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 Morris View Healthcare Center during CMS and state inspections, most recent first.
Failure to Thoroughly Investigate Alleged Abuse: A cognitively intact resident reported that an LPN yelled at them, poked them in the face, and stomped on their foot after a medication request. The facility treated the complaint as a grievance instead of an abuse allegation, and the RN who received the report was not interviewed or asked for a statement. Interviews and records showed the incident was not fully investigated, while the DON and LNHA acknowledged the allegation was not reported as abuse and the IP had no training in investigations.
Failure to Protect Resident from Abuse: An alert and oriented resident reported that an LPN yelled at them, got in their face, poked at their face, and stomped on their foot after a dispute over PRN medication. Another resident partially corroborated the account, while facility leaders treated the event as a grievance rather than an abuse allegation and did not report it as abuse.
Expired food items were found in dry storage in the kitchen, including three one-quart bottles of food dye past the manufacturer expiration date. The DOD stated the items should have been discarded and confirmed they were beyond the use-by date, and the RD stated the kitchen should not have had food items in stock past the use-by date. The facility policy reviewed did not address food storage policies and procedures.
Failure to protect a resident and fully investigate an abuse allegation. A resident reported that an LPN yelled at them, poked their face, and stomped on their foot during medication pass, and another resident confirmed parts of the account. The DON said the allegation was treated as a grievance rather than reported as abuse, the accused LPN was not removed from duty, and the facility could not provide documentation of witness interviews at the time of survey.
Failure to Complete Grievance for Missing Personal Items: A cognitively intact resident reported missing personal items after a room move, including clothing, toiletries, a charger, and head turbans. The DOA and AA looked for the items, but no grievance was written or documented, and both staff acknowledged the grievance process was not completed per facility policy.
The facility failed to report an allegation of staff-to-resident abuse involving a cognitively intact resident with COPD. The resident said an LPN yelled at the resident, delayed medication, then poked the resident’s face, spit on the resident, and stomped on the resident’s foot in front of cameras; another resident confirmed the yelling and poking. The RN and IP were notified, but the DON stated the allegation was not reported because it was treated as a grievance instead of abuse, despite the facility policy requiring immediate reporting of alleged abuse.
Two residents with BIMS scores of 15/15 were sent to the hospital, but the facility did not provide transfer notices that included the required appeal process and bed hold information. One resident’s transfer notice omitted the appeal process, while the other resident’s form listed only Ombudsman office information as the appeals contact. The SW said residents were not given copies of the transfer form because they knew they were going out, and the DON said this was the form the facility always used.
Failure to provide ordered eating utensils for a resident who required a specific spoon for meals. Staff were observed feeding the resident with regular dining spoons even though the tray tag specified only the circular spoon, and the resident’s activity log directed use of a metal tablespoon and no plastic utensils. The ADOD stated the facility had ordered the correct spoon, but regular plastic spoons were still being sent on the tray.
Hand hygiene and PPE were not followed during enhanced barrier precautions for a resident with a nephrostomy tube. An UM entered the room and removed the dressing without performing hand hygiene or donning the required gown, face shield, and mask, despite the resident’s care plan calling for enhanced barrier precautions and hand hygiene before and after care. In a separate observation, an LPN used a glucometer for a resident’s fingerstick blood glucose check and returned it to the med cart without cleaning it, even though the IP and facility policy required the device to be sanitized after each use.
A resident with multiple psychiatric and medical diagnoses reported missing vapes, with a roommate alleging that an LPN accessed the resident's belongings. The incident was investigated internally and by local police, and the items were later found and returned. However, the facility did not report the allegation of misappropriation to the state health department as required, nor was the incident documented in the resident's progress notes.
Two residents' care plans were not updated after significant incidents: one involving a family member altering a resident's prescribed liquid consistency, and another involving a resident reporting missing vapes and contacting police. Despite staff awareness of these events and the residents' complex medical histories, care plan interventions were not revised to address the new issues.
The facility failed to maintain the confidentiality of resident health information when two residents with intact cognition were referred to an external preventive care program without proper notification or consent. The administrator entered referrals and granted the external group access to electronic health records, resulting in the disclosure of protected health information and contact details to the outside provider, despite residents' objections.
An LPN documented completion of a physician-ordered mist humidifier for a resident with severe cognitive and physical impairments, but the device was found empty, dry, and unplugged during observation. The LPN admitted to signing off the order in the eMAR without actually performing the required task, resulting in a failure to meet professional nursing standards.
A resident with a history of spinal stenosis and stroke experienced an unwitnessed fall, leading to increased pain and limited mobility. The facility failed to timely assess the resident and provide adequate pain management, as the resident's complaints of pain were not effectively addressed or communicated to the physician. Additionally, the injury was not reported to the NJDOH, and the facility's policies on fall management and pain assessment were not properly implemented.
The facility failed to maintain proper kitchen sanitation and staff attire, risking foodborne illness. Expired juice boxes were found in use, and dietary aides wore inappropriate jewelry and lacked proper hair restraints. The FSD acknowledged these issues, which violated facility policies on food storage and staff attire.
The facility failed to verify licenses, conduct criminal background checks, and obtain reference checks for several staff members before their hire date. A CNA, LPN, and RN had issues with license verification, while a Unit Clerk started work before a background check was completed. Additionally, several staff members lacked documented reference checks. The Director of Human Resources acknowledged these deficiencies, and the facility lacked a policy for the new hire process.
The facility failed to ensure attending physicians signed and dated monthly orders and conducted required visits for several residents. For instance, a resident's attending physician did not document visits for several months, with only the APN covering some months. Another resident's records lacked signed monthly orders and documented visits for June and July. The facility's policy requires timely documentation and regular visits, which were not met, leading to deficiencies.
