Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hammonton Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Missing Pre-Employment Screening and Abuse Policy Compliance: The facility failed to follow its abuse policy by not completing required pre-employment screening for multiple employees before hire. Review of employee files found missing reference checks, missing licensure or registry verification, and missing criminal background checks for staff in roles including CNA, LPN, RN, Dietary, Housekeeping, Maintenance, and other departments. The HR Director acknowledged the checks were supposed to be completed before hire, and the LNHA stated the employee files were disorganized.
Unsafe Food Storage and Dishwashing Practices: Surveyors observed missing internal thermometers in multiple refrigerators, undated thawing meat and other unmarked foods, debris and liquid buildup in the walk-in, and improper storage of food brought from home. Staff also failed to record dish machine temperatures and sanitizer levels before washing dishes, and a metal ladle was stored inside an opened bag of flour, creating a cross-contamination concern.
The facility failed to implement its antibiotic stewardship program by not maintaining antibiotic tracking and surveillance and by not completing the infection assessment tool for several residents started on antibiotics in-house. The IP stated she did not have the 2025 tracking logs, and records showed no documented infection assessment tool for residents treated for UTI and other infections; the DON and RCD confirmed that surveillance and the Antibiotic Stewardship Program should have been in place.
A facility failed to document weekly skin assessments and to consistently carry out pressure-relieving measures for two residents with pressure-related skin issues. One resident with dementia, immobility, incontinence, and a sacral wound had weekly skin checks signed off on the TAR but no corresponding EMR documentation for several weeks, while another resident with a right heel DTI had weekly skin monitoring entries without the required detailed assessment, and heel boots were not in use during observation despite orders for offloading.
A facility failed to serve the correct menu items to several residents on mechanically altered diets during lunch. Residents with diet orders for advanced mechanical soft or mechanically altered diets were observed receiving chicken instead of the Salisbury steak listed on their meal tickets and cycle menu, and staff confirmed the mismatch when they reviewed the tickets and contacted the kitchen. One resident's tray also lacked the ordered Salisbury steak and did not include salt and pepper, while the ADOD and DOD described the issue as a mix up and stated the wrong item had been served.
Surveyors found that a dependent, cognitively impaired hospice resident with dementia, care-planned for bowel and bladder incontinence checks every 2–4 hours, was left sitting in a urine-saturated brief despite documentation of only one incontinence care episode that morning and staff acknowledgment that hospice residents should be included in 2-hour rounds. A hospice aide reported leaving the resident clean earlier and described finding the resident saturated on prior days. In a separate finding, a cognitively intact resident with an indwelling urinary catheter and a care plan requiring a privacy bag was repeatedly observed with the catheter bag uncovered and visible from the hallway and during therapy, despite staff confirming that privacy bags were available and should have been used to protect dignity.
A resident’s fitted sheet had a large embedded brown stain, and the resident said the stain was present when the sheet was received and that linens with holes were sometimes provided. Surveyors also found a washcloth with large red stains and particles, a fitted sheet with a golf ball-sized hole, and brown residue on the clean linen cart; staff stated linen should be intact, clean, and removed from circulation if stained or damaged.
MDS Did Not Reflect C-PAP Use A resident’s quarterly MDS did not accurately capture C-PAP use, and the ICCP also did not include it. The resident was observed with a C-PAP at the bedside, stated it was used a couple of times per week, and records from the pulmonologist and MD documented OSA and continued C-PAP use, while the OSR did not include a C-PAP order.
Failure to provide and follow through on foot care for two residents. One resident with neurologic impairment and a heel DTI had podiatry recommendations for proper foot hygiene and larger shoes due to painful digital deformities and poor vascular supply, but the facility did not ensure the shoes were obtained or the care plan was updated. Another resident with DM, weakness, and difficulty walking had long, sharp toenails despite a prior podiatry consult documenting painful, thick, discolored nails and debridement; staff and the DON acknowledged the nails needed care, but the resident still had not received it.
A resident with Parkinson's disease, DM2, HTN, dysphagia, and severe cognitive impairment had significant weight loss documented, but the facility did not obtain weekly weights as ordered and did not complete a re-weight after a large weight discrepancy was identified. The TAR entries did not match the EHR weight dates, several ordered weights were missing, and the DON, RD, LPN, and RCD all acknowledged the mismatch and the lack of a timely re-weigh.
A resident with OSA had a C-PAP mask left uncovered on the nightstand, and another resident with COPD had a nebulizer mask left uncovered and open to the air. Record review showed no current physician orders for the C-PAP, DuoNeb, or incentive spirometry despite pulmonology notes supporting continued use, and staff confirmed that respiratory treatments and medications require physician orders and that equipment should be stored in a bag when not in use.
The facility failed to complete Part 5 of the DEA 222 forms for narcotic medication receipts on 5 of 5 forms reviewed. The DON stated the process required two nurses to verify the delivery against the packing sheet and DEA 222 form, then document the number of packages received and the date received, but the facility copies reviewed did not contain that receipt information. The Medication Storage policy did not address the DEA 222 completion process.
A resident on EBP had a sign posted outside the room, but no PPE was readily available for staff use. A surveyor observed the resident in the room and found staff confusion about whether EBP applied, with a CNA saying PPE was not needed and an LPN/UM confirming that gown, gloves, mask, and face shield should have been available. The DON and RCD later confirmed that if active physician orders for EBP were in place, PPE should have been available at the door.
