Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Daughters Of Israel Pleasant Valley Home during CMS and state inspections, most recent first.
Improper food storage and wet pan handling were observed in the kitchen. A surveyor found 6 open spice containers in the food prep area and multiple steam table pans stacked while wet with water trapped between them in the dishwashing area. The GM stated the spice lids should have been closed and the pans should have been air dried instead of stacked wet.
Oxygen therapy orders were not followed for multiple residents. A resident with stroke-related deficits, a resident with COPD, a resident with CHF, and a resident with dementia were observed receiving oxygen at higher flow rates than ordered, and one resident had no humidifier attached despite oxygen being above 3 L. An LPN stated the humidifier was not used because there was no order, and the treatment record for one resident did not show oxygen treatments documented.
Surveyors found multiple infection control failures, including missing EBP signage at resident room entrances for residents with wounds, catheters, and enteral feeding tubes, despite orders and care plan interventions calling for EBP. Staff were unsure what the orange door markers meant and some believed the PPE bin alone indicated precautions. Surveyors also observed an LPN fail to disinfect a shared glucometer after use, place an insulin pen in a pocket and return it to the cart after it was dropped on the floor without cleaning, and store an eye drop bottle in a shirt pocket instead of the med cart.
Call devices were not kept within easy reach for four residents. One resident with severe cognitive impairment and dependence for ADLs had the call bell hanging out of reach while in bed, another resident with Alzheimer’s disease had the call device clipped above the headboard and out of reach, a third resident with hemiplegia and a BIMS of 0 had the call device on the floor under the bed, and a fourth resident with dementia and limited right-hand movement had the call device tied to the bed rail and hanging out of reach. Staff interviews confirmed the expectation that call bells be placed within the resident’s reach.
Disrepair and staining were observed in a resident room and in HP unit common areas, including peeling and missing wallpaper, broken wall protection, stained ceiling tiles, and a baseboard heater with a crusty brown substance and dents. The DBS, DON, Assistant Administrator, and Administrator acknowledged the areas were in disrepair and detracted from the homelike environment.
A resident with severely impaired cognition, a sacral pressure ulcer, and urinary retention had an indwelling catheter observed at the bedside, but the admission MDS did not code the catheter in the bowel and bladder section. The record also included a physician order to check the catheter every shift and a care plan focused on the indwelling catheter, and the RN/MDSC stated the catheter should have been coded.
A resident with pressure injuries had duplicate wound treatment orders for the same site, and an RN documented a wound treatment as completed in the eTAR before actually performing it. Another resident with DM had no care plan focuses or interventions for diabetes, and although a BG of 473 was treated with Humalog per sliding scale, there was no documentation that the physician or NP was notified as ordered.
A resident with severe cognitive impairment and G-tube feeding had CP recommendations left unsigned and not documented as followed up. The CP had recommended clarifying a Flomax order because the capsule should be swallowed whole and adjusting Lidoderm patch timing to 9 AM to 9 PM, but the MAR showed different patch times and the record initially showed no follow-up by the DON or nursing staff.
Surveyors found expired IV fluids, unclear dating on eye drops and insulin, and Duoneb medications in a cart that were not properly labeled, dated, or stored in resident-specific packaging. They also found a controlled-drug compartment that was not permanently affixed to the cart and could be removed, leaving controlled meds visible and accessible.
The facility did not update care plans to include new interventions after falls and failed to complete thorough fall investigations, including missing staff witness statements and incomplete documentation. Three residents with cognitive and physical impairments experienced multiple falls, and interventions such as increased monitoring and use of safety equipment were not consistently documented or communicated to staff, resulting in deficiencies in accident prevention and supervision.
The facility did not conduct performance reviews for five CNAs, as required by policy, which mandates reviews at least every 12 months. The DON stated that reviews were only conducted if competency concerns arose, which was not the case for these CNAs. The facility's policy requires consistent monitoring and training to ensure competent care, but this was not adhered to.