The facility failed to follow proper hand hygiene and transmission-based precautions, as observed by surveyors. A housekeeper did not perform hand hygiene after glove removal, and residents were not offered hand hygiene before and after meals. Additionally, staff did not consistently use PPE for residents on contact precautions, and a physician did not follow enteric contact isolation procedures. Room assignments for residents requiring isolation were also mishandled, with a resident with C. difficile sharing a bathroom with another resident not on isolation.
The facility failed to maintain a clean and safe environment, with issues such as a loose safety railing in a public toilet, uncleaned blood stains in the chapel, and disrepair in a resident's room. These deficiencies were reported by residents and confirmed by surveyors, highlighting a lack of adherence to the facility's policy for maintaining a sanitary and comfortable environment.
A facility failed to serve meals in a dignified manner when a resident was not served a lunch tray at the same time as others at their table. Despite the CNA's request, the tray was missing from the initial delivery. The RN acknowledged the issue, and the facility's policy requiring simultaneous service was not followed.
The facility failed to complete comprehensive assessments in a timely manner for three residents, as required by the RAI Manual. The MDS for a resident was completed 32 days after the ARD, another 15 days after, and a third 31 days after, all exceeding the 14-day requirement. The MDS Coordinator and facility management acknowledged the issue, but no additional information was provided during the exit conference.
The facility failed to complete quarterly MDS assessments within the required timeframe for two residents. The assessments were completed 19, 26, and 17 days after the ARD, exceeding the 14-day completion requirement. The MDS Coordinator and DON acknowledged the issue, but the facility did not provide additional information or refute the findings during the exit conference.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in their assessments. A pdMDS/RN completed assessments remotely without interviewing residents, resulting in inaccurate health condition documentation. One resident's hospice care was not coded, and another's pain assessment was inaccurately recorded. These issues highlight the facility's failure to ensure accurate resident assessments as per CMS guidelines.
A facility failed to provide an accurate discharge summary for a resident, including a documented medication reconciliation. The resident's discharge instructions listed Aspirin EC 81 mg to be taken twice a day, conflicting with the physician's prescription and notes, which specified once a day. The RN acknowledged the discrepancy and the need for clarification with the physician, which was not done, violating the facility's policy.
Two residents in an LTC facility experienced deficiencies in respiratory care. One resident had an unbagged nebulizer mask that was not changed as per policy, while another had an oxygen concentrator with a nasal cannula improperly stored and not in use despite a continuous oxygen order. The facility's records and care plans were incomplete, and staff interviews confirmed lapses in following procedures.
The facility failed to post the Nursing Home Resident Care Staffing Report (NHRCSR) daily as required. The report was missing for the day shifts on three separate occasions. The surveyor informed the DON and LNHA, but no additional information or refutation was provided by the facility management.
A medication nurse failed to securely store medications during a medication pass, leaving a card containing Xarelto unattended on top of a cart. This action was against the facility's policy, which requires all medications to be stored securely. The incident was confirmed by the RN/Unit Manager and acknowledged by the LNHA and DON.
A facility failed to follow physician's orders for a resident's hypertension medication by not documenting required blood pressure and pulse readings before administration. Additionally, the facility did not specify a site for a Lidocaine patch application for another resident, leaving the decision to the nurse or requiring resident input. These deficiencies were identified during a survey, and the facility management was informed but did not contest the findings.
A resident with dementia and hypertension experienced multiple unwitnessed falls, and the facility failed to conduct a comprehensive root cause analysis or implement new non-pharmacological interventions after each fall. Despite having a care plan, the facility repeatedly used psychiatric consults as interventions without introducing new strategies to prevent further falls. Interviews with staff revealed inconsistencies in the process for handling unwitnessed falls, and the facility's policy did not require documentation of interdisciplinary team discussions.
A resident received both Warfarin and Xarelto due to a documentation error, which the Consultant Pharmacist failed to identify during a drug regimen review. This led to the resident's health decline and hospital admission. The facility's policy on medication errors was not followed, resulting in this deficiency.
A resident in an LTC facility was hospitalized after receiving both Xarelto and Coumadin due to a transcription error by an RN. The resident, with a history of chronic conditions, became symptomatic and was diagnosed with an upper GI bleed. The error was discovered after 18 doses were administered, highlighting a failure to adhere to medication error policies.
Failure to Thoroughly Investigate Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not thoroughly investigating an allegation of staff-to-resident physical abuse made by a cognitively intact resident against an LPN. The resident, who had a BIMS score of 15 out of 15 and a diagnosis of COPD, reported that during the overnight shift the LPN yelled at them, poked them in the face and forehead, and stomped on their right foot after the resident asked for headache medication. The resident later told surveyors that the incident occurred in the day room while other residents were present and that they reported it to an RN the next morning. Facility records showed the allegation was handled as a grievance rather than as an abuse allegation requiring a full investigation. The facility summary stated that the resident felt dismissed when asking for medication assistance and that interviews were conducted with the involved nurse, staff present on the unit, and multiple alert and oriented residents in the area. However, the RN who received the report stated she was told the camera footage would be reviewed because of prior concerns about the resident making false allegations, and she said she was never interviewed or asked to write a statement and never heard the outcome of any investigation. Additional interviews showed conflicting accounts of what occurred. One resident who was present confirmed that the LPN yelled at the resident and poked a finger in the resident's face, and also stated the LPN stomped on the resident's foot. The DON stated the facility discussed allegations with the regional person to determine whether they were reportable or grievances and confirmed this allegation was not reported. The IP stated she was asked to obtain statements, had never been trained on investigating, documented what others told her instead of having them write statements, and stored the information in her filing cabinet without providing it to leadership. The LNHA stated the facility believed it reached the right conclusion and acknowledged that the LPN maybe should have been suspended, but was not.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to implement its abuse policy to protect a resident from abuse, including physical and verbal abuse, after a witnessed altercation occurred between an LPN and a cognitively intact resident. The resident involved had COPD and a BIMS score of 15 out of 15. During the overnight shift, the resident went to the medication cart to request medication for a headache, and the LPN told the resident to wait while medication was being counted. The resident later returned to the day room, and the LPN brought medication to the resident there. According to the resident’s account, the LPN yelled at the resident, got close to the resident’s face, poked a finger toward the resident’s face and forehead, and stomped on the resident’s right foot. The resident stated the interaction left them feeling unable to trust the LPN, that they had to watch the LPN retrieve medications before taking them, and that they no longer went to the day room to watch television because it brought back bad memories. Another resident who was present confirmed that the LPN yelled at the resident, poked a finger in the resident’s face, and stomped on the resident’s foot, although that resident could not confirm whether the finger actually touched the skin. Facility documentation and staff interviews showed the incident was treated as a grievance rather than reported as abuse. The DON stated the facility did not report all allegations and confirmed this allegation was not reported. The IP’s written statement reflected a different version of events, describing the resident as upset, throwing medication, using racial slurs, and the LPN bending down and speaking close to the resident’s face while retrieving the pill from the floor. RN #1 reported that the resident said the LPN was yelling, said nasty things, stomped on the resident’s foot, and poked the resident in the forehead. The LNHA stated the facility believed it reached the right conclusion and acknowledged that, in hindsight, the LPN maybe should have been suspended, but the facility still did not feel the allegation warranted that response.