A resident with intact cognition reportedly received a flu vaccine, but the EMR lacked a provider order, MAR entry, progress note documentation, and post-vaccine monitoring, despite a signed consent form. Another resident with severe cognitive impairment had an influenza declination on file, but the facility could not produce documentation showing the pneumococcal vaccine was offered, received, or declined. The IP said she handled vaccine offers and consents, while the DON and RCD acknowledged missing documentation and questioned whether the cognitively impaired resident could validly refuse vaccines.
The facility failed to ensure that two Assistant Administrators were licensed as NHAs as required by the job description. One was licensed in New York but not in New Jersey, and the other did not hold an NHA license. The Administrator was aware of the issue but did not provide further information.
A facility failed to update a resident's care plan after a smoking violation. The resident, with intact cognition, was found smoking in a non-designated area and was temporarily suspended from smoking. Despite this, the care plan was not revised to reflect the incident. Interviews revealed confusion over who was responsible for updating care plans, contributing to the deficiency.
The facility failed to maintain kitchen sanitation, with unlabeled and expired food items found in storage, a lack of paper towels at a handwashing sink, and a refrigerator without a thermometer. Expired thickened water was found in a pantry refrigerator, and improper dishwashing practices were observed, including wet nesting and a malfunctioning dish machine sanitizer pump. Additionally, a leaking refrigerator line was noted, indicating maintenance issues.
The facility failed to issue required Advanced Beneficiary Notices of Non-Coverage to two residents when their Medicare Part A coverage ended. Staff interviews revealed confusion over responsibility for issuing these notices, leading to the deficiency.
The facility failed to notify the NJ LTCO of resident hospital discharges, as required by federal law. This deficiency was identified for two residents, one with urinary tract issues and another with osteoarthritis and other chronic conditions. The Director of Social Work admitted to not sending notifications, as he was not informed of this responsibility. The discharge log lacked a column for hospital discharges, and there was no documentation of LTCO notifications for hospitalizations.
A resident with Alzheimer's disease was admitted to hospice care, but the facility failed to complete a significant change in status assessment (SCSA) within the required 14 days. The MDS Coordinator and DON acknowledged the oversight during the survey.
A resident at risk for impaired skin integrity due to decreased range of motion in the legs did not receive the care plan intervention of heel protectors as specified. Observations showed the resident without heel protectors, and staff interviews revealed a lack of awareness about the care plan. The resident preferred using a pillow instead, and the care plan had not been updated to reflect this preference.
The facility failed to update the comprehensive care plans for two residents following allegations of abuse. Despite incidents involving employee-to-resident and staff-to-resident abuse, the care plans did not reflect these allegations or any interventions. Interviews with facility staff confirmed that the care plans should have been updated to include such information.
A resident with diabetes did not receive prescribed Novolog insulin as per physician's orders on multiple occasions, despite having blood sugar levels above the hold parameter. The LPN responsible acknowledged the error, and both the LPN Unit Manager and DON confirmed the oversight after reviewing the MAR.
A facility failed to timely assess and care plan for a resident who smoked cigarettes, despite the resident initially denying smoking. The resident, with diagnoses including chronic atrial fibrillation and major depressive disorder, was found to have cigarettes after providing money to a Smoking Aide. The facility delayed the smoking assessment and care plan, which were required by their Smoking Program, until over a month later.
A facility failed to follow physician orders to change a piston syringe kit every 24 hours for a resident with severe cognitive impairment and reliant on tube feeding. Despite documentation indicating compliance, observations revealed the kit had not been changed for several days. Interviews with staff confirmed the oversight and the importance of daily changes to prevent infection and clogging.
The facility failed to implement infection control measures for respiratory equipment for two residents with COPD. Nebulizer masks were repeatedly observed uncovered and exposed on bedside tables, contrary to facility policy. Staff interviews confirmed awareness of proper procedures, yet they were not consistently followed.
The facility did not accurately complete DEA 222 forms for three narcotic medication orders, missing required details in Part 5. The DON acknowledged the oversight during a review with the surveyor. The facility's policy lacked guidance on completing these forms, contributing to the deficiency.
Missing Pre-Employment Screening and Abuse Policy Compliance
Penalty
Summary
The facility failed to implement its abuse policy by not completing required pre-employment screening for multiple employees before their start dates. A review of 77 employee files found that 38 files lacked reference checks, 8 files lacked verification through the appropriate licensing boards or registries, and 6 files lacked criminal background checks prior to employment. The deficiencies involved employees hired into a variety of positions, including CNA, LPN, RN, Activities, Dietary, Housekeeping, Maintenance, Social Services, Staffing, Administration, and Nursing Department roles. Specific file reviews showed repeated missing documentation across the employee records. Examples included employees hired as CNAs, LPNs, RNs, and other staff members for whom no evidence of reference checks was present before employment began. The review also identified employees hired as LPNs and CNAs for whom licensure or registry verification was not completed before the start of employment. In addition, several employee files lacked criminal background checks prior to employment, and in two instances the background checks were completed after the employees had already started work. During interview, the Director of Human Resources stated that after an applicant was interviewed, background checks were run and references were called, and that she was responsible for completing these checks before the applicant was hired. She also acknowledged that the criminal background checks, reference checks, and licensure or registry checks were required under the facility's abuse policy. The LNHA further acknowledged that the employee files were disorganized. The facility's Abuse Policy required screening for abuse, neglect, or mistreatment history during the hiring process, including inquiries into state licensing authorities, nurse aide registries, reference checks, and criminal background checks.
