Average — CMS composite of the measures below.
A standard survey is most likely before 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 Shrewsbury Llc during CMS and state inspections, most recent first.
Failure to maintain a resident's dignity during toileting assistance. A cognitively intact resident with an indwelling catheter, bowel incontinence, and substantial toileting needs was trying to get to his bathroom when a CNA told him he could not use it because housekeeping was cleaning and that he would have to wait while she helped another resident. The CNA also told him she would put him to bed and clean him up afterward, and the resident said he felt humiliated by the response.
Inaccurate MDS coding affected five residents. One resident on O2 had MDSs that did not code oxygen use, another had radiation therapy coded without supporting documentation, a resident with dementia had inaccurate wt/weight-loss coding, one resident enrolled in hospice was coded as not receiving hospice services, and another resident with a documented fall was coded as having no falls since admission.
Incomplete and unimplemented care plans were identified for several residents. Care plans did not reflect diagnoses such as Asperger's syndrome and conversion disorder, did not include a dialysis order not to change permacath end caps, did not match the fall-prevention intervention of floor mats on both sides of the bed, and did not address warfarin therapy for DVT prophylaxis. Staff and the DON acknowledged the missing or incomplete care plan content.
Failure to Offer Pneumococcal Immunizations: Four of five residents reviewed had no clear documentation that pneumococcal immunizations were offered and/or provided. One resident had no record of an offer, another had a representative’s authorization but no documented offer, a third signed a consent form that did not show whether she wanted the vaccine, and a fourth also had no documented evidence of an offer. The LPN unit manager, DON, and IP each described the admitting nurse and IP roles in the process, and the IP confirmed staff were not ensuring residents and/or representatives were offered the vaccines.
Failure to Complete Significant Change MDS After Hospice Enrollment: A resident with a hx of atherosclerotic heart disease, bipolar disorder, moderate protein calorie malnutrition, and HF was placed on hospice after a physician order for hospice eval and tx and acceptance into the hospice program. The MDS record showed the resident later as receiving hospice services on one quarterly MDS and not receiving hospice services on a later quarterly MDS, but no Significant Change MDS was completed for the hospice status change. The MDSC and Corporate MDS staff confirmed the SCSA should have been completed within the required timeframe.
The facility failed to revise care plans for two residents after changes in condition were documented. One resident with ESRD on dialysis had a fistula bleeding event after picking at the site, but the care plan did not reflect interventions for that behavior. Another resident with stroke and AKI had significant unplanned weight loss and updated nutrition needs, but the nutrition care plan was not revised to match the RD’s documented findings and recommendations.
Failure to assess and monitor a surgical incision: A resident admitted after right hip fracture repair had a surgical wound documented on admission, but the chart lacked further incision assessments and had no daily wound monitoring in the TAR/MAR. Later, the resident developed fever, abnormal vital signs, and a swollen, warm stapled hip site, and was sent to the hospital for possible sepsis. The DON stated the incision should have been assessed and monitored starting on admission.
Failure to monitor wander guard effectiveness and adjust interventions affected two residents. One resident with Parkinson’s disease and moderate cognitive impairment had an elopement history and a wander guard, but the record showed no further wandering behaviors and no care plan discussion about whether the device was effective. Another resident with psychiatric diagnoses and intact cognition was observed with a wander guard, but the chart lacked documentation explaining why it was placed, had no behavior monitoring for wandering or elopement, and showed no care plan review of the device’s effectiveness.
A resident with a recent stroke, depression, and adjustment disorder had an incomplete comprehensive social services assessment on admission. The SSD confirmed the assessment should have been completed after admission but was not, and she was unaware the resident had PTSD, a history of severe depression and prior suicide attempts, and difficulty coping with dependence after the stroke.
Staff failed to wear proper PPE when caring for two residents on EBP. One resident had a pressure ulcer and was observed receiving care from a CNA who entered the room without a gown and gloves, including while preparing a bed bath. Another resident had a foley catheter, dialysis permacath, and VRE history; the room lacked EBP signage and a PPE cart during tour, and an LPN entered without PPE to give meds and check the permacath dressing. The resident reported staff did not always wear a gown and gloves for care such as dressing checks or emptying the urinary drainage bag.
Incomplete COVID-19 Vaccination Offer and Documentation: The facility failed to ensure COVID-19 vaccination education, offer, and documentation were completed for four residents reviewed. Records showed one resident had no documentation that the vaccine was offered, another had a signed authorization but no evidence the vaccine was given, a third had a consent form without a documented choice, and a fourth also had no documentation that the vaccine was offered. The LPN, DON, and IP each described staff responsibilities for education, obtaining consent, and auditing records, but confirmed the forms were not fully completed.