Expired Food Items Found in Kitchen Storage
Penalty
Summary
The facility failed to ensure that food was not expired according to professional standards for food service safety in one of one kitchen. During an initial kitchen observation on 01/27/26 at 9:47 AM, three one-quart bottles of food dye were found in dry storage with a manufacturer expiration date of 03/27/25. The DOD stated that the bottles should have been discarded and later stated that they were past the use-by date. The DOD also stated that an audit of food items had been completed to ensure no other food items were past the use-by date. On 01/28/26, the RD stated that the kitchen should not have had food items in stock that were beyond the use-by date. Review of the facility policy titled Operation Manual-Dietary Services, dated 07/25, revealed that it did not address food storage policies and procedures.
Failure to Protect Resident and Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility’s LNHA failed to ensure staff followed the abuse policies and procedures after an allegation of staff-to-resident physical abuse involving a resident and an LPN. The facility policy stated that all reports of abuse, neglect, exploitation, mistreatment, and injuries of unknown source must be thoroughly investigated, that an accused employee must be suspended immediately pending the outcome of the investigation, and that any further potential abuse must be prevented. The report also stated that allegations of abuse must be reported immediately, and no later than 2 hours if the allegation involves abuse or serious bodily injury. Resident #194 reported that during the overnight shift, while in the day room with another resident, the resident asked the LPN for medication for a headache. The resident stated the LPN yelled at them, later returned with medication, and then got in the resident’s face, poked the resident’s face, eye, and forehead, yelled close enough for spit to land on the resident’s face, and stomped on the resident’s right foot. Resident #194 stated the next morning they reported the incident to RN #1 and said the LPN had done it in front of the cameras. Resident #158 confirmed hearing the LPN yell, poke the resident’s face, and stomp on the resident’s foot, and also stated that RN #2 and LPN #2 came to ask about what happened. RN #1 stated Resident #194 reported that the LPN had yelled, made nasty comments, stomped on the resident’s foot, and poked the resident in the forehead. The DON stated the facility’s process was to interview residents or staff who may have witnessed the incident, but she did not know which staff or residents were interviewed and could not provide documentation of those interviews at the time of the survey. The DON also stated the allegation was not reported because it was determined to be a grievance. The LNHA stated he was the point person for abuse allegations and that the team collected statements and tried to determine what happened, but he agreed that they may have should have suspended the LPN and stated they still did not feel the allegation warranted that response.
Failure to Complete Grievance for Missing Personal Items
Penalty
Summary
The facility failed to complete a grievance with resolution related to missing personal items after a resident was moved within the facility. The resident was admitted with a quarterly MDS showing a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During an interview, the resident stated that while out at dialysis, staff moved belongings to a new room and several items were missing when the resident returned, including perfume, lotion, two bottles of baby powder, a phone charger, a birthday t-shirt, and two head turbans. The resident stated the Director of Admissions and the Administrative Assistant looked for the items, but none were located. Facility interviews and record review showed the Social Service Director met with the resident about missing personal items and offered a lock box, which the resident declined. The Administrative Assistant stated no grievance was written for this incident, although staff had looked for the items. The Director of Admissions stated there was no documentation that the resident refused payment for the items and acknowledged that neither the Director of Admissions nor the Administrative Assistant filed a grievance or reported the incident per policy. Both staff members stated a grievance should have been completed, and the Administrative Assistant stated, "we dropped the ball on this report." The facility policy required grievances and complaints to be accepted orally or in writing and to receive prompt review, investigation, response, and resolution.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy and failed to report an allegation of staff-to-resident abuse involving a cognitively intact resident with COPD. The resident stated that during the overnight shift, after requesting medication for a headache, an LPN yelled at the resident, delayed giving the medication, then later entered the day room, got in the resident’s face, poked the resident’s face and forehead with fingers, yelled, spit on the resident’s face, and stomped on the resident’s right foot. The resident said this occurred in front of cameras and that the next morning the resident reported the incident to an RN. Another cognitively intact resident who was present confirmed that the LPN yelled at the resident and poked the resident’s face, and also stated that two nurses later asked about what happened and were told what was observed. The RN stated the resident reported an altercation with an evening nurse and that the RN immediately notified the in-house supervisor/RN supervisor and spoke with the IP, who directed a skin assessment. The DON stated the facility’s process was to interview residents or staff who may have witnessed the incident and determine whether it was reportable or a grievance, but confirmed the allegation was not reported because it was determined to be a grievance. The IP stated he/she was made aware of the incident and contacted the DON. The facility policy required alleged abuse to be reported immediately, and no later than two hours if the allegation involved abuse.
