed entries of No, NA, or Y for INR monitoring, and for the anticonvulsant order nurses documented a check mark rather than the required Y or N. The antidepressant and antipsychotic orders did not state how to document if a significant side effect was observed, and the progress notes did not include documentation of what side effect was observed for any of the documented "N" entries. The resident also had the same hypoglycemia order stating that if not alert or not able to swallow, a meal or snack should be given within 1 hour, and this order was not clarified. The facility also failed to follow appropriate TB testing and documentation for another resident. That resident was admitted with diagnoses including acute respiratory failure with hypoxia, encephalopathy, and chronic diastolic congestive heart failure, and had severe cognitive impairment with a BIMS score of 3 out of 15. The physician ordered PPD testing for TB screening, including a first dose and a second dose 14 days later only if the first dose was negative. The January eMAR showed the PPD solution documented as administered twice by two different nurses, and the PPD results were read as negative on both occasions. However, the progress notes did not document whether the PPD was actually administered or not administered on the second date, and the record did not contain documented evidence explaining the duplicate entry until after surveyor inquiry.
Failure to Follow Hospice Orders and Hypoglycemia Monitoring/Notification Orders
Penalty
Summary
Resident #12, who had diagnoses including dementia, hemiplegia/hemiparesis, and hypertension and a BIMS score of 10, was receiving hospice services. Hospice visit notes included recommendations for morphine 5 mg every 1 hour as needed for pain/dyspnea and lorazepam for muscle spasms if baclofen was not effective. The January eMAR/eTAR showed only one morphine order for pain management, with no separate order for dyspnea, and there was no progress note showing that the physician did not agree with the hospice recommendation. The record also did not reflect an order for lorazepam for muscle spasms, and there was no progress note documenting physician disagreement with that recommendation. Resident #120, who had diagnoses including end stage renal disease, type 2 diabetes mellitus, anxiety disorder, hypertension, and anemia, had a care plan reflecting palliative care and was on oxygen and dialysis. The physician order for fluid restriction was plotted every shift, but the chart did not document the ordered amounts and did not follow the prescribed restriction. The sliding-scale Humalog order required the MD to be called for blood sugar values under 70, but when the resident’s blood sugar was 69, there was no documented evidence that the MD was notified. The record also did not show administration of the PRN dextrose 40% gel or the PRN meal/snack order for that hypoglycemic episode, and there was no documented evidence that blood sugars were checked and followed per the order on two dates. A progress note documented a later hypoglycemic episode in which the resident’s blood sugar was checked at 0730 and found to be 36, glucagon and orange juice were given, the blood sugar was rechecked at 0735 and 0745, and additional checks were documented later that morning. However, the medical record did not show that the physician was notified of the blood sugar changes or the change in condition, and the PRN interventions documented in the progress note were not signed off as given in the eMAR. The DON stated that the facility’s practice was to use SBAR or eInteract for changes in condition and to notify the MD, but the record lacked documentation of those actions for this resident.
Infection Control Lapses During Wound Treatment
Penalty
Summary
The facility failed to maintain infection control practices during wound treatment for a resident with diagnoses including fracture of the left femur, dementia, and hypertension. The resident’s most recent MDS reflected severely impaired cognitive skills for daily decision making. During observation of wound care for both heels and the right ankle, the LPN removed gloves and performed hand hygiene, then used a marker taken from her pants pocket to date a dressing without disinfecting the marker before returning it to her pocket. During the same treatment, the LPN repeatedly doffed and donned gloves without performing hand hygiene after glove removal and before putting on new gloves. The LPN performed handwashing for 9 seconds outside the flow of water while treating the right heel, and later performed handwashing for 20 seconds outside the flow of water before rinsing her hands and turning off the faucet with a wet hand before drying with a paper towel. At the end of the treatment, after removing supplies and leaving the room, the LPN did not perform hand hygiene before touching the treatment cart handle, then reached into her pocket for the cart keys and opened the cart. The surveyor also observed that the ADON held the resident’s legs during the heel treatments, and no clean surface was placed under the resident’s heels during the procedure. The resident’s heels were observed close to touching the bed sheet and blanket on more than one occasion. When interviewed, the LPN acknowledged taking the marker from her pocket and stated she made a mistake and should have performed hand hygiene after removing gown and gloves. The IPN stated that hand hygiene should be performed before donning gloves and after removing gloves, that the faucet should remain running while drying hands, and that the faucet should be shut off after hands are dried with a new paper towel.