The facility failed to serve hot foods at acceptable temperatures and did not follow its Test Tray Policy. A test tray and meals for nine residents were delivered with food temperatures below the required 135 degrees Fahrenheit. The FSD confirmed the deficiency and admitted that test trays were only conducted upon receiving complaints, contrary to the policy requiring weekly random test trays.
The facility failed to verify the certification of an agency CNA, whose certification was suspended, before she provided care to residents. This oversight violated the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, as the facility could not provide documentation of certification verification, despite claims of checking through the Online Public Registry.
A resident with severe cognitive impairment and behavioral disturbances frequently wandered into other residents' rooms, leading to physical altercations. Despite a care plan addressing wandering, the facility failed to implement effective supervision or transfer the resident to a more appropriate setting, resulting in ongoing incidents and a high risk of abuse.
The facility failed to provide bed hold policy information to four residents during hospital transfers, as required by policy. This oversight was confirmed by staff interviews and a lack of documentation in the residents' records.
The facility failed to provide scheduled showers to seven residents, as per their care plans, due to insufficient staff assistance. Residents reported not receiving showers for several weeks, and staff interviews revealed a lack of documentation confirming the provision of showers.
The facility failed to timely report an injury of unknown origin for a cognitively impaired resident and an abuse incident between two residents. The injury was discovered in the morning but reported to the State Agency the next day. In another case, a cognitively impaired resident wandered into another's room and was nearly struck, but the incident was not reported, and the resident continued to wander unsupervised.
The facility failed to investigate an incident where a cognitively impaired resident wandered into another resident's room, leading to a potential altercation. The cognitively intact resident admitted to being about to punch the intruding resident. Despite the facility's policy requiring thorough investigation of such incidents, the Director of Nursing confirmed that no investigation was completed, and the wandering behavior continued.
The facility failed to notify the Ombudsman of two residents' transfers to the hospital. One resident was taken to the ER for altered mental status and hypotension, and another for chest tightness and congestion. The usual procedure of completing a Transfer/Bed Hold notice was not followed, and the Business Office Manager could not locate the notices for these transfers.
A resident with dementia and a history of wandering behaviors was admitted to a facility, but their MDS assessment failed to reflect these behaviors and the use of a wander-guard bracelet. Despite documentation in the Admission Elopement Assessment and a physician's order for a Wander Guard, these details were omitted from the MDS. Facility staff confirmed the oversight, acknowledging that the resident's status should have been accurately documented.
The facility failed to present a baseline care plan within 48 hours for a resident with a fractured hip and intact cognition, and did not address the use of a wander-guard for another resident with dementia and wandering behaviors. The care plans did not include necessary interventions, confirmed by staff interviews.
A resident with COPD, emphysema, and asthma was receiving continuous oxygen therapy without a physician's order, and the nebulizer tubing was not changed as required. Observations showed that the oxygen tubing and nebulizer tubing had not been changed since a specified date, and the oxygen concentrator was unclean. Staff interviews revealed a lack of awareness and adherence to the facility's policy on oxygen administration.
A facility failed to assess and document the use of one-quarter bed rails for a resident with heart surgery and diabetes, who had intact cognition. Despite a physician's order for side rails, there was no documented assessment, informed consent, or care plan inclusion. Observations confirmed the resident's use of side rails without proper documentation, and the Administrator acknowledged the lack of policies for maintenance and safety checks.
The facility failed to properly label, date, and maintain cleanliness of food items in a second-floor refrigerator, with various items found unlabeled, undated, and expired. Additionally, a third-floor freezer had significant ice buildup due to a faulty door seal. The Food Services Director confirmed these deficiencies, which were not in compliance with the facility's policies on food storage and labeling.
The facility failed to provide adequate PPE for residents on Enhanced Barrier Precautions. A resident with cellulitis and another with wounds did not have gowns available on their isolation carts. Staff entered rooms with only gloves, acknowledging the lack of gowns and uncertainty about restocking responsibilities. The Unit Manager admitted to not restocking the carts.
