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 Hartwyck At Oak Tree during CMS and state inspections, most recent first.
The facility failed to maintain the call bell system volume at an audible level on floor 3, as observed during a survey. Tests from two resident rooms revealed no audible notification of call bell activation. Nursing staff discovered the volume had been turned down and corrected it. The DOM confirmed these findings.
The facility failed to maintain its emergency generators as per NFPA 99:2012, with the generator not tested under load for the required duration and having a history of failures. Additionally, the emergency generator's remote annunciator panel was non-functional, lacking power indication and a lamp test switch. These issues were identified during a documentation review and observation, with no current MOU for a portable rental generator.
The facility failed to maintain proper fire separation between Healthcare and Residential occupancies, with unprotected wire penetrations and missing brick sections compromising the two-hour fire resistance rating. These deficiencies were confirmed during an inspection.
The facility failed to ensure proper functioning of delayed egress locking systems on stairway enclosures, as observed during a survey. The 15-second delayed egress locks near rooms on the second and third floors, as well as the mauve wing, did not function when tested, potentially affecting all residents. These deficiencies were confirmed through interviews with surveyors.
The facility failed to provide a directional exit sign near the kitchen's smoke barrier doors, as required by NFPA 101:2012. This deficiency, observed during a survey, was confirmed by the U.S. FOIA and had the potential to affect all residents due to unclear exit directions.
The facility failed to protect hazardous areas as per NFPA 101:2012, with a laundry room door that did not positive latch, compromising fire safety. This was observed and confirmed during a survey, potentially affecting all residents.
The facility did not maintain its kitchen fire safety equipment according to NFPA standards. Observations revealed that four of the eight discharge spray nozzles on the kitchen range-hood fire suppression system lacked protective caps or covers, and the Class-K fire extinguisher's monthly inspection tag was unsigned. These issues were confirmed by a staff member during an interview.
The facility did not conduct annual inspections of fire door assemblies as required by NFPA 80. Instead, monthly inspections were provided, which did not include all fire doors and assemblies and failed to meet the minimum requirements. This oversight had the potential to affect all residents. The deficiency was confirmed during an interview with a U.S. FOIA representative.
The facility's emergency generator remote annunciator panel was found non-functional at the nurse's station, lacking power indication and a lamp test switch, as per NFPA 99 standards. This deficiency was confirmed during an interview and reported at the Life Safety Code exit conference.
The facility failed to maintain its emergency generators as per NFPA 99:2012, with documentation revealing a lack of testing under load for four continuous hours every 36 months. Maintenance reports indicated potential fuel system issues and a history of generator failures. The facility representative confirmed the absence of repairs and a current MOU for a portable generator, posing a risk to all residents.
The facility failed to document the code status for two residents, both dependent on ventilators, leading to a deficiency in managing their medical instructions for resuscitation. Despite staff identifying them as full code, there was no physician's order (PO) in their records. The Director of Nursing confirmed the absence of a PO and acknowledged the need for such documentation at admission.
A facility failed to adjust medication administration times for a resident undergoing dialysis, resulting in missed doses of essential medications. The resident, with chronic kidney disease and end-stage renal disease, was on a dialysis schedule that conflicted with medication times. Despite procedures requiring adjustments, the facility did not consistently ensure medications were administered appropriately, as confirmed by staff interviews and record reviews.
Call Bell System Volume Deficiency
Penalty
Summary
The facility failed to ensure that the volume on the resident call bell system at the nurse's station on floor 3 was set to a level that could be heard. This deficiency was identified during observations and interviews conducted on 12/19/2024. At 11:50 AM, a test of the call bell from a resident's room revealed no audible notification of activation. A similar observation was made at 11:55 AM from another resident's room, where again, no audible notification was heard. Nursing staff later informed the surveyor that the volume on the call bell system had been turned all the way down, which they subsequently corrected. The Director of Maintenance confirmed these observations during the survey.