Transfer Notices Lacked Required Appeal Information
Penalty
Summary
The facility failed to ensure that two residents, both reviewed for emergent hospital transfer, and their resident representatives were provided with a written bed hold policy and a transfer notice that included the appeal process. One resident was admitted on [DATE], had a quarterly MDS with a BIMS score of 15 out of 15 indicating cognitive intactness, and on 12/26/25 had a change in condition with a new order to send the resident to the hospital for evaluation and treatment. The transfer notice provided for this resident did not include the appeal process required by the facility policy. The Social Worker stated during interview that the Ombudsman was notified and Ombudsman information was provided on the transfer form, but a copy of the transfer form was not provided to residents because they knew they were going out. The Social Worker also stated nothing was documented in the medical record about notification after transfer and nothing was explained to the residents because they knew they were going out. The second resident had a quarterly MDS showing a BIMS score of 15 out of 15, with diagnoses including CAD, HTN, PVD, DM, other fracture, anxiety disorder, depression, and tobacco use, and was sent to the local hospital after a fall in the room. The emergency transfer notice for this resident listed the Ombudsman office information as the entity for appeals, and the DON stated that was the form the facility always used.
Failure to Provide Ordered Eating Utensils
Penalty
Summary
The facility failed to ensure assistive eating devices were provided for one resident who required specific utensils during meals. Review of the resident’s Activity Log Report showed orders for a metal tablespoon only and instructions not to send a small teaspoon, and later instructions for no plastic utensils and two large tablespoons only. During observations, the resident was fed with two regular dining spoons on the tray, and the tray tag indicated, "Assist with feeding***Only the circular spoon***," showing the required spoon was not present. On multiple observations, the CNA continued to feed the resident with two regular spoons, and stated this had been the case for about a week and that the spoons had been obtained from the tray. The tray tag continued to specify only the circular spoon, but the spoon was not on the tray. Later, the resident’s tray still contained two regular spoons, and the newly arrived spoons were not on the tray. The ADOD stated the spoon was a soup spoon and that the facility had ordered them about a week earlier, and also stated that because the dishwasher was not working correctly, regular plastic spoons had been sent on the resident’s tray.
Hand Hygiene, PPE, and Glucometer Sanitization Failures
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of PPE during enhanced barrier precautions for a resident with a nephrostomy tube. The resident had diagnoses including renal and perinephric abscess, malignant neoplasm of the kidney, obstructive and reflux uropathy, and type 2 diabetes mellitus. The quarterly MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and the resident was dependent on staff for toileting hygiene, bathing, and personal hygiene. The care plan identified the resident as at risk for infection and directed enhanced barrier precautions for high-contact care activities, including gown and glove use and hand hygiene before and after care. During observation of a nephrostomy dressing change, the UM did not perform hand hygiene and did not don the required PPE, including gown, face shield, and mask, before entering the resident's room and removing the nephrostomy dressing. When interviewed at the time of the observation, the UM acknowledged forgetting to put on PPE and stated that PPE should have been worn and hand hygiene performed before and after the dressing change. The IP later stated that staff were expected to perform hand hygiene and don appropriate PPE when caring for residents on enhanced barrier precautions and that staff had received training on proper PPE use and enhanced barrier precautions. The facility also failed to ensure proper sanitization of a glucometer used for blood glucose monitoring. During observation, an LPN used a new glucometer to obtain a fingerstick blood glucose for a resident, performed handwashing, but did not clean the glucometer before placing it back into the medication cart and drawer. When questioned, the LPN stated the machine was new and therefore was not cleaned, but acknowledged it should have been cleaned anyway. The IP stated that glucometers were to be cleaned with purple Santi wipes before and after each use and that each resident had an individualized, marked glucometer. The facility policy required each glucometer to be wiped down with a sanitizing agent after each use and returned to individual storage.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation involving a resident's missing personal items to the New Jersey Department of Health (NJDOH) as required. The incident involved a resident with multiple diagnoses, including achalasia of cardia, narcolepsy with cataplexy, anxiety disorder, PTSD, major depression, and bipolar disorder, who was assessed as cognitively intact. The resident's vapes were reported missing, and the resident's roommate stated that an LPN was seen entering the room and accessing the resident's belongings. The resident notified the local police, who responded and interviewed both the resident and the LPN, who denied taking the items. The facility conducted an internal investigation, including review of video footage and interviews with involved parties. The video showed the LPN entering and exiting the resident's room, but there was no visual evidence of the LPN taking any items. The missing vapes were later found in a soiled utility room and returned to the resident by social services. Despite the investigation and the involvement of local law enforcement, the facility did not document the incident in the resident's progress notes as an allegation of misappropriation, nor did they report the allegation to the NJDOH as required by regulation. Interviews with facility leadership confirmed that the previous administration did not report the incident to the NJDOH, citing that the investigation was unsubstantiated and the items were eventually found. The facility was unable to provide documentation or video evidence to support their statements regarding the notification of the resident or the outcome of the investigation. The facility's own abuse prevention policy requires reporting of all allegations of abuse or misappropriation within required timeframes, which was not followed in this case.
