Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Imperial Care Center during CMS and state inspections, most recent first.
Outdoor Trash Areas Not Maintained Cleanly: Surveyors observed 2 garbage disposal areas with garbage, debris, carts, drums, and other discarded items scattered around the dumpster areas, and 1 of 3 garbage containers was left uncovered. The FSD, DOM, DHL, and LNHA acknowledged shared responsibility for maintaining the trash areas and confirmed the dumpster lid should remain closed, but the outdoor trash areas were still observed littered and one dumpster was open.
Respiratory infection control was not followed for a resident receiving continuous O2: the nasal cannula was observed on the floor next to a running O2 concentrator and later left on the resident’s bed, despite staff stating it should be kept in a paper or brown bag when not in use. The facility also failed to properly store soiled linen and use PPE in the laundry area, where uncovered bins of unbagged soiled laundry were observed and a laundry aide sorted dirty linen wearing gloves but no gown.
Failure to Report Fracture of Unknown Origin: A resident with severe cognitive impairment and a history of left clavicle fracture developed new left arm pain and swelling, and an x-ray later showed an acute distal clavicle fracture. The facility investigated but did not document reporting the fracture of unknown origin to NJDOH, with the DON and LNHA stating they did not report it because they believed it did not occur in the facility.
Inaccurate MDS Diagnosis Documentation: A resident admitted with dementia had orders for antidepressant and anti-anxiety medications, and the care plan identified impaired cognition and risk for adverse effects related to antidepressants. However, the admission MDS did not list active diagnoses for depression or anxiety in Section I, even though Section N showed antidepressant use and a BH note documented anxiety treatment recommendations. The MDS coordinator acknowledged the diagnoses should have been included, and the DON stated the MDS must be accurate for reimbursement and to avoid fines.
A resident with hemiplegia, hemiparesis, and dementia was observed in a wheelchair with a chair alarm attached to the shirt by a clip and string. The record had no MD order for the alarm, no documented assessment of the symptom prompting its use, no ongoing evaluation for continued use, and no documentation of less restrictive interventions or efforts to decrease or discontinue the alarm. Staff stated the resident moved around and leaned forward, while the DON acknowledged there had been no recent falls and no assessment or evaluation for continued alarm use.
A resident with hemiplegia/hemiparesis and a right-hand contracture was observed with the right fingers flexed into a fist and no splint, hand roll, or other positioning device in place. The resident said they could not move the right hand and did not recall recent therapy, and they ate lunch using only the left hand. The chart showed a 2022 therapy discharge recommendation for a right-hand splint at bedtime, but there was no current order, no PT/OT/restorative nursing involvement, and the care plan did not include the therapy recommendations for the contracture.
Improper storage of nebulizer equipment was observed for a resident with asthma and intact cognition. The nebulizer tubing and mouthpiece were seen exposed to air and uncovered on a bedside table, with moisture present in the chamber. An LPN later placed the tubing in a brown paper bag, and the Unit Manager stated the mouthpiece should be stored in a brown paper bag and not kept with moisture in it.
Failure to address consultant pharmacist recommendation for PRN medication: A resident with anxiety, multiple myeloma, and memory deficits had a PRN prochlorperazine order, and the consultant pharmacist repeatedly noted the need to address the duration of the PRN. Review of the MARs showed the facility did not act on the recommendation for several months, despite the pharmacist emailing monthly irregularities to the DON, ADON, and unit managers and the facility policy requiring timely follow-up.
PRN Psychotropic Order Exceeded 14-Day Limit: A resident with anxiety, multiple myeloma, and memory deficits had a PRN order for prochlorperazine maleate 5 mg q8h for anxiety/nausea that did not include the required 14-day stop date. The UM and DON both stated that PRN antipsychotic orders should be limited to 14 days, and the facility policy reflected the same requirement.
Improper medication storage was found in 2 medication carts when surveyors observed expired safety syringes, opened insulin products without expiration dates, loose unidentified pills, and resident food items stored with medications. An LPN confirmed loose pills should not be in the cart, while the DON stated opened insulin vials and pens are typically good for 28 days and that expired syringes and loose pills should not be present.
A facility failed to accurately complete the MDS for a resident with Chronic Obstructive Pulmonary Disease. The resident had a physician's order for continuous oxygen use, but the MDS incorrectly indicated no oxygen use. This error was confirmed by the MDS Coordinator.
A facility failed to conduct a new PASRR assessment for a resident newly diagnosed with schizophrenia. Initially, the resident's Level I PASRR showed no mental illness, but later assessments and psychiatry consultations confirmed schizophrenia. Despite this, the facility did not complete a new PASRR, as acknowledged by the Clinical Social Worker, which was against policy and regulations.
