Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Preferred Care At Wall during CMS and state inspections, most recent first.
A resident was physically restrained overnight when a staff member placed a bedside tray table and wheelchair against the bed, restricting movement. This action was not supported by medical necessity or the resident's care plan, and staff interviews confirmed the use of restraint for convenience, in violation of federal regulations and facility policy.
The facility failed to maintain kitchen and pantry equipment in a sanitary manner. A stand mixer had dried sediment, a worn can opener blade posed contamination risks, and a microwave was not cleaned per policy. Pantry areas in three units had debris, dirty refrigerator gaskets, and maintenance issues. The FSD and Director of Housekeeping acknowledged these deficiencies.
A facility failed to accurately complete a PASARR for a resident with documented mental health diagnoses, marking 'No' for major mental illness despite evidence of bipolar disorder and schizophrenia. The DON attributed the oversight to the responsible Social Worker being out of work, contrary to the facility's policy assigning PASARR tracking to the Social Services Director.
A resident's preference for wearing double incontinence briefs was not timely updated in their care plan, despite the resident's ability to communicate this preference. The deficiency was identified during a survey when a CNA and the resident confirmed the preference, but the care plan was only updated after the surveyor's inquiry. The LPN/UM and DON acknowledged the oversight and the need for timely updates to the care plan.
A resident with severe cognitive impairment was improperly double briefed, as observed during a survey. The CNA and DON confirmed that double briefing is not standard practice due to risks of skin irritation and dignity issues. The facility lacked a policy on proper incontinence care procedures.
A resident with dementia was prescribed lorazepam for anxiety without adequate documentation of behaviors or non-pharmacological interventions. Facility records lacked evidence of the resident exhibiting targeted behaviors prior to medication, and staff interviews revealed inconsistencies in behavior monitoring. The facility's policy on psychotropic drug use was not followed, as there was no documented diagnosis or condition justifying the medication.
A facility failed to maintain Enhanced Barrier Precautions (EBP) for a resident with severe cognitive impairment and a wound. An LPN provided care without wearing an isolation gown, despite the resident being on EBP. Interviews with staff confirmed the requirement to wear PPE, and facility policy indicated gowns and gloves should be used during high-contact activities.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
Surveyors identified a deficiency related to the improper use of physical restraints for one resident. During the overnight shift, a staff member placed a bedside tray table and wheelchair against the resident's bed, which restricted the resident's ability to move freely. This action was captured on video and reported by the resident's family, who alleged that the resident was restrained during the night. The staff member involved was suspended pending investigation, and the assigned LPN did not respond to facility inquiries regarding the incident. The resident involved had a documented medical history that included multiple diagnoses and was assessed using the Minimum Data Set (MDS), which indicated cognitive status and care needs. The resident's care plan included interventions requested by the family, but there was no documentation or evidence that the use of physical restraints was required to treat the resident's medical symptoms. The facility's policy on a restraint-free environment defines physical restraints as any device or equipment that the resident cannot remove easily and prohibits their use for discipline or convenience. Interviews with staff confirmed that the tray table and wheelchair were intentionally positioned to restrict the resident's movement, and staff acknowledged that this constituted a restraint. The facility failed to ensure that the resident was free from physical restraints imposed for purposes of discipline or convenience, as required by federal regulations. The deficiency was substantiated by direct observation, interviews, and review of facility documentation.