Unsafe Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. On 1/5/2026, the surveyor observed the kitchen with missing baseboard tile molding at the diet office doorway extending into the kitchen area toward the service line. In the juice box, temperatures had been recorded daily, but there was no internal thermometer inside the unit. The Assistant Director stated he was not aware an internal thermometer was needed and said the exterior digital thermometer was used instead. Also in the kitchen on 1/5/2026, the walk-in refrigerator had a temperature log showing daily AM and PM entries, but there was no internal thermometer inside the unit. The Assistant Director stated the thermometer had broken and had not been replaced. In the walk-in refrigerator, a sheet pan held four white plastic round bags filled with reddish liquid from defrosting meat, and the pan and bags were undated. Above that shelf, previously opened deli turkey was wrapped in plastic wrap and dated 12-19-26. The Assistant Director was unable to explain how long the deli meat was good after opening and stated it had been pulled on the third and was ground turkey intended for turkey meat loaf the next day. The surveyor also observed reddish-brown liquid on the floor beneath the storage rack, along with individual portion control creamers, plastic wrappers, cardboard, and other debris throughout the walk-in refrigerator. The Assistant Director stated the refrigerator was supposed to be cleaned daily and agreed it was in need of deep cleaning. The supplement refrigerator also had a current temperature log, but no internal thermometer was present when the surveyor observed it. Frost was visible inside the refrigerator, which contained portion control butter, Mighty Shakes, and creamers. The Assistant Director and ALNHA placed a new internal thermometer in the refrigerator during the survey. On 1/7/2026, in the First Floor Pantry used for foods brought from home, the surveyor found frozen milk, two clear plastic containers with unknown frozen contents, yogurt, orange juice, and several other containers of unknown food contents that lacked required names, dates, or room numbers. On the Second Floor Pantry, the surveyor found additional containers of unknown food contents in the refrigerator and freezer that also lacked names, dates, or room numbers. Staff stated that unmarked foods should be discarded. On 1/9/2026, the dish machine was observed in use washing breakfast dishware, but the low-temperature dish machine log had no recorded wash cycle, final rinse temperatures, or sanitizer level for that morning. A dietary aide stated he had not tested the sanitizer level before washing dishes and had started washing dishes about an hour earlier. The surveyor also observed an opened bag of all-purpose flour stored in a bulk container with a metal ladle inside the bag. The Assistant Director removed the ladle and agreed it could cause cross contamination. Facility policies reviewed by the surveyor required clean and properly maintained food storage areas, internal thermometers in refrigerators, date marking of high-risk foods, proper thawing and storage of foods, and monitoring of dish machine temperatures and sanitizer levels.
Failure to Monitor Antibiotic Use and Complete Infection Assessment Tools
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not maintaining ongoing monitoring and surveillance of antibiotic use for 12 of 12 months reviewed and by not using the infection assessment tool for 3 of 5 residents reviewed for antibiotics. During the survey, the Infection Preventionist stated that she assumed the IP role in October 2025 and did not have the antibiotic tracking logs for 2025, and she confirmed that the logs should have been updated when an antibiotic was initiated and kept in the infection control binder. The surveyor reviewed the binder and found Order Listing Reports for only June, July, September, October, November, and December 2025, with no evidence of tracking for the full year through January 2026. A review of December 2025 antibiotic use showed seven residents received antibiotics, and the IP identified three residents who started antibiotics in the facility but had no documented infection assessment tool completed in their records. Resident #106 was started on Bactrim 800-160 mg on 12/8/2025 for 5 days for a UTI, Resident #144 was started on Macrobid 100 mg on 12/1/2025 for 14 days for a UTI, and Resident #175 was started on vancomycin 1.5 gram on 12/5/2025 to be infused over 2 hours. The DON stated that the IP should be tracking all infections and doing surveillance for antibiotic usage, and the RCD stated that the IP should have been able to provide evidence of surveillance and that the Antibiotic Stewardship Program should have been implemented.
Missing Skin Assessments and Inconsistent Pressure Relief for Two Residents
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice by not documenting weekly skin assessments for a resident with a history of pressure ulcers, and it failed to consistently implement pressure-relieving interventions for two residents. The report identified these deficiencies for Resident #199 and Resident #8 based on observation, interview, record review, and review of facility documentation. Resident #199 was admitted with diagnoses including unspecified dementia, anxiety, and major depressive disorder, and the annual MDS showed the resident was dependent for all ADLs, had severe memory and decision-making impairment, and was at risk for pressure ulcers. The resident was observed lying in bed on an air mattress and was non-verbal. The record showed a physician order for weekly skin assessments to be completed and documented in the EMR, but the surveyor could not locate documentation for the weekly skin assessments on 10/6/25, 10/13/25, and 10/20/25. Nursing staff confirmed they signed the TAR to indicate the assessments were completed, but they acknowledged the EMR lacked documentation describing the resident’s skin condition. The RCD also confirmed she could not provide documentation for those assessments. The resident had a sacral wound that had been present on and off since August 2025, with documentation noting comorbidities, malnutrition, immobility, and incontinence, and later documentation showed the sacral area reopened and required a change in treatment. Resident #8 had diagnoses including nontraumatic intracerebral hemorrhage, monoplegia, generalized muscle weakness, and dysphasia. The resident’s MDS showed intact cognition and identified a right heel deep tissue injury that was not present on admission. The care plan included weekly wound assessment and heel offloading interventions, and the physician order required weekly skin evaluation with completion of the Weekly Skin Monitoring UDA. The TAR showed entries indicating weekly skin evaluations were completed, but the surveyor could not find corresponding UDA documentation describing the resident’s skin condition. During observation, the resident was in bed with the left heel on the bed, the right heel elevated, and heel boots were found on top of the wardrobe rather than on the resident. The resident stated the boots had not been used for a while, and staff stated they did not see them on the resident that day. Facility staff also acknowledged that the resident’s wound assessment was not fully documented and that the heel DTI was facility acquired.