Failure to Maintain Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to ensure that one resident was treated with dignity during toileting. The resident was admitted with benign prostatic hyperplasia with lower urinary tract symptoms, had a BIMS score of 13 out of 15 indicating intact cognition, was assessed as having an indwelling catheter and being always incontinent of bowel, and required substantial assistance with toileting. His care plan indicated he required one-person assistance with toileting and transfers. During observation, the resident was seen in his wheelchair trying to get into his room to use the bathroom, but a CNA told him he could not use the bathroom because housekeeping was cleaning it and that he would have to wait until she finished taking another resident to the shower. The CNA also told him she would put him to bed and clean him up afterward. In interview, the resident stated he had just returned from an appointment and needed to use the bathroom, and he felt humiliated by the CNA's statement that he could use the bathroom in his briefs. The CNA stated she was assisting another resident and did not have time to stop, and later acknowledged she did not realize she had humiliated the resident. An LPN stated the CNA could be brisk with residents and agreed the response was a violation of the resident's dignity.
Inaccurate MDS Coding for Oxygen, Radiation Therapy, Weight Loss, Hospice, and Falls
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for five residents. For one resident with chronic respiratory failure with hypoxia, the record showed oxygen at 2L via nasal cannula on admission and again after a hospital return, and the resident was observed wearing oxygen and unable to respond to questions because of significant shortness of breath, yet the modified quarterly MDS and the 5-day PPS MDS did not code oxygen use. The MDS Coordinator stated that oxygen had not been coded and needed correction. For another resident with a stroke and diabetes, the quarterly MDS showed a BIMS score of 9 and indicated radiation therapy during the observation period, but the EMR did not contain documentation explaining why radiation therapy was received, and the MDS Coordinator stated the coding was inaccurate. A resident with dementia had a discharge return anticipated MDS that showed no weight loss and a weight of 166 pounds, while the weights record showed 177.3 pounds on 02/03/25; the Registered Dietician stated the resident was refusing weights and that the assessment should have reflected the 166-pound weight and weight loss. Another resident had an order for hospice evaluation and treatment and was accepted into hospice, but the quarterly MDS documented that hospice services were not being received. A fifth resident had a documented fall on 06/30/25 and was assessed as a high fall risk, but the quarterly MDS stated the resident had not had any falls since admission. The MDS Coordinator and corporate MDS coordinators confirmed the hospice and fall coding were inaccurate.
Incomplete and Unimplemented Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and/or implemented for five residents in a sample of 33. Review of records, observations, interviews, and facility policy showed that the care plans for residents with Asperger's syndrome, conversion disorder with seizures, dialysis-related care, fall prevention needs, and warfarin therapy did not fully reflect the residents' diagnoses, physician orders, or required interventions. The facility policy required comprehensive, person-centered care plans with measurable objectives and timeframes to meet each resident's medical, nursing, and psychosocial needs. One resident was admitted with Asperger's syndrome, and the annual MDS listed that diagnosis as active, but the care plan did not address the diagnosis or its signs and symptoms. Another resident was admitted with conversion disorder with seizures or convulsions, but the care plan did not reflect the diagnosis or what signs and symptoms to observe. An LPN stated she was aware of both diagnoses and believed they should have been included in the care plans so staff would know what to expect and how to react. The DON stated the residents had these diagnoses prior to admission but felt there was no need to develop a care plan unless the residents exhibited those signs and symptoms while in the facility. A resident with chronic kidney failure and dependence on renal dialysis had physician orders for dialysis and for monitoring the left internal jugular permacath site, including an order not to change the end caps or dressing, but the care plan did not include that instruction. Another resident with metabolic encephalopathy and stroke had a fall care plan that called for floor mats on both sides of the bed after an actual fall, yet observation showed only one mat in place and staff confirmed the second mat was missing. A resident with TIAs and progressive bulbar palsy received warfarin for DVT prophylaxis, but the comprehensive care plan did not include a focus, goal, or interventions for warfarin use; the UM confirmed there was no care plan for that medication.
