Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Health Center At Galloway, The during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including recent pneumonia, thrombocytopenia risk, and renal issues, had weekly CBC/BMP labs ordered. One set of labs showed a critically low platelet count and significantly worsened renal function. The overnight LPN received the critical values and sent a text to the physician instead of establishing direct voice contact, then later texted about another resident. The physician only saw and responded to the second text and stated he never saw the message about the critical platelet count. No direct call was made, no new orders were obtained, and the critical results were not effectively communicated for approximately three days. The issue came to light when the resident’s representative questioned the labs during a care plan meeting, prompting a unit manager to call the physician, who then reviewed the results and ordered transfer to the ER. Interviews and policy review showed that facility expectations and protocols required emergent, direct phone communication and escalation for critical labs, which did not occur in this case, resulting in delayed care and treatment.
Failure to implement person-centered care plans for multiple residents: one resident with a known history of inappropriate sexual behavior had the behavior care plan cancelled during hospitalization and not restored on return, and later sexually touched another resident; a resident with dementia on psychotropic meds had behaviors such as agitation, sundowning, and exit-seeking without an individualized care plan or documentation of redirection; a resident on oxygen repeatedly changed the concentrator setting and had no care plan for that behavior; and a resident on Eliquis had no anticoagulant-related care plan to monitor for bleeding or bruising.
Surveyors found multiple infection control failures involving wound care, EBP, linen handling, tube feeding care, and medication administration. An LPN did not use a clean barrier, mixed soiled items with clean wound supplies, continued wound care with contaminated gloves, and carried unbagged soiled linen in the hallway. EBP signage and PPE were not in place for residents with a wound and a trach/laryngectomy status, a resident’s feeding pump area was visibly soiled with insects and residue, and an LPN failed to perform hand hygiene between residents and used a binder as a medication tray.
Failure to Notify Ombudsman of Hospital Transfer: A resident with acute respiratory failure, COPD, HF, and DM2 was sent to the ER for a low platelet count after the MD was contacted about a lab decline. The resident’s representative was notified and transport was arranged, but the facility did not notify the State LTC Ombudsman at the same time the transfer notice was given, as required.
A resident with COPD had oxygen running above the physician’s ordered flow rate, and the humidification bottle was found empty while the resident said it had been empty since the day before. Staff confirmed they had not checked the concentrator setting as required. A second resident with respiratory failure and OSA had a BiPAP machine left exposed on the bedside table instead of being cleaned and stored in a labeled protective bag when not in use.
A resident with dementia, DM, and severe cognitive impairment had an unstageable buttock wound and MASD requiring ongoing treatment, but PCP notes did not show physician assessment, awareness, or supervision of the wound care. The PCP stated she knew about the wound but relied on the wound care NP’s assessments and did not document the wound in her notes.
Incomplete Dementia Care Plan and Missing Behavior Documentation: A resident with dementia and severe cognitive impairment had an ICCP that addressed only elopement risk and lacked resident-specific interventions for agitation, sundowning, and other behaviors described by CNA staff and confirmed by LPNs. The chart also lacked progress note documentation of the resident’s evening behaviors and the redirection measures used, despite the facility’s dementia policy requiring a resident-centered care plan and documentation of changing needs.
A resident with DM, RA, and severe cognitive impairment received prednisone daily under an order that said the provider would taper the medication, but the order lacked a stop date. The pharmacy consultant’s monthly review was incomplete because one month’s recommendation was missing, and another recommendation questioning whether the taper was appropriate was not addressed. The MAR showed the resident continued receiving prednisone 15 mg for several months before the dose was later reduced.
Medication administration error rate exceeded the 5% threshold after surveyors observed an LPN give a resident Coreg and Metformin HCL without food, despite pharmacy cautionary labels directing both meds to be taken with food. Breakfast had not yet been delivered, and the LPN acknowledged the error when the EMR was reviewed. The ADON/IP, LPN/UM, and DON all confirmed that food such as a meal or snack should have been provided with the meds.
An LPN left a treatment cart unlocked, unattended, and out of sight during wound care while gathering supplies and entering a resident's room. The cart held NSS and Santyl ointment, which the unit manager identified as medication. The LPN and unit manager both confirmed the cart should have been secured when not in view because a resident could have accessed the supplies.
A facility failed to offer snacks between meals and at bedtime for several residents, including residents who said they did not receive nighttime snacks and one resident with diabetes who was concerned about blood sugars. Staff gave inconsistent accounts of snack delivery and documentation, and the Dining Director could not provide delivery confirmation records. The DON stated snacks should be offered in the afternoon and at night, and a surveyor also heard a resident request a sandwich at the nurse's station.