Incorrect Meal Items Served to Residents on Modified Diets
Penalty
Summary
The facility failed to provide the correct menu items in accordance with its weekly cycle menu for residents on mechanically altered diets during the lunch meal observation. Residents #22, #92, #179, #214, and #46 all had diet orders for advanced mechanical soft or mechanically altered diets, with some requiring small bites and one requiring nectar thick liquids. During the meal observation, several of these residents were served bite-sized or diced chicken instead of the Salisbury steak listed on their meal tickets and on the cycle menu for that meal. During the dining room observation, Resident #179, Resident #22, and Resident #214 were observed receiving bite size chicken instead of Salisbury steak. Resident #92 was also observed receiving bite sized chicken instead of the Salisbury steak written on the resident's food ticket. Staff members reviewed the meal tickets and confirmed the mismatch, then contacted the kitchen to ask why the correct item had not been served. The kitchen staff did not provide an explanation during those calls and stated that the correct meal item would be sent up. Resident #46's meal ticket showed a lunch meal of Salisbury steak with gravy, mashed potatoes, yellow squash, cinnamon applesauce, and beverages, but the resident was observed receiving diced chicken, mashed potatoes with gravy, yellow squash, plain applesauce, and beverages, with no Salisbury steak and no salt or pepper. The Assistant Director of Dietary stated there was a mix up and that diced chicken had been given instead of Salisbury steak, while the Director of Dietary Services stated the AM cook should not have provided diced chicken and that Salisbury steak was chopped after the issue was discovered. The facility policy stated that meal tickets are used to identify the resident and validate the diet order, food and fluid consistency, and adaptive devices.
Failure to Provide Timely Incontinence Care and Maintain Catheter Privacy
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary incontinence care to a dependent hospice resident and to maintain catheter privacy for another resident. During incontinence rounds, a surveyor observed a cognitively impaired hospice resident with dementia sitting in a brief that was saturated with brown-colored urine, which had seeped up the back of the incontinence brief. The resident had a documented wound on the buttocks, and the CNA present confirmed the brief was saturated. The CNA stated that the hospice aide had been providing care that morning but could not say when the aide had left. The resident’s MDS documented that the resident was always incontinent of bowel and bladder, and the care plan interventions included checking the resident every 2–4 hours and assisting with toileting as needed. Record review showed that CNA tasks for bowel/toileting care every 2–4 hours and as tolerated during waking hours and PRN reflected only one care entry at 6:22 AM on the day of observation. Interviews with nursing staff, including an LPN and the LPN/unit manager, confirmed that hospice residents were not to be excluded from incontinence rounds and should be checked every two hours. The hospice home health aide reported that she completed care for the resident at approximately 7:30 AM, left the resident clean and freshly changed, and gave report to the nurse. She further stated that on the prior two days, she had found the resident saturated to the point that urine had soaked through the brief, sheets, clothing, and onto the bed. Facility policy on ADL care required toileting and incontinence care to be provided with care and as needed, and CNA responsibilities included keeping incontinent residents clean and dry and checking residents who cannot call for help frequently. A separate deficiency was identified regarding catheter privacy for another resident with an indwelling urinary catheter due to neuromuscular bladder dysfunction, muscle weakness, and difficulty walking. On multiple observations, the resident’s catheter bag was hanging from the bed frame without a privacy bag and was visible from the hallway. The resident’s MDS documented an indwelling catheter, and the care plan included an intervention to maintain a privacy bag with catheter care. The resident, who was cognitively intact, stated they wanted a privacy bag and reported that when going to therapy, staff placed the catheter bag next to them with urine visible to others. The LPN/unit manager, CNA, and DON all acknowledged that a privacy bag should have been in place to maintain the resident’s dignity, consistent with the facility’s Quality of Life/Dignity policy requiring staff to promote, maintain, and protect resident privacy.
Stained and Damaged Linen Found on Clean Linen Cart
Penalty
Summary
The facility failed to maintain a clean, sanitary, and home-like environment on nursing unit 1C. During an interview in a resident’s room, a large brown embedded stain was observed on the resident’s fitted sheet, and the resident stated the stain was present when the sheet was received. The resident also stated that on occasions they received linens with holes. On the clean linen cart for the unit, surveyors observed a washcloth with multiple large red stains and two reddish-brown particles, as well as a fitted sheet with a golf ball-sized hole. The items were removed from the cart immediately. The cart itself had a build-up of brown residue on multiple areas across all three shelves. Staff interviews confirmed that stained or damaged linen should be removed from circulation and that linen carts should be kept clean, while the LNHA stated there was no cleaning schedule for the linen carts and that they were cleaned as needed.
MDS Did Not Reflect Resident’s C-PAP Use
Penalty
Summary
The facility failed to accurately complete the MDS for one resident during the quarterly assessment dated 10/28/2025. On 1/5/2026, the surveyor observed the resident in bed with a C-PAP machine on the nightstand next to the resident, and the C-PAP mask was uncovered and touching the surface of the nightstand. During the observation, the resident stated that the C-PAP was last used one day the prior week and was used a couple of times per week. The resident’s admission record and admission summary listed anemia, but did not include obstructive sleep apnea. The resident’s MDS did not reflect C-PAP use, and the resident’s ICCP also did not include the use of C-PAP. The OSR dated as of 1/6/2026 did not include a physician’s order for C-PAP. However, the Consultant Pulmonologist Progress Note dated 12/31/2025 stated that the resident had obstructive sleep apnea, was on C-PAP, and should continue using it at night. A prior pulmonologist note dated 10/28/2025 and a Physician’s Progress Note dated 10/23/2025 also documented obstructive sleep apnea and continued C-PAP use. The MDS coordinator stated that she looked at admitting doctor’s orders and would speak with the resident if needed, and the RCD stated that the MDS coordinator should also interview the resident when assessing the resident.