Failure to Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that four of five residents reviewed for immunizations had been offered and/or provided a pneumococcal immunization. R12, admitted with diagnoses including encounter for surgical aftercare following surgery of the digestive system, colostomy, and an incisional site infection, had no documentation in the paper medical record that a pneumococcal immunization had been offered. R129, admitted with diagnoses including enterocolitis, acute kidney failure, and chronic obstructive pulmonary disease, also had no documented evidence that the pneumococcal immunization had been offered. R82, admitted with diagnoses including acute cystitis without hematuria, unspecified injury to the head, muscle weakness, dysphagia, and severe protein calorie malnutrition, had an authorization for the pneumococcal immunization signed by the representative, but the record did not show that the resident had been offered the vaccine. R89, admitted with a diagnosis of encounter for aftercare from surgery on the circulatory system, had signed a consent form for a pneumococcal immunization, but the form did not indicate whether she wanted the immunization. During interviews, the LPN unit manager stated the admitting nurse was responsible for providing education and obtaining signed forms, and the DON stated the admitting nurse was responsible for offering the vaccine and completing the consent form. The IP stated her role was to ensure the forms were completed, and confirmed staff were not ensuring residents and/or representatives had been offered the vaccines.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to ensure that a Significant Change MDS was completed for one resident, R6, after the resident was placed on hospice services. R6 was admitted with diagnoses including atherosclerotic heart disease, bipolar disorder, moderate protein calorie malnutrition, and heart failure. The record showed a physician order dated 05/01/25 for Affinity Hospice to evaluate and treat, and an Affinity Care Facility Notification of Admission dated 05/05/25 showed the resident was accepted into the hospice program on 05/05/25. Review of R6’s quarterly MDS with an ARD of 05/20/25 showed the resident was assessed as receiving hospice services, while the quarterly MDS with an ARD of 08/20/25 showed the resident was not receiving hospice services. The MDS record did not reveal a Significant Change MDS for the resident being placed on hospice services. During interview, the Corporate MDS 1 and the MDS Coordinator confirmed that a Significant Change MDS should have been completed within the allotted time after the resident started hospice services.
Failure to Revise Care Plans After Changes in Condition
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents after changes in condition and new clinical information were documented. For one resident with end stage renal disease and dialysis dependency, the record showed dialysis orders, monitoring requirements for the left arm fistula, and a subsequent emergency room transfer for excessive bleeding from the fistula after the resident picked at the site. After hospitalization for a rupture of the fistula caused by picking at the fistula, the MDS Coordinator documented plans to revise the care plan to monitor for picking at the fistula, but the care plan revision dated 01/05/25 did not reflect interventions for that behavior. For another resident admitted with stroke and acute kidney injury, the quarterly MDS showed a BIMS score of 9, weight of 129 pounds, and sustained weight loss. The nutrition care plan identified risk for malnutrition and included diet and supplement interventions, but a nutrition follow-up note documented current weight of 114.6 pounds, a significant 10-pound/7% unplanned weight loss in one month, decreased appetite/intake, and recommendations for additional nutrition support and a change in the timing of the Glucerna order. During interview, the RD stated she should have changed the care plan to reflect the resident's current nutritional requirements, but the care plan was not updated to match the documented changes.
Failure to Assess and Monitor Surgical Incision
Penalty
Summary
The facility failed to ensure nursing assessments of a surgical incision were completed for a resident admitted with a right hip fracture and surgical repair. On admission, the comprehensive nursing assessment documented that the resident had a surgical wound, and the admission nursing progress note stated that the right hip surgical incision had a dressing intact, but there was no further documentation showing an assessment of the surgical site. The September 2025 TAR and MAR also contained no documentation of a daily assessment or monitoring of the right hip surgical wound. The care plan dated 09/18/25 identified an actual impairment to skin integrity of the resident’s right hip related to the surgical wound, with interventions focused on skin protection, education, and nutrition/hydration. On 09/22/25, a provider note documented fever, tachycardia, tachypnea, low blood pressure, oxygen saturation of 87% that improved with oxygen, and that the resident was not answering questions and had dementia. The right hip surgical site was noted to have staples, swelling, and warmth, and the resident was sent to the hospital for possible sepsis. A sepsis protocol was completed that day, and the DON stated that assessment and monitoring of the surgical site should have begun at admission.
Failure to Monitor Wander Guard Effectiveness
Penalty
Summary
The facility failed to monitor the effectiveness of wander guards and to modify interventions for two residents, R16 and R69. R16 was admitted with Parkinson’s disease and had a BIMS score of 12, indicating moderate cognitive impairment. His care plan identified him as an elopement risk with a history of attempts to leave the facility, and a wander guard was placed after he was found near the front door attempting to stand from his wheelchair and stating he had a car waiting for him. However, his record showed no further documented elopement attempts, no wandering behaviors on behavior tracking, and no discussion during care plan meetings about whether the wander guard was effective or whether other interventions should be tried. R69 was admitted with bi-polar disorder, anxiety disorder, and major depressive disorder and had a BIMS score of 13, indicating cognitive intactness. She was observed with a wander guard in place, and her care plan identified her as an elopement risk with a history of attempting to leave through the front door. The record showed a wander guard on the left ankle, but there was no documentation explaining why it was placed, no behavior monitoring or intervention report for wandering or elopement, and no discussion during care plan meetings about whether the wander guard was effective or whether other interventions should be attempted. The DON stated that wander guards were placed after attempts to elope and that assessments should be completed, but they were not completed prior to or when the wander guards were placed.