A resident with severe cognitive impairment and neurological conditions alleged abuse, prompting an investigation by facility staff. While initial steps such as reviewing logs and conducting a physical assessment were completed, required witness statements were not included in the investigation documentation provided to the surveyor, contrary to facility policy and training.
A resident admitted with intermittent oxygen use did not have a physician's order for oxygen administration, despite related orders for tubing changes and pulse oximetry monitoring. Staff interviews confirmed the lack of an order and care plan documentation for oxygen use, in violation of facility policy and professional standards.
A resident with multiple medical conditions was allowed to have a sick cat, which had undergone chemotherapy, visit and stay in their room without proper physician orders, care plan documentation, or immunization records for the animal. The cat was observed on the resident's bed with evidence of feces and urine stains, and staff interviews revealed inconsistent enforcement of the facility's pet policy and infection control procedures.
The facility did not ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. On six specific days, there was no RN coverage for the required hours. The DON acknowledged the requirement for 8-hour RN coverage daily. The facility's policy indicates efforts to fill open shifts and monitor staffing daily.
Surveyors found deficiencies in kitchen sanitation and food safety at the facility. Temperature logs for refrigeration units were incomplete, and food items lacked proper labeling. Improper storage of kitchenware and inconsistencies in food labeling policies were observed. Additionally, there were lapses in recording food temperatures during meal service, which the FSD and DM acknowledged as crucial for preventing foodborne illnesses.
The facility failed to document unusual incidents in resident progress notes, including a fracture, a verbal altercation between two residents, and an alleged verbal abuse incident. The lack of documentation violated the facility's policy requiring all services, progress, and changes in condition to be recorded in the medical record.
A facility failed to maintain resident dignity when a staff member was observed standing while feeding a resident in a wheelchair during a meal. The resident required moderate assistance with eating due to dementia and malnutrition. The facility's policy requires staff to be seated at eye level to ensure dignity, which was not followed in this instance.
The facility failed to report an injury of unknown origin and an allegation of staff-to-resident abuse to the NJDOH in a timely manner. A resident with a history of osteoporosis reported hip pain, and an x-ray revealed a fracture, but the cause was undocumented and unreported. Another resident alleged verbal abuse by a CNA, but the incident was not reported until the following day. The facility's policies lacked specific timeframes for reporting, leading to deficiencies in adherence to regulations.
The facility failed to implement comprehensive care plans for two residents, one receiving IV antibiotics through a PICC line and another with PTSD. The care plans did not address the PICC line management or the PTSD diagnosis, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives.
A facility failed to follow up on a psychiatry recommendation to discontinue an antipsychotic medication for a resident with dementia and traumatic hemorrhage. The resident's behavior was not monitored, and a care plan for the antipsychotic use was not developed. Despite a recommendation to discontinue quetiapine, there was no documentation of physician notification. Interviews with staff revealed inconsistencies in policy adherence, and facility policies emphasized the need for comprehensive care plans and monitoring.
Failure to Promptly Communicate Critical Lab Results Leading to Delayed Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s critical laboratory results were promptly and effectively communicated to the attending physician, resulting in a three‑day delay in physician notification and subsequent transfer to the hospital. The resident had multiple significant diagnoses, including acute respiratory failure, heart failure, COPD, type 2 diabetes, and a history of low platelet counts, and had recently completed antibiotics for pneumonia. The resident’s care plan identified risk for bleeding and bruising related to Plavix use, with an intervention to obtain labs as ordered and report abnormal results to the physician as soon as possible. Weekly CBC and BMP labs were ordered, and on 12/8 the resident’s platelets were already low at 59 K/CU.MM, with the physician’s subsequent progress notes referencing trending labs. On 12/15, a CBC and BMP were collected and later reported with critical abnormalities, including a platelet count of 20 K/CU.MM, elevated creatinine of 1.99 mg/dl, sodium of 130 mmol/L, and an eGFR of 27. A nursing progress note dated 12/16 documented that the lab called with critically low platelets (20) and that the physician was notified with no new orders, but the physician later stated he was not called about these labs at that time. Instead, the overnight LPN sent a text message to the physician around 1:28 AM reporting the critical platelet count and asking for orders, and then sent a second text at 5:26 AM about another resident’s dark red urine. The physician responded at 6:23 AM with two brief texts, “Noted” and “Hold Eliquis,” which he and the facility later clarified were in response to the second resident’s issue; he stated he never saw the earlier text about the critical platelet count, and no direct voice communication occurred regarding the critical labs. Over the next two days, there was no documented direct physician notification or follow‑up regarding