Plan Of Correction
1. The call bell volume at the 3rd floor nurses station was immediately restored to an audible level. Rooms 315 and 316 were tested and confirmed operational with both visual and auditory alerts. All nursing staff were notified of the deficiency and instructed on the importance of maintaining appropriate call bell volume levels. A reminder was issued emphasizing that adjusting the call bell volume downwards is unacceptable on 12/20/24. 2. All residents have the potential to be affected by this practice. All 3 call bell systems throughout the facility were checked to ensure appropriate volume levels and functionality. 3. A facility policy and procedure on call bell system management will be created by 1/15/25 to include: - Specific instructions regarding appropriate call bell volume levels. - A prohibition against turning down or muting call bell volumes. - A defined requirement for regular checks of call bell system functionality, including volume levels. - A process for documenting call bell system checks. - Clear instructions on how to troubleshoot call bell system issues. All nursing and maintenance staff will be re-educated on the new policy and procedure by 1/24/25 by the clinical nurse educator. 4. Daily audits of call bell system functionality and volume levels in all resident rooms and common areas will be completed by the maintenance department for 4 weeks and then monthly ongoing. Results will be tracked and reported to the Quality Assurance Committee quarterly and to the QAPI Committee monthly.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its emergency generators in accordance with NFPA 99:2012 Edition, which had the potential to affect all residents. During a documentation review, it was discovered that the generator had not been tested at least once every 36 months under load for a minimum of four continuous hours. Additionally, a maintenance report from August 6, 2024, indicated that the fuel system might need rebuilding, including the injection pump and injectors. A subsequent report on August 7, 2024, highlighted that the generator had over 1000 hours of operation and a history of failures, including an inability to carry load and erratic engine speed, compounded by water in the fuel system. The report recommended repairing or replacing the unit to ensure dependability. During an interview, it was confirmed that the necessary repairs had not been made, and there was no current Memorandum Of Understanding (MOU) for a portable rental generator, although efforts were underway to secure one. Furthermore, an observation on December 20, 2024, revealed that the emergency generator's remote annunciator panel at the nurse's station on floor 2 was not functioning properly. The panel lacked a means to show it was receiving power and was not equipped with a lamp test switch to test the operation of all alarm lamps. These deficiencies were communicated to the facility's representative during the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A qualified contractor, NJ Ex Order 26.4(b)(1) was contacted and came to assess the generator on 1/6/25 and will complete the following: - The Maintenance Director contacted NJ Ex Order 26.4(b)(10) and executed a new MOU for a portable rental generator on 1/6/25. Rental generator was installed and operational to begin generator repairs on 1/6/2025. - NJ Ex Order 26.4(b)(1) began work to rebuild the generator fuel pump on 1/6/2025. Work was completed on 2/10/2025. Upon completion of the fuel pump rebuild, NJ Ex Order 26.4(b)(1) will perform a four-hour generator load test. Load test was completed on 2/11/2025. - Upon completion of the fuel pump rebuild, NJ Ex Order 26.4(b)(1) will repair/replace the remote annunciator panel to include a means to show that it is receiving power and a lamp test switch(es) to test the operation of all alarm lamps. This work was completed by NJ Ex Order 26.4(b)(1) on 2/11/2025. 2. NJ Ex Order 26.4(b) has been contracted by the facility to provide the required 4 hour load test of the generator every 36 months. The Maintenance Director added the required 4 hour load test to the generator maintenance schedule and will ensure completion every 36 months. The Maintenance Director will be the designated individual responsible for ensuring a current MOU is in place for a rental generator and will provide evidence of this to the administrator annually. The Maintenance Director added a monthly annunciator panel test to the generator maintenance schedule and ensure completion monthly. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly ongoing to ensure that the required testing was completed timely. The results of this will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.
Deficient Fire Separation in Facility Occupancies
Penalty
Summary
The facility failed to ensure that sections of health care facilities classified as other occupancies were properly separated from areas of healthcare occupancies by construction with a two-hour fire resistance rating. This deficiency was identified during observations and interviews conducted on December 19, 2024. Specifically, the separation between the Healthcare occupancy and the Residential occupancy was compromised by a 1.5-inch and 2.5-inch unprotected penetration for wire pass-throughs. Additionally, a 2-inch-high by 48-inch-wide section of brick was missing above the fire-rated door assembly between the two occupancies. These observations were confirmed by the USTFOTAT at the time of the inspection. The facility's representative was informed of these deficient practices during the Life Safety Code exit conference on December 20, 2024.