Incomplete Social Services Assessment on Admission
Penalty
Summary
The facility failed to ensure the Comprehensive Social Services Assessment was completed upon admission for one resident, R66, in a sample of 33 residents. Review of the Social Services Director job description showed the Social Services Director is responsible for overseeing social services and completing and/or delegating the social services component of the comprehensive assessment. Review of R66’s admission record showed diagnoses that included a recent stroke with left-sided paralysis, major depressive disorder, and adjustment disorder with depression. Review of the Comprehensive Social Services Assessment dated 08/14/25 showed it was documented as incomplete, with no documentation that the Social Services Director had completed the assessment. The resident’s psychiatric note dated 08/19/25 documented a history of anxiety and severe depression with two past suicide attempts, difficulty coping with reliance on others after the stroke, and denial of suicidal or homicidal ideation at that time. During interview, R66 stated he had PTSD from a sexual assault during military service and said he could not take showers. The Social Services Director stated the assessment should have been done after admission, confirmed it was not completed, and stated she was not aware the resident had voiced PTSD and did not perform a trauma-informed care assessment unless the resident brought it up.
Failure to Use PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff wore the proper PPE when providing care to two residents who were identified as requiring Enhanced Barrier Precautions (EBP). One resident was admitted with moderate protein calorie malnutrition and later developed a pressure ulcer to the left buttocks; a physician order dated 09/07/25 placed the resident on EBP related to wounds. On 09/24/25 at 8:20 AM, a CNA entered the resident’s room carrying linen supplies without donning a gown and gloves, despite EBP signage on the door and a cart with face masks, gloves, and gowns outside the room. The CNA reentered the room again without gown and gloves and was observed preparing to give the resident a bed bath. During interview, the CNA stated she was an agency CNA, had worked with the resident for the past month, and was not aware the resident was on EBP or that PPE should be worn when providing care. The second resident was admitted with acute/chronic kidney failure and dependence on renal dialysis, and physician orders dated 06/05/25 required EBP related to a foley catheter, a permacath for dialysis, and a history of VRE infection. During the initial tour, the resident’s room did not have EBP signage or a PPE cart outside the door. Later, an LPN entered the room without donning PPE to administer medications and check the permacath dressing. The resident stated staff did not always wear a gown and gloves when entering the room to provide care such as checking the permacath dressing or emptying the urinary drainage bag. The LPN stated the resident had been on EBP precautions since admission and acknowledged being reminded that she had been observed entering the room without PPE.
Incomplete COVID-19 Vaccination Offer and Documentation
Penalty
Summary
The facility failed to ensure that four of five residents reviewed for COVID-19 immunizations were offered the vaccine and/or had a documented choice regarding vaccination. Review of the records for four residents showed missing or incomplete documentation related to COVID-19 vaccination status. One resident admitted with diagnoses including encounter for surgical aftercare following surgery of the digestive system, colostomy, and an incisional site infection had no documentation showing the COVID-19 vaccine was offered. Another resident admitted with diagnoses including acute cystitis without hematuria, unspecified head injury, muscle weakness, dysphagia, and severe protein calorie malnutrition had a signed authorization for COVID-19 immunization by a representative, but the record did not show the vaccine had been administered. A third resident admitted after surgery on the circulatory system had signed a consent form for COVID-19 immunization, but the form did not indicate whether the resident wanted the immunization. A fourth resident admitted with enterocolitis, acute kidney failure, and chronic obstructive pulmonary disease also had no documentation showing the COVID-19 vaccine was offered. During interviews, the LPN unit manager stated the admitting nurse was responsible for providing education to the resident and/or representative on immunizations and obtaining signed forms showing the choice made. The DON stated the admitting nurse was responsible for ensuring immunizations had been offered and the form completed with the resident's choice and signature, and that the IP followed up with an audit of records to ensure the forms had been signed and a choice made. The IP stated her role was to ensure the immunization forms had been filled out completely and confirmed staff were not ensuring the resident and/or representatives had been asked about immunizations. The facility policy stated residents or resident representatives would have the opportunity to accept or refuse a COVID-19 vaccination and change their decision based on current guidance.
