Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Wall Llc during CMS and state inspections, most recent first.
An LPN failed to properly identify a resident before giving medication, and one resident received methadone ordered for another resident. The resident who received the dose had dementia and a moderately impaired BIMS score, while the intended recipient had an opioid-related history and an active methadone order. After the error, Narcan was given and the resident was sent to the ED, where the resident was noted to be very sleepy.
Failure to obtain and document a resident’s admission weight and weekly weights for the first 4 weeks. A resident with severe cognitive impairment and diagnoses including CVA-related hemiplegia, aphasia, and CHF had a weight documented on the MDS and later in the chart, but the record lacked an admission weight within 24 hours and a weekly weight for the first week after admission. The LPN, Dietitian, DON, and LNHA confirmed the missing weights were required by facility protocol.
The facility failed to keep kitchen, storage, and food service areas clean and sanitary. Surveyors observed debris, stains, mold-like residue, soiled racks, dirty meal carts, contaminated equipment, and improper storage of food items and utensils. Staff were also observed using a handwashing sink area with a dirty drain and handling a garbage can lid with bare hands after washing, and a cook did not have all facial hair covered while preparing food. The emergency food supply was stored in a warm, non-air-conditioned closet.
The facility’s QAPI program did not include abuse-related review or grievance trend analysis, even though a resident reported rough handling, pressure on an incision line, pushing, and delayed response during care by two CNAs. The UM confirmed the resident’s representative had notified the facility, but she did not interview the resident or initiate an investigation. The LNHA stated there were no QAPI activities related to abuse and that grievances were not being reviewed as part of QAPI, despite the QAPI policy calling for data from multiple sources, including grievance logs.
Failure to Timely Report Abuse Allegations: Two residents with intact cognition and significant medical needs reported rough handling and verbal mistreatment by CNAs, including pushing, pressing on an incision, refusing care, calling a resident crazy, and threatening to move a resident to a crazy room. The UM did not interview one resident after the complaint and dismissed the other as confused, and the administrator initially had no grievance or reportable event. The allegations were not reported to NJDOH within the required timeframe.
Missing ADL Documentation for Multiple Residents: Surveyors found repeated blank spaces on CNA ADL flow sheets for several residents with documented needs for bathing, toileting, hygiene, transfers, and other ADLs. Residents had diagnoses such as muscle weakness, difficulty walking, incontinence, and orthopedic impairment, and staff interviews confirmed that the forms should be completed each shift and that missing documentation meant the care was not shown as provided. The facility could not provide other evidence that the ADL tasks were completed.
A resident with dysphagia, hemiplegia, severe malnutrition, and major weight loss did not consistently receive ordered nutritional interventions, including the prescribed Magic Cup supplement and proper puree portions. Staff prepared pureed foods without recipes, served a smaller-than-ordered portion of super mashed potatoes, and the meal was observed sitting untouched at the bedside for an extended period before the resident was fed. The DON and Dietitian confirmed the resident needed total meal assistance and the ordered supplements.
A facility failed to provide pain meds in a timely manner and according to MD orders for three residents with intact cognition and pain-related diagnoses. Records showed PRN Tylenol and oxycodone were missed or delayed, pain assessments were not documented for one resident, and one resident’s Percocet order was scheduled for the next morning without documentation that the MD was contacted when the dose was requested after the order was written.
A resident receiving HD for ESRD had an order to monitor bruit and thrill at a permacath site, and nurses documented repeated checks on the eTAR. During interviews, the RN described assessing the permacath for bruit and thrill, while the UM, ADON, and DON stated bruit and thrill are not assessed at a permacath and the order should have been clarified with the physician. The ADON and DON also confirmed the facility did not have HD competencies for nursing staff.
A facility failed to involve SW in the abuse process for two alert and oriented residents who alleged rough handling and verbal abuse by CNAs. One resident reported being called crazy and the other reported rough care, pain at an incision line, and delayed response to the call light; UM and LNHA did not ensure the allegations were promptly investigated through the SW/grievance process, and the abuse concerns were not initially entered into the grievance binder.