Plan Of Correction
1/9/25 1. All residents have the potential to be affected by this deficient Life Safety Code. The maintenance department repaired the 2 unprotected penetrations for the pass-through of wires on 1/8/25 using UL listed NUEX Order 26.4(DX LC 150 fire-stop sealant. The maintenance department repaired the 2 inch by 48 inch wide section of brick missing above the fire rated door assembly between the two occupancies on 1/8/25 using intumescent fire-stop pillows and UL listed NJ Ex Order 26.4(15) LC 150 fire-stop sealant. 2. The facility's maintenance schedule will be revised by the Director of Maintenance to include a monthly inspection of fire-rated assemblies between the healthcare occupancy and the residential occupancy to confirm that the two hour fire resistance rating is intact with no penetrations using an audit tool. 3. The Director of Maintenance will review the fire rated assembly inspection reports monthly ongoing and report the results to the administrator and to the QAPI committee monthly for 6 months.
Non-Functioning Delayed Egress Locking Systems
Penalty
Summary
The facility failed to ensure that the egress doors equipped with delayed egress locking arrangements were functioning properly, as required by NFPA 101:2012 Edition. During observations conducted on December 19, 2024, it was found that the 15-second delayed egress locking arrangements on the stairway enclosures near room 312 on the third floor, room 212 on the second floor, and the mauve wing did not function when tested. These deficiencies were confirmed through interviews with the U.S. FOIA present during the survey. The malfunctioning of the delayed egress locking arrangements had the potential to affect all residents within the facility. The observations were made by the USSROAD, US FOTIAD, and US FOJA, who confirmed the non-functionality of the locking systems. The facility's representative was informed of these deficient practices during the Life Safety Code exit conference held on December 20, 2024.
Plan Of Correction
1/7/25 1. All residents have the potential to be affected by this deficient Life Safety Code. NJ Ex Order 26.4(b) (1) repaired the delayed egress locks in the following locations on 1/6/25: floor 3 near room 312, floor 2 near room 212, and the stairway enclosure on the mauve wing. The Maintenance Department conducted an audit of all facility delayed egress locks to confirm function on 1/6/25. 2. The Maintenance Director will modify the scheduled maintenance calendar to include monthly delayed egress checks to confirm function. 3. The Maintenance Director will review the monthly delayed egress lock testing documentation to ensure compliance. The details of this testing will be submitted to the administrator and to the QAPI committee monthly for 6 months.
Deficient Exit Signage Near Kitchen
Penalty
Summary
The facility failed to ensure proper exit signage in accordance with NFPA 101:2012 Edition, Sections 19.2.10.1 and 7.10. During an observation at 11:00 AM, it was noted that there was no directional exit sign indicating the direction of travel to the nearest exit when exiting the smoke barrier doors near the kitchen. This deficiency was confirmed through an interview with the U.S. FOIA present at the time of the observation. The lack of appropriate signage had the potential to affect all residents, as the direction of travel to the nearest exit was not apparent.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A directional exit sign was installed near the kitchen on 12/31/24 by [R]. The sign is wall mounted, is internally illuminated, and clearly indicates the direction of travel to the nearest exit. A complete facility-wide inspection of all exit signs was conducted on 12/31/24 to ensure no other areas are lacking proper signage. 2. The Maintenance Director will modify the scheduled maintenance calendar to include a quarterly Exit Sign inspection to be conducted to ensure all facility exit signs are in the proper location and functioning. 3. The maintenance director will review the quarterly exit sign inspection reports with the administrator quarterly and submit to the QAA committee quarterly for 1 year.
Deficient Fire Safety Measures in Hazardous Areas
Penalty
Summary
The facility failed to ensure that hazardous areas were protected in accordance with NFPA 101:2012 Edition, specifically Sections 19.3.2.1, 7.2.1.8, 9.7, 8.4, and NFPA 13. This deficiency was identified during an observation on December 20, 2024, at 11:20 AM, when it was noted that the laundry room door did not positive latch when tested. This issue was confirmed through an interview with the U.S. FOIA present at the time of the observation. The deficiency had the potential to affect all residents, as it compromised the fire safety measures required for hazardous areas. The facility's representative was informed of this deficient practice during the Life Safety Code exit conference on the same day.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. The laundry room door and latching mechanism were repaired by the facility maintenance department on 12/20/24. The door was then tested and confirmed to latch positively. 2. All hazardous areas were audited to confirm door and latching mechanisms were functioning properly by the maintenance department on 12/20/24. 3. The Director of Maintenance will update the maintenance schedule to include a monthly inspection of Hazardous Areas to ensure that doors are functioning properly. 4. The Safety Committee will audit all hazardous area doors for proper function and submit the results to the administrator and to the QAPI committee monthly for 3 months.
