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 N J Eastern Star Home during CMS and state inspections, most recent first.
Failure to Complete Required Pre-Hire Screening Checks: The facility did not follow its abuse and recruitment policies by failing to complete required reference checks for two CNAs, background checks for a housekeeper, activities support staff, and a dietician, and license checks for two RNs before hire. Surveyors reviewed personnel files and found missing documentation for these pre-employment screenings, and facility leadership acknowledged that the checks should have been completed prior to employment.
Failure to Document Resident Code Status: The facility did not document code status for two residents in the EMR. One resident was on hospice with a POLST indicating DNAR/DNI, and the other resident also had a POLST indicating DNAR/DNI, but neither had a corresponding PO in the EMR; one resident’s care plan reflected comfort care and DNR/DNH preferences, while the other resident’s care plan did not reflect the code status. An LPN acknowledged the missing documentation and stated the code status was not reflected in the EMR dashboard.
A facility failed to ensure that low air loss mattresses were functioning properly and set to the correct weight for two residents with existing pressure ulcers. Surveyors observed the mattress pumps set to weights that did not match the residents’ documented weights, even though both residents had severe cognitive impairment, pressure ulcer risk, and physician orders for low air mattresses with shift checks for wound healing. An LPN acknowledged the settings were incorrect and that the mattress should be set according to resident weight.
Failure to follow a fall prevention PO for a resident with a fall history, impaired cognition, and prior fractures. Surveyors observed the floor mat folded up against the wall instead of placed beside the bed as ordered, while a CNA and an LPN described it as a nighttime protection measure for when the resident got out of bed without assistance.
Unlabeled Enoxaparin syringes and an opened liquid protein supplement were found in a subacute rehab med cart. The RN stated the syringes were not stock and should have been labeled, and the supplement was opened but lacked an open date. The Pharmacy Consultant stated the Enoxaparin should have had a patient-specific label and should not have been left unlabeled in the cart.
The facility failed to ensure the required QAPI committee member, the IP, was present for one of five QAPI meetings. Survey review showed the IP did not sign the meeting attendance sheet, and the ALNHA confirmed the IP was absent. The QAPI minutes reflected nursing skill competencies, but infection control was not presented, even though the facility's QAPI policy listed the Infection Control/Preventionist as a required committee member.
The facility failed to ensure proper hand hygiene during meal delivery and specimen handling, as observed on two units. CNAs delivered meal trays without performing hand hygiene or offering it to residents, and a lab technician handled specimens with soiled gloves. These actions were contrary to the facility's hand hygiene policy.
A facility failed to properly store a resident's indwelling urinary catheter drainage bag, leading to potential infection risks. The drainage bag was repeatedly observed in a used plastic bag with an uncapped port, contrary to facility policy. Staff interviews confirmed improper storage practices, and the resident's medical history included conditions like dementia and chronic kidney disease.
A facility failed to ensure proper medication administration, resulting in a 7.41% error rate. An LPN administered a chewable Aspirin instead of the prescribed enteric-coated version to a resident with coronary artery disease. Another error involved administering Glipizide ER without following timing instructions. The LPN, an agency nurse, was unfamiliar with the medication cart and had not attended relevant in-service training. The facility's oversight of agency nurses and adherence to medication administration policies were inadequate.
Failure to Complete Required Pre-Hire Screening Checks
Penalty
Summary
The facility failed to implement its abuse policy by not completing required pre-employment reference checks, background checks, and license checks for newly hired staff. A review of personnel files showed that Employee #4, a CNA with a start date of 6/28/25, and Employee #5, a CNA with a start date of 9/25/24, had no evidence of reference checks prior to employment. The facility also had no evidence of background checks for Employee #1, a housekeeper with a start date of 3/3/25; Employee #12, activities support staff with a start date of 10/7/24; and Employee #13, a dietician with a start date of 11/20/24. In addition, the personnel files showed no evidence of license checks for Employee #3, an RN with a start date of 10/27/25, and Employee #8, an RN with a start date of 10/9/24. During the survey, the IP, AA, and MDS Coordinator were informed of the concerns regarding the missing checks, and the AA acknowledged that background checks, reference checks, and license checks should be completed prior to hire in accordance with the facility's abuse policy. The Director of Administer Services and Human Resources also stated that these checks should be completed before employees are hired, with HR responsible for background checks and department heads responsible for reference checks.