the critical platelet count and worsening renal function, and no new orders were obtained based on those results. The overnight LPN reported that she assumed the physician’s text responses applied to both residents and endorsed to day shift that the critical labs had been communicated and that there were no new orders, expecting the physician to see the resident. The physician later confirmed that he only became aware of the critical labs when a unit manager called him on 12/18 after the resident’s responsible party questioned the lab results and lack of physician contact during a care plan meeting. Upon reviewing the labs at that time, the physician instructed that the resident be sent to the ER for evaluation due to the drop in platelet count and abnormal blood counts. The resident was transferred with the stated reason of a drop in platelet count and was subsequently admitted to the hospital with septic shock and pneumonia. Facility leadership, the physician, the medical director, and multiple nurses acknowledged that critical labs were expected to be communicated emergently by direct phone call, not solely by text, and that in this case there was a delay in care and treatment due to the failure to promptly and effectively notify the physician of the critical results. Interviews with the physician, medical director, DON, ADON/IP, and nursing staff further established that facility policy and expectations required direct voice communication for critical results, with escalation to the medical director if the attending physician did not respond within a specified time. The physician stated that critical labs must be called in emergently and that, had he been made aware immediately, he would at least have considered additional lab surveillance, escalation of care, or hospital evaluation. After later reviewing the chart, he noted that the substantial decline in renal function, which was not included in the initial text, would also have prompted emergency intervention. The medical director reported that he had previously educated staff that critical results, including labs, radiology, and ultrasounds, must be communicated by phone rather than text because texts are short and can create confusion. The facility’s own policies on lab/diagnostic results and acute condition changes required prompt physician notification, direct voice communication for urgent results, and contacting the medical director if the attending physician did not respond, but these standards were not followed in the handling of this resident’s critical laboratory findings. The resident’s responsible party reported learning during a care plan meeting that lab results had been available for three days without a physician call, and the physician confirmed he had not been notified until contacted by the unit manager on the day of transfer. The LNHA later stated he could not locate a formal investigation specific to the critical lab delay, while the ADON/IP stated she had reviewed the medical record and text messages as part of a review of acute discharges and acknowledged a delay in care. The DON also acknowledged a delay in treatment. Overall, the sequence of events shows that the facility did not ensure that critical lab results obtained on 12/15 were immediately and effectively conveyed to the physician, contrary to professional standards of practice, facility policy, and the resident’s care plan interventions, resulting in a three‑day delay in physician notification and transfer for evaluation and treatment.
Failure to Implement Person-Centered Care Plans for Behavior, Psychotropic Use, Oxygen Setting Changes, and Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for four residents with identified needs. One resident had a documented history of inappropriate sexual behavior, including prior care plan interventions for exposing self and inappropriate touching, but the behavior-focused care plan was cancelled during a hospitalization and was not reimplemented when the resident returned to the facility. The resident later was observed with a hand inside another resident’s shirt massaging the resident’s breast while the resident’s genitalia were exposed. Staff interviews confirmed the behavior history and acknowledged that the care plan should have been reimplemented upon readmission. A second resident with dementia was receiving psychotropic medications, including Haldol, Seroquel, and Citalopram, but the care plan did not include individualized interventions for the resident’s reported behaviors. CNA and LPN interviews described agitation, exit-seeking, sundowning in the evening, searching for the responsible party, and threatening to call the police, along with interventions such as redirection, wheelchair rides, one-to-one conversation, and food and fluids. However, the progress notes did not document these behaviors or the redirection interventions, and staff confirmed that the care plan was not resident-specific and did not address the behaviors associated with psychotropic medication use. A third resident who used oxygen therapy was observed changing the oxygen concentrator setting from the ordered 5 liters per minute to 8 and then 9 liters per minute, and the humidification bottle was empty. The resident stated they had turned up the oxygen setting themselves and that the humidification bottle had been empty since the previous day. Staff confirmed that the resident had a history of changing the oxygen setting, that the setting should have been checked every shift, and that the care plan should have included this behavior. A fourth resident prescribed Eliquis for atrial fibrillation had no care plan addressing anticoagulant use or the associated risk for bleeding and bruising until after surveyor inquiry. Staff acknowledged that the resident should have had a care plan to monitor for bruising, bleeding, dark stools, and lethargy.