Failure to Serve Hot Foods at Acceptable Temperatures
Penalty
Summary
The facility failed to serve hot foods at an acceptable temperature for residents and did not adhere to its Test Tray Policy. During a survey, it was observed that a test tray, along with meals for nine residents, was delivered to the second floor unit. The Food Service Director (FSD) was present and confirmed that the food temperatures were below the required 135 degrees Fahrenheit. Specifically, the baked ham was at 117.7 degrees, roasted potatoes at 123.9 degrees, and broccoli at 121.6 degrees. The FSD acknowledged that these temperatures did not meet the facility's standards for hot food service. Additionally, the facility's Test Tray Policy, which mandates weekly test trays at random mealtimes, was not followed. The FSD admitted that test trays were only conducted when a complaint was received, and there was no documentation of recent test trays or complaints. The facility's Food Temperatures and Holding Policy also required hot food to be served above 135 degrees Fahrenheit, which was not adhered to in this instance. The lack of compliance with these policies led to the identified deficiency.
Failure to Verify Certification of Agency CNA
Penalty
Summary
The facility failed to obtain and maintain a record of certification verification for a Certified Nursing Assistant (CNA) employed through an agency, which is a violation of their Abuse, Neglect, Exploitation, and Misappropriation Prevention Program. This deficiency was identified during a review of the employee file for one of three sampled agency employees. The facility's policy requires conducting background checks and not employing individuals with findings of abuse, neglect, or exploitation. However, the facility did not verify the certification of CNA #1, whose certification had been suspended prior to her providing care to residents. During the survey, it was revealed that the facility's Human Resources and License Nursing Home Administrator claimed to verify certifications through the Online Public Registry. However, they could not provide documentation that CNA #1's certification was verified before she began working with residents. The New Jersey Department of Health confirmed that CNA #1's certification was suspended, which would have been evident if the verification had been conducted as claimed. This oversight indicates a failure to adhere to the facility's own policies and state regulations regarding employee certification verification.
Inadequate Supervision Leads to Resident Wandering and Altercations
Penalty
Summary
The facility failed to ensure adequate supervision of a resident with severe cognitive impairment, leading to incidents of wandering into other residents' rooms and resulting in physical altercations. The resident, who was admitted with moderate dementia and behavioral disturbances, had a history of wandering and entering other residents' rooms, which was documented in the facility's records. Despite being aware of the resident's behavior, the facility did not implement effective measures to prevent these incidents, resulting in a high likelihood of physical abuse either by or to the resident. The resident's care plan, initiated shortly after admission, identified wandering as a concern and included interventions such as educating caregivers, redirecting the resident, and providing structured activities. However, these interventions were not sufficient to prevent the resident from continuing to wander into other rooms, as documented in multiple nurse notes. The facility's staff frequently had to redirect the resident, who was often combative and verbally aggressive, but these efforts were not consistently effective. The facility's failure to adequately supervise the resident and prevent wandering led to multiple incidents, including one where the resident was found in another resident's bed and another where a physical altercation nearly occurred. Despite recommendations for the resident to be transferred to a dementia unit, no documented attempts were made to facilitate this transfer. The facility's inaction and lack of a consistent protocol for managing the resident's behavior contributed to the ongoing risk of abuse.
Removal Plan
- Placing Resident #60 on 1:1 supervision until appropriate placement was found.
Failure to Provide Bed Hold Policy to Residents
Penalty
Summary
The facility failed to provide copies of its bed hold policy to four out of five residents reviewed for hospitalization, creating a potential lack of information for residents and their responsible parties regarding their return to the facility. Resident 343 was admitted and later discharged to the hospital without evidence of receiving the bed hold policy. The facility administrator confirmed this oversight during an interview. Similarly, Resident 17 was transferred to the emergency room for altered mental status and hypotension, but there was no documentation of bed hold information being issued. The Licensed Practical Nurse (LPN) stated that the bed hold notice should be completed and provided to the resident or responsible party, but the Business Office Manager (BOM) could not locate the notices for Resident 17. Resident 38 was sent to the emergency room due to chest tightness and congestion, yet no documentation of bed hold information was found in the electronic medical record. The BOM confirmed the absence of these notices. Resident 27 experienced two hospital transfers due to uncontrolled high blood pressure and generalized weakness, but did not receive bed hold notices for either transfer. The Regional Nurse provided transfer notices but confirmed the lack of bed hold notices. The facility's policy requires that written information about bed holds be given to residents and their representatives prior to transfer, but this was not adhered to in these cases.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that seven out of eight residents received adequate assistance with obtaining weekly showers, as per their care plans. During a group meeting, residents expressed concerns about not receiving showers according to their preferences. The facility's policy mandates that residents be provided with care to maintain or improve their ability to carry out activities of daily living (ADLs). However, residents reported that there was insufficient staff available to assist them with showers, leading to several weeks without receiving one. The report details specific instances where residents did not receive showers as scheduled. For example, one resident, with intact cognition, required substantial assistance with showers but only received one shower in May 2024. Another resident, also with intact cognition, was scheduled for showers twice a week but had not received any since the beginning of May. Similar patterns were observed for other residents, some of whom had moderately impaired cognition and required assistance, yet did not receive showers as per their care plans. Interviews with staff, including a CNA and the Director of Nursing, revealed that showers were scheduled twice a week, but there was a lack of documentation confirming that these showers were provided. The Director of Nursing acknowledged the absence of documentation, and the Administrator suggested that CNAs might have forgotten to document the showers, despite residents voicing concerns about not receiving them.