A facility failed to follow recipes and provide proper portions for therapeutic food items on modified diets. During meal observation, staff used the same scoop for puree lasagna, mashed potatoes, and super mashed potatoes, and the cook stated there were no recipes for some items and that ingredients were added by routine rather than recipe. A resident tray was observed with small portions that did not match the meal ticket, and residents in council said the meal portions were too small. The RD stated the super mashed potatoes were ordered for calories and that incorrect portions would mean residents did not receive the intended calories and protein.
Failure to follow menus and use standardized recipes led to inconsistent meal service and resident complaints about small portions, missing menu items, and poor taste. During meal observation, staff served a lasagna roll-up instead of the posted layered lasagna, could not locate a recipe, and also prepared puree items without recipes; the puree lasagna was thick, pasty, and bland, and the puree mashed potato tasted like thickener powder.
A facility failed to ensure that all portions of the resident call system were functioning when surveyors observed that the call system computer monitor on 2 [NAME] was not turned on. The MD was present and confirmed the observation during interview. The deficient practice was identified as affecting all 33 residents.
A resident who was alert and oriented reported staff called them crazy, moved them to another room, and handled them in a way the resident described as abusive. Interviews showed the SW team was not informed of the room change, no room change evaluation was completed, the DON found no progress note documentation, and the resident representative said the facility never notified them of the move despite policy requiring advance notice and Social Services involvement.
A surveyor observed bubbled and lifted vinyl plank flooring in a resident room on unit 2 East. The unsampled B side resident commented that someone could trip on the floor, and the Assist. Admin., RDM, and MD confirmed the condition during the observation.
A resident with DM2 and intact cognition received Lispro insulin instead of the ordered Humulin R U-500 insulin. The MAR, incident report, and progress note documented that the nurse administered Lispro without an order in place, and the DON, ADON, and Medical Director all identified this as a medication error and a failure to follow the physician’s order and the six rights of medication administration.
An LPN administered the wrong dose and form of Methadone to a resident, giving 105 mg of liquid Methadone intended for another patient instead of the prescribed 10 mg tablet. The nurse did not verify the order or follow the six rights of medication administration, leading to the resident becoming lethargic and requiring emergency intervention for Methadone overdose.
Wrong Resident Received Methadone After Failed Identification
Penalty
Summary
A nurse failed to identify a resident before administering medication, resulting in the wrong resident receiving methadone that had been prescribed for another resident. On 12/25/2025, LPN #1 gave 110 mg of methadone liquid by mouth to Resident #2, even though the medication was ordered for Resident #1. The report states that the nurse asked Resident #2 if they were Resident #1 and Resident #2 answered yes, after which the methadone was administered in Resident #2's room. Resident #1 had diagnoses including chronic multifocal osteomyelitis of the left femur, opioid dependence, and acquired absence of the left leg above the knee. Resident #1's order was for methadone HCl oral solution 10 mg/5 mL, 55 mL by mouth in the morning. The MAR showed the dose was documented with a code indicating other/nurse notes, and a nurse note stated the medication was not available. Resident #2 had diagnoses including traumatic subdural hemorrhage and unspecified dementia, with a BIMS score of 10 out of 15, indicating moderately impaired cognition. Resident #2 had no methadone or other opioid orders. After the medication was given, the nurse recognized the error, administered Narcan, and Resident #2 was sent by ambulance to the ED for evaluation and admission. The hospital note stated the resident was very sleepy in the ED. The DON confirmed that Resident #2 received methadone ordered for Resident #1 and stated the expectation was that residents be identified by their ID bracelets and photo in the EMR before medication administration.