Failure to Follow Tube Feeding and Weight Notification Orders
Penalty
Summary
The facility failed to clarify physician orders to ensure appropriate care and services for a resident receiving enteral feedings, and failed to notify the physician of a weight gain of 2 to 5 lbs as ordered. Resident #51 had diagnoses including pneumonia, acute respiratory failure with hypoxia, dysphagia, and chronic diastolic congestive heart failure, and the MDS showed severe cognitive impairment with a BIMS score of 3 and that the resident was receiving tube feeding. The care plan identified the resident as NPO and requiring TF related to dysphagia, and the order summary showed an enteral feeding order for Jevity 1.5 bolus via PEG five times daily. The order summary also listed PRN orders for Milk of Magnesia and acetaminophen as being given by mouth, and a daily weight order requiring physician notification for a weight gain of 2 lbs or more within 24 hours and/or 5 lbs or more within one week. The resident’s weight increased from 102.8 lbs to 105.6 lbs, a gain of 2.8 lbs, but the physician was not notified. The RN/UM confirmed that the oral medication orders had been entered incorrectly and that the doctor should have been called for the weight gain, and confirmed that the physician was not notified and the order was not followed.
Failure to Follow Dialysis Medication Timing and Fluid Restriction Orders
Penalty
Summary
The facility failed to provide dialysis-related care and services in accordance with professional standards for a resident with type 2 diabetes mellitus with diabetic chronic kidney disease and end stage renal disease who was receiving hemodialysis on Tuesdays, Thursdays, and Saturdays. The resident’s comprehensive assessment showed a BIMS score of 11, indicating moderate cognitive impairment, and the care plan identified renal insufficiency related to ESRD. The physician order for dialysis specified a 10:00 AM pickup time and 10:30 AM chair time, and the facility’s hemodialysis policy required communication with the attending physician regarding withheld medications and inclusion of any ordered fluid restriction in the dialysis plan. Medication administration records showed that Brimonidine Tartrate ophthalmic solution and Gabapentin were scheduled for administration on dialysis days, but on multiple dates the medications were not given and were documented with a legend indicating the resident was out to dialysis. The record review showed this occurred on several dialysis days, and the RN/UM and LPN reviewed the nursing progress notes and confirmed the medications should have been adjusted according to the dialysis time. The RN/UM also acknowledged that the medication timing issue had not been corrected at the time of the survey review. The resident also had a physician order for a 1000 mL fluid restriction, with specific amounts assigned across shifts, but the eMAR showed the restriction was not followed on multiple dates. Documented total fluid volumes exceeded the ordered limit on several days, including totals of 1050 mL, 1770 mL, 2180 mL, 1290 mL, and 1770 mL. During interview, the DON stated the resident was noncompliant with the fluid restriction, and the surveyor’s review found no documented clarification with the physician for the noncompliance at the time of the survey.
Inaccurate Daily Staffing Report Posting
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report (NHRCSR) accurately reflected licensed nurse staffing, CNA staffing, and resident census at the beginning of the shift on 3 of 6 observed days during the annual recertification survey. On 1/21/26, the survey team entered the facility at 9:07 AM and observed the NHRCSR posted at the front desk for the 7 AM-3 PM shift showing a resident census of 118, while the LNHA stated the census was 117 with no bed hold. On 1/22/26, the posted NHRCSR showed a census of 117, but the staffing sheet later provided by the LNHA reflected a census of 118. On 1/27/26, the posted NHRCSR showed a census of 116, while the LNHA provided a staffing sheet with a census of 118. During interviews, the Receptionist stated the Staffing Coordinator was responsible for posting the NHRCSR around 8 AM, while the Staffing Coordinator stated she ran the schedule, completed the count, entered the information into the state report, printed it, and posted it in the lobby around 7 to 7:30 AM, sometimes asking a Supervisor to post it if she was out or late. On 1/29/26, the Staffing Coordinator stated she sent out staffing with the census the night before and changed it in the morning, and that the posting for those days should have been accurate. The LNHA stated the staffing reporting was done the night before, that two discharges did not come in after midnight, and that the posted NHRCSR was not changed before 7 AM. The facility's Staffing Policy dated 9/1/25 stated the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents, but it did not include information about the regulations for posting, and management stated there were no other staffing policies.