Failure to Update and Revise Care Plans After Significant Resident Incidents
Penalty
Summary
The facility failed to update and revise care plans in response to significant events for two residents. For one resident with cerebral palsy, aphasia, and quadriplegia, the care plan did not include new interventions after the resident's father was observed altering the consistency of the resident's liquids and confronting staff about it. Despite this incident, there were no updates to the care plan to address the tampering of liquids, and the Director of Nursing acknowledged that best practice would be to update interventions following such incidents. For another resident with multiple diagnoses including achalasia, narcolepsy with cataplexy, anxiety disorder, PTSD, major depression, and bipolar disorder, the care plan identified the resident as a smoker and included interventions for managing smoking supplies. However, after the resident reported missing vapes and accused a staff member of taking them, and subsequently called the police, there was no evidence that the care plan was revised to address these new developments. Interviews with staff confirmed the resident's smoking status and use of vapes, but the care plan did not reflect updated interventions following the incident.
Failure to Protect Resident Health Information During Introduction of External Care Program
Penalty
Summary
The facility failed to protect the confidentiality of residents' health information when it introduced an external medical practice, Newave Care, to residents without proper notification or consent. The program involved the collection and disclosure of residents' protected health information (PHI) for preventive care purposes. In two cases, residents with intact cognition reported that they were approached by Newave Care staff without prior warning from facility administration. One resident stated that their medical records were accessed to determine eligibility for the program, and that the referral was made by facility administration rather than their physician. The resident did not consent to participation and expressed concern about a potential HIPAA violation. Documentation confirmed that the facility administrator entered orders referring residents to Newave Care for various programs. Another resident reported that Newave Care staff persistently contacted both the resident and their family member, despite the resident's clear refusal and capacity to make their own decisions. The resident questioned how the external group obtained their family member's contact information and medical details. Interviews with facility staff revealed that the external group was given access to the electronic health record system (PCC) and that referrals were made for all eligible residents by the administrator. The social worker indicated that the external group had access to resident information prior to direct contact. These actions resulted in the unauthorized disclosure and use of residents' PHI.
Failure to Follow Physician Order and Accurate Documentation for Respiratory Device
Penalty
Summary
A deficiency occurred when an LPN failed to follow a physician's order for a mist humidifier for a resident. The order required the mist humidifier to be turned on and filled with distilled water to the appropriate level every shift while the resident was in the room. During an observation, the resident was seen in their room with the mist humidifier present but it was empty, dry, and not plugged in. When questioned, the CNA indicated that the nurse was responsible for the device. Upon review of the electronic Medication Administration Record (eMAR), it was found that the LPN had signed off as if the order had been completed for that shift, despite the device not being in use or filled as required. The LPN confirmed in the presence of the surveyor that she had documented the order as completed in the eMAR without actually performing the task. The resident involved had significant medical conditions, including cerebral palsy, aphasia, quadriplegia, seizures, and microcephaly, and was assessed as severely cognitively impaired and dependent on staff for all activities of daily living. The failure to carry out the physician's order and the inaccurate documentation constituted a breach of professional nursing standards and facility policy.
Failure to Timely Assess and Manage Pain After Resident Fall
Penalty
Summary
The facility failed to timely assess a resident after an unwitnessed fall, which occurred on 9/16/23 at 01:20 AM. The resident, who had a history of spinal stenosis, stroke, and unsteadiness on feet, was found on the floor by a CNA. The RN conducted a body assessment, and the resident initially denied pain. However, the resident later experienced increased pain and limited mobility, which was not adequately addressed by the facility. The resident's pain was not effectively managed, as evidenced by the lack of timely administration of appropriate pain medication and failure to notify the physician of the resident's persistent pain. The facility's documentation revealed multiple instances where the resident complained of pain, but the nursing staff did not provide adequate pain management or notify the physician for further intervention. The resident's pain was documented at various levels, ranging from mild to severe, yet the facility continued to administer only Tylenol, which was ineffective. The resident's complaints of pain were not consistently communicated to the physician or adequately documented by the therapy staff, leading to a delay in appropriate medical evaluation and treatment. Additionally, the facility did not report the injury to the New Jersey Department of Health, as required. The Director of Nursing and other staff members were interviewed, and it was noted that there was a lack of communication and documentation regarding the resident's fall and subsequent pain management. The facility's policies on managing falls, pain assessment, and incident reporting were not effectively implemented, contributing to the deficiency in care provided to the resident.
Deficiencies in Kitchen Sanitation and Staff Attire
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, which could lead to foodborne illness. During an inspection, the surveyor observed that the juice dispenser machine was connected to several large juice boxes with expired 'Best if Used by' dates. Specifically, an unsweetened black iced tea juice box had a date of 5/20/2024, a cranberry juice fusion box had a date of 11/28/2023, and a thickened water nectar consistency juice box had a date of 4/19/2024. The Food Service Director (FSD) acknowledged that these boxes should have been disposed of and could not explain why they were still in use. Additionally, the surveyor noted issues with staff attire that could compromise food safety. Dietary Aide #1 was observed wearing drop earrings more than an inch long, and Dietary Aide #2 was wearing medium hoop earrings. Both aides were unsure of the facility's policy regarding earrings in the kitchen. The FSD confirmed that ServSafe guidelines indicated such jewelry should not be worn. Furthermore, another dietary aide, DA #3, was observed with exposed facial hair, which was not covered with a beard restraint as required by the facility's policy. The FSD instructed DA #3 to put on a beard cover. The facility's policies on food storage and staff attire were reviewed, indicating that all foods should be consumed within their use-by dates and that dietary staff should wear hair restraints and minimal jewelry.