Infection Control Failures During Wound Care, EBP, Linen Handling, Tube Feeding Care, and Medication Pass
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound and for a resident with a tracheostomy/laryngectomy status, despite facility policy stating that EBP are indicated for residents with wounds and indwelling medical devices. For the resident with a left buttocks wound, the record showed diagnoses including dementia, diabetes, heart failure, and a history of falls, with severe cognitive impairment and bowel and bladder incontinence. The resident had an order for daily wound care and a care plan noting actual skin breakdown and a history of pressure ulcer, but there was no documented evidence that EBP had been implemented when the wound was identified. Surveyors observed no EBP signage or PPE available outside the room. During observed wound care, an LPN performed hand hygiene and donned gloves, but placed treatment supplies directly on the bedside table without a clean barrier. The resident was incontinent of urine during the treatment, and the nurse placed soiled washcloths and the resident’s soiled garment on the bedside table with the clean supplies. The nurse then left the room carrying soiled garments in gloved hands, walked in the hallway, and continued the wound treatment without removing gloves or performing hand hygiene. The nurse reached into a package of clean gauze with contaminated gloves, applied NSS to the gauze, cleansed the wound, and used a gloved finger to apply Santyl. The nurse also attempted to return contaminated supplies to the treatment cart before being stopped by the surveyor. The facility also failed to transport linen in a manner that prevented spread of infection for the resident with the wound. The nurse walked through the hallway carrying unbagged soiled linen and soiled garments. In addition, the facility failed to maintain the feeding tube environment in a sanitary manner for a resident receiving tube feeding, where surveyors observed small black insects crawling on the feeding bottle, pump, and tubing, along with dried tan-colored substance on the feeding pole and wall. The facility also failed to follow infection control practices during medication pass when an LPN exited one resident’s room, pushed a vital signs monitor, went directly to the medication cart, donned gloves, wiped the blood pressure cuff, and then prepared medications for another resident without hand hygiene between residents. The same LPN used a nurse’s binder as a tray to carry medications, which the unit manager later confirmed should not be done because it could cross-contaminate surfaces and spread infection.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident transfer to an acute care hospital at the same time the transfer notice was provided to the resident and representative. Resident #123 had diagnoses including acute respiratory failure, COPD, heart failure, and type 2 diabetes mellitus, and the most recent MDS showed a BIMS score of 11 out of 15, indicating moderately impaired cognition. The resident also had a care plan focus for risk of easy bleeding and bruising related to Plavix, with interventions to monitor labs and report abnormal results to the physician. On 12/18/25, the resident had a physician order to send to the ER for a low platelet count after the MD was contacted about a drop in platelet levels. A progress note documented that the resident’s representative was informed and agreed, transport was called, and the resident was awaiting pickup. The resident was later admitted to the hospital with septic shock and pneumonia. The LNHA confirmed that the resident’s responsible party was notified of the bed-hold notice on 12/18/25, but the Ombudsman was not notified at that time, and the DSS stated he did not know the notice had to be faxed and sent the Ombudsman notification later.
Respiratory Equipment and Oxygen Orders Not Followed
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following oxygen and BiPAP-related requirements. One resident with COPD, emphysema, morbid obesity, anemia, and atrial fibrillation was observed receiving humidified oxygen through a nasal cannula connected to an oxygen concentrator. The resident’s physician order called for oxygen at 5 liters per minute via nasal cannula for 18 to 24 hours daily, but the concentrator was observed set at 8 liters and later at 9 liters. The humidification bottle was also observed with only a small amount of liquid and later empty. The resident stated the humidification bottle had been empty since the day before. During interview, an LPN stated she had given medication but had not checked the oxygen concentrator setting, and confirmed that the setting should be checked every shift and maintained according to the physician’s order. The LPN/UM confirmed the concentrator was set at 9 liters and the humidification bottle was empty, and the resident stated they had turned the oxygen up to 9 liters. The LPN/UM and ADON/IP stated that nurses were expected to verify the physician’s order against the oxygen setting, check that humidification was present, and monitor for respiratory distress. The DON stated that the nurse should check each shift to ensure the oxygen was set at the correct flow rate and that humidification was in place. A second resident with acute and chronic respiratory failure with hypoxia and obstructive sleep apnea was observed receiving oxygen and had a BiPAP machine that was not in use and was not stored in a protective, labeled bag. The BiPAP machine was observed on the bedside table in an open area and exposed. The resident’s care plan addressed oxygen therapy and BiPAP use, but did not specify how the BiPAP machine should be stored when removed. An LPN confirmed the BiPAP should be cleaned and stored in a labeled bag when not in use, and the LPN/UM and ADON/IP stated that respiratory equipment with masks should be cleaned, bagged, and labeled when not in use for infection control purposes.
Physician Oversight Not Documented for Resident Wound Care
Penalty
Summary
The facility failed to ensure physician supervision and oversight of medical care for one resident with dementia, diabetes mellitus, severe cognitive impairment, and ongoing wound care needs. The resident’s records showed an unstageable wound on the left buttocks that had been present since December 2025, measured 2.5 cm x 4.5 cm x 0.3 cm, and was accompanied by moisture-associated skin damage to the scrotal area. The resident’s care plan identified actual skin breakdown on the buttocks with a previous history of pressure ulcers, and treatment orders were reflected on the MAR for the buttock wound and later for the scrotal MASD. Review of the PCP documentation over multiple visits showed no evidence that the physician addressed the wound condition, documented awareness of the wound, or demonstrated medical supervision of the wound. During interview, the PCP stated she was aware of the buttock wound but did not document an assessment because the facility wound care NP performed the assessments, and she acknowledged that she should have mentioned the wound care in her notes. The facility policy stated that the licensed physician supervised each resident’s medical care, including participating in assessment and care planning, monitoring changes in medical status, and overseeing a relevant plan of care.