Failure to Obtain and Document Admission and Weekly Weights
Penalty
Summary
The facility failed to monitor a resident’s weight upon admission and then weekly for the first 4 weeks in accordance with facility protocol and professional standards of practice. Resident #7, who was not at the facility during the survey and whose closed record was reviewed, had diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, and congestive heart failure. The resident’s MDS dated 1/13/26 showed a BIMS score of 5 out of 15, indicating severe cognitive impairment, and listed a weight of 126 pounds. However, the Nursing Comprehensive Assessment dated 1/6/26 did not include a weight for the resident. The medical record showed weights of 126.4 pounds on 1/13/26 and 124.0 pounds on 1/29/26, but no additional weights were documented. A nutrition note on 1/13/26 documented the admission weight, height, and BMI, but there was no documented admission weight within the first 24 hours and no weekly weight for the week of 1/20/26. During interviews, the LPN, Dietitian, DON, and LNHA confirmed that admission weight and weekly weights for the first four weeks should have been obtained and documented, and that any refusal should have been documented and reported to the Dietitian. The facility’s undated Weight Assessment and Intervention policy stated that weights should be obtained at admission and then weekly for four weeks.
Unsanitary kitchen and food storage conditions with improper staff hygiene
Penalty
Summary
The facility failed to maintain the kitchen, food storage areas, kitchen equipment, and food transport equipment in a clean and sanitary manner, and staff did not consistently use proper hand hygiene and facial hair covering practices during food preparation and service. During an initial kitchen tour with the Food Service Director (FSD), the surveyor observed stained and debris-covered ceiling tiles throughout the kitchen, visibly soiled racks in the walk-in refrigerator, food debris and black residue in the walk-in, and stains and debris around the food preparation sink area. The FSD stated there was no cleaning schedule for the kitchen and acknowledged that the refrigerator racks were not clean. Additional observations showed unsanitary conditions in multiple food storage and service areas. The dry storage room had debris on and under racks, splatters on walls, and a warm temperature of 76 to 77 degrees F, while the FSD stated the kitchen air conditioner had not been functioning for two months and that food storage should be around 60 degrees F. The cold cut and chilled salad refrigerator had crumbs and embedded debris on the lids and inside the cover, meal carts and tray line shelves were visibly soiled, the can opener insert contained thick black grease-like substance, and the knife rack had debris on top. Two bins of bread crumbs and flour had unprotected scoops resting on top, and chipped insulated tray lid covers were observed on a clean rack. The surveyor also observed staff handling food and equipment in ways that did not maintain sanitation. A staff member washed hands at a sink with black embedded substance in the drain and then used bare freshly washed hands to pick up the lid of the only garbage can in the area. During meal service, another cook was slicing kielbasa without all facial hair covered. The three-day emergency food supply was stored in a closet on a resident unit that was not air conditioned and measured 80 degrees F. The facility provided a dry food policy stating dry foods should be received, inspected, and put away in a timely fashion, but the observations showed widespread sanitation and storage deficiencies.
