Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Excel Care At The Pines during CMS and state inspections, most recent first.
Failure to complete pre-employment screening before hire. The facility did not consistently complete reference checks and criminal background checks before new hires began work. Survey review of employee files found multiple missing reference checks and background checks completed after the hire date for an RN, LPNs, an LNHA, a CNA, a maintenance assistant, a staffing coordinator, an assistant administrator, and a social worker assistant. Interviews confirmed that several employees started working before the required screening was finished.
The facility failed to ensure the designated IP was dedicated solely to the IPCP. The interim DON/IP stated she was hired as a part-time IP but later took on the full-time DON role as well after the former DON resigned, and facility leadership confirmed she was serving in both roles.
Incomplete Care Plans for Wounds, PICC Line, and Anticoagulant Therapy: A resident with a PICC line and foot wounds, another resident receiving Lovenox, and a third resident receiving apixaban all lacked comprehensive care plan documentation for those conditions and related interventions. Staff interviews confirmed the PICC line, wound care needs, and anticoagulant-related monitoring for bleeding and bruising were not included in the residents’ care plans.
Failure to document and report repeated anticoagulant refusals. A resident with pelvic and other fractures was ordered Lovenox for DVT prevention, but the MAR showed multiple refusals over several months. The resident said they sometimes refused the injections because they questioned the need for them and disliked the abdominal injections. RN and MD interviews, along with record review, showed no documented progress note entries reflecting timely physician notification or resident education for the repeated refusals.
A resident with osteomyelitis and DM had a PICC for IV ertapenem, but the MAR/TAR showed no orders for PICC dressing changes, cap changes, or site monitoring for infection, bleeding, or dislodgement during the month reviewed. The PICC dressing was observed intact but undated with peeling tape, and the resident was unsure when it had last been changed. The LPN, DON, MD, and VPCS all confirmed the lack of PICC maintenance orders and that the last documented dressing change had been weeks earlier.
A CP failed to report repeated irregularities during monthly MRR for a resident receiving Lovenox for clot prevention after fractures. The resident’s MAR showed numerous refusals of the anticoagulant over several months, while the CP’s monthly reports did not identify the refusals as an irregularity. The resident questioned the need for the injections, and facility staff and the CP acknowledged the refusals should have been recognized and reported.
The facility failed to ensure required core members attended and signed quarterly QAPI committee meetings. Review of four meeting sign-in sheets showed missing signatures from the DON and LNHA, with no documented designee attendance when signatures were absent. The LNHA stated the Medical Director, LNHA, DON, and IP were mandatory attendees and that their signatures were needed to validate attendance.
A resident room on the Veteran's Unit had a loose, chipped ceramic floor tile with an opening in the flooring and heavy dirt buildup along the floor-wall edges. A resident said the broken tile had previously been reported to staff, but staff interviewed by the surveyor had not noticed it, and maintenance reported no documented nursing notification through the electronic reporting system. The LNHA, DON, and VPCS discussed the tile as a safety and infection control issue, and the facility could not provide evidence that the room had been carbolized before surveyor inquiry.
Failure to provide timely incontinence care to two residents was identified during an incontinence tour. One resident stated they had been wet since early morning after asking a CNA for help, and the brief was confirmed to be soiled with urine. Another resident was found in bed with a large amount of dried feces protruding from the brief onto both legs, while the assigned CNA said care was delayed because she was occupied with other residents. Records showed both residents had significant incontinence needs, and one was dependent on staff for all ADLs.
A resident with a sacral pressure ulcer, ventilator dependence, and total staff dependence was observed on an air mattress set at 200 pounds, then later at 300 pounds, despite a documented weight of 114.6 pounds. The record included wound care orders but no order for an air mattress. Staff stated they checked that the mattress was inflated and functioning, while the DON stated the setting should be based on the resident’s weight and checked each shift.
A resident with COPD and acute respiratory distress syndrome had an order for continuous O2 at 3 L/min via NC, but surveyors repeatedly observed the resident without oxygen and found no concentrator or tank in the room. The MAR showed nursing signatures documenting oxygen administration despite staff statements that the resident was usually non-compliant and had refused O2. The care plan did not reflect a history of refusal, and the DON and VPCS confirmed the resident should have had oxygen available and that the MAR should not have shown oxygen as given when it was refused.