Failure to Timely Report Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident who was severely impaired in cognition. The resident was found with bruising on her right hand, and upon inquiry, indicated that she had been harmed. The incident was reported to the police, and an investigation was initiated. However, the facility did not report the incident to the State Agency until the following day, despite the injury being discovered early in the morning. Additionally, the facility did not report an allegation of abuse between two residents in a timely manner. One resident, who was severely cognitively impaired, wandered into another resident's room and was found on the floor, seemingly in a defensive position. The other resident admitted to being about to strike the intruding resident. Despite this incident, it was not reported to the State Agency, and the cognitively impaired resident continued to wander into other residents' rooms daily. The facility's policy requires all such incidents to be reported to local, state, and federal agencies, but this was not adhered to in these cases.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident of resident-to-resident abuse involving two residents. One resident, who had severe cognitive impairment with a BIMS score of three out of 15, wandered into another resident's room. The second resident, who was cognitively intact with a BIMS score of 15 out of 15, admitted to being about to punch the first resident for entering her room. The incident was not investigated, and the cognitively impaired resident continued to wander into other residents' rooms daily. The Director of Nursing confirmed that the facility did not complete a thorough investigation of the incident. The facility's policy on abuse, neglect, exploitation, and misappropriation requires all reports of resident abuse to be thoroughly investigated and documented. However, this policy was not followed in this case, as the incident was not investigated, and no interventions were put in place to prevent further occurrences.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman program of the transfer of two residents, R17 and R38, to the hospital, which was identified during a review of the facility's transfer form and interviews. For R17, the electronic medical record (EMR) showed that the resident was taken to the emergency room for altered mental status and hypotension, but there was no documentation of a transfer notice being issued. Similarly, R38 was sent to the emergency room due to chest tightness and congestion during a doctor's appointment, but there was no documentation of notification to the responsible party or attending physician regarding transfer rights. Interviews with staff revealed that the usual procedure involved the assigned nurse completing a Transfer/Bed Hold notice and providing it to the resident or their responsible party before hospitalization. However, the Business Office Manager, responsible for compiling and sending transfer notices to the Ombudsman, could not locate the notices for R17 and R38. The facility's policy required a transfer form to be prepared and the representative notified during emergency transfers, but this was not adhered to in these cases.
Inaccurate MDS Assessment for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident, specifically regarding wandering behaviors. The resident, identified as R29, was admitted with diagnoses including dementia with behavior disturbances, repeat falls, and unsteadiness on feet. Despite having a history of wandering behaviors documented in the Admission Elopement Assessment and a physician's order for a Wander Guard/Wander Elopement Device, these details were not included in the resident's admission MDS. This omission was identified during a review of the resident's records and confirmed through interviews with facility staff. Observations and interviews revealed that R29 was wearing a wander-guard bracelet, which was not documented in the MDS. The Unit Manager/Licensed Practical Nurse and the Director of Nursing both acknowledged that the resident's wandering behaviors and the use of a wander-guard bracelet should have been documented in the MDS. The RAI Manual, revised in October 2023, specifies that information should be validated for accuracy by the Interdisciplinary Team completing the assessment, which was not adhered to in this case.