QAPI Program Did Not Address Abuse Investigations or Grievance Trends
Penalty
Summary
The facility failed to ensure its QAPI program identified and addressed areas for improvement related to abuse prevention, abuse investigations, and staff participation in investigations. During interview, the LNHA stated he was responsible for the QAPI process and described current QAPI plans focused on items such as consent, medication removal, code status, survey results, deep cleaning, agency employee training, MDS completion, weights, call bell response, tray accuracy, and medication administration. When asked whether there were any QAPI plans related to abuse allegations, the LNHA stated there were none prior to the survey. The survey identified two allegations involving Resident #110. The resident, who was alert and oriented and had a shattered femur, reported that two CNAs rough handled them during care, pressed on the incision line, pushed them, and continued care even when the resident screamed. The resident stated the concerns were reported to their representative, who informed the facility on 7/28/25. The UM confirmed the representative told her the CNAs were not gentle and that they took three hours to answer the call light and were not nice during care. The UM also confirmed she did not interview the resident regarding the concerns and did not initiate an investigation. The LNHA stated there were no QAPI activities related to abuse before the survey and that the facility was reviewing the Social Worker job description because the Social Worker was supposed to be involved in the abuse investigation process but was not part of it. The LNHA further stated the facility was not reviewing grievances as part of the QAPI process, despite the QAPI policy stating the facility draws data from multiple sources, including grievance logs.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the New Jersey Department of Health within 2 hours for two residents. One resident, admitted with diagnoses including a right femur fracture, muscle weakness, gait and mobility abnormalities, and pain related to orthopedic implants, had a BIMS score of 15/15 and required extensive assistance with activities of daily living and mobility. That resident reported that two CNAs rough handled them during care, pressed on the incision line, pushed them, and did not stop when the resident screamed. The resident also stated that the concern had been reported to a representative, who had informed the facility the day before the surveyor’s interview. A unit manager confirmed that the resident’s representative had told her the CNAs were not gentle, including that they took three hours to answer the call light and were not nice during care. The unit manager stated she did not interview the resident after speaking with the representative and had no documentation because the report was verbal. The administrator initially stated there was no grievance or reportable event for the resident, and the 24-hour reports reviewed for the surrounding days contained no entries about the concern. A later reportable event record dated after the concern documented the representative’s statements and the resident’s handwritten account of being treated roughly by two aides in the middle of the night. A second resident, admitted with diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, muscle weakness, and pain related to orthopedic implants, had a BIMS score of 15/15 and was described by the unit manager as usually very quiet but sometimes refusing care. In the surveyor’s presence, the resident cried and reported that a CNA refused to change them, called them crazy, threatened to move them to the crazy girl room, closed the door, and left them screaming. The unit manager later stated the resident was confused and did not follow up. A statement from the resident was not obtained until several days later and included additional details about the aide yelling, moving the resident to another room, and staring at the resident while they continued to scream for help. The administrator later acknowledged the concern had not been reported to NJDOH and stated it could have been verbal abuse; the facility did not report the allegation until several days later, beyond the required timeframe.
Missing ADL Documentation for Multiple Residents
Penalty
Summary
The facility failed to provide documented evidence of ADL care for multiple residents and failed to follow its CNA job description, ADL policy, and documentation policy. Surveyors reviewed closed records and ADL flow sheets for residents with documented care needs and found repeated blank spaces on the CNA documentation forms, with no other record evidence showing that the care had been completed. Facility staff interviewed during the survey repeatedly stated that blank spaces meant the care was not documented, and several staff members confirmed that documentation was expected each shift and that the forms should not contain gaps. Resident #101 had diagnoses including anemia, muscle weakness, difficulty walking, and need for assistance with personal care. The resident’s MDS showed moderately impaired cognition, and the care plan identified an ADL self-care deficit related to fatigue, shortness of breath, muscle weakness, and dysphagia. The resident was scheduled for showers twice weekly, but the care plan did not include an intervention reflecting showers per facility protocol or the unit shower schedule. The February 2025 CNA ADL sheet contained blank spaces for day shift documentation, and the record did not show whether additional showers were provided after 2/15/25 until 2/28/25. Staff interviews described expected shower practices and documentation, but the UM stated that if there was no documentation, then the resident did not receive the shower. Resident #97 had diagnoses including muscle weakness and difficulty walking, with intact cognition on the MDS. The resident was frequently incontinent of bowel and required extensive assistance from staff after toilet use and for personal hygiene, and the care plan called for extensive assist by two staff for toileting. The September 2023 CNA ADL sheet contained numerous blank spaces for toilet use and bowel documentation on both day and night shifts, with no evidence in the record that the tasks were completed. Staff interviews confirmed that ADL care should be documented every shift, that gaps on the ADL sheet were a problem, and that if documentation was missing, the care was considered not done. Resident #95 had diagnoses including difficulty walking, unsteadiness on feet, and acquired absence of the right leg below the knee. The resident’s MDS showed intact cognition and need for ADL assistance, and the care plan included assistance with bed mobility, dressing, personal hygiene, toilet use, and transfers. The April 2024 CNA ADL sheet contained multiple blank spaces for bladder, bowel, chair/bed-to-chair, eating setup supervision, lower body dressing, lying-to-sitting, oral hygiene, personal hygiene, sit-to-stand, toilet transfer, and toilet hygiene across day, evening, and night shifts. Resident #125 had diagnoses including unilateral primary osteoarthritis of the left knee and presence of a left artificial knee joint, with intact cognition and total assistance needed for ADLs. The July 2023 CNA ADL sheet contained blank spaces for personal hygiene, toilet use, bladder documentation, bowel documentation, and oral care on multiple shifts. The ADON, DON, LPNs, UM, and CNA staff all stated that blank spaces meant the care was not documented, and the facility could not provide evidence that the tasks were completed.