Deficiencies in Staff Hiring Process
Penalty
Summary
The facility failed to ensure proper verification of licenses, criminal background checks, and reference checks for several staff members, leading to deficiencies in their hiring process. Specifically, three out of seven licensed staff members did not have their licenses verified before their date of hire, and one out of ten staff members did not have a criminal background check completed before starting work. Additionally, six out of ten staff members did not have reference checks from past employers documented in their files. During the survey, it was revealed that a Certified Nursing Assistant, a Licensed Practical Nurse, and a Registered Nurse had issues with license verification, either lacking documentation or having verification completed after their hire date. Furthermore, a Unit Clerk began working before their criminal background check was completed, and several staff members, including a Recreation Aide and an Occupational Therapist, lacked documented reference checks. The Director of Human Resources acknowledged the deficiencies, stating that license verifications were sometimes completed after the date of hire and that reference checks were supposed to be in the file. The facility did not have a policy for the new hire process, and the Licensed Nursing Home Administrator confirmed that the date of hire was not always the date the employee started working. The facility's policy on abuse prevention requires background checks and prohibits hiring individuals with certain findings or disciplinary actions, but these procedures were not consistently followed.
Deficiency in Physician Documentation and Visits
Penalty
Summary
The facility failed to ensure that the attending physicians signed and dated monthly physician orders and conducted required visits for several residents. Specifically, the attending physician did not document visits for Resident #18 for March, April, May, or June 2024, with only the Advanced Practice Nurse (APN) documenting visits in April and June. Similarly, Resident #80's attending physician did not document visits for March, April, May, or June 2024, with the APN only documenting a visit in March. Resident #227's attending physician also failed to document visits for April, May, or June 2024, with the APN documenting only in May. Resident #257's attending physician did not document visits for May or June 2024, although the APN covered these months. The surveyor's review of Resident #466's electronic medical record revealed that the attending physician and APN had not signed monthly orders for June and July 2024. Additionally, there was no documentation of visits by the attending physician for these months, nor was there a history and physical or progress notes documented. The Registered Nurse (RN) interviewed was unsure of the process for signing orders and could not locate the necessary documentation in the electronic medical record. The Director of Nursing (DON) was also unable to find the required documentation upon review. The facility's policy and procedure for physician responsibilities, signatures, and visits require that all physician orders and progress notes be signed and dated in a timely manner. Physicians are expected to conduct initial visits within 48 hours of admission and regular visits every 30 days for the first 90 days, then at least once every 60 days thereafter. The surveyor's findings indicated that these requirements were not met for the residents reviewed, leading to the identified deficiencies.
Infection Control Deficiencies in Hand Hygiene and Precautionary Measures
Penalty
Summary
The facility failed to adhere to proper hand hygiene and transmission-based precautions, as observed by surveyors. In one instance, a housekeeper was seen wearing gloves while cleaning a toilet room and then proceeded to move through the hallway without removing the gloves or performing hand hygiene. This was contrary to the facility's policy and CDC guidelines, which require hand hygiene after glove removal and before leaving a room. Additionally, during a dining observation, residents were not offered hand hygiene before and after meals, which is a requirement according to the facility's hand hygiene policy. The facility also failed to implement appropriate transmission-based precautions for residents on contact precautions. For instance, a resident with MRSA in the urine was placed on contact precautions, but the necessary signage and PPE bins were not consistently present or utilized by staff. A housekeeper entered the resident's room without wearing a gown, despite the contact precaution signage indicating the need for gown and gloves. Furthermore, a physician was observed exiting a room under enteric contact isolation without removing PPE or performing hand hygiene, which is against the facility's infection control policy. There were also issues with room assignments for residents requiring isolation. A resident with C. difficile was placed in a room with another resident who was not on isolation, and both residents shared a bathroom. The infection preventionist was not aware that the non-isolated resident used the shared bathroom, which could pose a risk of infection transmission. The facility's policy requires residents on contact precautions to be placed in private rooms or assessed for appropriate roommate placement, which was not adequately followed in this case.
Deficiencies in Facility Cleanliness and Safety
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in both resident and common areas. In one instance, a resident reported a loose safety railing in a public toilet room, which was confirmed by the surveyor and the Licensed Nursing Home Administrator (LNHA). Additionally, the chapel, used for religious services, had blood stains on the carpet from an incident a month prior, which had not been cleaned despite being reported. Housekeeping staff were unaware of the stain, and the Infection Preventionist/Registered Nurse (IP/RN) confirmed the presence of the stain and observed additional black stains and discolored ceiling tiles. In another instance, a resident's room was found to have chipped and faded paint with black streaks on the walls, and the floor tiles were discolored. The resident, who was dependent on a wheelchair and had conditions such as obesity and osteoarthritis, pointed out these issues to the surveyor. The Housekeeping staff acknowledged the need for cleaning and maintenance, while the Director of Maintenance admitted the room's condition was unacceptable and noted a previous leak that had not been addressed. The facility's Safe and Homelike Environment Policy mandates maintaining a sanitary, orderly, and comfortable environment, which was not upheld in these cases. The policy requires prompt reporting and addressing of maintenance issues, which did not occur as evidenced by the unresolved environmental concerns in both the resident's room and common areas. The facility management was informed of these findings during the survey, but no additional information or refutation was provided.
Failure to Serve Meals Dignifiedly
Penalty
Summary
The facility failed to ensure that residents were served their meals in a dignified manner during meal service, as observed by a surveyor. On the specified date, the surveyor noted that a lunch food truck was parked in front of the nursing station and then taken into the dining room where five residents were present. However, one resident was not served a lunch tray at the same time as the other residents at their table. The Registered Nurse (RN) was questioned by the surveyor about the missing tray and acknowledged that the Certified Nursing Aide (CNA) had already requested it, but it was not included in the initial delivery. The CNA eventually received and set up the lunch tray for the resident, but this delay was noted as a failure to serve all residents at a table together, as per the facility's Dining Environment Policy. The surveyor informed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and other facility management of the issue, and the facility did not provide additional information or refute the findings. The policy review confirmed that all residents seated at a table should be served together when feasible, which was not adhered to in this instance.