Incomplete Dementia Care Plan and Missing Behavior Documentation
Penalty
Summary
The facility failed to develop an individualized Comprehensive Care Plan (ICCP) with specific interventions to address dementia care for a resident admitted with diagnoses including dementia and diabetes mellitus. The resident’s MDS dated 12/14/2025 indicated a BIMS score of 3 out of 15, reflecting severe cognitive impairment, and also noted that the resident did not exhibit behaviors, required supervision and assistance with ADLs, and was receiving psychotropic medications. Psychiatry documentation dated 1/29/26 described dementia with forgetfulness, memory loss, confusion, anxiety, depression, delusions, and mood swings, and the resident had an order for Namenda 10 mg twice daily for dementia. During the survey, the resident’s RP reported that the resident had fallen, was sent to an acute care facility, and then admitted to the facility for rehabilitation with plans for long-term care. The RP stated there were no concerns with care. The resident was observed sitting in a recliner with the call light within reach, well-groomed, wearing clean clothes, and without complaints. No behaviors were observed during the survey observations with the RP present. Facility staff interviews and record review showed that CNA #1 described behaviors including agitation, exit seeking, repeated requests to go home, sundowning beginning around 7:00 PM, and calming interventions such as wheelchair rides, one-to-one conversations, peanut butter and jelly sandwiches, and ice water. The CNA stated these interventions were generally effective. However, the ICCP only identified elopement risk with limited interventions such as encouraging independence while in the building, ensuring supervision outside, and using a security bracelet. The progress notes did not document sundowning, searching for the RP, threatening to call the police, or the redirection interventions used. LPN #2 and LPN/UM #1 both confirmed that the ICCP was not resident specific, did not include individualized interventions for agitation or sundowning during the evening shift, and did not include a resident-specific dementia-focused care area with related goals and interventions, which was inconsistent with the facility’s dementia clinical protocol requiring a resident-centered care plan and documentation of changing needs.
Pharmacy Review and Prednisone Order Not Addressed
Penalty
Summary
The facility failed to ensure that the pharmacy consultant completed and communicated monthly medication regimen reviews and that a physician order was clarified when prednisone was ordered to be tapered. Resident #113 had diagnoses including type 2 diabetes mellitus and rheumatoid arthritis, and the quarterly MDS dated 1/12/26 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. On 2/12/26, the resident was observed lying in bed. Record review showed that the facility did not have the pharmacy consultant recommendation for August 2025 for Resident #113. The September 2025 pharmacy consultant recommendation stated that the resident was receiving prednisone 15 mg daily for CHF and asked whether the taper was appropriate at that time, but there was no evidence that this recommendation was addressed. The order summary showed a 7/5/25 physician order for prednisone 5 mg, 3 tablets daily for CHF with instructions that the provider would taper the medication, but the order did not include a stop date. The MAR showed prednisone 15 mg was administered daily throughout July, August, September, and October 2025, and then continued in varying doses in November 2025 as the dose was reduced from 15 mg to 10 mg and then to 5 mg. Staff interviews indicated that pharmacy recommendations were supposed to be sent monthly and addressed by the unit manager, but the LPN/UM could not explain the missing August recommendation or why the September recommendation was not addressed. The DON stated that taper orders should be clarified right away or as soon as noted, and the NP stated that pharmacy recommendations were placed in a communication binder for provider review.
Medication Pass Error Rate Exceeded Threshold
Penalty
Summary
Medication administration error rate exceeded 5% when surveyors observed 3 nurses administering medications to 3 residents with 26 opportunities for error and identified 2 errors, resulting in a 7.6% error rate. During a medication pass observation, an LPN prepared five medications for a resident, including Coreg 25 mg and Metformin HCL 1000 mg, both of which had directions to be taken with food. At the time the medications were given, breakfast trays had not yet been delivered, and the LPN did not provide, offer, or instruct the resident to take the medications with food. When the surveyor stopped the medication pass and reviewed the EMR with the LPN, the nurse acknowledged that the two medications should have been given with food and stated she should have offered food such as applesauce, a sandwich, or crackers. The LPN then gave the resident applesauce. The ADON/IP, the LPN/UM, and the DON all stated that medications ordered to be taken with food should be given with a meal or snack such as pudding, applesauce, a sandwich, or similar food, and that the LPN should have administered the medications with food or waited until breakfast was served.