Insufficient CNA staffing led to delayed incontinence care for two residents. One resident reported being wet for hours after asking for a change, and another was found with feces protruding from the brief and dried on the legs while the assigned CNA said she was the only CNA on the unit and was tied up with other residents. Records showed one resident was cognitively intact but frequently incontinent and needed toileting help, while the other was nonverbal, highly sensory impaired, ventilator-dependent, and fully dependent for ADLs. Staffing logs showed repeated day-shift CNA shortages over multiple weeks, and the LNHA confirmed the facility was not meeting required ratios.
Daily Nursing Home Resident Care Staffing Report was not properly displayed in the front lobby. The surveyor observed the staffing report on the receptionist's desk instead of being posted for visitors and patients, and the LNHA stated that staffing reports should be posted daily and adjusted for call outs. The facility's staffing policy did not include details on the required daily posting of the report.
A resident on a renal diet with double portions did not receive the ordered lunch tray items, including the full chicken portion and rice, and the DD confirmed the chicken was not weighed before plating. Another resident ordered a regular diet with small starch portions, double entree and vegetable portions, and extra sandwiches did not receive double portions on the meal tray, and staff could not find a dietary slip showing the order had been processed.
A resident with multiple chronic conditions did not have several administered treatments and a required skin assessment documented on the eTAR, with blank spaces found for various topical medications and wound care orders. Nursing staff and leadership confirmed that all treatments should be documented and that blank spaces indicate treatments were not performed or not recorded, in violation of facility policy.
The facility was found to have deficiencies in food handling and sanitation practices, including expired and improperly labeled food items, inadequate cleaning of kitchen equipment, and improper handwashing techniques. Expired mustard, undated frozen French fries, and spoiled lettuce were observed, along with a lack of an internal thermometer in the milk box. A stand-up mixer was found with food debris, and a cook was observed not following proper handwashing procedures.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as damaged linens, broken furniture, and dust accumulation on bathroom vents. Observations included a resident's bed with a sheet that had holes, a broken dresser drawer, flies around a bed, peeling wallpaper, and a hole in the wall. The Regional Director of Maintenance and the Director of Housekeeping acknowledged these issues, indicating lapses in maintenance and cleaning protocols.
A resident with diabetes had blood sugar levels exceeding established parameters on multiple occasions, but the facility failed to notify the physician as required. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the lack of documentation and communication, which was not in accordance with the facility's policies.
The facility failed to make State of New Jersey inspection results readily accessible to residents. Although the survey results binder was visible on the receptionist's desk, residents could not access it without staff assistance due to a locked door requiring a code. Residents expressed a desire to access the results, and the Licensed Nursing Home Administrator acknowledged the inaccessibility prior to relocating the binder to the nursing units.
A facility failed to implement infection control measures for a resident's respiratory equipment. A nebulizer mask was observed uncovered and exposed to contamination between uses. The resident, with acute respiratory failure and asthma, confirmed the last treatment was the previous night. Interviews with staff revealed the procedure to store the mask in a plastic bag was not followed, and no written policy was provided.
The facility failed to follow proper infection control practices and hand hygiene during medication administration and tracheostomy care. An LPN did not perform hand hygiene between glove changes or wash hands for the recommended duration. A RRT entered a resident's room with gloves on and did not perform hand hygiene between glove changes. Interviews revealed a lack of understanding of the facility's hand hygiene policy, which aligns with national standards but was not followed.
Failure to Complete Pre-Employment Screening Before Hire
Penalty
Summary
The facility failed to implement its abuse policy by not completing reference checks and criminal background checks before employees began work. A review of the facility policy stated that no employees were to begin work without completion of required pre-employment screening, including criminal background checks and verification that the individual had no history of abuse, neglect, or exploitation. The surveyor reviewed 50 employee files for newly hired staff since the last standard survey and found incomplete screening documents in multiple files, including missing reference checks for several employees and criminal background checks completed after the hire date for others. Specific examples included a CNA, RN, LPNs, an LNHA, a maintenance assistant, a staffing coordinator, an assistant administrator, and a social worker assistant. One LPN had a criminal background check completed more than two months before the hire date, while several others had no reference checks or no criminal background checks in the file. During interviews, the LNHA and VPHR stated that reference checks were supposed to be completed for all employees before hire and that background checks were to be completed before orientation, but the LNHA later confirmed that the referenced employees started working before the reference checks and/or criminal background checks were completed.