The facility failed to ensure the Infection Control Preventionist (IP) attended three consecutive quarterly Quality Assurance (QA) meetings. The IP was absent due to working the evening shift and serving as the nursing supervisor. Although the IP provided reports to the Director of Nursing (DON), their absence was noted as a deficiency. The facility's QAPI Program did not explicitly require the IP's attendance, but their role in infection control was deemed essential.
The facility did not maintain and display the most recent State inspection results in an accessible area. Six residents were unaware of where to find these results. The surveyor found outdated inspection results at the LP and HP Nursing Stations, with the latter's binder hidden in a closet. The DON confirmed the absence of the 2023 results, which were later found mixed with other binders, not accessible to residents or the public.
The facility failed to follow physician's orders for side rail use for a resident, using two side rails instead of one as prescribed. Additionally, an LPN did not adhere to the medication administration policy by not taking a resident's vital signs within the required 15-minute window before administering blood pressure medications. These deficiencies were confirmed by the Director of Nursing and the LPN involved.
A resident with severe cognitive impairment and multiple health issues was observed with long, jagged, and soiled fingernails, indicating a failure in personal hygiene care. Despite the resident's request for nail care, the CNA did not address the issue, citing that activity staff were responsible for clipping and filing nails. However, the LPN stated that CNAs were responsible for all aspects of nail care. The resident required moderate assistance with personal hygiene, as documented in their care plan, but had not received adequate care since their last salon visit over a month prior.
A facility failed to administer oxygen therapy according to a physician's order and did not ensure proper storage of nasal cannula tubing for a resident with dementia and chronic respiratory failure. The resident received oxygen at 2.5 LPM instead of the prescribed 2 LPM, and the tubing was not stored in a bag as required. Both a CNA and an LPN confirmed these lapses during interviews.
The facility failed to ensure proper reconciliation and accountability of narcotic medications, with discrepancies found in the records for a resident's Tramadol administration. The CDIR was not consistently signed by two nurses, and there were inconsistencies between the IPCDR and eMAR. The resident, who was cognitively impaired, confirmed receiving medication but could not recall specific dates. Additionally, missing signatures were found on the shift-to-shift log for another medication cart.
A facility failed to ensure proper infection control practices during dining services. A CNA did not perform hand hygiene between assisting residents, and an AC failed to sanitize hands between residents while also tying a trash bag to a resident's wheelchair. Both staff members acknowledged the need for hand hygiene but did not follow procedures.
Improper Food Storage and Wet Pan Handling
Penalty
Summary
Food storage and sanitation practices were deficient in the kitchen. During observation with the General Manager and Executive Chef present, the surveyor found 6 spice containers on a shelf in the food preparation area with their tops opened on the dairy side of the kitchen. The surveyor also observed 2 large shallow steam table pans and 3 two-thirds sized steam table pans on the dairy side of the dish washing area that were stacked while wet and nested with water between them. The General Manager stated the spice container lids should have been closed and that the steam table pans should not have been stacked when wet and should have been air dried first. Facility policy stated that all foods are to be labeled, dated, and securely covered, and that dishes should be air dried and wet dishes should not be stacked.
