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 Pine Acres Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Kitchen sanitation and food handling deficiencies were observed during a kitchen tour. Open food items in the freezer, spice rack, and dry storage lacked required labels and use-by dates, thermometers were missing from two refrigerators/freezers, and multiple surfaces and equipment had sticky buildup or debris. Two dietary aides with facial hair were observed without beard guards, and during a later meal temperature check, a chef’s thermometer touched baked chicken and contaminated it.
Surveyors found that dependent, incontinent residents were not receiving timely incontinence care, with multiple residents observed in urine-saturated briefs and soiled underpads, and strong urine odors present on a nursing unit. Residents with conditions such as dementia, epilepsy, aphasia, diabetes, CHF, and hemiplegia—many with severe cognitive impairment and documented dependence on staff for personal hygiene—had care plans and facility policy requiring incontinence care every 2 hours and as needed, yet were left wet for extended periods, including one cognitively intact resident who removed a saturated brief independently after waiting without CNA assistance. Staff interviews revealed that CNAs were unable to provide 2-hourly incontinence care due to having assignments of 21 residents, and the staffing coordinator and leadership acknowledged that the unit was not staffed according to state-mandated CNA-to-resident ratios and that required staffing levels were not met.
A surveyor observed a broken heater cover, chipped paint exposing wallboard in a resident room, and broken floor tiles, a broken toilet seat, a heavily soiled shower mat, and a floor covered in a thick brown substance in the shower room. The DHK confirmed the shower room had not been cleaned recently, and the assigned housekeeper stated he had not cleaned it that day or during his prior shift on the unit. The DOM was unaware of the disrepair and confirmed the areas should have been repaired.
A facility failed to follow fall safety measures and care plan interventions for three residents with a history of falls. One resident had a nursing order for a floor mat at bedside and a care plan directing the bed to remain in the lowest position, but the mat was not present and the bed was observed in a high position. Two other residents with severely impaired cognition were observed in bed with their fall mats folded and not placed on the floor, despite care plan interventions calling for floor mats next to the bed and monitoring on all rounds; the OSR did not include floor mat orders for those two residents.
A resident with CHF and severe cognitive impairment was observed receiving O2 via NC at 3 lpm, while the physician’s order specified 2 lpm PRN for low SpO2 or SOB. The LPN confirmed she had not checked the order and acknowledged the O2 flow was set higher than ordered; the facility policy required oxygen to be provided in compliance with the physician’s order.
Insufficient CNA staffing on a unit with 21 residents led to multiple dependent residents being found with wet or saturated briefs and, in one room, a strong urine odor. An LPN/UM observed several residents with severe cognitive impairment, dependence for personal care, and care plans calling for incontinence care every 2 hours or throughout the shift. The CNA and LPN stated the assignment was too large to provide timely care, and the staffing coordinator and LNHA were unaware the unit staffing was not sufficient.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in meeting their needs. One resident, with hemiplegia and hemiparesis, had a care plan that did not reflect their refusal to wear a right-hand splint. Another resident, with severe cognitive impairment, had a care plan that did not document the use of a physician-ordered resting hand splint at night. The facility's policy requires comprehensive care plans with measurable objectives, which was not followed.
A facility failed to follow proper hand hygiene and urinary catheter care protocols. A CNA did not perform hand hygiene after glove removal and washed hands for only eight seconds, contrary to guidelines. Additionally, a urinary catheter bag was improperly stored without a plastic bag, with exposed tubing. The facility's policies were not adhered to, as confirmed by staff.
The facility failed to notify CMS of a name change from 'Pine Acres Convalescent Center' to 'Pine Acres Rehab + Healthcare,' as observed by surveyors. The LNHA admitted that the necessary 855B form was not filed, and documents provided to surveyors reflected the unapproved name.
