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 Reformed Church Home during CMS and state inspections, most recent first.
The facility failed to meet the required CNA staffing ratios for three day shifts, having only 10 CNAs for 89 to 90 residents instead of the mandated 11. The staffing coordinator acknowledged the difficulty in covering call-outs despite efforts to fill vacancies with per diem staff and agencies.
The facility failed to maintain the integrity of smoke barrier partitions, with three out of twelve smoke barriers having penetrations that compromised their fire resistance rating. Observations revealed holes with wires and cables running through smoke barrier walls on multiple floors, potentially affecting all 88 residents.
The facility failed to maintain proper emergency communication systems in two of its four elevators. During testing, the emergency phones in elevators #1 and #2 malfunctioned, disconnecting calls prematurely and lacking pre-recorded messages. This issue had the potential to impact the safety of 88 residents.
The facility failed to ensure a fire-rated door to a hazardous area was properly separated by smoke-resisting partitions. The basement Activities room door did not self-close due to the removal of its automatic closure mechanism. Inside, combustible items were observed, and the room exceeded the size threshold for requiring proper fire separation.
A resident with Parkinson's disease and dementia, identified as high risk for falls, experienced a fall resulting in injuries due to the facility's failure to follow the fall prevention interventions outlined in their care plan. The interventions, which included keeping the bed in the lowest position and placing a thick floor mat next to the bed, were not in place at the time of the incident. An agency CNA unfamiliar with the resident's needs was responsible for their care at the time.
Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for three of the fourteen day shifts reviewed. Specifically, on three separate days, the facility had only 10 Certified Nurse Aides (CNAs) for 89 to 90 residents during the day shift, whereas the state requirement was at least 11 CNAs. This deficiency was identified through a review of staffing records for the period from November 17, 2024, to November 30, 2024. During an interview, the staffing coordinator acknowledged awareness of the CNA staffing ratios and admitted that while the facility usually meets these ratios, covering call-outs can be challenging. The facility's staffing policy, reviewed on December 11, 2024, outlines that the staffing coordinator is responsible for filling vacancies, initially attempting to cover shifts with per diem staff and, if unsuccessful, reaching out to agencies. Despite these procedures, the facility was unable to meet the mandated staffing levels on the specified days.
Plan Of Correction
To ensure all residents have access to the care they need, Reformed Church Home has cross-trained our nursing staff to perform CNA duties during the day shift in emergencies. All residents have the potential to be affected by the staffing shortage. In addition to using our nurse managers to perform direct care, we have also contracted with additional staffing agencies to provide temporary CNAs in the event of shortages. Overtime is offered to existing staff since we are usually trying to fill vacancies due to illness. The facility has taken multiple steps to address the CNA concern. Efforts are made to stay ahead of the pay scale and to have Reformed Church Home at the top of the wage scale. Reformed Church Home is also offering an additional health family plan which is lower in cost than our traditional plans. The hope again is that we will be able to attract more CNAs with families due to our competitive rates and enhanced health coverage for families. We have also partnered with the CNA school, Above and Beyond in Colonia NJ to provide guidance and graduating CNAs job opportunities. We have also contracted with additional staffing agencies to provide temporary CNAs in the event of shortages. We have also petitioned 6 visas for CNAs from United Methodist Healthcare Recruitment out of Chicago. To ensure the deficient practice does not recur, the Director of Nursing and Staffing Coordinator will review daily/weekly staffing levels daily to ensure compliance with the required ratios. A quarterly report will be made at the QA committee.
Smoke Barrier Integrity Compromised
Penalty
Summary
The facility failed to maintain the integrity of smoke barrier partitions in accordance with NFPA 101:2012 Edition, Sections 19.3.6.2.3, 8.5.6, 8.5.6.2, and 8.5.6.3. During observations conducted on December 5 and December 9, 2024, in the presence of Facility Management, it was found that three out of twelve smoke barriers had penetrations that compromised their fire resistance rating. Specifically, on the third floor above the ceiling tiles by the 1-1/2 hour fire-rated double corridor doors leading into the "A-Wing," two approximately 1-inch diameter holes with wires running through the smoke barrier wall were observed. Further observations revealed additional deficiencies on the second and first floors. On the second floor, above the ceiling tiles by the 1-1/2 fire-rated double corridor doors leading into the "A-Wing," a 1-1/2 inch diameter hole with nine black wires running through the smoke barrier wall was noted. On the first floor, above the ceiling tiles by the 1-1/2 fire-rated double corridor doors next to the Social Services office, two 1-1/2 inch diameter holes with one BX electrical cable and a 1/2-inch diameter white plastic tubing running through one penetration were found. These deficiencies had the potential to affect all 88 residents in the facility.