Unsecured Treatment Cart During Wound Care
Penalty
Summary
The facility failed to secure a treatment cart during a wound treatment observation on the third floor nursing unit. During the observation, an LPN gathered treatment supplies from the cart, placed the supplies on top of the cart, and entered a resident's room while leaving the cart unlocked, unattended, and out of her line of sight. The treatment supplies left on the cart included one bottle of normal saline solution and one tube of Santyl ointment, which the unit manager identified as medication. The LPN returned to the cart for additional supplies and again left it unsecured while re-entering the resident's room. The surveyor observed the LPN later exit the room carrying soiled garments and walk past the unlocked treatment cart without securing it. The LPN then placed trash bags on top of the cart, re-entered the resident's room to obtain another trash bag, and again left the cart unlocked, unsecured, and out of view. During interview, the LPN stated the cart should have been locked and secured when not in sight because a resident could have accessed the treatment supplies. The unit manager confirmed the cart should be kept secured and locked when not in sight and stated that the ointments and creams in the cart were considered medications.
Failure to Offer Snacks Between Meals and at Bedtime
Penalty
Summary
The facility failed to offer snacks to residents between meals and at bedtime. During a resident group meeting, two alert and oriented residents stated that bedtime snacks were not passed out at night, and one resident with diabetes said they were concerned about blood sugars because snacks were not being provided. Two additional residents interviewed separately also stated they had not received a snack at night but would have liked one. Staff interviews showed inconsistent practices for snack delivery and documentation. A CNA stated snacks came from the kitchen at every meal and aides were supposed to offer them, but receipt was not signed out. An LPN stated snacks were offered at 10 AM, 2 PM, and between 5 and 6 PM, and that residents with physician orders for items such as sandwiches, health shakes, or bedtime snacks had those orders reflected on the MAR and signed out by nursing. Another LPN stated diabetics should have that process in place, while a different LPN stated diabetics received snacks on their meal trays and that some residents' families brought snacks from home. The Dining Director stated bulk snacks were delivered to the nursing units at 7:00 PM and also at breakfast, lunch, dinner, and 7:00 PM, but the only documentation provided was a blank meal service delivery log that did not show confirmation of snack delivery to the units. The DON stated snacks should be offered in the afternoon and at night, and the Lead Dietician stated snacks came to the nursing units on a snack tray and nursing handed them out. The surveyor also observed an unsampled resident calling out at the nurse's station, "I want my sandwich," and an LPN/UM confirmed the resident was requesting their snack.
Failure to Document Complete Abuse Investigation
Penalty
Summary
The facility failed to maintain an accurately documented and complete investigation in accordance with accepted professional standards following an allegation of abuse made by a resident. The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 5, and multiple neurological diagnoses including cerebral infarction, hemiplegia, and hemiparesis. The resident alleged that someone had raped them, describing the perpetrator as a short black male wearing tan, seen outside the window of their second-floor room. The facility's initial investigation included a review of the visitor log and staff schedule, which did not match the description, and a physical assessment of the resident. However, the investigation documentation submitted to the surveyor did not include any witness statements at the time of review. Interviews with facility leadership confirmed that obtaining witness statements is a required part of the abuse investigation process, as outlined in facility policy and training materials. Despite this, no witness statements were provided to the surveyor during the initial documentation request. The Assistant LNHA acknowledged that witness statements are essential and indicated they would continue searching for them. The surveyor did not receive any additional documentation, including witness statements, before exiting the facility. The absence of these statements constituted a failure to follow established investigative procedures for abuse allegations.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for a resident who was admitted with intermittent oxygen use. Review of the resident's medical record showed that while there were orders for changing oxygen tubing, conducting a 6-minute rest/walk test on room air, and monitoring pulse oximetry every shift, there was no physician's order for the actual administration of oxygen. Additionally, the resident's care plan did not reflect that the resident was receiving oxygen. Interviews with facility staff, including the social worker, LPN, unit manager, DON, and ADON, confirmed that the resident used oxygen intermittently and that there was no corresponding physician's order or care plan entry for oxygen administration during the period it was used. Facility policy requires verification of a physician's order prior to oxygen administration and review of the care plan for any special needs related to oxygen use. Staff interviews further revealed that the expectation was to ensure a physician's order was in place for any resident receiving oxygen and to update or discontinue the order as appropriate. The absence of a physician's order and care plan documentation for oxygen use was acknowledged by the DON and ADON, confirming the deficiency in following professional standards and facility policy.