A facility failed to accurately complete the MDS for a resident with severe cognitive impairment, leading to a deficiency. The MDS incorrectly indicated that the resident did not receive antipsychotic medications, despite a physician's order for Risperdal, which was administered. The MDS Coordinator admitted to not coding the medication correctly, contrary to CMS RAI Manual guidelines.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices during a kitchen tour observed by the surveyor in the presence of the FSD. In the three-door standing freezer, an open bag of French fries, vegetable burgers, all-beef hamburger, and shrimp were observed without open and use-by labels. In the ice cream freezer and milk refrigerator, thermometers were not present. In the beverage preparation area, 4 of 7 tubes on the juice dispenser had sticky buildup. On the food preparation table, the can opener had blackish debris and the microwave had a yellowish grease-like substance. In the cooking area, the top of the standing two-door oven and a shelf above the 6-range stove top had a sticky substance. On the spice rack, multiple open items including honey, paprika, egg shade liquid color, sugar, ground cinnamon, barbeque sauce, and strawberry gelatin mix were observed without open and use-by labels. In the dishwashing area, two dietary aides with facial hair were observed without beard guards. In the dry storage area, three bags of hamburger buns and one loaf of white bread were open without open and use-by labels. During a follow-up kitchen inspection, the chef was observed checking the temperature of baked chicken, and the plastic portion of the food thermometer touched the chicken, contaminating it. The chef stated they did not realize the plastic portion touched the chicken and that the chicken should be discarded due to contamination. Facility policies provided later stated that food items must be labeled and dated, that the dietary service director monitors sanitation daily, that beard guards should be worn by employees with facial hair, and that food temperatures must be verified using a thermometer that is clean, sanitized, and calibrated.
Failure to Provide Timely Incontinence Care and Maintain Required Staffing Ratios
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to dependent residents on the first-floor nursing unit, resulting in multiple residents being found with saturated briefs, strong urine odors, and soiled underpads. During a unit tour, a surveyor detected a strong urine odor throughout the unit and observed a cognitively intact resident sitting in a wheelchair next to their bed with a urine-saturated adult brief lying on the bed. The resident reported that the brief had been there for 45 minutes and that they had removed it themselves because a CNA had not checked on them. This resident’s records showed diagnoses including pneumonia, generalized muscle weakness, and type 2 diabetes mellitus, with MDS documentation that they were frequently incontinent of bowel and bladder and required staff assistance for personal hygiene. The resident’s care plans directed staff to provide incontinence care throughout the shift and to check for incontinence throughout the shift, wash, rinse, and dry the perineum, and change clothing after incontinence episodes. During an incontinence tour of the first-floor east nursing unit with the LPN/unit manager, several additional residents who were dependent on staff for care were found with inadequate incontinence care. One resident with dementia, anxiety, and hypertension, and a BIMS score indicating severe cognitive impairment, was observed in bed with a brief that was saturated with urine; the LPN/unit manager confirmed the saturation. The MDS for this resident documented that they were always incontinent of bowel and bladder and required staff assistance for personal hygiene, and the care plan included interventions to provide incontinence care throughout the shift. Another resident with epilepsy, aphasia, and diabetes mellitus was observed in bed in a room with a strong urine odor; their brief was wet and the underpad was saturated with urine, which the LPN/unit manager confirmed. This resident’s MDS showed severely impaired cognitive skills, dependence on staff for personal hygiene, and that they were always incontinent of bowel and bladder, with a care plan directing staff to provide incontinence care every two hours and as needed. Further observations on the same tour revealed additional failures to provide timely incontinence care. One resident with seizures, hemiplegia, hemiparesis, and hypertension was found in bed in a room with a strong urine odor; when the LPN/unit manager exposed the resident’s brief, there was a second brief inserted inside the first, and both briefs and the underpad were saturated with urine. The MDS for this resident documented severely impaired decision-making, dependence on staff for personal hygiene, frequent bladder incontinence, and constant bowel incontinence, with a care plan instructing staff to provide incontinence care as needed. Another resident with dementia, congestive heart failure, and hypertension, and a BIMS