Deficiency in Kitchen Fire Safety Equipment Maintenance
Penalty
Summary
The facility failed to maintain cooking equipment in accordance with NFPA 101:2012 Edition, Sections 9.2.3, NFPA 17:2009 Edition, Section 4.3.1.5, 7.2.2, and NFPA 96. During an observation, it was noted that the kitchen range-hood fire suppression system had eight discharge spray nozzles, four of which were not equipped with a cap or cover device to protect against grease vapors or moisture. Additionally, the Class-K fire extinguisher's monthly inspection tag was not signed for monthly inspections. These deficiencies were confirmed by a staff member during an interview and were discussed at the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. - Nozzle Caps/Covers: Missing caps/covers were installed on all four affected discharge nozzles on 1/7/25 by NJ Ex Order 26.4(b). - Class K Extinguisher Inspection: The Class K fire extinguisher was inspected on 1/7/25 by [R]. The inspection tag was signed and dated to document the inspection. - System Inspection: The entire kitchen fire suppression system was inspected by [R] on 1/7/25 to ensure proper operation and compliance with NFPA 101. 2. The maintenance director modified the facility maintenance schedule to include a requirement for quarterly inspections of the entire kitchen fire suppression system, including checking for missing nozzle caps/covers and inspecting the associated Class K fire extinguisher. 3. The maintenance director, or designee, will audit the kitchen fire suppression system quarterly to check for missing nozzle caps/covers and to confirm inspection of the Class K fire extinguisher. The results of the quarterly audit of the kitchen fire suppression system will be submitted to the administrator and to the QA committee quarterly for one year.
Failure to Conduct Annual Fire Door Inspections
Penalty
Summary
The facility failed to ensure that fire door assemblies were inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. This deficiency was identified during a documentation review and interviews conducted on December 20, 2024. The review revealed that the facility did not conduct annual inspections of fire door assemblies as required. Instead, the facility provided monthly fire door inspections, which did not include all fire doors and assemblies and did not meet the minimum requirements set by the standard. This oversight had the potential to affect all residents in the facility. The observation was confirmed during an interview with the U.S. FOIA representative, and the facility's representative was informed of the deficiency at the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. Facility maintenance department completed an annual fire door assembly inspection on 1/10/25. 2. The Maintenance Director modified the facility maintenance schedule to include a fire door assembly inspection and testing to be completed annually. 3. The Maintenance Director will audit the fire door assembly inspection and testing to confirm completion and submit the report to the administrator and to the QAA committee annually.
Emergency Generator Annunciator Panel Deficiency
Penalty
Summary
The facility failed to ensure compliance with NFPA 99 standards regarding the emergency generator's remote annunciator. During an observation, it was noted that the remote annunciator panel for the emergency generator was not functioning properly at the nurse's station on the second floor. Specifically, the panel lacked a means to indicate it was receiving power and did not have a lamp test switch to verify the operation of all alarm lamps. This deficiency was confirmed through an interview with the U.S. FOIA representative present during the survey. The issue was communicated to the facility's representative during the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A qualified contractor, NJ Ex Order 26.4(b)(1), was contacted and came to assess the generator on 1/6/25 and will repair/replace the remote annunciator panel to include a means to show that it is receiving power and a lamp test switch(es) to test the operation of all alarm lamps. This work was completed by NJ Ex Order 26.4(b)(1) on 2/11/2025. 2. The Maintenance Director added a monthly annunciator panel test to the generator maintenance schedule. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly to ensure that the required testing was completed timely. The results of this review will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its emergency generators in accordance with NFPA 99:2012 Edition, as evidenced by a documentation review conducted on December 19, 2024. The review revealed that the generator was not tested at least once every 36 months under load for a minimum of four continuous hours. Additionally, a routine maintenance report from August 6, 2024, indicated potential issues with the fuel system, suggesting that the injection pump and injectors might need rebuilding. A subsequent report on August 7, 2024, highlighted that the generator had over 1000 hours of operation and a history of failures, including an inability to carry load and erratic engine speed, compounded by water in the fuel system. During an interview, the facility representative confirmed the findings and acknowledged that repairs had not yet been made. Furthermore, the representative admitted that there was no current Memorandum Of Understanding (MOU) for a portable rental generator, although efforts were underway to secure one to facilitate repairs to the onsite generator. This deficiency had the potential to affect all residents, as it compromised the reliability of the emergency power source.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. A qualified contractor, [R] was contacted and came to assess the generator on 1/6/2025 and performed a four-hour generator load test on 2/11/2025. 2. The Maintenance Director added the required 4-hour load test every 36 months to the facility maintenance schedule. 3. The Maintenance Director will review the generator maintenance and inspection reports monthly to ensure that the required testing and maintenance was completed timely. The results of this review will be submitted to the administrator and to the QAPI committee monthly and to the QA committee quarterly ongoing.