Infection Preventionist Assigned Dual DON Duties
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was dedicated solely to the infection prevention and control program (IPCP). During interview, the interim DON stated that she had been hired as a part-time, 20-hour-per-week IP, but after the former DON resigned she began serving as both the full-time DON and the part-time IP, with assistance from the VPCS. The interim DON/IP stated that she took on both roles on 2/11/26 after being asked by administration to cover both positions until a permanent DON was hired. Facility leadership, including the VPCS, LNHA, DON, and Assistant Administrator in training, confirmed that the IP assumed the DON role in addition to the IP role after the former DON resigned.
Incomplete Care Plans for Wounds, PICC Line, and Anticoagulant Therapy
Penalty
Summary
The facility failed to develop, implement, revise, and update comprehensive care plans for 3 of 28 residents reviewed. For Resident #17, the record showed diagnoses including osteomyelitis and diabetes mellitus, a BIMS score of 12 out of 15, use of a wheelchair, open foot lesions, and antibiotic therapy. The resident stated he/she had wounds on the left foot and had a single lumen PICC in the left upper arm. The record review found no treatment orders or dressing change orders for the PICC line, and the interdisciplinary care plan did not document the PICC line or any interventions for its care. Resident #17 also had treatment orders for cleansing and dressing the right and left foot wounds, and a wound care consult documented wounds on the left plantar foot and left mid plantar foot with continued topical wound dressing therapy, offloading, and weekly follow-up. Even with these findings, the interdisciplinary care plan did not include documentation of the left foot wounds or interventions for their care. Staff interviews confirmed that the PICC line and foot wounds were not care planned and that resident-specific interventions had not been implemented on the care plan. For Resident #7, the record showed multiple fractures, difficulty walking, generalized muscle weakness, and use of Lovenox 30 mg subcutaneously every 12 hours for blood clot prevention with instructions to rotate the site and monitor for severe bleeding/bruising. The comprehensive care plan did not identify the anticoagulant or include interventions for its potential side effects. For Resident #8, the record showed unspecified dementia with mood disturbance, paroxysmal atrial fibrillation, hypertensive heart disease, severe cognitive impairment, and an active order for apixaban with instructions to observe for bruising, dark urine, and black tarry stool. The individualized comprehensive care plan did not include a focus area or interventions for atrial fibrillation or anticoagulant use. Interviews with nursing leadership and clinical services staff confirmed that these care plans should have been developed and included monitoring for bleeding, bruising, and other medication-related concerns.
Failure to Document and Report Repeated Anticoagulant Refusals
Penalty
Summary
The facility failed to ensure that a resident’s repeated refusals of Lovenox, an anticoagulant ordered for blood clot prevention, were promptly communicated to the physician and documented in the resident’s EMR progress notes. Resident #7 was admitted with multiple fractures, including pelvic and tibial fractures, clavicle fracture with delayed healing, difficulty walking, and generalized weakness. The resident’s MDS showed a BIMS score of 13, indicating cognitive intactness, and the resident was documented as receiving an anticoagulant. The resident had a physician order for Lovenox 30 mg subcutaneously every 12 hours for blood clotting prevention. The MAR showed multiple refusals across January, February, March, and April 2026 at both scheduled administration times. During interview, the resident stated that they had asked the doctor whether they still needed Lovenox because they were able to walk around more, did not like the abdominal injections, and sometimes refused the medication. RN #1 stated that if a medication were refused, she would educate the resident and notify the doctor or POA and document the education and notification in the progress notes. The Medical Director stated that the resident was ordered Lovenox because the risk for DVT was high due to the fractured acetabulum and pelvic fracture, and that he had personally discussed the medication with the resident. However, the MD also stated that documentation could go by the wayside in a burdened health care environment. The CP stated that the repeated refusals should have been identified as an irregularity, that physician notification and documentation were not noted in the progress notes, and that the refusals should have been addressed because of the number of doses refused. The facility policy stated that refused scheduled medications must be documented in the EMR and that if two consecutive doses of a vital medication are withheld or refused, the physician is notified.