Outdoor Trash Areas Not Kept Sanitary
Penalty
Summary
The facility failed to provide a sanitary environment by not keeping 2 of 2 garbage disposal areas free of garbage and debris and by not keeping 1 of 3 garbage containers closed. On 1/07/26 at 8:55 AM, the surveyor observed garbage disposal area #1 with 3 garbage containers, including one uncovered container exposed to the elements. The area also contained 2 black trash bags, parts of a truck with wheels and a grey piece of cloth, a wet flattened cardboard box, pieces of cardboard, used bottles, used disposable gloves, 2 wheelchairs, 2 small trash bins, blue vinyl coverings, paper, multiple plastic pipes, and worn sponges discarded beside a grey metal storage container. On 1/07/26 at 10:40 AM, the surveyor observed garbage disposal area #2 with 4 bread carts stacked on a red container transport dolly, a pink rag and part of a cardboard box on top of a black bread crate, and additional debris including 4 empty white laundry drums, plastic, wood pieces, worn disposable gloves, and a plastic cup. Facility staff from food service, maintenance, housekeeping, and administration acknowledged responsibility for maintaining the outdoor trash areas and confirmed that the dumpster lid should remain closed. The LNHA also confirmed that waste was not properly contained in the dumpster and that one dumpster lid was open.
Respiratory Equipment and Soiled Linen Infection Control Failures
Penalty
Summary
Infection prevention and control measures were not implemented for Resident #40’s respiratory equipment. During an initial tour, surveyors observed the resident’s nasal cannula on the floor next to an oxygen concentrator that was turned on, and the tubing was dated 01/07/2026 at 6:00 AM. Later, the same resident was observed in therapy with the nasal cannula in place, and then the tubing was again seen laying on the resident’s bed next to the resident. The resident’s record showed a diagnosis of pneumonia, an MDS indicating continuous oxygen use, and a physician’s order for oxygen at 2 liters via nasal cannula continuously. The IP stated the nasal cannula should be kept in a paper bag when not in use and should never be on the floor, and the DON stated it should be kept in a brown bag when not in use and should not be on the floor. The facility policy stated oxygen masks, cannulas, and nebulizer tubing require weekly changing and must be dated. The facility also failed to properly contain soiled linen and follow PPE practices during laundry handling. Surveyors observed large bins of unbagged soiled laundry in the laundry service corridor, with bins filled to the brim and uncovered, along with smaller uncovered bins containing unbagged linens; the bins were not marked as clean or dirty, and no staff were sorting laundry at that time. On a later tour, a laundry aide was observed sorting soiled laundry in large blue bins while wearing gloves but no gown, and no gown was immediately available. An uncovered bin containing unbagged soiled laundry was also observed near the chute area. The HSKPD stated the bins needed to be covered while not being sorted, the IP stated soiled linen needed to be bagged with bins covered while stored and that laundry staff should wear gloves and gown when sorting soiled laundry, and the DON stated soiled laundry should be bagged, bins should always be closed, and staff should wear gown and gloves when sorting soiled laundry. The facility policy stated soiled laundry must be handled to prevent gross microbial contamination and that anyone handling soiled laundry must wear protective gloves and other appropriate PPE.
Failure to Report Fracture of Unknown Origin
Penalty
Summary
The facility failed to report a fracture of unknown origin to the New Jersey Department of Health within 2 hours as required for Resident #43. Resident #43 was admitted with diagnoses including a fracture of the left clavicle, hemiplegia, and hemiparesis following a cerebral infarction, and the most recent MDS dated 1/3/2026 indicated severely impaired cognitive skills for daily decision making. On 1/1/2026, the resident was assessed with new left arm pain rated 3/10 and swelling of the left hand, and documentation stated there was no fall prior to reentry to the facility. The resident received acetaminophen for the pain, and the NP was notified of the swelling, pain, and guarding behavior on the left arm. An x-ray was ordered and later showed a mildly displaced acute fracture of the distal clavicle with mild osteopenia and osteoarthritis. The attending physician then ordered an orthopedic consult and a sling for the resident's left arm. The facility's investigation of the fracture did not include documentation that NJDOH was notified of the fracture of unknown origin. During interview, the DON stated the fracture was not reported because the facility believed it did not happen in the facility, and the LNHA gave the same explanation. The facility policy stated that the Department of Health and the Office of the Ombudsman must be notified no later than 24 hours of the incident.
Inaccurate MDS Diagnosis Documentation
Penalty
Summary
The facility failed to accurately complete the MDS for one resident who was admitted with dementia and had physician orders for Zoloft 100 mg daily for social anxiety and buspirone 7.5 mg twice daily for anxiety. The resident’s care plan included a focus for impaired cognitive function/dementia or impaired thought process related to dementia and mental disorder, as well as a focus for risk for adverse effects related to the use of antidepressants. The admission MDS dated [DATE] did not list an active diagnosis for depression or anxiety in Section I, even though Section N indicated the resident was taking an antidepressant. A behavioral health progress note dated 10/09/25 documented an initial evaluation for anxiety and recommended Sertraline 25 mg daily for social anxiety and Xanax 0.25 mg every 8 hours as needed for anxiety. During interview, the MDS coordinator stated diagnoses should have been included on the MDS, and the DON stated the MDS must be accurate because it affects reimbursement and avoids fines for false information.