Failure to Implement Baseline Care Plans and Address Wander-Guard Use
Penalty
Summary
The facility failed to discuss and present a baseline care plan within 48 hours of admission for one resident, identified as R84. This resident was admitted with a diagnosis of a fractured hip and had an intact cognition as indicated by a BIMS score of 14 out of 15. Despite the creation of a baseline care plan on 05/15/24, neither the resident nor their family member was informed about the care plan, which should have included details on activities of daily living, toileting, therapy frequency, and care goals. This oversight was confirmed by the Minimum Data Set Coordinator during an interview. Additionally, the facility did not adequately address the use of a wander-guard for another resident, identified as R29, who was admitted with dementia, behavior disturbances, repeat falls, and unsteadiness. Although the resident was identified as an elopement risk and had a physician's order for a wander-guard, the baseline care plan did not reflect this intervention. The Director of Nursing confirmed that the care plan failed to include the use of the wander-guard bracelet, despite the resident's history of wandering behaviors and the presence of the device during an observation.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R76, who was receiving oxygen therapy. R76 was admitted with chronic obstructive pulmonary disease (COPD), emphysema, and asthma. The facility did not have a physician's order for the continuous oxygen therapy that R76 was receiving. Additionally, the nebulizer tubing for R76 was not changed as per the physician's orders, which required it to be changed and dated every Wednesday on the 11-7 shift. Observations revealed that the oxygen tubing and nebulizer tubing had not been changed since 05/15/24, and the oxygen concentrator had a significant buildup of dust debris and was sticky to the touch. Interviews with staff, including an LPN and the Unit Manager, confirmed that the night shift was responsible for changing the tubing and cleaning the oxygen concentrator. However, the Unit Manager was unaware that the tubing had not been changed and that R76 was receiving oxygen therapy without a physician's order. The facility's policy on oxygen administration requires verification of a physician's order for oxygen therapy, which was not adhered to in this case.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of one-quarter bed rails for a resident, identified as R75, who was reviewed for bed rail use among 21 sampled residents. The resident had been admitted with diagnoses including heart surgery and diabetes and had an intact cognitive status with a BIMS score of 14 out of 15. Despite a physician's order for bilateral enablers (quarter) side rails for mobility, the facility's electronic medical records lacked documentation of an assessment for the use of these side rails. Additionally, there was no evidence that the risks versus benefits were discussed with the resident, nor was informed consent obtained. Observations over several days confirmed that the resident was using the side rails without a documented assessment or inclusion in the care plan. The facility's policy required informing the resident and family about the benefits and potential hazards of side rails and completing an assessment to determine the least restrictive means for the resident. However, during an interview, the Administrator confirmed the absence of an assessment for R75 and acknowledged the lack of policies and procedures for routine maintenance and safety checks of side rails on residents' beds.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling, dating, and cleanliness of food items stored in a refrigerator on the second floor nourishment room. During an observation, it was found that various food items, including to-go containers, beverages, and snacks, were not labeled or dated, and some were expired. The refrigerator shelves were also observed to be dirty and sticky. The Food Services Director (FSD) confirmed these observations and acknowledged that the food should have been labeled, dated, and expired items discarded. Additionally, the facility did not maintain a freezer on the third floor nourishment room in proper condition, as it was observed to have ice buildup throughout. The FSD confirmed that the freezer door did not seal properly, contributing to the ice accumulation. The facility's policies on receiving and storage, as well as foods brought by family or visitors, require that all foods be labeled, dated, and follow the first in, first out (FIFO) method, which was not adhered to in these instances.
Inadequate PPE Availability and Usage for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was readily available and appropriately used for residents on Enhanced Barrier Precautions (EBP). Specifically, for Resident 9, who was admitted with cellulitis of the right lower leg and required dressing changes with Medi Honey ointment, the isolation cart outside the room lacked gowns, which were necessary according to the EBP signage. Certified Nurse Aide 7 entered the room with only gloves, acknowledging the absence of gowns and uncertainty about who was responsible for restocking the isolation carts. Similarly, for Resident 140, who was placed on EBP due to wounds, the isolation cart outside the room was also missing PPE, specifically gowns. Licensed Practical Nurse 3 entered the room with only gloves to perform wound care, citing the resident's urgency to be discharged as a reason for not obtaining a gown. The Unit Manager/LPN later confirmed that she was responsible for ensuring the isolation carts were stocked and admitted to not restocking them on the day of the observations.
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.
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What surveyors actually found near you
We read the 616 citations issued within 25 miles in the last 12 months — including the 19 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 Shrewsbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atrium At Navesink Harbor, The | 0.5 mi | ★★★★★ | 20 | 0 |
| Redbank Center For Rehabilitation And Healing | 1.3 mi | ★★★★★ | 0 | 0 |
| Shore Pointe Care Center | 3.8 mi | ★★★★★ | 1 | 1 |
| De La Salle Hall | 4 mi | ★★★★★ | 1 | 0 |
| Careone At Middletown | 4.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.