PICC Dressing Changes and Site Monitoring Not Ordered
Penalty
Summary
The facility failed to ensure that Resident #17 received PICC line dressing changes and related monitoring consistent with professional standards of practice. Resident #17 was admitted with diagnoses including osteomyelitis and diabetes mellitus, had a single-lumen PICC in the left upper arm, and was cognitively intact. The resident was receiving IV ertapenem for osteomyelitis during the month of March 2026. On 4/1/2026, the surveyor observed the PICC dressing to be intact but undated, with tape peeling on the sides, and the resident stated they were not sure when the dressing had last been changed. Review of the MAR and TAR showed no physician order for PICC cap changes, PICC dressing changes, or monitoring of the PICC site for signs and symptoms of infection, bleeding, or dislodgement for the entire month of March 2026. The February TAR showed the last documented PICC dressing change was on 2/11/2026. During interviews, the LPN confirmed there was no order for PICC dressing changes, cap changes, or site monitoring. The DON stated that PICC orders should include catheter details, flushes, dressing changes, cap changes, and weekly site inspection for infection and patency, and the MD stated that PICC maintenance orders should include dressing changes and monitoring of the access site. The VPCS confirmed there were no dressing change orders since 2/11/2026 and that this was the last documented dressing change.
CP Failed to Report Repeated Lovenox Refusals
Penalty
Summary
The Consultant Pharmacist failed to identify and report irregularities related to Resident #7’s anticoagulant therapy during monthly drug regimen review. Resident #7 was admitted with multiple fractures, difficulty walking, and generalized muscle weakness, and the medical record showed an order for Lovenox 30 mg subcutaneously every 12 hours for blood clotting prevention. The resident’s MDS indicated the resident was cognitively intact and was taking an anticoagulant, but the care plan did not identify the anticoagulant therapy. Review of the January, February, March, and April 2026 MARs showed repeated refusals of Lovenox at both the 10:00 AM and 10:00 PM administration times on numerous dates. The resident told the surveyor that the medication had been prescribed because of immobility, but now questioned the continued need for it because he/she was able to walk around more and sometimes refused the injections. RN #1 stated that medication refusals would normally be addressed with resident education and notification of the physician or POA, but she had no knowledge that the resident had refused Lovenox. The Consultant Pharmacist’s monthly reports for January and February 2026 did not identify the repeated refusals as an irregularity, despite the facility policy requiring monthly review of each resident’s drug regimen and reporting of irregularities to the attending physician, medical director, and DON. The CP stated that the refusals should have been picked up as an irregularity and acknowledged that the repeated refusals in February and March should have been noted and brought to the facility’s attention.
QAPI Committee Attendance Not Documented
Penalty
Summary
The facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Committee meetings. During review of the last four quarters of QAPI meeting sign-in sheets, dated April 2025, July 31, 2025, October 2025, and 1/29/2026, the surveyor and the Licensed Nursing Home Administrator found that required signatures were missing on multiple occasions. The LNHA stated that the Medical Director, LNHA, DON, and Infection Preventionist were mandatory core staff for these meetings and that their signatures were needed to validate attendance. The LNHA reviewed the April 2025 sign-in sheet and confirmed the DON had not signed to show attendance, with no documented evidence of a designee attending on her behalf. The July 31, 2025 sign-in sheet also lacked the DON’s signature and no designee was documented. On the October 2025 sign-in sheet, the LNHA stated he had not signed to indicate attendance. On the 1/29/2026 sign-in sheet, the former DON was still employed at the facility but had not signed to indicate attendance. The LNHA stated that without the required staff signatures, there was no way to validate that they had attended the QAPI meetings as required.