Failure to Provide Ordered Nutrition and Timely Meal Assistance
Penalty
Summary
The facility failed to consistently implement identified nutritional interventions for a resident with dysphagia, hemiplegia/hemiparesis following cerebral infarction, severe fat and muscle wasting, impaired skin integrity, and increased nutritional needs. The resident’s diet order was puree texture with thick liquids and feed assistance. The care plan, initiated for severe malnutrition, included feeding at mealtimes and providing Magic Cup twice daily. The resident’s weights showed a decline from 87 pounds to 74.9 pounds in less than one month, reflecting a 12-pound, 13% weight loss. During a lunch meal observation, the surveyor observed kitchen staff preparing pureed foods without using recipes for super mashed potatoes, super cereal, or puree white lasagna. The Food Service Consultant and Food Service Director confirmed that recipes should have been used and that the facility was serving a smaller portion of super mashed potatoes than the ordered 1/2 cup portion, affecting nutritional adequacy. The pureed lasagna was observed as thick, pasty, and bland, and the super mashed potatoes tasted like thickener powder; the Food Service Director confirmed the thickener taste. At the resident’s bedside, the meal tray was observed sitting untouched while the resident remained in bed. The tray did not contain the ordered Magic Cup, although it was listed on the ticket, and the beverages and food were unopened. The resident shook their head no when asked if the food was good. On a later observation, the resident again had an untouched meal tray at the bedside for over half an hour after delivery, and staff had not fed the resident until prompted. The Assistant Director of Nursing stated the resident should have been fed in a timely manner, and the Dietitian stated the resident required total assistance with all meals and needed the ordered supplements because of severe malnutrition and low body mass index.
Delayed and Missed Pain Medication Administration
Penalty
Summary
The facility failed to ensure that pain medication was administered in a timely manner and in accordance with physician orders for three closed resident records reviewed for pain. Resident #94 had diagnoses including pain related to orthopedic prosthetic devices and aftercare following joint replacement surgery, intact cognition, and a care plan focused on acute pain after right total hip arthroplasty. The record showed physician orders for Tylenol 650 mg every 6 hours as needed for breakthrough pain and Oxycodone ordered on 10/04/23, but Tylenol was not given that day and Oxycodone was not administered until 8:32 PM, nearly 7 hours after the order was transcribed. Resident #96 had diagnoses including surgical aftercare following digestive system surgery, rheumatoid arthritis, and difficulty walking, with intact cognition and a pain-related care area assessment trigger. The physician orders included Tylenol 650 mg every 6 hours as needed for mild pain, Oxycodone 5 mg every 4 hours as needed for moderate pain, and Oxycodone 10 mg every 4 hours as needed for severe pain. The MAR showed pain medication was not administered as ordered, there was no documentation that the resident was assessed for pain, and the first dose of Oxycodone 5 mg was not given until 10/16/24 at 7:38 PM. Resident #103 was admitted for rehabilitation after orthopedic surgery and had diagnoses including orthopedic aftercare, muscle weakness, difficulty walking, and spinal stenosis, with intact cognition. The record showed an order for Oxycodone-Acetaminophen 10-325 mg every 4 hours as needed for pain, but the first dose was not given until 10:08 PM, about 7 hours later, and the next dose was given 12 hours later. A later order for Percocet 10-325 mg once daily for back pain was scheduled for 9:00 AM the next day, and there was no documentation that the physician was called when the resident requested the daily dose after it was ordered; the medication was then administered the following morning at 9:00 AM.