Failure to Document Resident Code Status
Penalty
Summary
The facility failed to document the code status for 2 of 3 residents reviewed, including a resident with dementia, anemia, urinary tract infection, and hospice services, and another resident with dementia, anemia, and depression. For the first resident, the electronic medical record and hybrid paper chart did not contain a physician order for code status, although the paper chart included a NJ POLST form signed by the resident and a physician indicating DNAR and DNI. The resident’s care plan included comfort care and preference for DNH/DNR status related to terminal prognosis and hospice enrollment, but the code status was not entered as a physician order in the EMR. For the second resident, the hybrid paper chart contained a NJ POLST form signed by the resident representative and a physician indicating DNAR and DNI, but the EMR and paper chart did not contain a physician order for code status. The resident’s care plan also did not reflect the DNR/DNI status. During interview, an LPN acknowledged that the residents’ code status was not reflected in the EMR dashboard, that the first resident’s code status had not been updated after returning from the hospital, and that the second resident’s care plan should have been updated to reflect the POLST.
Improper Air Mattress Settings for Residents With Pressure Ulcers
Penalty
Summary
The facility failed to ensure that low air loss mattresses were functioning properly and set according to resident weight for two residents with existing pressure ulcers. Resident #15 had diagnoses including Alzheimer’s disease, dementia, polyosteoarthritis, and cervical spine fusion, and the most recent MDS showed severe cognitive impairment, risk for pressure ulcer/injury, and two Stage 3 pressure ulcers. The resident’s care plan included a pressure relieving/reducing device on the bed and repositioning to reduce shearing, and physician orders included a low air mattress with placement and function checks every shift for wound healing. Resident #38 had diagnoses including dementia, primary generalized osteoarthritis, and low back pain. The most recent MDS showed severe cognitive impairment, risk for pressure ulcer/injury, and one unstable pressure ulcer. The resident’s care plan included a pressure relieving/reducing device on the bed, repositioning to reduce shearing, and use of a pressure reduction mattress. Physician orders included a low air mattress with placement and function checks every shift for wound healing. Surveyors observed both residents lying in bed on air mattresses on multiple occasions, and the mattress pumps for Resident #15 and Resident #38 were each set to weights that did not match the residents’ documented weights. During interview, the LPN acknowledged that the mattress should be set according to resident weight and stated that if it was set to the wrong setting, it would defeat the purpose of having an air mattress. The AA also acknowledged that the air mattresses should be set according to a resident’s weight to prevent skin breakdown.
Failure to Follow Fall Prevention Order for Floor Mat
Penalty
Summary
The facility failed to follow the physician order for fall prevention for one resident who had a history of falls, a right intertrochanteric femur fracture, a left ankle injury, and difficulty walking. The resident’s comprehensive assessment dated 12/29/25 showed moderate impaired cognition, a fall history in the month before admission, and fractures related to a fall prior to admission. The care plan identified the resident as at risk for falls related to gait and balance problems secondary to the fracture, ankle injury, fall history, and ambulatory dysfunction. On 1/21/26, the surveyor observed the resident in bed with eyes closed and saw a floor mat folded up and leaning against the wall under the window. The electronic record showed an active physician order dated 12/26/25 for a floor mat on the left side of the bed with placement to be monitored every shift for prevention. During interview, a CNA stated the mat might be something new and was for nighttime, and an LPN stated the mat was important for protection when the resident got out of bed without assistance in the evenings. The facility’s order summary therefore did not match the observed placement of the floor mat at the time of survey.
Unlabeled Enoxaparin Syringes and Open Supplement Found in Medication Cart
Penalty
Summary
The facility failed to appropriately label medications in accordance with professional standards of practice. During inspection of the Subacute Rehab side 2 medication cart, five syringes of Enoxaparin 30mg/3mL were found in the third drawer with no resident label or date and were not in a bag, even though they were in their original packaging. The RN stated the syringes were not stock and should have been labeled, then disposed of them in the sharps container. The RN also stated the pharmacy checks the carts but did not know how often, and was unaware whether nursing staff checked the carts. The same cart also contained a bottle of liquid protein supplement in the bottom drawer that was opened but not labeled with an open date. The RN stated the supplement was good for 30 days. During a later interview, the Pharmacy Consultant stated that Enoxaparin in the cart should have a patient-specific label, should not be floating unlabeled, and that he makes sure the facility is compliant with medication storage and labeling. The facility policy titled Cleaning and Disinfection of Medicine Carts stated that medication carts are shared medical equipment and must be maintained in a clean, sanitary, and safe condition at all times.