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to maintain a clean, safe, and home-like environment in one resident room on the Veteran's Unit. On 3/31/2026, a surveyor observed that one square ceramic floor tile had been removed from the subfloor and placed over the opening where it had been adhered, with a shallow opening in the flooring at the foot of bed C, which was unoccupied at the time. The surveyor also observed a thick buildup of dirt along the perimeter where the floor met the walls. An unsampled resident stated that one of the other two residents in the room had previously reported the broken floor tile to staff, but did not know which staff member was told. On 4/1/2026, a CNA and an LPN both stated they had not noticed the chipped, loose tile, and both acknowledged that the condition created a safety concern. The CNA said she would alert maintenance through the electronic reporting system because the tile needed to be glued down or replaced to avoid someone slipping. The LPN stated the repair should be reported to maintenance as soon as possible. Maintenance later stated that no nursing staff had used the electronic reporting system to notify maintenance about the broken tile and that he had only received a telephone call after surveyor inquiry. The LNHA, DON, and VPCS later discussed that the loose tile was a safety issue, and the DON stated that taping the tile down would create an infection control issue. The facility also did not provide documented evidence that the room had been carbolized prior to surveyor inquiry.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care to residents who were unable to perform activities of daily living for 2 of 8 residents observed during an incontinence tour. One resident was found lying in bed and stated that their incontinence brief was wet and that they had been wet since 5 AM. The resident said they had asked their assigned CNA to change them at that time, but the CNA left and did not return. When the LPN/NS checked the brief, the outer layer showed a blue line indicating wetness, and the brief was confirmed to be soiled with urine. The resident also stated that for the past week they had not been changed at the usual early morning time and that nothing happened when they needed to be changed between breakfast and lunch. A second resident was observed resting in bed with a large amount of dark brown loose feces protruding from the brief and onto both legs, with dried feces around the perimeter. The CNA assigned to the unit stated she had not yet changed this resident during her shift and was delayed because she was waiting for another resident on the commode and had a resident waiting to be showered. She stated she was the only CNA assigned to the unit that shift and that the resident was a heavy wetter who needed more frequent checks. The LPN/NS stated that residents on the ventilation unit required more frequent checks at a minimum of every hour because they could not use the call bell. Record review showed that the first resident had diagnoses including paralytic gait, communication deficit, and cardiac arrhythmias, with intact cognition, frequent bladder and bowel incontinence, and a care plan focused on bladder incontinence with interventions for toileting assistance and establishing voiding patterns. The second resident had diagnoses including ventilator dependence, a sacral pressure ulcer, and anxiety, was absent of spoken words, had highly impaired hearing and vision, and was always incontinent of bowel and frequently incontinent of urine, with dependence on staff for all ADLs. The resident's care plan did not include ADLs. The DON stated that CNAs should check residents every couple of hours and ensure they were clean and dry, especially heavy wetters, and that residents should be fresh for the next shift.
Air Mattress Set Incorrectly for Resident Weight
Penalty
Summary
The facility failed to ensure that an air mattress was accurately set according to a resident’s weight. On 3/31/2026, the surveyor observed the resident in bed on an air mattress set at 200 pounds. The resident’s record showed diagnoses including dependence on a ventilator, pressure ulcer of the sacral region, and anxiety. The quarterly MDS dated 3/12/2026 indicated the resident was absent of spoken words, had highly impaired hearing and vision, was at risk for pressure ulcers, required a pressure-reducing device for the bed, and was totally dependent on staff. The care plan included a focus area for potential impaired skin integrity with an intervention to educate the resident/representative about proper usage of pressure-reducing devices. The resident’s weight summary showed a weight of 114.6 pounds on 3/5/2026, and the physician’s orders included wound care for the left buttock but no order for an air mattress. On 4/2/2026, the surveyor again observed the resident on the air mattress, which was then set at 300 pounds, and the LPN/NS confirmed the setting. The LPN stated staff checked that the mattress was plugged in, inflated, and functioning, and that she had not received training on the air mattress. The DON stated nurses should check the setting every shift and that the mattress setting was based on the resident’s weight. The facility policy stated air mattresses should be set according to resident weight per manufacturer guidelines and monitored at least once per shift.