Chair Alarm Used Without Order or Ongoing Evaluation
Penalty
Summary
The facility failed to obtain a physician’s order for the use of a chair alarm for Resident #43, failed to identify the medical symptom that warranted the alarm, failed to conduct ongoing evaluations for continued use, and failed to document the least restrictive interventions used before the alarm was applied. The report also states that interventions to decrease and/or discontinue the chair alarm were not documented in accordance with professional standards of clinical practice. This deficient practice was identified for 1 of 1 resident reviewed for restraints. Resident #43 was admitted with diagnoses including fracture of the left clavicle, hemiplegia and hemiparesis following cerebral infarction, and dementia. The most recent MDS dated 1/3/2026 reflected severely impaired cognitive skills for daily decision making and indicated that no chair alarm was used. On 1/7/2026, the surveyor observed the resident sitting in a wheelchair with a yellow chair alarm hanging at the back of the wheelchair and attached to the resident’s shirt by a clip and string. On 1/8/2026, CNA #1 stated the resident moves around, and LPN #1 stated the resident would lean forward, get up, and move around the building. The record review showed no order for chair alarm use in the active OSR and no order for assessment, monitoring, or evaluation for continued chair alarm use. Skilled evaluation notes dated 1/7/2026 and 1/8/2026 did not reveal chair alarm use, and the facility’s standard assessments did not show any assessment of the resident’s ability to remove the clip from the body independently. The ICCP revised on 1/2/2026 included a fall-risk focus with the intervention of using a chair alarm so staff would know when the resident gets up without assistance. The resident’s falls risk assessments showed no documented falls since admission and prior to admission in 2021. RN/UM #1 stated alarms need a doctor’s order, and the DON stated the alarm was for safety because the resident slides down in the wheelchair, that there were no recent falls, and that the resident had not been assessed or evaluated for continued alarm use.
Failure to Maintain ROM for Resident With Right-Hand Contracture
Penalty
Summary
The facility failed to ensure that a resident with hemiplegia and hemiparesis following cerebrovascular disease received services to maintain or improve ROM after therapy discharge for a right hand contracture. The resident was observed resting in bed with the right fingers flexed into a fist, the right hand resting on the lap, and no positioning device, hand splint, or hand roll present in the room, bed, wheelchair, or on the resident. The resident stated they could not move the right hand and fingers, did not go to therapy, and could not recall the last time they attended therapy. During lunch, the resident ate using only the left hand and denied that staff applied any device to the right hand. The medical record showed the resident had diagnoses including hemiplegia and hemiparesis affecting the right dominant side, with a BIMS score of 11. The most recent therapy discharge summary from 2022 documented a flexion contracture of the right elbow and right hand and recommended a right-hand splint at bedtime, but the resident had no current order for a positioning device and no participation in PT, OT, or restorative nursing. The comprehensive care plan for limited mobility related to CVA did not include interventions from therapy recommendations addressing the right-hand contracture. The RN/UM stated therapists queue orders for positioning devices in the EMR for nursing to activate, and the DOR confirmed the last therapy related to the contracture was in 2022 and that no recent comprehensive evaluation had been completed; no CNA training documentation for the discharge recommendations was provided.
Improper Storage of Nebulizer Equipment
Penalty
Summary
Failure to store respiratory equipment in accordance with infection control standards was identified for one resident with respiratory concerns. On 01/07/2026, the surveyor observed the nebulizer machine on a bedside table with stuffed animals, with the tubing positioned across the table open to air and not in a bag. On 01/08/2026, the surveyor again observed the nebulizer tubing and mouthpiece exposed to air and uncovered on the bedside table, and moisture was seen in the chamber of the mouthpiece attached to the tubing. The resident involved had diagnoses including asthma. The most recent MDS dated 12/06/2025 showed a BIMS score of 14 out of 15, indicating intact cognition. A physician order dated 01/01/2026 directed ipratropium-albuterol nebulization every 6 hours for cough for 5 days and as needed every 4 hours for shortness of breath, not to exceed 6 doses daily. During interview, the Unit Manager stated the nebulizer mouthpiece should be in a brown paper bag and that when not in use the nebulizer mouthpiece and chamber should not be stored with moisture in it. The facility policy reviewed did not refer to how to store nebulizer tubing.