Missed pharmacist review and delayed response to CP medication recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review for a resident with dementia, hemiplegia and hemiparesis, and hypertension. The resident’s record showed the last pharmacy consultant visit documented in the progress notes was on 11/30/25, and the electronic medical record did not contain a consultant pharmacist document. The DON stated the consultant pharmacist was expected to review all residents and had access to the EMR, but the resident’s record did not reflect a monthly review documented in the chart. The facility also failed to act in a timely manner on consultant pharmacist medication regimen review recommendations for another resident with prostate cancer, obstructive and reflux uropathy, severe cognitive impairment, and frequent bowel incontinence. During medication pass observation, an LPN administered both docusate sodium 100 mg capsule and docusate sodium liquid to the resident. The resident’s eMAR showed both orders scheduled at 9:00 AM and 5:00 PM and documented as given. The consultant pharmacist had previously recommended changing the docusate capsule to liquid because the resident needed medications crushed, and later noted that Colace appeared twice on the eMAR as liquid and capsules. The consultant pharmacist report dated 12/30/25 asked the facility to confirm both orders and discontinue one if needed, but no response was documented on the report. The facility’s pharmacy services policy did not include a time frame for responding to or acting on consultant pharmacist recommendations. The surveyors notified the LNHA and DON of the duplicate medication orders and the lack of documented response to the consultant pharmacist’s recommendations.
Unclear Diclofenac Gel Dose Administration
Penalty
Summary
The facility failed to ensure that Resident #15 did not receive an unnecessary medication by using an inaccurate or unknown dose of diclofenac sodium topical gel. The resident was admitted with diagnoses including atrial fibrillation, essential hypertension, and muscle weakness, and had a BIMS score of 15 out of 15, indicating no cognitive impairment. The comprehensive care plan noted left foot pain. The active physician orders and eMAR showed diclofenac sodium external gel 1% ordered for the left hip twice daily for pain and separately for the left knee twice daily for pain. During interview, the resident stated the nurse brought the gel in a small cup. The assigned RN stated the amount given depended on the area and described it only as a little for a small area or more for a bigger area, and then said maybe the size of a fingertip or more, without identifying a specific dose. The consultant pharmacist stated the gel should be measured on the dosing card as either 2 grams or 4 grams depending on the application site. The manufacturer package insert stated lower extremities require 4 grams and upper extremities require 2 grams, and the facility medication administration policy required verification of the dose and reference to drug information when unfamiliar with a medication.
Medication Storage and Labeling Deficiency
Penalty
Summary
Medication storage and labeling were not maintained in accordance with accepted professional principles and the facility’s own policy. During a medication pass observation, an LPN left a bottle of Aspirin 81 mg chewable tablets unattended on top of the med cart while administering medications to one resident, and later left a package of methylprednisolone tablets unattended on top of the med cart covered only by a sheet of paper while administering medications to another resident. The consultant pharmacist stated that medications should not be left on top of the med cart and should have proper labels or be removed from active medications and stored elsewhere such as the med room. During a medication storage observation, surveyors found a plastic bag containing a Trelegy inhaler in the bottom drawer of a med cart. The inhaler had a resident’s name and a date written in black marker, but it did not have a pharmacy label affixed by the facility provider pharmacy or another pharmacy. A second Trelegy inhaler for the same resident was also present in the cart in a manufacturer box with a pharmacy label on both the box and inhaler. The LPN stated the labeled inhaler from the provider pharmacy was the one being used, while the unlabeled inhaler was kept there because it belonged to the resident and had likely come from the hospital or home.