Failure to Provide Ordered Continuous Oxygen
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident with COPD and acute respiratory distress syndrome who had a physician order for continuous oxygen at 3 liters per minute via nasal cannula. The resident’s quarterly MDS indicated the resident was cognitively intact and independent with ADLs. During multiple observations, the surveyor did not see the resident wearing oxygen and did not find an oxygen concentrator or oxygen tank in the resident’s room, despite the active continuous oxygen order and MAR entries showing nursing signatures documenting oxygen administration. The surveyor observed the resident ambulating in the halls and elevator without oxygen and later eating breakfast in the room without oxygen available. When asked, the resident stated they had not used oxygen in approximately 5 months and said they did not need it. The resident became agitated and ended the conversation. A CNA stated she had never seen the resident using oxygen, and an LPN stated the resident was non-compliant with oxygen use most of the time, had refused oxygen, and that if a resident refused multiple times the physician should be notified and the order changed to PRN. The LPN also confirmed there was no oxygen available in the room. The MAR showed only four documented refusals in March, while the care plan included oxygen therapy related to COPD but did not document a history of refusing oxygen. The DON stated that a resident ordered continuous oxygen should have an oxygen concentrator in the room and should be receiving oxygen via nasal cannula, and that refusals should be documented in the MAR and progress notes with physician notification for an order change. The VPCS stated the resident was refusing oxygen, that nurses should not have signed the MAR indicating oxygen was being given when the resident was refusing, and that the oxygen order should have been discontinued. The facility policy required safe, clinically appropriate oxygen use with proper storage and handling of oxygen equipment in resident rooms.
Insufficient CNA Staffing and Delayed Incontinence Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, and this was reflected in delayed incontinence care for two residents and repeated CNA staffing shortages on the day shift. During an incontinence tour, one resident stated that their brief had been wet since 5 AM and that they had asked their assigned CNA to change them, but the CNA left and did not return. The surveyor and LPN/NS confirmed the brief was wet and soiled with urine. The resident also stated that for the past week they had not been changed at the usual 5 AM time and that nothing happened when they needed to be changed between breakfast and lunch. On the same tour, another resident was found lying in bed with a large amount of dark brown loose feces protruding from the brief and onto both legs, with dried feces around the perimeter. The CNA assigned to that unit stated she had not yet changed that resident during her shift because she was waiting for another resident to finish on the commode and also had a resident waiting to be showered. She stated she was the only CNA assigned to the unit on that shift and that if she went to change the resident, she would not be able to hear the call bell for the resident on the commode. She also stated that the resident was a heavy wetter and needed more frequent checks. The record review showed that one resident had diagnoses including paralytic gait, communication deficit, and cardiac arrhythmias, with a quarterly MDS indicating intact cognition, assistance needed with toileting, and frequent urinary and bowel incontinence. The other resident had diagnoses including dependence on a ventilator, a sacral pressure ulcer, and anxiety, with an MDS showing no spoken words, highly impaired hearing and vision, and total dependence on staff for all ADLs. The LNHA stated there were 10 residents on the vent unit and that there should have been 2 CNAs and a nurse, or 2 nurses and a CNA, for those residents. Staffing records also showed that for four weeks reviewed, the facility was below its required CNA ratios on every day shift listed, and the LNHA confirmed the facility was not meeting the ratios.
Daily Staffing Report Not Properly Posted
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report was posted and displayed in the front lobby. On 4/6/2026 at 10:15 AM, the surveyor observed the facility's Nursing Home Staffing Report Form dated 4/2/2026 posted on the receptionist's desk in the front main lobby rather than displayed in the front lobby. During an interview at 10:20 AM, the LNHA stated that he posts the schedule out front so visitors and patients know what the staffing is like, that on Fridays he preprints staffing reports for Saturdays and Sundays and places them behind Friday's report, and that the supervisor was responsible for posting the staffing report in his absence and adjusting it for call outs. He acknowledged that the daily staffing should be accurate and posted daily. A review of the facility's Staffing policy dated 5/1/2025 did not include details related to the required daily posting of the Nursing Home Resident Care Staffing Report.
Diet Orders Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received diets in accordance with physician orders. One resident, who had anemia, acute respiratory failure, iron deficiency, dependence on renal dialysis, and ESRD, was ordered a renal diet with regular texture, thin consistency, and double portions. The resident’s care plan also directed staff to provide and serve the diet as ordered. During lunch observation, the resident’s tray ticket indicated a renal-regular diet with double portions, but the tray contained only one chicken breast, about one-half cup of green beans, applesauce, juice, and coffee, and there was no rice provided. The resident stated that rice was usually received and did not know why it was missing at that meal. The Director of Dietary reviewed the tray ticket and stated the resident should have received 6 oz of chicken and double servings of green beans, and also stated the resident should have received everything on the ticket, including rice. The DD further stated that the facility had rice available at lunch, but the resident only received one chicken breast because the chicken boxes were labeled as 4-6 oz portions. The DD stated that the chicken was not weighed after cooking and before plating to confirm that it met the ordered 6 oz portion. A second resident, admitted with multiple fractures, difficulty walking, and generalized muscle weakness, had a physician order for a regular diet with regular texture, thin consistency, small portion starches, double portion entree and vegetables, and an extra sandwich with lunch and dinner. The resident’s care plan reflected this diet order. During breakfast observation, the resident’s meal ticket listed items including a vegetable frittata, cereal, biscuit, banana, juice, milk, and condiments, but the tray did not include any double portions. The resident stated that double portions were supposed to be provided but were not received. Staff interviews showed that the RD expected the diet order to be reflected on the meal ticket, the DD stated double portions should have appeared automatically, and an LPN confirmed that no dietary slip was found in the resident’s paper chart to show the order had been completed and sent to dietary.