Failure to Provide and Follow Through on Foot Care
Penalty
Summary
The facility failed to ensure proper foot care for two residents by not following through on podiatry recommendations and by not providing timely nail care. One resident with a history of nontraumatic intracerebral hemorrhage, left-sided weakness, generalized muscle weakness, and dysphasia had a right heel deep tissue injury documented in the care plan. The resident also had podiatry consults that recommended proper foot and shoe hygiene, walking with socks and proper shoe gear, monitoring pressure areas, and using larger shoes to accommodate painful digital deformities because of poor vascular supply to both feet. The record showed that the facility notified the resident’s brother and daughter that larger shoes were needed, but the DON stated the facility did not close the loop and did not ensure follow-up with the responsible party to obtain the larger shoes. The DON also stated the care plan should have been updated in October, not after surveyor inquiry. The resident’s quarterly MDS did not identify foot problems in the foot problems section, despite the documented podiatry recommendations and the existing skin integrity issue. A second resident with type 2 diabetes mellitus, generalized muscle weakness, difficulty walking, morbid obesity, and B-cell lymphoma was observed with long toenails and stated the toenails were sharp and needed to be cut. The resident had a podiatry consult on record that documented painful nails and digital ends, nails digging into the skin, thickened and discolored nails, and debridement of 10 nails with follow-up in 2 to 3 months. However, when surveyed afterward, the resident still had not had the toenails cut. Staff interviews showed that nursing was expected to initiate podiatry requests through the scheduler, and the LPN/UM stated the toenails needed to be cut to prevent a wound. The DON stated it was her expectation that aides notify the unit manager when toenail care was needed, and that the resident could get an infection or ingrown toenail if the nails were not maintained.
Failure to Follow Ordered Weights and Re-Weight Policy
Penalty
Summary
The facility failed to obtain weekly weights according to a physician's order and failed to obtain re-weights according to its policy for one resident who was reviewed for nutrition. The resident had diagnoses including Parkinson's disease, anxiety, type 2 diabetes, hypertension, dysphagia, and severe cognitive impairment, and the quarterly MDS documented significant weight loss. The resident also told the surveyor they were vegetarian, wanted better food such as fresh fruits and vegetables, and had lost a lot of weight since admission. The record showed a physician's order for weekly weights for four weeks beginning 11/24/25, and the TAR was initialed on multiple dates to indicate the weights were completed. However, the EHR weight record did not match the TAR entries, with documented weights appearing on different dates than those listed on the TAR, and several ordered weight dates had no corresponding weight documentation. The surveyor also found that the resident weighed 200 pounds on 10/7/25 and 164.2 pounds on 11/11/25, a 17.9% difference in one month, but there was no documented evidence that a re-weight was done to verify the significant weight loss. During interviews, the LPN, LPN/UM, RD, DON, and RCD acknowledged the mismatch between the TAR and EHR weight dates and confirmed that the resident should have been re-weighed after the significant weight loss was recorded. The facility's Weight Management policy stated that re-weighs should be completed within 48 hours after a discrepancy such as a five-pound monthly loss or three-pound weekly loss is identified, and the resident's documented weight changes met that threshold.
Respiratory Equipment Left Uncovered and Missing Physician Orders for Treatments
Penalty
Summary
The facility failed to ensure respiratory equipment was stored appropriately to prevent the spread of infection and failed to obtain physician orders for respiratory treatments for two residents. One resident with obstructive sleep apnea and intact cognition was observed with a C-PAP machine on the nightstand, and the C-PAP mask was uncovered and touching the surface of the nightstand on two separate observations. The resident stated the C-PAP was used only a couple of times per week, and the record review showed no physician order for C-PAP use, settings, or maintenance, although a pulmonologist note stated the resident had obstructive sleep apnea and should continue using C-PAP at night. A second resident with COPD and intact cognition was observed with a nebulizer machine on the nightstand and the mask uncovered and open to the air on two separate observations. The resident stated the nebulizer had last been used a couple of days earlier. Record review showed orders for changing and cleaning the nebulizer kit and storage bag, but no current physician order for DuoNeb or incentive spirometry, despite pulmonologist notes stating the resident should continue both treatments. Nursing staff stated the resident was receiving breathing treatments via the nebulizer, but the current order was not present in the record. Staff interviews confirmed that respiratory equipment should have been bagged when not in use and that medications required physician orders. The DON stated the nebulizer mask should not have been left on the counter for infection control reasons, that consultant recommendations should have been reviewed and orders obtained if the physician agreed, and that if a consultant recommendation was not addressed it would be considered a missed order. Facility policies also stated that medications are to be administered only upon written or entered orders and that dried nebulizer equipment should be stored in a labeled plastic bag.
Incomplete DEA 222 Receipt Documentation
Penalty
Summary
The facility failed to ensure accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms, DEA 222 forms, because Part 5 was not completed with the number of items received and the date received on 5 of 5 forms reviewed. The forms reviewed included order form #240870463 dated 3/11/25, #240870454 dated 5/27/25, #250798148 dated 7/31/25, #250798149 dated 9/5/25, and #250798150 dated 10/15/25. The surveyor observed that the facility’s copy of each form did not contain the required receipt information upon delivery of the medications from the provider pharmacy. During interview, the DON stated the process was for the DON to complete Part 1 and Part 2, have the Medical Director review and sign the form, keep a copy for reconciliation, and send the original to the provider pharmacy. She explained that after delivery, two nurses were to sign and verify the contents against the packing sheet and DEA 222 form, and Task 5 was then to be completed with the number of packages received and the date received. The surveyor and DON reviewed the forms and confirmed Task 5 had not been completed as instructed. The Medication Storage policy, revised 12/17/25, did not address the process for completing the DEA 222 form.