Failure to Timely Complete Comprehensive Assessments
Penalty
Summary
The facility failed to complete the Comprehensive Assessment in accordance with the Resident Assessment Instrument (RAI) for three residents. The deficiency was identified through interviews and record reviews, revealing that the facility did not adhere to the required timeline for completing the Minimum Data Set (MDS) assessments. Specifically, the MDS for Resident #6 was completed 32 days after the Assessment Reference Date (ARD), and for Resident #135, it was completed 15 days after the ARD. Both assessments exceeded the mandated completion period of no later than 14 days after the ARD. Additionally, the MDS for Resident #14 was completed 31 days after the ARD, further indicating non-compliance with the required timeline. The surveyor's interviews with the part-time MDS Coordinator/RN and facility management confirmed awareness of the issue, with the MDS Coordinator acknowledging previous similar concerns. Despite being informed of these findings, the facility did not provide additional information or refute the surveyor's observations during the exit conference.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments within the required timeframe for two residents. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, the quarterly MDS should be completed within 92 days after the Assessment Reference Date (ARD) of the previous MDS, and the completion date should be no later than 14 days after the ARD. However, for Resident #6, the quarterly assessment was completed 19 days after the ARD, and for Resident #135, the assessments were completed 26 and 17 days after the ARD for two separate quarters. During the survey, the part-time MDS Coordinator/RN acknowledged the late submissions and stated that the facility follows the RAI Manual guidelines. The Director of Nursing also recognized the issue of late completion and submission of MDS assessments. Despite these acknowledgments, the facility did not provide additional information or refute the findings during the exit conference with the survey team, which included the Licensed Nursing Home Administrator, Chief Nursing Officer, Corporate Compliance Officer, and Regional Administrator.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in their assessments. For Resident #135, the MDS was inaccurately completed by a per diem MDS/Registered Nurse (pdMDS/RN) who worked remotely and did not interview the resident in person. The MDS Coordinator RN (MDSC/RN) acknowledged that the pdMDS/RN did not conduct the necessary interviews, resulting in an inaccurate assessment of the resident's health conditions, particularly regarding pain management. Resident #138's MDS assessments contained inconsistencies in coding related to the resident's ability to understand and the omission of hospice care. The resident was coded as sometimes able to understand, yet the Brief Interview for Mental Status (BIMS) was not conducted. Additionally, the resident was not coded as receiving hospice care despite a physician's order indicating hospice admission. The MDSC/RN acknowledged these discrepancies and noted that different staff completed sections B and C at different times, contributing to the inconsistency. For Resident #198, the MDS was completed by the pdMDS/RN, who recorded a pain assessment without directly interviewing the resident. The MDS indicated that the resident experienced pain, but the assessment was completed remotely, raising concerns about the accuracy of the information. These deficiencies highlight the facility's failure to ensure accurate and reliable resident assessments, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines.
Failure to Provide Accurate Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to provide an accurate discharge summary for a resident at the time of discharge, which included a documented medication reconciliation, post-discharge instructions, and a physician's prescription. The deficiency was identified during a review of the closed medical records of a resident who was admitted with multiple diagnoses, including cellulitis, hypothyroidism, major depressive disorder, cerebrovascular disease, and seizures. The resident's discharge instructions listed a medication regimen that was inconsistent with the physician's prescription and progress notes, specifically regarding the dosage frequency of Aspirin EC 81 mg. The discrepancy was noted between the discharge instructions, which indicated the medication should be taken twice a day, and the physician's prescription and notes, which specified once a day. The RN interviewed acknowledged that the discharge instructions are what the resident or family follows and stated that the nurse should have clarified the order with the physician. The physician confirmed the correct dosage was once a day. The facility's policy required a medication reconciliation as part of the discharge summary, which was not properly conducted in this case.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order and did not ensure proper storage of respiratory equipment for two residents. Resident #111 was observed with an unbagged nebulizer mask that had a foggy appearance and was dated two months prior, indicating it had not been changed as per facility policy. The resident's physician orders did not include instructions for changing the nebulizer mask, and the facility's electronic records did not reflect any such orders. Interviews with the LPN/Unit Manager and the Infection Preventionist confirmed that the mask should be changed weekly and stored properly to prevent infection. Resident #466 was observed with an oxygen concentrator at the bedside, and the nasal cannula was not stored in a bag when not in use. The resident's medical records indicated a physician's order for continuous oxygen therapy, but observations showed the oxygen was not in use, and the nasal cannula was improperly stored. The resident's care plan was incomplete, lacking specific goals and interventions for respiratory care. Interviews with the Assistant Director of Nursing and the assigned LPN revealed inconsistencies in following the physician's orders and proper storage procedures. The facility's Oxygen Administration Policy required the replacement of the entire setup every seven days and proper storage of equipment when not in use. However, the surveyor's findings indicated that these procedures were not consistently followed, leading to potential risks for infection and non-compliance with physician orders. The facility management was notified of these deficiencies, but no additional information was provided to refute the findings.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of the Nursing Home Resident Care Staffing Report (NHRCSR) as required. During the survey, it was observed that the NHRCSR was not posted for the day shifts on three separate occasions. On 7/08/24, the report for the day shift was not posted, with the previous day's report still displayed. Similarly, on 7/09/24, the report for that day's shift was missing, and on 7/12/24, the report for the day shift was also absent. The surveyor informed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) about these concerns, and it was noted that the Assistant Administrator was responsible for posting the NHRCSR. However, no additional information or refutation of the findings was provided by the facility management during the exit conference.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and appropriately, as observed during a medication pass on the South Side of the 2A Unit. A surveyor noted that a medication nurse placed medication cards on top of a medication cart while preparing and administering medications to a resident. After administering the medications, the nurse left a medication card containing Xarelto, a blood-thinning medication, unattended on top of the cart. This was contrary to the facility's policy, which mandates that no medications should be left on top of the cart and that all medications should be stored securely. The surveyor confirmed with the medication nurse and the RN/Unit Manager that leaving medications unattended was inappropriate and against the facility's policy. The facility's policies, reviewed by the surveyor, emphasized the importance of storing all drugs and biologicals in a safe, secure, and orderly manner. The incident was acknowledged by the Licensed Nursing Home Administrator and the Director of Nursing during a discussion with the survey team.