Failure to Document Administered Treatments on eTAR
Penalty
Summary
The facility failed to document administered treatments on the electronic Treatment Administration Record (eTAR) for a resident with multiple medical conditions, including atherosclerotic heart disease, type 2 diabetes mellitus, and anemia. The resident had an intact cognitive status and a care plan addressing behavioral challenges such as refusal of care, with interventions requiring documentation of all interactions. Physician's orders included various topical medications and wound care treatments to be administered on specific schedules. A review of the March 2025 eTAR revealed multiple blank spaces on several dates for various prescribed treatments, including clotrimazole-betamethasone cream, collagen cream, bacitracin, Dakins solution, hydrocortisone gel, mupirocin ointment, and gentamicin cream. Additionally, a required weekly skin assessment was not documented on one of the scheduled days. Corresponding progress notes did not contain any documentation explaining the missed or undocumented treatments or assessments on those dates. Interviews with nursing staff, including an RN, Nursing Supervisor, and DON, confirmed that all treatments should be documented on the eTAR and that blank spaces indicate treatments were not performed or not documented. The facility's own policy emphasized the importance of timely and accurate documentation, with no allowance for unexplained blanks. The DON verified the presence of blanks on the eTAR for the resident in question.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by the surveyor. During an inspection of the kitchen, several issues were identified, including expired and improperly labeled food items. A gallon container of deli mustard was found to be expired, and bags of frozen French fries and an apple pie were not dated after being removed from their original containers. Additionally, shredded lettuce and heads of iceberg lettuce were found to be spoiled and were subsequently discarded. The facility also lacked an internal thermometer in the milk box, which is necessary for monitoring temperatures. Further observations revealed sanitation issues with kitchen equipment. A stand-up mixer, which was reportedly cleaned and sanitized, was found with a wet substance in the bowl and food debris on the metal cage surrounding the mixing blade. The mixer was left uncovered and exposed after cleaning. Additionally, the faucet on the steam table was surrounded by an abundance of food debris, indicating a lack of regular cleaning. The facility's handwashing practices were also found to be deficient. A cook was observed improperly washing their hands, failing to apply soap to both hands and not washing for the recommended duration. The facility's policies on equipment cleaning, dating and labeling, infection control, and handwashing were reviewed, revealing discrepancies between the documented procedures and the observed practices.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several observations made by surveyors. On the 2nd and 3rd floors, issues included a resident's bed with a sheet that had holes, exposing the mattress, and a broken dresser drawer. Additionally, flies were observed around a bed, and wallpaper was peeling between two beds. A hole was also noted in the wall between the window sill and baseboard molding. The Regional Director of Maintenance acknowledged these issues and agreed they needed repair. The Director of Housekeeping confirmed that linens in disrepair should not have been used and should be returned to the contractor. Further deficiencies were noted regarding the cleanliness of bathroom vents. Surveyors observed significant dust accumulation on bathroom vents across multiple rooms over several days. Despite a grievance form indicating a previous resolution of dust concerns, the issue persisted. The Director of Housekeeping stated that vents are supposed to be cleaned weekly and during monthly deep cleaning, but acknowledged that the observed dust levels were unacceptable. The facility's policy on surface dusting was reviewed, which includes dusting vents, but the practice was not effectively implemented.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify a physician of a resident's blood sugar levels exceeding the established parameters, which is a deficiency in meeting professional standards of quality. The resident in question was admitted with diagnoses including bipolar disorder, cirrhosis of the liver, and diabetes mellitus. The resident's medical records indicated that their blood sugar levels were frequently recorded above the specified thresholds, yet there was no documentation that the physician had been notified as required by the physician's orders. The resident's blood sugar levels were recorded as greater than 300 mg/dl on 34 occasions in April 2024 and greater than 350 mg/dl on 17 occasions in June 2024. Despite these elevated levels, the corresponding progress notes did not include any documentation that the physician had been informed of these readings. This lack of communication and documentation was acknowledged by the Director of Nursing and the Licensed Nursing Home Administrator during an interview with the surveyor. The facility's policies on physician medication orders and charting and documentation did not provide clear instructions for following a physician's orders, which contributed to the deficiency. The Director of Nursing confirmed that nurses were required to notify the physician if blood sugar levels exceeded the parameters set by the physician's orders, and the Licensed Nursing Home Administrator confirmed that such notifications should have been documented in the resident's medical record.