Oxygen Therapy Orders Not Followed and Humidifier Not Provided
Penalty
Summary
The facility failed to ensure that physician orders for oxygen therapy were followed for four residents reviewed for respiratory care. Resident #8, who had diagnoses including dysphagia, cerebral infarction, left hemiplegia, and severe cognitive impairment, was observed receiving oxygen via nasal cannula at 3.5 lpm even though the physician order directed continuous oxygen at 2 lpm. A nurse later confirmed the order and adjusted the flow to the prescribed rate. Resident #72, who had COPD and severely impaired cognition, was observed receiving oxygen via nasal cannula at 4 lpm, while the physician order directed continuous oxygen at 2 lpm. The care plan for this resident included oxygen therapy as ordered. Resident #108, who had CHF and severely impaired cognition, was observed receiving oxygen via nasal cannula at 3.5 lpm and later at 4.5 lpm. The physician order directed oxygen at 3 lpm via nasal cannula continuously every shift for shortness of breath. The surveyor also observed that no oxygen humidifier was attached to the concentrator during the observations. An LPN stated that he did not place a humidifier in the room because there was no order. The facility policy stated that if oxygen is more than 3 liters, a humidifier bottle with sterile water is to be used. Resident #114, who had unspecified dementia with psychotic disturbance, was observed receiving oxygen via nasal cannula at 3 lpm and later at 3.5 lpm. The physician order directed oxygen at 2 lpm via nasal cannula as needed for oxygen saturation less than 92%, shortness of breath, or respiratory distress. The resident treatment administration record did not show oxygen treatment entries for the dates reviewed. The facility’s oxygen therapy policy required staff to check the order for the amount and frequency of oxygen administration and to use a humidifier bottle when oxygen is more than 3 liters.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to follow infection prevention and control practices in multiple areas, including Enhanced Barrier Precautions (EBP), medication handling, and glucometer disinfection. Surveyors observed that EBP signage was not posted at the entrances or doorways of multiple resident rooms, even though residents had orders or care plan interventions for EBP related to wounds, indwelling catheters, or enteral feeding tubes. In several rooms, the facility used bins with PPE and orange markers on the door frame, but staff members interviewed were unable to explain the meaning of the orange dot or identify the required signage for EBP. The facility’s EBP policy did not address signage, while another infection control document did include instructions to place appropriate isolation signage outside resident rooms. Residents identified in the observations included residents with significant medical needs such as severe cognitive impairment, dependence for activities of daily living, dysphagia with gastrostomy tube feeding, indwelling urinary catheters, wounds, and pressure injuries. For example, one resident with a gastrostomy tube had no EBP signage at the room entrance, and the assigned LPN stated there was no signage in use and acknowledged the resident was on EBP due to the tube. Other residents with wounds or urinary catheters also had no visible EBP signage despite physician orders and care plan interventions indicating EBP. Staff interviews showed that some nurses believed the PPE bin itself indicated EBP, while others were unaware of the signage requirement. The survey also identified medication and equipment handling concerns during observation. One LPN did not clean or disinfect a glucometer after using it on a resident, and later stated the wipes were not at the cart. The glucometer had no resident label and was marked only with a letter that the nurse did not understand, while the administrator later stated the glucometers were shared among residents. In another observation, an LPN placed an insulin pen in a pocket after administration, dropped it on the floor, and then returned it to the medication cart without cleaning or sanitizing it. A separate medication storage review found an eye drop bottle stored in an LPN’s shirt pocket instead of in the medication cart, and both the LPN and RN supervisor acknowledged that storing medications in clothing pockets was not correct.
Call Devices Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure that call devices were readily accessible for four residents. Resident #19 was observed in bed awake and able to make needs known, but the call device was hanging on the bed and out of reach while the resident leaned to the opposite side and asked where it was, stating they could not reach it. Later the same day, the call device was again observed out of reach. The resident’s record showed severe cognitive impairment with a BIMS score of 6 and dependence on staff for ADLs, and the care plan included keeping the call bell within easy reach when the resident was in bed. Resident #61 was observed asleep in bed with the call device hanging on top of the headboard and clipped to the wall, four inches from the outlet, and it remained out of reach on a later observation. The resident’s record showed Alzheimer’s disease, severe cognitive impairment with a BIMS score of 3, and dependence on staff for ADLs. The care plan activity report did not include any call light intervention, even though the resident required assistance and the call light was expected to be within easy reach. Resident #108 was observed with the call device on the floor under the bed, and the resident stated they could not find it because they wanted the television turned on; the device remained under the bed on a later check. The resident’s record showed hemiplegia following cerebral infarction, severely impaired cognition with a BIMS score of 0, and dependence on staff for ADLs, with a care plan intervention to keep the call bell within reach when in the room. Resident #114 was observed with the call device tied to the right-side rails and hanging off the bed out of reach, and the resident could not reach it because of limited movement in the right hand. The resident’s record showed unspecified dementia with psychotic disturbance and a care plan noting declining ADLs secondary to renal cancer and progressing dementia, with an intervention to keep the call bell within reach when in the room.