Missing PPE for Resident on EBP
Penalty
Summary
The facility failed to follow infection control practices by not having personal protective equipment readily available for a resident who was on Enhanced Barrier Precautions (EBP). During observation, a surveyor saw a sign outside the resident’s closed door indicating EBP, but no PPE was readily available in or outside the room. Inside the room, the resident was seated in a wheelchair, had disheveled hair, and smelled of smoke. When asked whether staff wore a gown and gloves during care, the resident said, “I don’t know.” Interviews confirmed confusion and inconsistency among staff about the resident’s EBP status and PPE requirements. A CNA stated she did not need to wear PPE and believed the red sign was for the resident in the next room. An LPN stated the resident was on EBP related to a communicable disease and that staff must wear a gown and gloves for care, but also confirmed there was no PPE readily available at the door. The LPN/UM stated EBP required gown, gloves, mask, and face shield for direct care and confirmed there should have been a kit or caddy with PPE outside the room, but none was present. The DON stated the resident did not require EBP based on the communicable disease, though the physician had ordered EBP, and the RCD confirmed that if active physician orders for EBP existed, PPE should have been available for staff use.
Vaccination Documentation and Consent Failures
Penalty
Summary
The facility failed to document the administration of the influenza vaccine for one resident after signed consent was obtained. Resident #41 had diagnoses including unspecified dementia, bipolar disorder, and osteoarthritis, and a BIMS score of 15 out of 15, indicating intact cognition. The EMR did not contain a physician order for the flu vaccine, did not include documentation in the progress notes or MAR that the vaccine was administered, and did not show documentation that the resident was monitored for side effects after administration. Although the resident later verified that the flu vaccination had been given during the 2025 flu season, the record did not contain the required documentation to support it. The facility also failed to ensure that influenza and pneumococcal vaccines were properly offered to a resident with impaired cognition. Resident #6 had diagnoses including schizophrenia, major depressive disorder, and anxiety disorder, and the quarterly MDS documented a BIMS score of 0 out of 15. The care plan identified impaired cognition related to schizophrenia and included interventions such as asking yes/no questions and giving simple directions. Psychiatric progress notes described the resident as confused and only oriented to name. The facility had an influenza consent form showing the vaccine was declined and signed above the line for a recipient unable to sign, but it could not produce any documentation that the pneumococcal vaccine was received or declined. During survey interviews, the IP stated that she was responsible for offering flu and pneumonia vaccines, obtaining consents and declinations, and contacting providers for orders. She also stated that residents with low BIMS scores should not sign the form and that guardians should be contacted for consent. When the survey team questioned whether Resident #6, given the documented cognitive impairment, could refuse vaccines, the facility stated the resident was their own guardian; the RCD stated the consent should have gone to the IDT and physician to determine whether it should have been administered. The facility’s policies stated that residents should be assessed for pneumococcal vaccine eligibility after admission and that residents without decision-making capacity and without a representative would be immunized annually with influenza vaccine as ordered by the healthcare provider.
Unlicensed Assistant Administrators in Facility
Penalty
Summary
The facility failed to ensure that two staff members working as Assistant Administrators were licensed as Nursing Home Administrators (NHA) as required by the facility's job description. During the survey conducted on multiple dates, it was discovered that Assistant Administrator #1 was licensed in New York but not in New Jersey, while Assistant Administrator #2 did not hold an NHA license at all. Both individuals confirmed their job titles as Assistant Nursing Home Administrators. The facility's Administrator acknowledged awareness of the licensing issue and confirmed the job description requirement for an NHA license in good standing, but did not provide further information.
Failure to Update Resident Care Plan Following Smoking Incident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, which included actions taken by staff to educate the resident regarding alternatives and consequences. This deficiency was identified during a survey conducted on multiple dates. The resident in question was observed self-propelling a wheelchair and had a history of smoking violations. Despite having an intact cognition as indicated by a perfect score on the Brief Interview for Mental Status, the resident's care plan was not updated to reflect a recent smoking incident. The resident was found smoking in a non-designated area, leading to a temporary suspension from smoking. However, the care plan, which initially included reeducation on facility smoking rules, was not revised or updated following the incident. Interviews with the Director of Social Services and the Director of Nursing revealed a lack of clarity regarding responsibility for updating care plans, contributing to the oversight. The facility's policy required care plans to incorporate identified problem areas and associated risk factors, which was not adhered to in this case.