Inaccessible State Survey Results for Residents
Penalty
Summary
The facility failed to make the State of New Jersey inspection results readily accessible to residents. On the morning of November 12, 2024, the surveyor observed the state survey results binder placed on the receptionist's desk in the facility's reception area. However, during a Resident Council Meeting the following day, four alert and oriented residents reported that they were unaware of the location of the State Survey results and expressed a desire to access them upon survey completion. Further investigation revealed that although the binder was clearly labeled and visible on the receptionist's desk, residents could not access it without staff assistance due to a locked door requiring a code to enter the lobby. The Licensed Nursing Home Administrator acknowledged that the survey results were not accessible to residents prior to being moved to the nursing units, as residents did not have the code to access the lobby where the binder was initially located.
Inadequate Infection Control for Respiratory Equipment
Penalty
Summary
The facility failed to implement proper infection control measures for the handling and storage of respiratory equipment for a resident requiring respiratory care. During an initial tour, a surveyor observed that a nebulizer mask belonging to a resident was left uncovered and exposed to contamination while not in use. On a subsequent observation, the nebulizer mask was found in an open drawer, still unprotected between uses. The resident, who was admitted with acute respiratory failure with hypoxia and mild persistent asthma, confirmed that the last nebulizer treatment was received the previous night, indicating the mask had been exposed for an extended period. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that the facility's procedure was to rinse the nebulizer mask after use, allow it to dry, and then store it in a plastic bag to prevent contamination. However, the facility was unable to provide a written policy or procedure regarding the storage of nebulizer equipment. This lack of adherence to infection control practices was identified as a deficiency during the survey.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices and hand hygiene during medication administration and tracheostomy care. On the ventilator unit, an LPN was observed administering medication to a resident via a J tube without performing hand hygiene between glove changes. The LPN also failed to wash hands for the recommended duration and used the same towel to turn off the faucet after washing hands. Additionally, the LPN did not perform hand hygiene before donning gloves to administer medication to another resident, and again after spilling mouthwash and leaving the room to obtain more. During tracheostomy care, a Registered Respiratory Therapist (RRT) entered a resident's room wearing gloves without performing hand hygiene. The RRT changed gloves without washing hands between glove changes and only used alcohol-based hand rub after completing the procedure and exiting the room. Interviews with the LPN and RRT revealed a lack of understanding of the facility's hand hygiene policy, particularly regarding the necessity of hand hygiene between glove changes. The Infection Control Preventionist and Director of Nursing provided conflicting information about the facility's hand hygiene policy, particularly concerning hand hygiene between glove changes and the proper procedure for handwashing. The facility's policy, as reviewed, aligns with national standards, indicating that hand hygiene should be performed before and after resident care, after removing gloves, and before donning sterile gloves. However, the observed practices did not comply with these standards, leading to the identified deficiencies.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Atlantic City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Our Ladys Center For Rehabilitation & Healthcare | 6.2 mi | ★★★★★ | 0 | 0 |
| Preferred Care At Absecon | 6.8 mi | ★★★★★ | 0 | 0 |
| Excel Care At Egg Harbor | 6.9 mi | ★★★★★ | 1 | 0 |
| Meadowview Nursing And Rehabilitation Center | 7 mi | ★★★★★ | 0 | 0 |
| Complete Care At Linwood, Llc | 9 mi | ★★★★★ | 17 | 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 August 2026) and official state health department websites.