Disrepair and Staining in Resident Room and HP Unit Common Areas
Penalty
Summary
The facility failed to maintain a resident's room and the HP unit hallway/common area in a clean, sanitary, and homelike manner. In Resident #3's room, the surveyor observed approximately 10 inches of wallpaper peeling off the wall near the bottom of the window sill and an approximately 2-inch break in the plastic corner protector on the wall. In the HP unit hallway near the smoke doors by room [ROOM NUMBER], the surveyor observed an approximately 24-inch-wide by 4-foot-tall area of missing wallpaper with hanging ragged edges, a second approximately 8-inch-wide by 4-foot-tall area of torn missing wallpaper, and several large brown stains on three ceiling tiles. In the common room marked as the living room for the HP unit, the surveyor observed an approximately 6-foot-wide area of torn missing wallpaper above the heating baseboard unit under the window, with dried brown stains on the exposed wall area and a baseboard heater with a crusty brown substance and dents. The DBS, DON, Assistant Administrator, and Administrator reviewed the findings and acknowledged the disrepair and that the areas detracted from the facility's homelike environment.
MDS Not Accurately Coded for Indwelling Catheter
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident who was reviewed for MDS accuracy. During survey observations on 3/6/26 and 3/9/26, the resident was awake and lying in bed with an indwelling catheter and privacy bag attached to the lower side of the bed. The resident’s admission record showed diagnoses including a sacral pressure ulcer, unstageable, and the admission MDS dated 2/12/26 documented a BIMS score of 0 out of 15, indicating severely impaired cognition. Review of the admission MDS showed that in section H, Bowel and Bladder, the indwelling catheter was not coded under appliances. The physician order dated 2/6/26 directed staff to check for indwelling catheter placement every shift, and the care plan activity report initiated 2/8/26 addressed the resident’s indwelling catheter due to urinary retention. During interview, the RN/MDS Coordinator stated that the resident’s indwelling catheter should have been coded. The survey team later met with the LNHA, Asst. LNHA, and DON regarding the concern, and no further information was provided.
Failure to Clarify Wound Orders, Document Treatment Accurately, and Manage Diabetes Care
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for two residents. For one resident with no cognitive deficits and admitted with unstageable pressure injuries and skin tears, the electronic record contained two treatment orders for the same right lateral lower leg wound: one order for a medicated topical paste with a covered dressing and another later order for lanolin and petrolatum ointment with the wound left open to air. The wound consultant’s most recent recommendation was to continue the medicated paste, medicated gauze, and thick pad daily until discontinued, yet both treatments were documented as completed on multiple days for the same site. During observation, an RN applied the lanolin and petrolatum ointment and left the wound open to air while the resident questioned why no cover dressing was being used. The RN stated the resident was confusing the order with an older previous order, then documented the treatment as completed in the eTAR before it had actually been performed. The surveyor observed that the treatment had been charted hours earlier, and the RN acknowledged documenting completion before the treatment was done. The LNHA later stated that a wound care consultation had not been uploaded into the electronic record until after the duplicate order issue had occurred. For another resident with type 2 diabetes, COPD, and CHF, the care plan did not include focuses, interventions, or goals for diabetes management despite an active insulin sliding scale order. The order required Humalog insulin before meals and at bedtime based on blood glucose results and directed staff to notify the physician or NP when blood glucose was above 450. The resident had a blood glucose reading of 473, and the MAR showed 12 units of Humalog were given as ordered, but there was no documentation in the MAR or elsewhere in the EHR that the physician or NP was notified as required. The DON confirmed the absence of diabetes care plan documentation and the lack of documented provider notification.