Leaking Kitchen Sink Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition when a sink in the middle of the food preparation area was observed leaking during surveyor observation with the Food Services Director present. The FSD was unable to turn off the sink using the faucet handles and stated she did not know about the leaking sink. On a follow-up kitchen tour the next day, the sink in the meal prep area was still observed with a steady leak. The facility’s Kitchen cleaning policy dated 9/1/25 stated that staff shall maintain the sanitation of the kitchen, and the concern was discussed with the LNHA and DON during interview.
Failure to Obtain and Document Resident Weights per Physician Orders
Penalty
Summary
The facility failed to follow professional standards of clinical practice regarding the assessment and documentation of residents' weights and the implementation of physician orders. Specifically, three residents with various medical conditions, including urinary tract infection, congestive heart failure, hypertension, respiratory failure, COVID-19, pneumonia, anemia, and muscle weakness, had physician orders for weights to be collected on admission and then weekly for four weeks. However, for each of these residents, weights were either not collected as ordered or were only collected once, with no documentation in the progress notes explaining the omissions. Interviews with facility staff, including the Dietitian and Director of Nursing, revealed that there were established expectations and policies for weight monitoring and documentation, including procedures for documenting refusals or missed weights. Job descriptions for CNAs, LPNs, RNs, and the Dietitian outlined responsibilities related to weighing residents and documenting or reporting weight changes. Despite these policies and procedures, the required weights were not consistently obtained or documented, and there was no evidence in the medical record to explain the missed assessments.
Failure to Screen and Enforce PPE Use for EMTs
Penalty
Summary
The facility failed to properly screen outside vendors and ensure that Personal Protective Equipment (PPE) was worn on the COVID unit, specifically involving two Emergency Medical Technicians (EMTs) who were observed transporting a resident. The resident's electronic medical record indicated an admission date, but the report does not specify any medical history or condition at the time of the deficiency. During an observation, the EMTs were seen on the facility elevator without masks while transporting the resident to the third floor, which was under COVID precautions. Interviews revealed that the EMTs were not informed of the COVID outbreak, nor were they screened or instructed to wear masks on the affected units. The facility Receptionist admitted to not properly screening the EMTs, and the Director of Nursing (DON) confirmed the expectation that all individuals entering the facility should be screened according to the COVID outbreak protocol. The facility's policy for emergent infectious diseases required screening and temperature checks for all administrative staff, contractors, and visitors before entering the facility, which was not followed in this instance.
Infection Control Deficiencies in Glucometer Disinfection and PPE Disposal
Penalty
Summary
The facility failed to properly disinfect a multi-use glucometer with an EPA-registered disinfectant, as observed during a survey. A Licensed Practical Nurse (LPN) was seen using an alcohol wipe to clean the glucometer after using it on a resident, which is not in accordance with the facility's policy that requires the use of an EPA-registered disinfectant effective against HIV, Hepatitis C, and Hepatitis B. This practice was observed on the East medication cart, where the same glucometer was used for multiple residents, increasing the risk of transmitting blood-borne pathogens. The LPN confirmed that she had been educated to use alcohol pads for disinfection, which contradicts the facility's policy. Additionally, the facility did not ensure proper doffing and disposal of Personal Protective Equipment (PPE) to prevent infection spread. Observations revealed that a visitor exiting a resident's room on isolation precautions disposed of used PPE in hallway trash receptacles instead of inside the room. The facility's policy mandates that PPE should be disposed of in appropriate waste receptacles within the room to prevent contamination. The Director of Nursing (DON) confirmed that the expectation was to dispose of PPE inside the rooms, but the trash cans were placed in the hallway by housekeeping staff. The survey also noted that the facility had two rooms on isolation precautions, with signage and PPE equipment posted on the doors. However, there was inconsistency in the availability of trash receptacles for PPE disposal inside these rooms. One room had a large trash can near the door, while the other did not, leading to improper disposal practices. The Housekeeping Director stated that training was provided to staff on cleaning isolation rooms, but the placement of trash receptacles was not consistent with the facility's infection control policy.