Failure to Document Code Status for Residents
Penalty
Summary
The facility failed to document the code status for two residents, leading to a deficiency in the management of their medical instructions regarding resuscitation and other lifesaving measures. Resident #31, who was observed with a tracheostomy and dependent on a ventilator, did not have a physician's order (PO) for code status in their electronic medical record (EMR) or hard paper chart. Although a nurse identified the resident as a full code, this was not supported by a documented PO. The nurse found an admission sheet listing the resident as a full code, but acknowledged it was not a PO. Similarly, Resident #49, who was ventilator-dependent and had a history of traumatic brain injury and epilepsy, also lacked a documented PO for code status. Despite staff stating the resident was a full code, they could not provide evidence of a signed PO. The Admissions Director mentioned checking hospital EMRs for code status before admission, but this information was not translated into a formal PO. The Director of Nursing confirmed the absence of a PO for both residents and acknowledged the need for such documentation at the time of admission. The facility was unable to provide a policy related to code status.
Plan Of Correction
1. Resident #31 and Resident #49 had their [R] clarified with the resident/resident representative and physician by the Director of Nursing. A physician order was obtained and documented in the electronic medical record and a hard copy placed in the appropriate area of the paper chart on 12/18/24. An in-service education was conducted on 12/19/24 by the Director of Nursing for all nursing staff and interdisciplinary team members regarding obtaining a physician's order and the importance of accurate and readily accessible code status documentation, including the facility's process on obtaining, documenting, and verifying code status. Attendance was documented. It was determined by Root Cause Analysis that the deficient practice occurred as a result of not having a formalized process supported by policy regarding the documentation of code status. 2. All residents have the potential to be affected by the same deficient practice. A chart audit was conducted by the Director of Nursing and Unit Managers with the use of an audit tool on 12/19/24 for 100% of current residents to ensure physician's order and code status documentation was present, accurate, and readily accessible. Any issues identified were immediately corrected. 3. A policy and procedure on code status documentation will be developed by 1/15/2025 by the interdisciplinary team and the administrator to include: - Specific location within the medical record for code status documentation (e.g., first page of physician orders, designated tab). - Requirement for code status to be reviewed and updated upon admission, change in condition, and at least annually. - Process for verifying code status during emergencies. - Designated staff responsible for ensuring code status documentation is complete. - Process for obtaining physician order for resident code status. - The nurse admitting the patient will confirm the code status and will get an order from the physician. - The Code status will then be entered into the EMR. A hard copy of the code status will be filed in the designated section of the medical records and scanned into the EMR. - The Code status order will be a part of the admission orders. - During the admission review meeting, the unit manager will ensure that the accurate code status order is obtained from the physician and entered in the EMR and the hard copy of the Advance Directive and/or POLST are filed in the resident's medical record designated code status section and scanned into the EMR. - An alert Icon for the code status will be entered into the EMR as a visual cue. - During the admission, quarterly and significant change care planning meeting, the IDC team will confirm the Code status of the resident and ensure it is documented in the EMR and hard copy is scanned and properly filed into the medical record. - The Social Worker will confirm the code status of the resident when they complete their social assessment and ensure a copy of the code status is properly filed in the code status section of the resident's record. All nursing staff will be re-educated on the revised policy and procedure on Code status order and documentation by the Clinical educator or designee by 1/24/25. Education on new Policy and Procedure on Code status documentation will be integrated into the new nurse orientation program and annual education program by the Clinical Educator. 4. The Social Worker will perform a weekly audit using an audit tool of 10% of resident charts to verify code status order(s) and documentation compliance for 3 months, then monthly for 3 months. Results of the audit will be tracked and reported to the administrator, and will be presented to the Quality Assessment and Assurance Committee quarterly and to the QAPI committee monthly.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident requiring dialysis by not adjusting medication administration times to accommodate the resident's dialysis schedule. The resident, who had a history of chronic kidney disease, end-stage renal disease, and hypertension, was on a dialysis schedule of Tuesday, Thursday, and Saturday. Despite this, the facility did not ensure that the resident's medications were administered at times that would not conflict with the dialysis schedule. The resident's electronic medication administration record (EMAR) showed that medications such as Sevelamer Carbonate and Hydralazine were not administered on days when the resident was out for dialysis. The Licensed Practical Nurse (LPN) confirmed that the medications were not given because the resident was out for dialysis, and there was no documentation of the reason for the missed doses in the electronic progress notes. The facility's procedure required medication times to be adjusted for residents out for dialysis, but this was not consistently done. Interviews with the facility's staff, including the Consultant Pharmacist and the Unit Manager/Registered Nurse, revealed that there was a lack of communication and follow-through in adjusting medication times. The Licensed Nursing Home Administrator and the Director of Nursing acknowledged the oversight, and it was noted that the facility's policies did not specifically address medication timing adjustments for dialysis. This deficiency in care was identified through observation, interview, and record review by the surveyor.