Failure to Follow Up on Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to address Consultant Pharmacist recommendations for Resident #113, who had diagnoses including a left above-knee amputation, severe cognitive impairment with a BIMS score of 3, and was receiving nutrition and medications through a gastrostomy tube. During observation, the resident was lying in bed, alert and verbally responsive, with an enteral feeding pump in use and a urinary drainage bag hanging from the bed frame. The Consultant Pharmacist’s admission medication review dated 2/13/26 included a recommendation to clarify the resident’s Flomax capsule order with the physician because the medication should be swallowed whole and the resident received medications via G-tube. The review also included a recommendation for lidocaine 5% patch timing so it would be applied at 9 AM and removed at 9 PM for a 12-hour effect. The recommendations were left unsigned, and the record review found no documentation that the recommendations had been followed up when first reviewed by surveyors. The physician’s order for tamsulosin 0.4 mg documented administration by G-tube once daily, and the March 2026 MAR showed the lidocaine patch scheduled from 7 AM to 3 PM and 3 PM to 11 PM rather than the timing recommended by the Consultant Pharmacist. The RN supervisor stated that the DON was responsible for reviewing and following up on CP recommendations and that reports would be signed to indicate completion, but the surveyor found no evidence of follow-up before inquiry. The facility policy for admission medication reconciliation addressed review and clarification of new admission orders but did not further address follow-up of CP recommendation reports.
Improper Medication Storage and Controlled Drug Compartment Security
Penalty
Summary
Drugs and biologicals were not properly stored and labeled in the HP unit medication storage room and medication cart. In the medication storage room, surveyors found two 0.45% Normal Saline one-liter IV bags that were past the manufacturer's expiration date, and an LPN confirmed they were expired and removed them for disposal. The same room contained eye drops with no clear opening date, and a Novolin R FlexPen for a resident that had conflicting open dates written on the storage bag and on the pen itself; the LPN stated the correct open date was 9/11 rather than 9/1. In medication cart A, surveyors observed an opened Duoneb foil packet with a written date but no resident name, and the LPN could not identify which resident it belonged to or confirm the correct expiration after opening. Resident-specific Duoneb supplies were also found stored loosely in the drawer, including one resident's manufacturer box containing an opened foil packet with no date and four attached vials without dates, and another resident's box containing a foil packet with a written date. In addition, medication cart B had a controlled-drug compartment that was not permanently affixed to the cart; the surveyor was able to lift and fully remove it, and the controlled medications were visible and accessible when the compartment was lifted.
Failure to Update Care Plans and Complete Fall Investigations
Penalty
Summary
The facility failed to ensure that residents' care plans were updated to include interventions implemented after falls, and did not thoroughly complete fall investigations as required by facility policy. For three residents reviewed, care plans did not reflect new or revised interventions following multiple fall incidents, such as increased monitoring, use of anti-roll back wheelchairs, or placement of floor mats. In several cases, interventions that were implemented post-fall were not documented in the care plan, and there was no evidence that staff were consistently informed or able to follow these interventions. Additionally, fall investigations were incomplete for two residents, with missing staff witness statements and incomplete documentation of the circumstances surrounding the falls. The facility's own policies required that all incidents be thoroughly investigated, including obtaining written statements from all witnesses and completing all sections of the accident and incident reports. However, in multiple instances, only partial information was collected, and staff statements were not included, limiting the ability to determine the cause of the falls and the effectiveness of interventions. The residents involved had significant cognitive impairments and were at high risk for falls, as indicated by their medical diagnoses and fall risk assessments. One resident with severe dementia experienced multiple falls in the dining room, another with toxic encephalopathy and muscle weakness had unwitnessed falls resulting in injuries, and a third resident with hemiplegia and moderate cognitive impairment was transferred by a single CNA despite a care plan requiring two-person assistance. In each case, the lack of updated care plans and incomplete investigations contributed to the deficient practice.
Failure to Conduct CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Aides (CNAs) received performance reviews, as evidenced by the absence of such reviews in the files of five randomly selected CNAs. The review of facility documentation from January 2023 to October 2024 did not reveal any performance reviews for these CNAs. During interviews, the Human Resources Director indicated that the Director of Nursing (DON) was responsible for education, competencies, and performance reviews. The DON stated that performance reviews were only conducted if there were concerns with a CNA's competencies, which was not the case for the five CNAs in question. The facility's policy, dated February 6, 2023, required staff to be monitored and trained to ensure competent, effective, and safe care for residents. However, the policy was not followed as the CNAs did not receive performance reviews at least every 12 months, and their education was not based on performance reviews. The surveyor discussed this concern with the DON and noted that no additional information was provided to address the deficiency.