Removal Plan
- Facility wide staff education on proper disinfection of multi-use glucometers
Failure to Maintain Proper Oxygen Orders and Labeling
Penalty
Summary
The facility failed to ensure that a resident had the appropriate physician orders for the use of oxygen and that the oxygen tubing was properly labeled. The electronic medical record for the resident showed no active order for oxygen use, yet the resident was observed using oxygen at 2 liters per minute from a wall delivery system. The oxygen tubing and water humidifier were unlabeled, and the tubing was improperly wrapped around the bed's side rail, with an oxygen mask left uncovered and dangling to the floor. A staff nurse administered medication to the resident without addressing the oxygen system. A Licensed Practical Nurse confirmed that the oxygen should be continuously administered via nasal cannula and acknowledged the lack of proper labeling and contamination of the dangling tubing. It was also confirmed that the resident did not have any active oxygen orders, with the last order having expired over a month prior.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Nursing Home Resident Care Staffing Report was posted in areas accessible to residents, as required by their policy. The policy, revised on 08/14/24, mandates that nurse staffing information be readily available in a readable format to residents and visitors at any time. However, an observation on 09/25/24 at 10:30 AM revealed that there was no staff posting on the third, fifth, and sixth floors where residents lived. During interviews, the Director of Nursing (DON) indicated that the posting should be on the clerk's desk downstairs and sometimes in the window next to activities, but both the DON and the Administrator confirmed that it was not available on the resident floors. This oversight had the potential to prevent residents from knowing the staffing levels provided for all 96 residents in the facility.
Inadequate Pain Management and Care Plan Revision
Penalty
Summary
The facility failed to implement and revise care plan interventions for Resident #1, who was experiencing pain resulting in a decline in condition. Despite the CP indicating pain related to a disease process and interventions to address pain symptoms, the facility did not adequately manage Resident #1's pain when it exceeded a Pain Scale (PS) of 3. Orders for pain medication were in place, but Resident #1 reported significant pain levels on multiple occasions, including a PS of 9 on 2/2/24, without appropriate intervention or revision of the care plan. Documentation revealed Resident #1's steady decline in skilled interventions due to pain and fatigue, with reports of significant pain levels in various body parts. The facility's failure to address Resident #1's pain adequately led to a decline in functional abilities and overall well-being. Despite reports of pain and weakness, there was no indication that the care plan was revised or that stronger pain management measures were considered, as required by the facility's policy on pain management and comprehensive care planning.
Inconsistent Pain Management and Documentation
Penalty
Summary
The facility failed to consistently follow the care plan, evaluate pain, and ensure proper administration of pain medications for Resident #1, who was experiencing pain related to various conditions including falls, difficulty in walking, and adult failure to thrive. Despite the care plan indicating the need for analgesia as per physician's orders, there were instances where pain assessments were not conducted or documented appropriately. The medication administration records revealed discrepancies where Resident #1 reported pain levels above the prescribed threshold, but there was no indication that the ordered pain medication was administered accordingly. Documentation from the Occupational Therapy Treatment Encounter Notes indicated Resident #1's continuous complaints of pain and decline in skilled interventions due to pain and fatigue. The Certified Occupational Therapy Aide (COTA) acknowledged the lack of communication to nursing regarding the resident's pain and emphasized the importance of documenting such interactions for proper care coordination. The facility's policy on pain management highlighted the need for comprehensive, person-centered care plans addressing individual pain management needs, including both pharmacological and non-pharmacological interventions. During interviews with the Occupational Therapist/Director of Rehab (OT/DOR), COTA, and LPNs, it was revealed that there were communication gaps regarding Resident #1's pain status and management. LPN #3 mentioned the challenges in managing Resident #1's pain with only PRN medication and the resident's distress during episodes of severe pain. The facility's policy emphasized the interdisciplinary approach to pain management, incorporating non-pharmacological interventions alongside pharmacological treatments tailored to each resident's specific pain needs.