score indicating severe cognitive impairment, was observed in bed with a brief saturated with urine; the LPN/unit manager confirmed the saturation. This resident’s MDS showed they were always incontinent of bowel and bladder and required staff assistance for personal care, and the care plan called for incontinence care every two hours and as needed. A further resident with hypertension and congestive heart failure, on oxygen via concentrator at 3 LPM, was also observed in bed with a brief saturated with urine, confirmed by the LPN/unit manager; this resident’s MDS showed severe cognitive impairment, dependence on staff for personal hygiene, and constant bowel and bladder incontinence, with a care plan directing staff to keep skin clean and dry and provide incontinence care throughout the shift and as needed. Interviews with staff revealed that incontinence care was not being provided every two hours as required by facility policy and resident care plans. The LPN/unit manager confirmed that the residents had not received timely and appropriate incontinence care every two hours per facility policy. A 7 PM–7 AM LPN stated that CNAs should have provided incontinence care every two hours but suggested that the CNA had too many residents to accomplish this. The 11 PM–7 AM CNA confirmed that she was responsible for 21 residents and was only able to make rounds twice during her shift, stating it was not possible to provide incontinence care every two hours with that assignment. The staffing coordinator initially reported being unsure of state-mandated CNA-to-resident ratios and later confirmed not being aware of those ratios, and also stated they believed nurses could be counted as CNAs even if they were the only nurse on the unit. The Director of Operations acknowledged that the night shift CNA-to-patient ratio on the first floor was 1:21 instead of the required 1:14 and confirmed that the unit was not staffed in accordance with state regulations. The facility’s incontinence care policy stated that it is the policy of the facility to promote resident comfort by keeping residents clean and dry to prevent skin breakdown, and the DON confirmed that incontinence care should be provided by CNAs every two hours and as needed.
Homelike Environment Deficiencies in Resident Room and Shower Area
Penalty
Summary
The facility failed to provide a homelike environment in resident rooms and the shower room on the 1st floor nursing unit. During the initial tour on 01/13/2026, the surveyor observed a broken heater cover in the bathroom of one resident room, chipped paint on the wall behind the door bed exposing wallboard, and chipped paint across the wall by the window bed exposing wallboard. These conditions were observed in 1 of 3 units during the tour. In the shower room, the surveyor observed broken floor tiles, a broken toilet seat, a heavily soiled shower mat, and a floor beneath the mat covered in a thick brown substance. The DHK stated housekeeping staff were responsible for cleaning and mopping the shower rooms daily and confirmed the floor had not been cleaned recently. The housekeeper assigned to the 1st floor unit stated he was responsible for cleaning the shower room daily but had not cleaned it that day or when he worked on the unit on Monday, stating, "I just didn't get to it." The DOM stated he was not aware of the broken tiles, broken toilet seat, broken heater cover, or chipped paint, and confirmed these areas should have been repaired.
Failure to Maintain Fall Safety Measures for Residents With a History of Falls
Penalty
Summary
The facility failed to provide safety measures and follow nursing orders and care plan interventions for three residents with a history of falls. Resident #3 had diagnoses including hemiplegia, aphasia, and muscle weakness, and the annual MDS indicated the resident was unable to complete the BIMS interview. The resident had a nursing order for a floor mat at bedside and a care plan intervention to keep the bed in the lowest position, but the surveyor observed the resident in bed without a floor mat present and the bed in a high position. The Regional RN acknowledged that the floor mat was not at bedside and the bed was not in the lowest position as directed by the care plan. Resident #5 had diagnoses including metabolic encephalopathy, muscle weakness, and severe protein-calorie malnutrition, and the quarterly MDS showed severely impaired cognition. The resident’s care plan included interventions for a floor mat in place next to the bed and monitoring on all rounds, but the surveyor observed the resident in bed with the fall mat folded and leaning against the nightstand, with no floor mat on the floor. Resident #66 had unspecified dementia, severely impaired cognition on the quarterly MDS, and three falls documented in the MDS. The resident’s care plan included a floor mat in place next to the bed and monitoring on all rounds, but the surveyor observed the resident in bed with the fall mat folded between the end of the bed and leaning against the nightstand, with no floor mat on the floor. The OSR did not include a physician order for floor mats for Residents #5 and #66.