Infection Control Preventionist Absence from QA Meetings
Penalty
Summary
The facility failed to ensure that the required staff attended the quarterly Quality Assurance (QA) meetings, as evidenced by the absence of the Infection Control Preventionist (IP) from three consecutive meetings. The surveyor reviewed the QA meeting sign-in sheets for the last three quarters and found that the IP was not present at the meetings held on September 5, 2024, July 16, 2024, and May 23, 2024. During an interview, the Director of Nursing (DON) explained that the IP was unable to attend the meetings due to working the evening shift and serving as the nursing supervisor. Although the IP provided reports to the DON, their absence from the meetings was noted as a deficiency. The facility's Quality Assurance Performance Improvement (QAPI) Program, dated July 2024, listed the required members of the QAPI team, which did not explicitly include the IP. However, the absence of the IP from the meetings was still identified as a deficiency by the surveyor, as the IP plays a crucial role in infection control within the facility.
Failure to Maintain and Display State Inspection Results
Penalty
Summary
The facility failed to maintain and make accessible the prior year's State of New Jersey inspection results, as required by regulations. During a group meeting with six alert and oriented residents, all participants stated they were unaware of where to find the State inspection results. The surveyor's investigation revealed that the inspection results from 2017 and 2018 were available at the LP Nursing Station, while the HP Nursing Station had a binder with 2019 results hidden in a closed closet. The SP Nursing Station's inspection results were not mentioned, indicating they were not readily accessible either. The Director of Nursing (DON) confirmed that the most recent inspection results from August 10, 2023, were not posted in the binders. Although the Administrator later found the current inspection reports on the nursing units, they were mixed with other binders on the counter and not in an area accessible to residents, families, or the public. This oversight led to the deficiency, as the facility did not comply with the requirement to post the location of inspection results in a readily accessible area.
Failure to Follow Physician's Orders and Medication Administration Policy
Penalty
Summary
The facility failed to ensure that staff followed the physician's order for the use of side rails for a resident. The surveyor observed the resident in bed with two full padded side rails in use, despite the physician's order and care plan specifying only one side rail for positioning. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, had a care plan and side rail assessment indicating the use of one side rail. The Director of Nursing confirmed the discrepancy and acknowledged that a side rail assessment should have been completed quarterly, and a physician's order should have been obtained before using two side rails. Additionally, the facility failed to ensure that an LPN followed the physician's order and facility policy during medication administration for another resident. The LPN administered blood pressure medications without taking the resident's vital signs within the required 15-minute window before medication administration. The LPN admitted to taking the vital signs about an hour before administering the medications, contrary to the facility's policy, which requires vital signs to be taken no more than 15 minutes prior to medication administration. The surveyor's interview with the LPN and the Director of Nursing confirmed the failure to adhere to the facility's medication administration policy. The facility's policy clearly states that vital signs should be taken within 15 minutes before removing medications from their packaging, which was not followed in this instance. No further information was provided by the facility regarding these deficiencies.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident dependent on staff for Activities of Daily Living (ADL) received personal hygiene care in accordance with the facility policy. This deficiency was identified for a resident who was observed multiple times with long, jagged, and soiled fingernails. Despite the resident expressing a desire to have their nails cleaned and manicured, the Certified Nursing Assistant (CNA) assigned to their care did not address the issue. The CNA stated that while they were responsible for cleaning the residents' nails, the activity staff were responsible for clipping and filing them. However, the Licensed Practical Nurse (LPN) contradicted this by stating that CNAs were responsible for cleaning, clipping, and filing the residents' nails. The resident in question had been admitted with diagnoses including dementia, end-stage heart failure, and chronic respiratory failure with hypoxia, and had a severe cognitive impairment as indicated by a BIMS score of 0 out of 15. The resident required moderate assistance with personal hygiene, as documented in their care plan. Despite being on the salon list, the resident's nails had not been attended to since their last salon visit over a month prior. The facility's ADL policy and procedure emphasized the importance of providing assistance according to residents' personal preferences, and the job description for CNAs included assisting residents with ADLs, which was not adhered to in this case.