Dialysis Assessment Order Not Clarified and HD Competencies Missing
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident receiving HD. The resident was admitted with ESRD, hypertension, and muscle weakness, had a BIMS score of 15 indicating cognitive intactness, and was documented as receiving HD on Tuesdays, Thursdays, and Saturdays. The care plan identified the resident’s dialysis schedule and included interventions to encourage attendance at scheduled dialysis appointments and to monitor for signs and symptoms of infection. The facility had an active physician order to monitor bruit and thrill to the resident’s right arm permacath every shift, and this order was transcribed into the eTAR. Nurses documented repeated checks for bruit and thrill on the eTAR from mid-June through early August 2025. During interview, the RN stated she assessed the resident’s RCW permacath for bruit and thrill, signs and symptoms of infection, and pain, and documented findings in nursing notes. The RN demonstrated placing a stethoscope at the permacath site to listen for bruit and then palpating for thrill. However, the UM and ADON stated that bruit and thrill are assessed for an AV fistula or graft, not for a permacath, and that a permacath site should be monitored for signs and symptoms of infection. The ADON and DON both confirmed that the order to monitor bruit and thrill at the permacath site should have been clarified with the physician because bruit and thrill could not be assessed at that site. The ADON also stated the facility did not have HD competencies for nursing staff, and the DON confirmed that no HD competencies were available for the nurses.
Social services not involved in abuse allegations
Penalty
Summary
The facility failed to ensure medically related social services were provided and that the social workers were incorporated into the abuse process for two residents who alleged abuse by staff. Resident #110, who was alert and oriented and reported having a shattered femur, told the surveyor that CNA #1 and CNA #2 rough handled them during care, pressed very hard on the incision line, pushed them around, and did not stop care when they screamed. Resident #110 also stated that their representative had already informed the facility that the CNAs were not gentle and that the call light was taking hours to be answered. UM #1 confirmed the representative had notified her of these concerns, but she did not interview the resident or initiate an investigation. Resident #109, who was alert and oriented and visibly upset and crying, told the surveyor that CNA #1 called them crazy the prior night. UM #1 was immediately brought to the room, but she did not report the verbal abuse allegation to the Administrator and did not initiate an investigation. CNA #1 continued to care for residents after the allegation was made. The social worker later stated she was not aware of any recent concerns on the unit, and the grievance binder did not contain a grievance for either resident at that time. The LNHA stated he was the Compliance Officer and responsible for the abuse process, while the social worker was responsible for the grievance process and not the abuse process. The facility’s grievance policy stated the Social Worker was the designated Grievance Official and that allegations involving neglect, abuse, injuries of unknown source, or misappropriation were to be reported immediately to the Administrator and handled under the abuse procedures. The social workers’ job description also stated they were responsible for identifying medically related social services needs and, when there was an allegation of suspected abuse, reporting to the Administrator and appropriate state agency and leading a thorough investigation. Despite this, both social workers stated they were not made aware of Resident #110’s allegations, and one social worker stated she only documented Resident #109’s grievance after the surveyor asked about it.