Oxygen Therapy Not Given Per Physician Order
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician’s order for one resident who had diagnoses including hypertension and congestive heart failure and a BIMS score of 7, indicating severe cognitive impairment. During observation, the resident was found in bed with oxygen via nasal cannula connected to an oxygen concentrator set at 3 liters per minute. The LPN/UM confirmed the flow rate was set at 3 lpm but stated she was not sure whether that matched the physician’s order. Record review showed a current physician’s order for oxygen at 2 lpm as needed for SpO2 less than 92 every 6 hours as needed for shortness of breath. The nurse’s note documented the resident slept through the night in no distress with SpO2 97% on oxygen at 3 lpm. During interview, the 7 PM-7 AM LPN confirmed she had not checked the physician’s order to verify the oxygen was being administered as ordered and acknowledged that the order was for 2 lpm, not 3 lpm. The facility’s oxygen administration policy stated oxygen is to be provided in compliance with the physician’s order.
Insufficient CNA staffing led to delayed incontinence care
Penalty
Summary
The facility failed to ensure sufficient and competent staff were available to provide timely incontinence care to dependent residents on the 1st-floor nursing unit. During an incontinence tour, the surveyor and the LPN/UM observed five residents with wet or saturated incontinence briefs and, in one room, a strong urine odor. The residents observed were all documented as cognitively impaired, dependent on staff for personal hygiene, and always or frequently incontinent of bowel and bladder. Their care plans included interventions such as providing incontinence care every 2 hours, as needed, or throughout the shift. Resident #13 was observed in bed with a brief saturated with urine. The resident’s record showed diagnoses including dementia, anxiety, and hypertension, with a BIMS score of 3 indicating severe cognitive impairment and dependence on staff for personal hygiene. Resident #16 was observed with a wet brief and saturated underpad, with a strong urine odor in the room. The resident’s record reflected diagnoses including epilepsy, aphasia, and diabetes mellitus, severe cognitive impairment, dependence for personal hygiene, and a care plan directing incontinence care every 2 hours and when needed. Resident #68 was found with two briefs inserted within one another, both saturated with urine and an underpad also saturated; the resident had diagnoses including seizures, hemiplegia, hemiparesis, hypertension, and aphasia, and was documented as severely cognitively impaired and dependent for personal hygiene. Resident #41 was observed with a saturated incontinence brief. The resident’s record reflected diagnoses including dementia, congestive heart failure, and hypertension, a BIMS score of 3, dependence on staff for personal care, and a care plan calling for incontinence care every two hours and as needed. Resident #83 was observed in bed with an oxygen concentrator in place and a saturated brief. The resident’s record reflected diagnoses including hypertension and congestive heart failure, a BIMS score of 7 indicating severe cognitive impairment, dependence on staff for personal hygiene, and a care plan directing staff to keep skin clean and dry and provide incontinence care throughout the shift and as needed. The staffing records showed that the 1st-floor nursing unit had a census of 21 residents with only 1 CNA assigned on the 11:00 PM to 7:00 AM shift. The 7 PM to 7 AM LPN stated that the CNA should have provided incontinence care every 2 hours but had too many residents and might not have been able to do that. The CNA confirmed she should have provided care every 2 hours but was only able to make rounds twice during the shift because she had 21 residents and it was not possible to provide incontinence care every 2 hours. The staffing coordinator stated that 1 CNA was scheduled for the unit and believed the nurse could be counted as a CNA, and the LNHA stated he was not aware the staffing on the unit was not sufficient.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for two residents, leading to deficiencies in meeting their needs. For one resident, who was observed using their left hand due to weakness in the right hand, the care plan did not reflect their refusal to wear a right-hand splint. Despite the resident's intact cognition and a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, the care plan lacked documentation of the resident's refusal, which was confirmed by both a CNA and an LPN. Another resident, who had severe cognitive impairment and a physician's order for a resting hand splint at night, also had an incomplete care plan. The care plan did not document the use of the splint, despite observations and staff interviews confirming its application. The facility's policy requires comprehensive care plans to be developed within seven days of assessment, including measurable objectives and timetables, but this was not adhered to for these residents.