Plan Of Correction
Immediate Corrective Action: **Inspection of Fire-Rated Barriers and Doors:** A comprehensive inspection of all fire-rated barriers, including walls and ceilings around fire doors, will be conducted immediately to identify any penetrations that lack proper fire blocking. Areas of focus will include penetrations above fire doors, walls with ducts, pipes, cables, or conduits passing through, and other vulnerable areas in the building. **Sealing Penetrations:** All identified penetrations that lack appropriate fire-blocking will be immediately sealed using approved fire-resistant materials. These materials will include fire-rated caulk, intumescent sealants, or other materials that meet NFPA 101 and NFPA 80 requirements for fire blocking. The materials used will be selected based on NFPA guidelines to ensure that they provide an effective barrier against fire and smoke. **Verification of Fire Blocking:** Once penetrations have been sealed, the Maintenance Director will perform a follow-up inspection to verify that all fire-blocking measures are properly implemented and meet required safety standards. Any issues found during this inspection will be corrected immediately. **Systematic Changes to Prevent Recurrence:** **Contractor Instructions and Oversight:** Moving forward, any contractors who perform work involving penetrations in fire-rated walls, ceilings, or around fire doors will be instructed as follows: Contractors will be required to ensure that all penetrations made during their work are properly fire-blocked in accordance with NFPA 101 and NFPA 80 standards. Contractor contracts will include a clause requiring compliance with all fire safety and building code regulations, including sealing all penetrations with fire-resistant materials. A checklist for contractors will be developed to ensure they have followed fire-blocking protocols before finalizing any work that involves penetrations in fire-rated barriers. **Maintenance Staff Oversight:** Maintenance staff will be tasked with monitoring and inspecting any penetrations made by contractors during construction, repair, or maintenance projects. Maintenance staff will perform follow-up inspections to ensure that any penetrations made by contractors are sealed correctly and fire-blocked immediately. If any deficiencies are found, the Maintenance Director will ensure that the issue is addressed before the area is considered fully operational or before the contractor leaves the job site. **Ongoing Inspections of Fire-Barriers:** The facility's maintenance team will develop a schedule for quarterly inspections of all fire-rated barriers, including doors, walls, and ceilings, to ensure that no unsealed penetrations have been made. Any new penetrations, whether by contractors or facility staff, will be immediately sealed with appropriate fire-blocking materials, and will be included in the inspection schedule for verification. **Fire Safety Training for Staff and Contractors:** Maintenance staff will receive additional training to ensure they are fully knowledgeable about the proper methods for sealing penetrations in fire-rated barriers and identifying potential fire-blocking deficiencies. Contractors will receive orientation or written instructions regarding the facility's fire safety protocols related to penetrations and fire-blocking. This will be reinforced during contractor onboarding before starting any project that involves fire-rated walls. **Follow-Up Monitoring and Compliance:** **Follow-Up Inspections:** A follow-up inspection will be performed within 30 days of completing the immediate corrective actions to verify that all fire-blocking has been implemented properly and that the facility remains in compliance with K372. The inspection will be performed by the Maintenance Director to confirm that all fire-rated barriers are intact and that all penetrations are properly sealed. **Quarterly Audits:** A quarterly fire-safety audit will be conducted to ensure continued compliance. This will include: - A review of all areas where penetrations have occurred. - Verification that all penetrations are properly fire-blocked and meet fire-safety codes. - Auditing the contractor checklist and documentation to ensure that all work completed by contractors adheres to fire safety regulations. **Ongoing Documentation:** Documentation will be maintained for all inspections, corrections, and training sessions. This includes: - Logs of contractor instructions regarding fire-blocking requirements. - Maintenance inspection records and follow-up reports. - Audit results and corrective actions taken. **Responsible Parties:** - **Maintenance Director:** Oversees inspections, repairs, and ensures all penetrations are properly sealed. Also responsible for ensuring maintenance staff follow procedures. - **Contractors:** Responsible for ensuring compliance with fire safety regulations and properly sealing penetrations made during work. **Completion Date for Corrective Action:** All immediate corrective actions, including sealing penetrations and inspecting fire-rated barriers, will be completed by 12/27/24. Ongoing monitoring and quarterly audits will begin immediately and continue per the established schedule. The results will be discussed in the facility's quarterly safety committee meetings.