Improper Recipes and Portion Sizes for Therapeutic Diet Items
Penalty
Summary
The facility failed to ensure recipes were followed for therapeutic food supplements and that proper portions were provided to residents receiving modified diets. During a lunch meal observation, the posted menu included Cheddar Baked Tilapia or Cheese Lasagna with [NAME] Sauce, seasoned spinach, potato wedges, and butterscotch pudding. The surveyor observed staff plating puree cheese lasagna with [NAME] sauce, mashed potatoes, and spinach for Resident #7 using a green-handled scoop. The cook stated he used the same 3 1/4-ounce scoop for puree lasagna, mashed potatoes, and super mashed potatoes, and he acknowledged there was no recipe for super mashed potatoes or super cereal, stating he added milk, butter, brown sugar, and oatmeal as directed. The Food Service Director and Food Service Consultant were unable to locate a recipe for the served item, and the consultant stated the item was supposed to be regular lasagna, not a lasagna roll-up. Resident #49 was observed with a meal tray containing three scoops of white food and one scoop of green, while the meal ticket listed super mashed potato, mashed potato, puree fish, and puree spinach, each as 1/2 cup servings. The resident had only one spoon inside an unidentified white item and no other items on the tray, and when asked if the food was good, the resident shook their head no. In Resident Council, all five residents stated the meal portions were too small. The Dietitian stated she ordered super mashed potatoes mostly for calories and confirmed that using the correct recipe and portion size was necessary so residents received the intended calories and protein; she also stated that giving less would mean residents did not get the calories.
Failure to Follow Menus and Use Standardized Recipes
Penalty
Summary
The facility failed to ensure menus were followed and standardized recipes were consistently used to provide palatable meals with consistent portion sizes. During a Resident Council meeting, five residents stated that portions were too small, menu items did not always match what was posted, soup tasted salty, and weekly menu selections were not always received. Three of the five residents also stated that when items were not prepared, a packaged cookie was substituted for a homemade cookie. During lunch meal observation, the posted menu included cheese lasagna with sauce or cheddar baked tilapia, potato wedges, seasoned spinach, and butterscotch pudding. The cook was observed plating a rolled lasagna noodle item with cheese inside and pouring cream sauce over it; when asked, the cook stated it was a homemade recipe and confirmed it was not a layered lasagna. The FSD and FSC were unable to locate a recipe in the kitchen, and the FSC stated the item should have been regular layered lasagna, not a lasagna roll-up. For puree items, the cook stated no recipe was used for puree lasagna or super mashed potato, and the surveyor observed the puree items appeared overly thick and glazed. When tasted by the surveyor with the FSD and FSC present, the puree lasagna was thick, pasty, and bland, and the super mashed potato tasted like thickener powder. The FSC confirmed the cook should have been using recipes.
Resident Call System Monitor Not Turned On
Penalty
Summary
The facility failed to ensure that all portions of the resident call system were functioning in accordance with 483.90(g) Resident Call System. During observations on 8/5/2025 and 8/6/2025, surveyors found that the call system computer monitor on 2 [NAME] was not turned on. The Maintenance Director was present during the 8/6/2025 observation and confirmed that the call system computer monitor was not turned on during interview at 8:02 AM. The deficient practice was identified as affecting all 33 residents.
Failure to Notify Resident and Representative of Room Change
Penalty
Summary
The facility failed to ensure that a room transfer was appropriate and failed to ensure that the resident and resident representative were notified of the room change. Resident #109, who was alert and oriented and visibly upset during the survey, reported that a CNA called them crazy and that staff moved them from their room to another room after an interaction in which the resident said the aide yelled back, "If you don't stop, you'll go to crazy room." The resident stated the aide then moved them to room 211A, closed the door, and later picked up the resident's head and stared into their eyes. The resident also reported hearing another aide say, "cut them some slack, they just lost their brother," followed by the aide saying, "good." Interview and record review showed that the social workers were not informed of the room change when it occurred. SW #1 stated she did not know there was a room change and explained that the process should include a room change evaluation, completion of a room change form, and notification of the family. SW #2 stated she was not made aware of the room change and would have completed a room change evaluation if she had known. The census list showed the resident was moved on 7/28/25 at 10:46 PM, but the DON stated there was no documentation in the progress notes regarding the room change. The LNHA and DON stated the move was based on shift-to-shift report from the nursing supervisor, and the DON stated she was not aware of the resident's statement that staff threatened the resident with the "crazy room." The resident representative stated the facility never informed them of the room change and that the resident told them they were placed in the "bad" room, described as the psychiatric room. The facility's Change of Room or Roommate policy required advance notice to residents and representatives when possible, written notice in a language and manner understood by the resident and representative, and communication of room change requests to Social Services. The report also states that the social workers and administration were not aware of the room change at the time it occurred and that the room change evaluation was not completed before the move.