Failure to Follow Infection Control Guidelines for Resident's Visiting Sick Cat
Penalty
Summary
The facility failed to follow infection control guidelines regarding a resident who had a sick cat visiting and staying in their room. The resident, who was cognitively intact and had multiple medical diagnoses including spondylosis, dysphagia, sepsis, and muscle weakness, did not have a physician order or care plan entry for pet therapy or pet presence at bedside. Documentation showed that the cat, which had undergone chemotherapy, was present on the resident's bed and had left feces and urine stains. The facility's policy required that animals be monitored to prevent the spread of infection and that personal pet visits be approved by the resident's physician and primary care nurse, but these steps were not followed. No immunization records for the cat were available, and the cat's presence and condition were not properly managed according to policy. Interviews with staff revealed inconsistent knowledge and enforcement of the pet policy. The administrator acknowledged that the cat was allowed to stay with the resident under certain conditions, such as being kept in a crate and not having a litter box in the room, but these conditions were not consistently enforced. Staff were not able to provide required documentation for the cat, and there was evidence of noncompliance with infection control protocols, including the presence of animal waste in the resident's room. The facility's infection prevention and control program policies were not adhered to in this instance.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the Nurse Staffing Reports for specific weeks, revealing that there was no RN coverage for 8 consecutive hours on six specific days. The days without adequate RN coverage were 11/05/2023, 11/08/2023, 11/11/2023, 12/31/2023, 01/01/2024, and 01/06/2024. During an interview, the Director of Nursing (DON) confirmed that the facility should have an RN on duty for a minimum of 8 hours per day. The facility's policy, revised in October 2017, states that efforts are made to fill open shifts and call-outs using incentive programs and agency staffing, and that staffing is monitored daily.
Deficiencies in Kitchen Sanitation and Food Safety
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food safety standards, as observed by surveyors. Temperature logs for the walk-in refrigerator and freezer were incomplete, with no recorded temperatures on specific dates. Additionally, frozen hamburger patties and nutritional supplements were found without proper labeling or dates, and dessert plates and kitchenware were improperly stored, exposing them to potential contamination. The Food Service Director (FSD) acknowledged these issues, attributing the lack of temperature recordings to an aide's absence. Further observations in the resident pantries revealed inadequate monitoring of freezer temperatures and inconsistencies in food labeling and storage policies. The 3rd Floor pantry had a refrigerator with an unidentified substance and improperly labeled resident food items. The facility's policy on food brought by family members was inconsistent with posted signage, leading to confusion about the appropriate use-by dates. The District Manager (DM) admitted the need for a consistent policy and acknowledged the lack of freezer temperature monitoring. The surveyors also found significant lapses in recording food temperatures during meal service, with multiple instances of missing temperature logs for hot and cold foods. The FSD and DM recognized the importance of monitoring food temperatures to prevent foodborne illnesses. Facility policies outlined procedures for food preparation, storage, and labeling, but these were not consistently followed, leading to the observed deficiencies.
Failure to Document Unusual Incidents in Resident Progress Notes
Penalty
Summary
The facility nursing staff failed to document unusual incidents in the progress notes for several residents, leading to a deficiency in meeting professional standards of quality. For Resident #13, there was no documentation in the Electronic Medical Record (EMR) regarding a fracture found on an x-ray, despite a physician order for a bilateral hip x-ray and an orthopedic evaluation. The Director of Nursing (DON) was unaware of how the fracture occurred and acknowledged that it should have been reported to the New Jersey Department of Health (NJDOH). The facility's policy on charting and documentation requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented, which was not adhered to in this case. In another incident, a Facility Reported Event (FRE) involving a verbal altercation between two residents, Resident #5 and Resident #48, was not documented in the progress notes. The nurse, LPN #3, was unaware of the altercation and described the facility's process for reporting such incidents, which includes separating the residents, notifying management, and entering a risk management report in the medical record. However, the progress notes for both residents did not reflect any documentation of the incident, despite the facility's policy requiring documentation of events, incidents, or accidents involving residents. Additionally, an alleged verbal abuse incident involving Resident #257 and a Certified Nursing Aide (CNA #1) was not documented in the progress notes. The resident alleged that the CNA spoke to them in an aggressive manner, but there was no documentation of the incident in the EMR. The Certified Social Worker (CSW) confirmed that such encounters should be documented in the social service progress notes, but this was not done. The DON acknowledged that a summary of the alleged incident should have been documented in the resident's progress notes, as per the facility's policy.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain resident dignity during meal assistance on one of its nursing units. A staff member was observed standing while feeding a resident, who was seated in a wheelchair, during a lunch meal. The staff member, identified as an LPN, did not attempt to sit at eye level with the resident, which is contrary to the facility's policy. The resident, who required partial/moderate assistance with eating due to conditions including dementia and moderate calorie-protein malnutrition, was fed from a standing position throughout the meal. During an interview with the facility administration, including the DON and LNHA, it was confirmed that the facility's practice is for staff to be seated at eye level when assisting residents with meals, as it is considered a dignity issue. The facility's policy on meal assistance, revised in March 2022, explicitly states that residents who cannot feed themselves should be assisted with attention to safety, comfort, and dignity, specifically noting that staff should not stand over residents while assisting them with meals.