Kitchen Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper kitchen sanitation, leading to several deficiencies that could potentially result in foodborne illnesses. During an inspection, it was observed that a package of frozen sausage and a bag of frozen zucchini slices in the walk-in freezer were not labeled with dates, violating the facility's policy on food storage. Additionally, in the walk-in refrigerator, bags of chopped lettuce and carrots were found with expired 'best if used by' dates, and some of the lettuce appeared slimy. A container of slaw was also past its 'best if used by' date. Furthermore, the designated handwashing sink lacked paper towels, and a refrigerator/freezer lacked an internal thermometer, with an undated styrofoam container of unknown food contents. In the pantry refrigerator on the 2nd floor, several containers of thickened water used for residents were found with expired 'use by' dates. The Infection Preventionist confirmed that nurses were responsible for checking these dates when stocking the fridge. In the kitchen, a dietary aide was observed washing pots and pans, but they were not air-dried before stacking, leading to wet nesting, which can promote microorganism growth. The dish machine temperature log was incomplete, and the sanitizer container was empty, resulting in dishes not being properly sanitized. The Food Service Director acknowledged the issue and attempted to rectify it, but the dish machine's sanitizer pump was malfunctioning, preventing proper sanitization. Additionally, the reach-in refrigerator had a significant amount of clear liquid on its floor due to a leaking line, which the Food Service Director admitted had been an ongoing issue. Beverages stored above the liquid level were not directly affected, but the situation indicated a lack of timely maintenance. These observations highlight the facility's failure to adhere to its own policies and procedures regarding food storage, sanitation, and equipment maintenance, posing a risk of foodborne illness to residents.
Failure to Issue Required Beneficiary Notices
Penalty
Summary
The facility failed to issue the required beneficiary notices for two residents, resulting in a deficiency. The Advanced Beneficiary Notice of Non-Coverage (ABN) is a requirement for original Medicare beneficiaries when Medicare payment is expected to be denied. The facility's policy mandates that the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 should be given to residents when their Medicare Part A coverage ends. However, for two residents, the facility did not provide these notices, and there was no documentation explaining the omission. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for issuing these notices. The Assistant Administrator acknowledged the oversight, while the Director of Rehabilitation and the MDS coordinator indicated that the responsibility for issuing Part A notifications was unclear. The surveyor confirmed with the Assistant Administrator that the required notices were not given to the residents, confirming the deficiency.
Failure to Notify LTCO of Resident Hospital Discharges
Penalty
Summary
The facility failed to notify the New Jersey Long-Term Care Ombudsman's office (LTCO) in writing of resident emergency transfers to the hospital or discharges, as required by federal law. This deficiency was identified for two residents. The facility's policy, last revised in February 2023, mandates that copies of all facility-initiated discharge notices be provided to the LTCO. However, the Director of Social Work (DSW), who had been in the position for a few months, admitted to not sending any notifications to the LTCO regarding resident discharges to the hospital, as he was not informed of this responsibility. The Assistant Administrator (AA) confirmed that the Social Worker was responsible for sending notifications to the LTCO for hospital discharges and maintaining a monthly list. Upon review, it was found that the discharge log did not include a column for hospital discharges, and there was no documentation of LTCO notifications for hospitalizations. The AA acknowledged that notifications were only being sent for discharges against medical advice and to home, not for hospital discharges. The facility's failure to notify the LTCO of hospital discharges was evident in the cases of two residents, one with urinary tract issues and another with osteoarthritis and other chronic conditions.
Failure to Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) for a resident who elected hospice services, as required by the Resident Assessment Instrument (RAI) process. This deficiency was identified for a resident with Alzheimer's disease, metabolic encephalopathy, and dysphagia, who was admitted to hospice care. The facility's policy mandates that all Minimum Data Set (MDS) assessments, including significant change assessments, be completed and transmitted to the CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with OBRA regulations. The MDS Coordinator confirmed that a SCSA was not completed within the required 14 days after the resident's admission to hospice care. The resident's medical record indicated that hospice care was initiated with a physician's order on November 18, 2023, but the subsequent MDS assessment conducted on December 7, 2023, was only a quarterly review, not a SCSA. Interviews with the MDS Coordinator and the Director of Nursing revealed that the facility was aware of the requirement to complete a SCSA when a resident is placed on hospice care. However, the necessary assessment was not performed within the stipulated timeframe, as confirmed by the facility staff during the survey.
Failure to Implement and Revise Care Plan for Heel Protection
Penalty
Summary
The facility failed to consistently implement and revise a care plan intervention for a resident at risk for impaired skin integrity due to decreased range of motion in the legs. The care plan specified the use of heel protectors when the resident was in bed, but observations by the surveyor revealed that the heel protectors were not in place during multiple visits. The resident was observed with bare feet or wearing non-skid socks, and no heel protectors were found in the room. The resident, who had diagnoses including chronic pain syndrome, multiple sclerosis, and muscle weakness, was dependent on staff for various activities of daily living and was at risk for developing pressure ulcers. Despite this, the Treatment Administration Record for the month did not reference heel booties, and the care plan had not been updated to reflect the resident's current preferences or needs. The resident expressed a preference for using a pillow instead of heel protectors, which had not been worn for approximately three years. Interviews with facility staff, including a CNA and RN, indicated a lack of awareness or clarity regarding the resident's care plan for heel protection. The RN was unaware of any order for heel protectors and suggested that an air mattress might negate the need for them, although the resident did not have an air mattress. The facility's Director of Nursing confirmed that care plans are reviewed quarterly and as needed, but the resident's care plan had not been updated to reflect their current preferences or the absence of heel protectors.