Failure to Address Consultant Pharmacist Recommendation for PRN Medication
Penalty
Summary
The facility failed to follow the Consultant Pharmacist’s recommendation regarding Resident #57’s PRN prochlorperazine maleate order. Resident #57 was admitted with diagnoses including anxiety and multiple myeloma, and the most recent MDS dated 11/06/2025 reflected long- and short-term memory deficits. A physician order dated 08/21/2025 directed prochlorperazine maleate 5 mg every 8 hours PRN for anxiety/nausea, and the Consultant Pharmacist’s medication regimen recommendations dated 09/30/2025, 10/27/2025, 11/26/2025, and 12/17/2025 identified a need to address the duration of the PRN prochlorperazine. Review of the September, October, November, and December 2025 MARs showed the facility did not address this recommendation until 01/10/2026. During interview, the Unit Manager stated that when the pharmacy consultant sends monthly recommendations, the nurse or unit manager reviews them with the physician and follows instructions, and that she tries to get them done right away. The Consultant Pharmacist stated she reviews resident charts and EHRs once or twice a month and submits irregularities by email to the DON, ADON, and Unit Managers monthly. The facility policy titled Consultant Pharmacy, revised 1-2024, stated the DON or Administrator should review the entire report and assign someone to follow up on findings in a timely manner.
PRN Psychotropic Order Exceeded 14-Day Limit
Penalty
Summary
The facility failed to ensure that a physician’s order for a PRN psychotropic medication was limited to 14 days for one resident reviewed for unnecessary medications. Resident #57 was observed sitting up in bed on 01/08/2026. The resident’s admission face sheet listed diagnoses including anxiety and multiple myeloma, and the most recent comprehensive MDS dated 11/06/2025 reflected long- and short-term memory deficits. A review of the resident’s August 2025 eMAR showed a physician order, started on 08/21/2025, for prochlorperazine maleate 5 mg every 8 hours as needed for anxiety/nausea. The order did not include a stop date after 14 days. The Unit Manager stated that PRN antipsychotic medications are ordered for 14 days and then reevaluated, and the DON stated the medication should have only been ordered for 14 days. The facility’s Use of Psychotropic Medications policy stated that PRN antipsychotic orders have a 14-day time limitation with no exception.
Improper Medication Storage and Expired Drugs in Medication Carts
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in 2 of 2 medication carts reviewed. On 01/07/2026, the surveyor observed the 1st Unit Low Side medication cart with an LPN and found 6 safety syringes that had expired on 12/31/2025, a multidose vial of insulin glargine U-100 flex-pen marked opened on 12/03/2025 with no expiration date listed, and 2 opened bags of melted marshmallows belonging to an unsampled resident placed on top of other medications in the drawer. On 01/08/2026, the surveyor observed the 2nd Unit High Side medication cart room with another LPN and found 11 loose, unidentified pills in a drawer and 1 Fiasp Flex Pen marked opened on 12/2/2025 with no expiration date on the bag or pen. The LPN stated there should be no loose pills in the cart and discarded them. During interviews, the LPNs gave different discard dates for opened insulin products, while the DON stated opened insulin vials and pens are typically good for 28 days and confirmed there should not be loose pills or expired syringes in the medication carts. Facility policy stated medications must be stored to maintain integrity and safety, discontinued or contaminated medications must be removed, and opened insulin flex-pens and multidose vials should be discarded after 28 days.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, leading to a deficiency. The resident in question was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease and had a physician's order for continuous oxygen use at 2 liters per minute via nasal cannula. Despite this, the Quarterly MDS dated July 19, 2024, incorrectly indicated that the resident was not using oxygen. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged that the MDS was coded incorrectly.
Failure to Conduct New PASRR Assessment for Resident with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) assessment for a resident who was newly diagnosed with a mental illness. This deficiency was identified for a resident who was initially assessed with a Level I PASRR on 07/04/2020, which indicated no mental illness diagnoses that could lead to a chronic disability. However, subsequent assessments and consultations revealed changes in the resident's mental health status, including a new diagnosis of schizophrenia. The resident's quarterly Minimum Data Set (MDS) dated 12/22/2021 did not reflect a diagnosis of schizophrenia, but a later MDS indicated the presence of this condition. Psychiatry consultations on 02/01/2022 and 03/01/2022 confirmed the diagnosis of schizophrenia. Despite these developments, the facility did not complete a new PASRR assessment as required. The Clinical Social Worker acknowledged during an interview that a new PASRR should have been conducted following the new diagnosis, but it was not completed, which was contrary to the facility's policy and state and federal regulations.
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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 Neptune
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Care At Seabrook | 0.8 mi | ★★★★★ | 0 | 0 |
| Aster Creek Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 1 | 1 |
| Jersey Shore Post Acute Rehabilitation And Nursing | 1.7 mi | ★★★★★ | 0 | 0 |
| King Manor Care And Rehabilitation Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Coral Harbor Rehabilitation And Healthcare Center | 2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.