Inaccurate MDS Assessment of Resident's Pressure Ulcer
Penalty
Summary
The facility failed to accurately encode a resident's wound in the Minimum Data Set (MDS) assessment for one of the three residents reviewed for MDS accuracy. Specifically, Resident #1 was admitted with diagnoses including Difficulty in Walking, Adult Failure to Thrive, and Protein Calorie Malnutrition. The MDS assessment dated 12/10/23 indicated that the resident did not have a pressure ulcer. However, a review of the resident's Skin Integrity/Diagram (SID) dated 12/8/23 showed that the resident had a sacral pressure ulcer described as redness. Additionally, the Order Summary Report (OSR) dated 4/15/24 revealed an order for preventative skin care, including the application of barrier cream after cleansing with soap and water every shift and as needed after each incontinent episode, starting from 12/6/23. The Treatment Administration Record (TAR) for December 2023 confirmed that the barrier cream was applied to the resident's skin from 12/7/23. During interviews with the surveyor, the Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed the documentation on the SID, and the MDS Coordinator (MDSC) confirmed that the previous MDS staff, who no longer work at the facility, had miscoded the 12/10/23 assessment in Section M. The facility's policy titled MDS Completion and Submission Timeframes, dated 10/2019, indicated that the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. This discrepancy in the MDS assessment led to the deficiency noted in the report.
Failure to Provide Adequate Toileting Assistance
Penalty
Summary
The facility failed to provide adequate assistance in toileting services to a resident, leading to a deficiency. The resident, who was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, muscle weakness, and a need for assistance with personal care, was found in a severely neglected state. During a skin check, the resident was observed lying in a soaked and wet incontinence brief, with fecal matter on their back, and stained bed linens. The resident's care plan indicated a need for assistance with hygiene and comfort measures due to impaired mobility and incontinence, but these needs were not met. The CNA responsible for the resident admitted to not checking or changing the resident's incontinence underwear since the beginning of the shift, citing staff shortages as the reason for the oversight. The facility's policy requires residents to be checked for wetness every two hours and changed immediately if soiled, but this protocol was not followed. The facility's documentation and interviews with staff revealed that the third floor, where the resident was located, had three CNAs assigned to 27 residents on the day of the incident. The CNA job description and facility policies emphasize the importance of keeping residents dry and providing necessary perineal care to prevent skin breakdown and maintain hygiene. However, the failure to adhere to these policies resulted in the resident being left in an unsanitary and uncomfortable condition, highlighting a significant lapse in the standard of care provided by the facility.
Inadequate Staffing Leads to Neglect of Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, specifically Resident #2, who was admitted with diagnoses including Urinary Tract Infection, Metabolic Encephalopathy, Muscle Weakness, and required assistance with personal care. On 4/15/24, during a skin check at 10:36 am, Resident #2 was found lying in bed with a soaked and wet incontinent brief, and the bed sheets were stained with urine and feces. The resident's lower to mid-back had fecal matter, indicating that the resident had not been checked or changed since the beginning of the shift at 7:00 a.m. The CNA assigned to Resident #2 confirmed that she did not provide care until 10:36 a.m. due to being short-staffed that day. The third floor had 27 residents and only 3 CNAs on duty, which contributed to the inadequate care provided to Resident #2. The care plan for Resident #2, initiated on 4/9/24 and revised on 4/15/24, indicated that the resident had actual impairment to skin integrity related to impaired mobility, incontinence, and nutritional concerns. The Minimum Data Set (MDS) assessment dated 4/13/24 indicated that Resident #2's cognition was moderately impaired and required assistance with Activities of Daily Living (ADLs). The MDS also noted that the resident was incontinent of bowel and bladder. The CNA job description included specific functions such as making residents comfortable, keeping them dry, and assisting with bowel and bladder functions, which were not adequately performed due to staffing shortages. This deficiency highlights the facility's failure to provide sufficient nursing staff to meet the needs of its residents, as required by NJAC 8:39-27.1(a).
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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 Hackensack
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Careone At Wellington | 0.7 mi | ★★★★★ | 0 | 0 |
| Atlas Rehabilitation And Healthcare At Maywood | 0.8 mi | ★★★★★ | 25 | 0 |
| Complete Care At Regent Llc | 1.1 mi | ★★★★★ | 0 | 0 |
| Alaris Health At The Chateau | 1.2 mi | ★★★★★ | 4 | 0 |
| Careone At Teaneck | 2.5 mi | ★★★★★ | 0 | 0 |
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