Failure to Update Care Plans After Abuse Allegations
Penalty
Summary
The facility failed to revise comprehensive care plans in a timely manner following allegations of abuse for two residents. Resident #265, who was admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and legal blindness, was involved in an employee-to-resident abuse allegation. Despite this incident, the individualized comprehensive care plan (ICCP) for Resident #265 did not include an update regarding the allegation of physical abuse or any interventions implemented after the incident. Similarly, Resident #515, admitted with chronic obstructive pulmonary disorder, diabetes mellitus, and hypothyroidism, was involved in a staff-to-resident abuse allegation. The ICCP for Resident #515 also lacked updates about the abuse allegation and any subsequent interventions. Interviews with facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse/Unit Manager (RN/UM), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), confirmed that the ICCPs should have been updated with any allegations of abuse, whether substantiated or unsubstantiated. The LPN and RN/UM emphasized the importance of including such allegations in the ICCP to ensure comprehensive care for the residents. The DON and ADON further confirmed that the ICCP should reflect interventions following any abuse allegations to prevent future incidents. The failure to update the care plans was identified as a deficiency by the surveyors.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice by not administering insulin as per the physician's orders for a resident with diabetes. The resident, who had a fully intact cognition, was prescribed Novolog insulin to be administered subcutaneously before meals, with a hold parameter for blood sugar levels below 100 mg/dl. However, on five occasions, the resident's blood sugar levels were recorded as above 100 mg/dl, yet the nurse documented that no insulin was required, contrary to the physician's orders. The deficiency was identified through observations, interviews, and a review of the facility's Medication Administration Record (MAR) for July 2024. The Licensed Practical Nurse (LPN) responsible for the resident acknowledged the error upon review with the surveyor, confirming that the insulin should have been administered as ordered. The Licensed Practical Nurse Unit Manager and the Director of Nursing also confirmed the oversight after reviewing the MAR, acknowledging that the insulin was not administered according to the physician's orders on the specified dates.
Failure to Timely Assess and Care Plan for Resident Smoking
Penalty
Summary
The facility failed to ensure the safety of a resident who smoked cigarettes by not conducting a timely smoking assessment, providing education on facility smoking rules, and developing a care plan for smoking safety. The resident, who was admitted with diagnoses including chronic atrial fibrillation, difficulty walking, and major depressive disorder, initially denied smoking. However, an incident was reported where the resident provided money to a Smoking Aide to purchase cigarettes, indicating the resident was smoking. Despite this, the facility did not complete a smoking assessment or initiate a care plan until over a month later. The facility's Smoking Program required a smoking assessment for new admissions identified as smokers and for residents who later expressed a desire to smoke. The resident's comprehensive care plan and smoking safety agreement were not initiated until after the facility observed the resident asking another resident for a cigarette. Interviews with facility staff, including the Activities Director and Director of Nursing, confirmed that smoking assessments were supposed to be completed upon admission and quarterly. The Licensed Nursing Home Administrator acknowledged that the smoking assessment and care plan should have been completed when the facility became aware of the resident's smoking behavior.
Failure to Change Piston Syringe Kit as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely replacement of a piston syringe kit for a resident receiving tube feeding. The deficiency was identified during a survey when it was observed that the piston syringe kit, which should have been changed every 24 hours as per physician orders, had not been replaced for several days. The kit was dated 7/19, and observations on subsequent days confirmed it had not been changed, despite documentation in the Treatment Administration Record (TAR) indicating otherwise. Resident #37, who was affected by this deficiency, had severe cognitive impairment and was reliant on tube feeding for more than 51% of their caloric intake. The facility's policy on enteral feedings did not include specific instructions for changing the piston syringe kit, contributing to the oversight. Interviews with facility staff, including the LPN/Unit Manager and the Director of Nursing, confirmed the failure to follow the physician's order and highlighted the importance of changing the syringe kit daily to prevent infection and clogging of the feeding tube.
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 two residents receiving respiratory care. The surveyor observed that the nebulizer masks for both residents were left uncovered and exposed on bedside tables when not in use, contrary to the facility's policy which requires that nebulizer equipment be cleaned, air-dried, and stored in a plastic bag with the resident's name and date. This practice was observed multiple times for both residents, indicating a consistent failure to adhere to infection control protocols. Resident #22, who has a history of chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia, was observed with an uncovered nebulizer mask on several occasions. The resident's Medication Administration Record (MAR) confirmed that nebulizer treatments were administered as scheduled, yet the equipment was not stored properly between uses. Interviews with nursing staff revealed an awareness of the requirement to cover nebulizer masks when not in use, yet the practice was not consistently followed. Similarly, Resident #63, also diagnosed with COPD, was observed with an uncovered nebulizer mask on the bedside table. Despite the resident's intact cognition and awareness of their treatment schedule, the nebulizer equipment was not stored according to the facility's policy. Interviews with the nursing staff confirmed that the responsibility for maintaining the cleanliness and proper storage of respiratory equipment was shared among nurses and CNAs, yet the expected procedures were not consistently implemented.
Failure to Complete DEA 222 Forms for Narcotic Medications
Penalty
Summary
The facility failed to ensure accurate ordering and receiving of narcotic medications as required by Federal regulations. Specifically, the facility did not complete the necessary details on the DEA 222 forms for three orders of narcotic medications. The forms, identified by order numbers 221690894, 221690895, and 221690896, were missing the completion of Part 5, which requires the purchaser to fill out the number of packages received and the date received for each line item. This omission was confirmed during a review by the surveyor and the Director of Nursing (DON), who acknowledged the oversight. The facility's Medication-Narcotic Management policy, revised in April 2023, did not include guidance on completing the DEA 222 forms, contributing to the deficiency.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 305 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hammonton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Grove Respiratory And Nursing Center | 9.8 mi | ★★★★★ | 0 | 0 |
| The Fountains Of Atco | 10 mi | ★★★★★ | 38 | 1 |
| Berlin Rehabilitation And Healthcare Center | 10.5 mi | ★★★★★ | 0 | 0 |
| The Pines At Medford | 14 mi | ★★★★★ | 2 | 0 |
| Atlas Rehabilitation And Healthcare At Washington | 14.6 mi | ★★★★★ | 7 | 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 October 2026) and official state health department websites.