QAPI Committee Missing Required Infection Preventionist
Penalty
Summary
The facility failed to ensure the required QAPI committee member, the Infection Preventionist (IP), was present for one of five QAPI meetings. During survey review of QAPI sign-in sheets from the prior survey date to the present, the surveyor found that the IP did not sign the QAPI meeting sign-in sheet for the meeting dated 04/07/2025. The Assistant Licensed Nursing Home Administrator reviewed the sign-in sheet and confirmed the IP was not present, stating that in the IP's absence the DON would review infection prevention information. Review of the QAPI minutes for that meeting showed discussion under the Nursing section regarding skill competencies, but infection control was not presented. The ALNHA later acknowledged that the minutes provided were complete and that there was nothing additional to add. The facility's QAPI policy identified the committee as including the Infection Control/Preventionist.
Inadequate Hand Hygiene Practices During Meal Delivery and Specimen Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene (HH) practices during meal delivery services and the removal of soiled gloves, which could potentially spread infections. On two of the three units observed, Certified Nursing Aides (CNAs) were seen delivering breakfast trays to residents without performing HH or offering residents the opportunity to clean their hands. CNAs on both the A and B units did not wash their hands between resident interactions or after handling meal trays. Additionally, the facility's kitchen did not provide any means for residents to cleanse their hands with the meal trays. Interviews with CNAs revealed a lack of adherence to HH protocols, despite some having attended HH education sessions. Furthermore, a contracted laboratory technician (LT) was observed exiting a resident's room on the B unit while still wearing soiled gloves after drawing a blood sample. The LT then handled specimens in the hallway and at the nursing desk without removing the gloves, which is against the facility's hand hygiene policy. The facility's policy emphasizes the importance of HH as a primary means to prevent infection spread, yet the observed practices did not align with these guidelines. The facility's documentation showed inconsistencies in staff attendance at HH training sessions.
Improper Storage of Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper storage of an indwelling urinary catheter drainage bag for a resident, leading to a potential risk of urinary tract infections. The surveyor observed that the drainage bag was stored in a used plastic bag tied to a handrail in the resident's bathroom, with the drainage port uncapped and in direct contact with the plastic bag. This improper storage was noted on multiple occasions over several days, indicating a consistent failure to adhere to proper catheter care protocols. The resident involved had a suprapubic catheter and wore a leg bag during the day and a Foley catheter drainage bag at night. The facility's staff, including a CNA and an LPN, were interviewed and confirmed the improper storage practices. The CNA did not mention disinfecting the drainage port before switching bags, and the LPN stated that the bags were to be cleaned and stored in a plastic bag in the bathroom, but this was not done correctly. The LPN also confirmed that the drainage port should be capped, which was not observed during the surveyor's visits. The resident's medical history included diagnoses such as unspecified dementia, benign prostatic hyperplasia, and chronic kidney disease. The facility's policy on Foley catheter care required maintaining universal precautions, cleaning the drainage bag, and capping the port before storage. However, these procedures were not followed, as evidenced by the repeated observations of the uncapped drainage port and improper storage of the catheter bag.
Medication Administration Errors Observed in LTC Facility
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 7.41%. This was observed during a medication administration session involving an LPN and two residents. The first error occurred when the LPN administered a chewable Aspirin 81 MG tablet to a resident instead of the prescribed enteric-coated (EC) Aspirin. The LPN, who was an agency nurse unfamiliar with the medication cart, acknowledged the mistake after reviewing the electronic medication administration record (eMAR) with the surveyor. The second error involved the administration of Glipizide ER 5 MG to another resident. The LPN administered the medication without adhering to the cautionary label instructions, which specified that the medication should be taken 30 minutes before a meal. The LPN was unaware of the specific timing requirement and administered the medication after the scheduled time. The LPN admitted to not being familiar with the medication's timing requirements and followed a routine of administering medications room by room. The facility's policies and procedures for medication administration were not adequately followed, particularly concerning agency nurses. The LPN had not attended a medication pass in-service, and there were no medication administration observations completed for her. The facility relied on the agency to ensure competency for medication administration, and the Infection Preventionist only conducted observations if issues were identified. The facility's failure to ensure proper medication administration practices and oversight contributed to the observed errors.
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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 Bridgewater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Arbor At Laurel Circle | 1 mi | ★★★★★ | 8 | 0 |
| Complete Care At Green Knoll | 2.9 mi | ★★★★★ | 16 | 0 |
| Waterfront Rehabilitation And Healthcare Center | 3 mi | ★★★★★ | 13 | 0 |
| Bridgeway Care And Rehab Center At Bridgewater | 3 mi | ★★★★★ | 3 | 1 |
| Somerset Woods Rehabilitation & Nursing Center | 3.3 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.