Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Gardens At Monroe Healthcare And Rehabilitation, T during CMS and state inspections, most recent first.
Surveyors found that two CNAs removed PPE in the hallway instead of inside resident rooms after caring for residents on transmission-based precautions for influenza and COVID-19, contrary to CDC guidance and facility policy. Additionally, an LPN was observed wearing a surgical mask below her nose while administering medications during an outbreak, despite facility-wide masking requirements and posted instructions. These actions occurred while the facility was under outbreak protocols and source control measures.
A resident with severe cognitive impairment and osteoporosis experienced a fall, which was documented by an LPN, but there was no documentation of an RN assessment in the medical record. Staff interviews confirmed that RNs were expected to assess residents after falls but were not required to document these assessments, and the facility's policy did not specify RN documentation requirements.
Two residents did not receive proper pharmaceutical services when an LPN failed to obtain an apical pulse with a stethoscope before administering Digoxin, and another LPN administered Doxazosin based on a blood pressure reading taken more than two hours prior, rather than immediately before administration as required. Both actions were contrary to professional standards and facility policy, despite staff education on these requirements.
A resident with a history of femur fracture and pneumonia was discharged home, but the MDS was incorrectly coded as a discharge to a hospital. The error was confirmed by the MDS Coordinator after reviewing the medical record and discharge documentation.
Improper PPE Removal and Facemask Use During Outbreak
Penalty
Summary
Surveyors identified that two Certified Nurse Aides (CNAs) failed to properly remove personal protective equipment (PPE) after caring for residents on transmission-based precautions for influenza and COVID-19. In both cases, the CNAs donned appropriate PPE before entering the residents' rooms but removed and discarded their gowns and face shields in the hallway outside the rooms, rather than inside the rooms as required by CDC guidance and the facility's own policy. Both CNAs stated they removed PPE in the hallway because the designated PPE trash bins were located there, and signage at the residents' doors clearly indicated the correct procedures for donning and doffing PPE. The residents involved had significant medical histories, including influenza, asthma, cancer, multiple sclerosis, and major depressive disorder, and were under physician orders for contact and droplet precautions. Additionally, a nurse was observed wearing a surgical mask improperly, with her nose exposed, while administering medications and providing care to a resident during a facility-wide outbreak. The nurse, who was an agency staff member, acknowledged she was aware of the mask requirement but stated she always wore her mask below her nose due to discomfort. Facility signage throughout the building instructed staff on proper mask usage, specifically stating not to wear masks under the nose or mouth. The DON confirmed that all staff were required to wear masks covering both the nose and mouth and that alternative mask styles were available to accommodate different needs. The facility was under outbreak protocols, as indicated by posted signage and the DON's statements, with source control measures implemented per CDC and local health department recommendations. Despite these measures and clear policies, staff did not consistently follow proper infection prevention and control procedures, specifically regarding the removal of PPE and the correct wearing of facemasks while providing resident care.
Failure to Document RN Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when a Registered Nurse (RN) failed to document an assessment of a resident after the resident experienced a fall. The incident involved a resident with diagnoses including age-related osteoporosis and mild cognitive impairment, as evidenced by a Brief Interview for Mental Status score indicating severely impaired cognition. The fall was documented in the medical record by an LPN, and both the incident/accident report and the facility's investigation worksheet were completed and signed by the LPN. There was no evidence in the electronic medical record that an RN assessed or documented an assessment of the resident following the fall. Interviews with facility staff revealed that the standard practice was for the nurse assigned to the resident, typically an LPN, to complete all incident documentation, and that RNs or supervisors did not document their assessments in the electronic medical record or on any separate form. The Director of Nursing confirmed that while RNs were expected to assess residents after a fall, they were not required to document these assessments. Additionally, the facility's fall assessment and management policy did not specify that RN documentation was required after a resident sustained a fall.
Failure to Obtain Required Vital Signs Prior to Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that an apical pulse was obtained before administering Digoxin to a resident. An LPN was observed preparing to administer Digoxin and stated awareness of the need for an apical pulse, but instead took a radial pulse by holding the resident's wrist for 60 seconds. The LPN acknowledged not having a stethoscope and confirmed that the correct procedure was to use a stethoscope to obtain an apical pulse for Digoxin administration. The Director of Nursing, Unit Manager, and Consultant Pharmacist all confirmed that the standard practice is to obtain an apical pulse with a stethoscope for 60 seconds before giving Digoxin, and the physician's order for the resident specified to hold Digoxin if the apical pulse was 60 or below. Additionally, the facility did not ensure that required vital sign parameters for medication administration were obtained in a timely manner. Another LPN was observed administering Doxazosin to a resident based on a blood pressure reading taken over two hours earlier during morning rounds, rather than immediately before medication administration as required by facility policy and professional standards. The LPN stated that it was her routine to use blood pressure readings from earlier in the shift for medication passes, and the Unit Manager confirmed that this was a common practice unless the earlier reading was low. The Consultant Pharmacist and Director of Nursing both indicated that blood pressure should be taken within an hour, and ideally just before administering medications with hold parameters. Review of inservice education materials showed that staff had been instructed to take vital signs such as apical pulse and blood pressure immediately before pouring medications with specific hold parameters. However, one LPN involved in the Digoxin incident had not attended the relevant inservice, while the LPN involved in the Doxazosin incident had attended. The facility's failure to ensure adherence to these standards resulted in the deficient practices observed during the survey.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) assessment according to the Resident Assessment Instrument (RAI) guidelines. Specifically, a resident who was admitted with diagnoses including an intracapsular fracture of the right femur and lobar pneumonia was discharged home with family, as documented in the physician's orders and nursing notes. However, the MDS was coded as a discharge to a short-term general hospital with a status of 'discharge return not anticipated,' which did not reflect the actual discharge destination. During the survey, the MDS Coordinator confirmed that the MDS was incorrectly coded after reviewing the resident's records and acknowledged the error in the presence of the surveyor. The RAI manual specifies that discharges to a private home or community setting should be coded differently, and the facility's documentation supported that the resident was discharged home, not to a hospital. This discrepancy was identified through interviews, record reviews, and examination of facility documentation.
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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 Monroe Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cranbury Center | 1.6 mi | ★★★★★ | 10 | 2 |
| The Elms Rehab And Healthcare Center Of Cranbury | 2.8 mi | ★★★★★ | 15 | 1 |
| Meadow Lakes | 3.1 mi | ★★★★★ | 0 | 0 |
| Village Point | 4.6 mi | ★★★★★ | 1 | 1 |
| Excel Care At Manalapan | 6.8 mi | ★★★★★ | 24 | 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.