Oxygen Therapy and Infection Control Deficiency
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order and did not ensure proper storage of respiratory nasal cannula tubing for a resident. The surveyor observed the resident receiving oxygen at 2.5 liters per minute, contrary to the physician's order of 2 liters per minute. Additionally, the nasal cannula tubing was not stored in a bag as required by infection control measures, and this was confirmed by both a CNA and an LPN during interviews. The CNA acknowledged that the tubing should have been discarded and replaced, while the LPN admitted to not verifying the oxygen flow rate and proper storage of the tubing during morning rounds. The resident involved had a history of dementia, end-stage heart failure, and chronic respiratory failure with hypoxia. The care plan for the resident included oxygen therapy as per the physician's order, but the facility's failure to adhere to these orders and infection control policies was evident. The facility's policy required oxygen tubing to be stored in a bag when not in use, and the oxygen therapy policy specified that a licensed nurse should administer oxygen as prescribed. Despite these guidelines, the facility did not provide additional information or corrective actions during the survey team's meeting with the LNHA and DON.
Failure in Narcotic Reconciliation and Accountability
Penalty
Summary
The facility failed to consistently provide pharmaceutical services in accordance with professional standards, specifically in the reconciliation and accountability of controlled dangerous substances. During an inspection of the narcotic medication cart on the high side of the LP unit, it was observed that the Controlled Drug Inventory Record (CDIR) was not signed by two nurses for the day in question. The Registered Nurse (RN) on duty noted that the previous shift nurse had not signed the Individual Patient Controlled Drug Record (IPCDR) for Tramadol 50 mg administered to a resident the night before. This discrepancy was not identified by the nurses conducting the shift-to-shift count, and the RN reported the issue to the Nursing Supervisor and Director of Nursing (DON). Further review revealed inconsistencies between the IPCDR and the electronic Medication Administration Record (eMAR), with instances of Tramadol being signed as removed from inventory but not administered, and vice versa. The resident involved was admitted with a diagnosis that included low back pain and was receiving scheduled and as-needed pain medications. The resident was cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 7 out of 15. The eMAR for October and September showed discrepancies in the administration and inventory records of Tramadol, with some doses signed as removed but not administered, and others administered but not signed as removed. The resident confirmed receiving Tramadol the previous night but could not recall other dates. Additionally, the inspection of the narcotic medication cart on the B-side of the HP unit revealed missing signatures on the shift-to-shift log for several dates in October. The RN/Nursing Supervisor confirmed the missing signatures and acknowledged that the log should have been signed by two nurses. The facility's policy requires narcotics to be counted shift-to-shift, with discrepancies reported to the Supervisor or DON, and proper documentation of medication removal and administration. The DON investigated the discrepancies and acknowledged the errors.
Infection Control Deficiency in Dining Services
Penalty
Summary
The facility failed to ensure proper infection control practices during dining services on one of its nursing units. Observations revealed that a Certified Nursing Assistant (CNA) did not perform hand hygiene between assisting residents with hand wipes and applying clothing protectors. The CNA was seen cleaning a resident's hands, applying a clothing protector, and then proceeding to assist another resident without sanitizing her hands. Additionally, the CNA handed out wipes to four residents, who returned the soiled wipes to her, which she discarded without performing hand hygiene before applying clothing protectors to them. Further observations showed that an Activity Coordinator (AC) also failed to sanitize her hands between residents. The AC donned gloves, cleaned a resident's hands, discarded the gloves and wipe, and then donned a new pair of gloves without sanitizing her hands. The AC also tied a trash bag to the back of a resident's wheelchair, which was questioned by the surveyor as a potential infection control and dignity concern. Interviews with the CNA and AC confirmed their awareness of the need for hand hygiene, but they did not follow the proper procedures during the observed incidents.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near West Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Summit Ridge | 0.4 mi | ★★★★★ | 3 | 0 |
| Alaris Health At West Orange | 1.2 mi | ★★★★★ | 1 | 0 |
| Stratford Manor Rehabilitation And Care Center | 1.8 mi | ★★★★★ | 10 | 0 |
| Livingston Post Acute Care | 1.8 mi | ★★★★★ | 21 | 0 |
| Inglemoor Rehabilitation And Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
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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.