Lifted Vinyl Plank Flooring in Resident Room
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible on unit 2 East. During an observation at approximately 11:06 AM, the vinyl plank floor in room [ROOM NUMBER] A and B was found bubbled and lifted from its substrate. At approximately 11:08 AM, the unsampled B side resident stated, "isn't that awful, someone could trip on the floor." The Assistant Administrator, Regional Director of Maintenance, and Maintenance Director were present during the observation and confirmed the findings, and the Regional Director of Maintenance stated, "yes, we have to get this taken care of."
Wrong Insulin Administered Instead of Ordered Medication
Penalty
Summary
A medication error occurred for a resident with type 2 diabetes mellitus who was cognitively intact with a BIMS score of 15 out of 15. The physician’s order was for Humulin R U-500 insulin, 15 units subcutaneously before meals, scheduled for 11:30 AM. The electronic medication administration record documented that at 10:56 AM the nurse administered Lispro insulin instead of the ordered insulin. The incident report stated that Lispro was administered by the primary nurse with no orders in place, and the progress note documented that Lispro 15 units was given. A disciplinary action form for unsafe practice also stated that Lispro was given even though the resident was not on Lispro. During interviews, the DON stated the nurse gave Lispro 15 units from house stock and should have followed the physician’s order. The ADON stated Lispro should not have been given and that the expectation was to follow the doctor’s order and the medication administration policy to identify the correct resident, medication, time, and dosage. The Medical Director stated that giving the wrong medication was a medication error.
Significant Medication Error Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered an incorrect dose and form of Methadone to a resident. The LPN gave 105 mg of liquid Methadone, which was prescribed for another resident for opioid dependence, instead of the 10 mg Methadone tablet ordered for pain management. The LPN did not verify the physician's order prior to administration and failed to follow the facility's medication administration policy, specifically neglecting to ensure the six rights of medication administration. The error was not recognized by the LPN at the time of administration, and the nurse only became aware of the mistake after being contacted by another staff member regarding a missing bottle of Methadone. The affected resident had a history of unspecified pain, hypertension, and depression, with a moderately impaired cognitive status as indicated by a Brief Interview of Mental Status (BIMS) score of 11 out of 15. After receiving the incorrect medication, the resident was initially found alert but later became lethargic and semi-responsive. The resident required emergency intervention, including administration of Narcan, oxygen therapy, and transfer to a hospital, where they were admitted with a diagnosis of Methadone overdose. Interviews with staff and review of facility documentation confirmed that the LPN did not follow established protocols for medication administration, including verifying the correct medication, dose, and form against the medication administration record (MAR) and physician's order. The Director of Nursing (DON) and the LPN both acknowledged that the facility's policy was not followed during the incident. The failure to adhere to these protocols resulted in a significant medication error that required emergency medical intervention.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 298 citations issued within 25 miles in the last 12 months — including the 11 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 Wall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Careone At Wall | 0.5 mi | ★★★★★ | 12 | 0 |
| Tower Lodge Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Sunnyside Manor | 1.8 mi | ★★★★★ | 0 | 0 |
| Jersey Shore Post Acute Rehabilitation And Nursing | 3.2 mi | ★★★★★ | 0 | 0 |
| Coral Harbor Rehabilitation And Healthcare Center | 3.3 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.