Failure to Follow Physician's Orders and Specify Medication Application Site
Penalty
Summary
The facility failed to adhere to physician's orders for a resident regarding the administration of Metoprolol Succinate ER, a medication prescribed for hypertension. The physician's order specified that the medication should be withheld if the resident's systolic blood pressure was less than 100 or if the pulse was less than 60. However, from June 10 to June 14, 2024, the medication was administered without documenting the resident's systolic blood pressure and pulse in the electronic Medication Administration Record (eMAR). The Registered Nurse responsible for administering the medication on several of these days admitted to the oversight but could not provide an explanation for the lack of documentation. In another instance, the facility did not specify a site for the application of a Lidocaine patch for a resident who frequently complained of pain. The physician's order for the Lidocaine patch, intended for pain management, did not include instructions on where to apply the patch on the resident's body. The Director of Nursing confirmed that the order was incomplete and acknowledged that the location for patch placement should have been specified to ensure the correct pain site was treated. The absence of specific instructions left the determination of the application site to the discretion of the nurse or required consultation with the resident or their medical history. These deficiencies were identified during a survey, and the facility's management, including the Licensed Nursing Home Administrator and Director of Nursing, were informed of the findings. Despite being notified, the facility did not provide additional information or contest the findings during the exit conference with the survey team.
Failure to Implement Non-Pharmacological Interventions After Falls
Penalty
Summary
The facility failed to ensure a comprehensive investigation and implementation of non-pharmacological interventions following unwitnessed falls for a resident. The resident, who had medical diagnoses including dementia and hypertension, experienced multiple unwitnessed falls. The facility's investigation into these falls did not include a documented conclusion for the root cause analysis, which is a critical step in understanding and preventing future incidents. The facility's care plan for the resident included interventions such as keeping personal items within reach and providing a safe environment. However, after each fall, the interventions were not adequately updated to include new non-pharmacological strategies. For instance, after a fall on 4/25/24, the intervention was a psychiatric consult, but no additional non-pharmacological intervention was implemented. Similarly, after a fall on 6/04/24, the same intervention of a psychiatric consult was repeated without introducing a new strategy to prevent further falls. Interviews with facility staff, including the LPN, Unit Manager, ADON, and DON, revealed inconsistencies in the process for handling unwitnessed falls. The staff acknowledged that while an incident report was initiated, there was no documented conclusion or root cause analysis. Additionally, the facility's policy on managing falls did not explicitly require documentation of an interdisciplinary team meeting or discussion, which contributed to the lack of comprehensive follow-up on the resident's falls.
Consultant Pharmacist Fails to Identify Medication Error
Penalty
Summary
The facility's Consultant Pharmacist (CP) failed to identify and report a medication irregularity for a resident, leading to a significant health decline. On January 11, 2024, a nurse mistakenly documented a physician's order for Warfarin Sodium, a blood thinner, for a resident who was already prescribed Xarelto, another blood thinner. This error resulted in the resident receiving 18 doses of Warfarin from January 12 to January 29, 2024. During this period, the CP conducted a drug regimen review on January 15, 2024, but did not document any recommendations regarding the concurrent administration of both blood thinners. The resident, who had a history of chronic kidney disease, atrial fibrillation, and other health issues, became symptomatic and experienced a decline in health due to the administration of both medications. The resident's condition worsened, leading to an admission to an acute care hospital with a diagnosis of an upper gastrointestinal bleed and diarrhea. The CP admitted to seeing the new medication order but did not take action to clarify or stop the administration of Warfarin, as she thought it was for a short period and did not confirm with the nursing staff or the Director of Nursing (DON). The facility's policy on adverse consequences and medication errors emphasizes the importance of monitoring residents for potential adverse effects and ensuring that medication regimens do not include incompatible drugs. Despite this policy, the CP did not adhere to the guidelines, resulting in the resident's adverse health event. The deficiency was identified during a surveyor's review of the resident's medical records and interviews with the CP and facility staff.
Medication Transcription Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in a serious health decline. A registered nurse incorrectly transcribed a medication order for Coumadin, a blood thinner, intended for another resident, into the medical record of Resident #2, who was already prescribed Xarelto, another blood thinner. This error led to Resident #2 receiving both medications concurrently from January 12, 2024, to January 29, 2024, for a total of 18 doses. Resident #2, who had a history of chronic kidney disease, atrial fibrillation, and other significant health conditions, became symptomatic and experienced a decline in health due to the medication error. On February 5, 2024, the resident was found to be weak, lethargic, and unable to be safely transferred back to bed. The resident was subsequently sent to the hospital, where they were diagnosed with an upper gastrointestinal bleed and diarrhea, conditions likely exacerbated by the concurrent administration of two blood thinners. The error was discovered on January 30, 2024, when Resident #2 exhibited significant bleeding and hypotension. The Director of Nursing confirmed the transcription error during an investigation, noting that the registered nurse responsible could not recall the incident or provide an explanation. The facility's policy on medication errors emphasizes monitoring for adverse consequences and ensuring that residents are not taking incompatible medications, which was not adhered to in this case.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 888 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Morristown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holly Manor Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Careone At Madison Avenue | 3.8 mi | ★★★★★ | 1 | 0 |
| Morristown Post Acute Rehab And Nursing Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Excel Care At Dover | 4.2 mi | ★★★★★ | 4 | 1 |
| Dwelling Place At St Clares | 4.6 mi | ★★★★★ | 0 | 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.