Plan Of Correction
F-604 Right to be Free from Physical Restraints Element 1: Resident number 2 was immediately assessed by Licensed Nurse with [R]. Resident was also assessed by Nurse Practitioner or [R] with [R]. Involved [R] was immediately suspended pending investigation on [R]. The [R] received a one-on-one re-education from the Director of Nursing and licensed nurse educator on Residents' rights, identifying and reporting [R] prevention and reporting or [R]. The involved [R] was reported to the Board of Nursing on 06/09/2025 and blocked from returning to the facility. A FRIDAY form was completed and submitted to the Department of Health for the [R] on 6/9/2025. The [R] returned to work on [R]. A repeat in-service education was provided by the Director of Nursing on Residents' rights, identifying and reporting [R] prevention and reporting. The [R] is placed on a 30-day Performance Improvement probationary period and will be monitored and reviewed by the Director of Nursing/designee. Element 2: Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this cited practice. Element 3: Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On NJ Executive Order 26.451, and ongoing, ALL staff were re-educated by the Director of Nursing and licensed nurse staff educator on Federal regulations on restraint use and prohibition under F604. Abuse prevention, reporting, and intervention. Steps to protect residents when restraint use is observed, or abuse is suspected. ALL staff signed attendance sheets and demonstrated understanding through return demonstrations, written quizzes, or verbal validation. This in-service education and competencies will be given during orientation for newly hired staff, annually, and as deemed necessary by the nurse educator. Element 4: Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing/Designee will do weekly random audits of 15 residents for 4 weeks covering all shifts to ensure that residents are free from physical restraint, then monthly for 3 months. Negative findings will be addressed immediately through one-on-one re-in-service education, progressive disciplinary measures as appropriate by the Director of Nursing and/or nursing supervisors. The results of all audits will be submitted to the Quality Assessment and Assurance (QAA) committee, who meets quarterly for review and will determine the necessity of future audits and recommendations. Completion date: 07/09/2025.
Failure to Maintain Sanitary Kitchen and Pantry Equipment
Penalty
Summary
The facility failed to maintain kitchen and pantry equipment in a clean and sanitary manner, as observed during a survey. In the kitchen, a stand mixer was found with hard dried white sediment on its connecting bearing, despite being covered with a plastic bag indicating it was clean. The Food Service Director (FSD) acknowledged that the mixer was not properly cleaned. Additionally, the can opener blade was worn, discolored, and had a rolled pointed edge, which the FSD admitted had not been changed in a while, posing risks of injury and contamination. The microwave's interior ceiling was also covered with dried debris of various colors, which the FSD confirmed was not cleaned according to policy. In the pantry areas of three units, further deficiencies were noted. The B-unit pantry had debris on the counter, in a cabinet drawer, and on lower cabinets, with refrigerator door gaskets showing particle buildup. The C-unit pantry had a water dispenser requiring maintenance and cabinet drawers with sediment and debris, along with dirty refrigerator gaskets. The D-unit pantry had stains and debris in cabinet drawers and on the counter, with a refrigerator door gasket that was torn, discolored, and falling off. The Director of Housekeeping acknowledged these issues, confirming that the pantry equipment was not maintained in a sanitized manner, as required by facility policy and regulations.
Inaccurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed accurately for a newly admitted resident. This deficiency was identified during a survey when it was observed that the PASARR Level I screening for a resident was incorrectly marked as 'No' for having a diagnosis or evidence of a major mental illness, despite the resident having documented diagnoses of bipolar disorder and schizophrenia. The resident's medical records, including the Minimum Data Set (MDS) and comprehensive care plan, clearly indicated these mental health conditions, which were not reflected in the PASARR screening. The Director of Nursing (DON) acknowledged the oversight, attributing it to the Social Worker responsible for the PASARR being out of work at the time. The facility's policy on Resident Assessment-Coordination with PASARR, revised in July 2024, assigns the responsibility of tracking each resident's PASARR evaluation report to the Social Services Director. This lapse in accurately completing the PASARR screening for the resident with known mental health diagnoses led to the identified deficiency.
Failure to Update Care Plan for Resident's Incontinence Preference
Penalty
Summary
The facility failed to revise an individual comprehensive care plan (ICCP) to include a resident's personal preference for incontinence care, specifically the use of double incontinence briefs. This deficiency was identified during a survey when a Certified Nursing Aide (CNA) informed the surveyor that a resident preferred to wear two incontinence briefs for better support. The resident confirmed this preference during an interview. However, the resident's care plan was not updated to reflect this preference until after the surveyor's observation and inquiry. The resident, who was admitted with diagnoses including major depressive disorder, type two diabetes, and chronic kidney disease, had a Brief Interview for Mental Status (BIMS) score indicating fully intact cognition. Despite being able to communicate their preferences, the care plan was not updated in a timely manner. The Licensed Practical Nurse/Unit Manager (LPN/UM) and the Director of Nursing (DON) acknowledged that the care plan should have been updated sooner and that the nursing staff was responsible for educating the resident and updating the care plan within 24 hours of knowing the resident's preference.