Plan Of Correction
1. The medication administration records (MARS) for resident #56 were immediately reviewed by the Director of Nursing with the Administrator to ensure the medication administration times were adjusted appropriately to accommodate the NU EX Ordar 26 schedule. The attending physician of resident #56 was notified on 12/18/24 of the medication timing issues on & and the missed doses of medications: On and the doses for NJ Ex Order 26.4(b)(1) at 2:30pm was not administered. On and the doses for NJ Ex Order 26.4(b)(1) at 2pm were not administered. On and the dose for NJ Ex Order 26.4(b)(1) was not administered at 12 noon. An in-service education was conducted by the Director of Nursing for all nursing staff involved in medication administration for Resident #56 on 12/19/24. The training emphasized the importance of coordinating medication times with dialysis schedules, identifying medications affected by dialysis, and reviewing physician orders for specific instructions. Attendance was documented. A root cause analysis was conducted to identify the underlying causes of the deficient practice. It was determined from RCA that the underlying cause was lack of education/training of agency nurses on adjusting the timing of medication for individuals on dialysis to accommodate dialysis schedules. It was also identified that adjustment of timing of medication was not included in the dialysis policy. 2. All dialysis patients have the potential to be affected by the same deficient practice. No other dialysis residents were identified in the facility. 3. The facility's Dialysis Policy and Procedure was revised on 1/7/24 to include: Adjustment of medication administration times per doctors order to accommodate dialysis schedule. A process for clear communication between the dialysis unit and the facility nursing staff regarding medication administration. All nursing staff will be re-educated on the revised policy and procedure by 1/15/24. The facility orientation process of agency nurses will be revised to add the updated Dialysis policy to general orientation of agency nurses upon hire and annually. The updated Dialysis Policy will be included in the general orientation and annual education for all clinical team members. The unit manager will check the medication administration record of patients on dialysis to ensure the medication administration time is adjusted to accommodate the dialysis schedule. Pharmacy consultant to review the dialysis medication administration record to ensure proper medication times and any identified concerns with medication adjustment will be immediately communicated verbally to the administrator or Director of Nursing. During the daily clinical meeting, the medication administration record of each dialysis resident will be reviewed by the clinical team for appropriate adjustment of medications. 4. The Director of Nursing, or designee, will audit 2 agency nurse's education files monthly for one year to ensure that education on the dialysis policy was provided. The Director of Nursing, or designee, will audit the medication administration record of all dialysis patients weekly and ongoing for one year for proper medication administration time adjustment to accommodate dialysis schedule. The Director of Nursing will report the audit results to the QAA Committee quarterly and to the QAPI team monthly.
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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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Nursing homes near Edison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brighton Gardens Of Edison | 1.2 mi | ★★★★★ | 1 | 0 |
| Careone At The Highlands | 1.6 mi | ★★★★★ | 2 | 0 |
| Complete Care At Woodlands | 2.2 mi | ★★★★★ | 1 | 0 |
| Complete Care At Plainfield Llc | 2.5 mi | ★★★★★ | 0 | 0 |
| Roosevelt Care Center | 2.6 mi | ★★★★★ | 3 | 0 |
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