Deficiencies in Hand Hygiene and Urinary Catheter Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene practices, as observed during the care of a resident. A Certified Nursing Assistant (CNA) was seen touching a resident's blanket with clean gloves, then removing the gloves and discarding them without performing hand hygiene. The CNA then proceeded to another resident's room and performed hand hygiene for only eight seconds, contrary to the facility's policy and CDC guidelines, which require at least 20 seconds of handwashing. The Infection Preventionist confirmed that the CNA should have performed hand hygiene after glove removal. Another deficiency was observed in the care of a resident with an indwelling urinary catheter. The surveyor found a urinary catheter bag hanging on a rail in the bathroom without a plastic bag, and the catheter tubing was exposed and uncapped. The CNA responsible for the resident's care admitted to omitting the plastic bag and acknowledged that the urinary bag should not have been stored in that manner. The facility's policy requires the urinary bag to be cleaned, capped, and stored in a plastic bag when not in use. The facility's Infection Preventionist and other staff confirmed the improper handling of the urinary catheter bag. The facility's policy on the care and maintenance of the Foley drainage system was not followed, as the urinary bag was not properly stored, increasing the risk of contamination. The surveyor discussed these concerns with the facility's administration, but no further information was provided.
Failure to Notify CMS of Facility Name Change
Penalty
Summary
The facility failed to notify CMS and obtain authorization for a change in its facility name, as required by 42 CFR 424.516. Upon arrival, surveyors observed signage outside the facility displaying the name 'Pine Acres Rehab + Healthcare,' which did not match the CMS-licensed name 'Pine Acres Convalescent Center.' During the entrance conference, the surveyor noted that various documents and policies provided by the Licensed Nursing Home Administrator (LNHA) were titled 'Pine Acres Rehab + Healthcare,' and the facility's admission agreement and business cards also reflected this name. The LNHA explained that the facility's official name is 'Pine Acres Convalescent Center' and admitted that they had not filed the necessary 855B form with CMS to report the name change. A review of the facility's license, issued by the New Jersey Department of Health, confirmed that the licensed name was 'Pine Acres Convalescent Center.' This discrepancy between the facility's operating name and its licensed name constituted a failure to comply with federal and state regulations regarding provider enrollment and active status maintenance in the Medicare Program.
Inaccurate MDS Completion for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, leading to a deficiency in the management of care. The surveyor observed the resident, who was admitted with unspecified dementia and other behavioral disturbances, and reviewed their electronic medical record. The Admission MDS indicated a severe cognitive impairment with a Brief Interview for Mental Status score of 04 out of 15. However, there was a discrepancy in the MDS regarding the use of antipsychotic medication. The MDS incorrectly noted that the resident did not receive antipsychotic medications, despite a physician's order for Risperdal, an antipsychotic drug, which was administered on specific dates in July 2024. The part-time MDS Coordinator acknowledged the error, stating that the medication was not coded correctly in the MDS. The surveyor referenced the CMS Resident Assessment Instrument (RAI) Manual, which mandates that any medication classified as an antipsychotic must be recorded, regardless of its use. The survey team discussed the issue with the facility's administration, including the Licensed Nursing Home Administrator and Director of Nursing, but no further information was provided to address the discrepancy.
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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 Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Florham Park Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 7 | 0 |
| Cheshire Home | 1.3 mi | ★★★★★ | 8 | 0 |
| Chatham Hills Subacute Care Center | 1.7 mi | ★★★★★ | 17 | 0 |
| Morristown Post Acute Rehab And Nursing Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Careone At Madison Avenue | 3.5 mi | ★★★★★ | 1 | 0 |
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