Failure to Timely Report Injury and Abuse Allegations
Penalty
Summary
The facility failed to report an injury of unknown origin and an allegation of staff-to-resident abuse to the New Jersey Department of Health (NJDOH) in a timely manner for two residents. Resident #13, who had a history of HIV, chronic pain syndrome, and osteoporosis, reported hip pain but denied any falls. An x-ray revealed a fracture of the right distal femur, but there was no documentation explaining the cause of the injury. The Director of Nursing (DON) acknowledged the injury as of unknown origin and admitted it should have been reported to the NJDOH. The Licensed Nursing Home Administrator (LNHA) confirmed that the report was made only after the surveyor's inquiry, indicating a communication failure among the staff. In another incident, Resident #257 alleged verbal abuse by a Certified Nursing Assistant (CNA #1) during the night shift. The resident claimed that the CNA spoke aggressively after being asked to lower their voice. The incident was not reported to the DON until the following morning, resulting in a delay in addressing the alleged abuse. The facility's policy requires immediate reporting of such incidents, but the delay was attributed to a presumed lapse in communication. The facility's policies on reporting abuse, neglect, and injuries of unknown origin were reviewed, revealing that they lacked specific timeframes for reporting. The policies stated that any suspicion of abuse or injury must be reported immediately to the administrator and relevant authorities. However, the incidents involving Resident #13 and Resident #257 were not reported within the required timeframes, highlighting deficiencies in the facility's adherence to its own policies and state regulations.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their medical and nursing needs. Resident #86, who was receiving an intravenous antibiotic through a PICC line for an infection, did not have a care plan that included the management of the PICC line and the antibiotic treatment. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have included these elements. The absence of a care plan for the PICC line and antibiotic administration was identified during a review of the resident's records and physician orders. Similarly, Resident #99, who was admitted with a diagnosis of PTSD, depression, and anxiety disorder, did not have a care plan addressing PTSD. Despite being medicated for PTSD and exhibiting anxiety during an interview, the care plan failed to reflect this diagnosis. The Licensed Nursing Home Administrator and Director of Nursing agreed that PTSD should have been care planned. The LPN responsible for developing care plans admitted to not having experience with PTSD and acknowledged the oversight. The facility's policy on comprehensive person-centered care plans emphasizes the inclusion of measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Failure to Discontinue Antipsychotic Medication and Monitor Resident
Penalty
Summary
The facility failed to follow up on a psychiatry recommendation to discontinue an antipsychotic medication for a resident, failed to monitor the resident's behavior for the use of the antipsychotic, and failed to develop a care plan for the use of the antipsychotic. This deficiency was identified for a resident who was admitted with diagnoses including traumatic hemorrhage of the cerebrum and unspecified dementia without behavioral disturbance. The resident was observed multiple times without exhibiting any behaviors that would necessitate the use of an antipsychotic medication. The resident's Electronic Medical Record (EMR) revealed a physician order for quetiapine fumarate, an antipsychotic medication, to be given at bedtime for altered mental status. However, the Medication Administration Record (MAR) for several months did not include monitoring for behaviors or the use of quetiapine. A psychiatric progress note recommended discontinuing the medication, but there was no documentation that the physician was notified of this recommendation. Additionally, the resident's care plan did not include care and monitoring for the use of quetiapine. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed inconsistencies in the facility's policy regarding follow-up on consultant recommendations and monitoring of psychotropic medications. The LPN was not familiar with care plans, and the DON confirmed that there should be behavior monitoring documented in the EMAR and a care plan for residents on quetiapine. Facility policies reviewed by the surveyor indicated that non-immediate notification situations should be communicated to the physician at the next routine communication, and comprehensive, person-centered care plans should be developed and implemented for each resident.
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What surveyors actually found near you
We read the 123 citations issued within 25 miles in the last 12 months — including the 3 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Galloway Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Suites Health Care & Rehabilitation | 0.2 mi | ★★★★★ | 0 | 0 |
| Atlas Healthcare At Seashore Gardens | 0.4 mi | ★★★★★ | 0 | 0 |
| Preferred Care At Absecon | 3.3 mi | ★★★★★ | 0 | 0 |
| Excel Care At Egg Harbor | 4.5 mi | ★★★★★ | 1 | 0 |
| Meadowview Nursing And Rehabilitation Center | 6.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.