Improper Incontinence Care Due to Double Briefing
Penalty
Summary
The facility failed to provide proper incontinence care to a resident, as observed during a survey. The resident was found wearing an adult incontinence brief with a pull-up incontinence brief on top, a practice known as double briefing. The resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene, was unable to express a preference regarding this practice. The CNA confirmed that residents should not be double briefed and should be checked every two hours to ensure they remain dry. Interviews with the LPN/UM and the DON revealed that double briefing is not a standard practice due to the risk of skin irritation, breakdown, and infection, as well as the potential impact on resident dignity. The facility was unable to provide a policy outlining the proper procedure for incontinence care, and the LNHA acknowledged that residents should not have been double briefed. The deficiency was identified for one resident during the survey, highlighting a lapse in adherence to proper incontinence care protocols.
Inadequate Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide adequate documentation and justification for the initiation of an antianxiety medication for a resident with dementia and unspecified psychosis. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was observed to be pleasantly confused and unable to be interviewed. Despite being prescribed lorazepam for anxiety, there was no supporting documentation of the resident exhibiting behaviors such as yelling or being difficult to redirect prior to the medication order. The facility's records, including the Physician Order Summary Report and nursing progress notes, lacked evidence of the resident's targeted behaviors or any non-pharmacological interventions attempted before the administration of the antianxiety medication. The Medication Administration Record showed that the resident received lorazepam on three occasions, but corresponding progress notes did not document any clinical behaviors justifying its use. The individualized comprehensive care plan mentioned monitoring and documenting targeted behaviors, but the Psychotropic Monthly Review indicated zero episodes of such behaviors. Interviews with facility staff, including an LPN, LPN/Unit Manager, CNA, and the Director of Nursing, revealed inconsistencies in behavior documentation and monitoring. The LPN/UM admitted that the reported behaviors were based on the resident's roommate's account rather than clinical staff observations. The Director of Nursing confirmed the absence of documentation for the resident's behaviors or non-pharmacological interventions prior to the medication order. The facility's policy on psychotropic drug use emphasized the necessity of documented diagnoses and conditions, which was not adhered to in this case.
Failure to Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain Enhanced Barrier Precautions (EBP) while providing direct care to a resident with dementia and rheumatoid arthritis, who was also suffering from severe cognitive impairment and required maximum assistance with activities of daily living. During an observation, a Licensed Practical Nurse/Unit Manager (LPN/UM) was seen providing incontinence care to the resident without wearing an isolation gown, despite the resident being on EBP due to a wound. The LPN/UM acknowledged the oversight and recognized the importance of wearing a gown to prevent the transfer of microorganisms from her clothing to the resident. Interviews with the primary care Certified Nursing Aide (CNA) and the Infection Preventionist (IP) confirmed that staff were required to don personal protective equipment (PPE) before providing direct care to residents on EBP. The facility's policy and the resident's care plan both indicated that gowns and gloves should be worn during high-contact activities for residents with wounds. The Director of Nursing (DON) also confirmed that proper PPE should be worn as specified by the signage on the resident's door.
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What surveyors actually found near you
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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 Allenwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyside Manor | 2.3 mi | ★★★★★ | 3 | 0 |
| Willow Springs Rehabilitation And Healthcare Ctr | 3.1 mi | ★★★★★ | 14 | 0 |
| Complete Care At Wall Llc | 3.4 mi | ★★★★★ | 2 | 1 |
| Careone At Wall | 3.9 mi | ★★★★★ | 12 | 0 |
| Complete Care At Laurelton, Llc | 4.1 mi | ★★★★★ | 1 | 1 |
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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.