Elevator Emergency Communication Deficiency
Penalty
Summary
The facility failed to maintain emergency communications in proper working condition for two of the four elevators tested, as observed during a survey conducted on December 5, 2024, and December 9, 2024. During the inspection, it was found that the emergency communication telephones in elevators #1 and #2 were not functioning correctly. In elevator #1, when the emergency communication button was pressed, the operator answered, but no words were exchanged, and the call disconnected automatically within approximately 20 seconds. A second test confirmed that the phone did not function properly, as it lacked a pre-recorded message. Similarly, in elevator #2, the emergency communication phone also malfunctioned. When tested, the operator answered and requested the caller to hold, but the call disconnected automatically within approximately 20 seconds. These deficiencies were confirmed by the facility's representative during the observations and were reported during the Life Safety Code survey exit. The malfunctioning emergency communication systems in these elevators had the potential to affect the safety of 88 residents in the facility.
Plan Of Correction
The facility must ensure that all elevator systems, including emergency communication devices (e.g., emergency phones in elevators), are properly maintained and functioning to ensure the safety and well-being of residents and staff. **Immediate Corrective Action:** **Inspection of All Elevators:** An immediate inspection of all elevator emergency communication systems (phones) was conducted to assess functionality. This inspection was performed by the facility's maintenance team and qualified elevator service provider to ensure that all emergency phones are working. The inspection focused on: - Ensuring each emergency phone connects to a 24-hour monitoring service or can directly communicate with emergency personnel. - Verifying that phones are in working condition with clear audio and uninterrupted functionality. **Immediate Repair or Replacement:** Any non-functional or damaged emergency phones was repaired or replaced immediately to ensure they met operational requirements. All phones that are out of service will be marked as "out of order" until repaired and will not be used until fully functional. **Test All Emergency Phones:** Once repairs or replacements were made, each elevator emergency phone was tested for connectivity to emergency services, ensuring they work properly in the event of an emergency. **Systematic Changes to Prevent Recurrence:** **Scheduled Inspections and Preventive Maintenance:** A monthly inspection will be established for all elevator emergency phones. The inspection will include: - Functionality testing to ensure clear, immediate communication with emergency personnel. - Visual inspection to check for physical damage or wear. These inspections will be documented, and the results will be reviewed by the Maintenance Director. **Documentation and Record-Keeping:** A logbook will be created and maintained to record each inspection and test result, including: - Date and time of inspection. - Description of any identified issues. - Actions taken (repair, replacement, etc.). - Confirmation that repairs have been completed and phones are operational. **Training of Maintenance Staff:** Maintenance personnel will receive training on the proper testing and repair of elevator emergency phones, including how to ensure they are properly connected to emergency services. **Follow-Up Monitoring and Compliance:** **Ongoing Monitoring:** To ensure long-term compliance, the monthly inspection schedule will be adhered to and documented. **Responsible Parties:** Maintenance Director: Responsible for overseeing the inspection, repair, and maintenance of all elevator emergency communication systems. Oversees all safety systems, including elevator emergency phones, ensuring compliance with fire safety codes. **Completion Date for Corrective Action:** All immediate corrective actions, including repairs and testing of emergency phones, was completed. Monthly inspections and preventive maintenance will commence immediately after the corrective actions have been implemented and will continue regularly. The results of the inspections will be discussed at the quarterly safety committee meetings.
Failure to Maintain Fire Safety in Hazardous Area
Penalty
Summary
The facility failed to ensure that one of eight fire-rated doors to hazardous areas was properly separated by smoke-resisting partitions, as required by NFPA 101, 2012 Edition. During an observation on December 5, 2024, at approximately 9:20 AM, it was noted that the basement level Activities room door did not close to the frame when tested. The automatic door closure mechanism had been removed, preventing the door from self-closing into its frame. This deficiency was confirmed by the surveyor and facility representatives during the Life Safety Code survey exit on December 9, 2024. Inside the Activities room, the surveyor observed several combustible items, including cardboard boxes and activity crafts, which posed a potential fire hazard. The room was measured to be 91.875 square feet, exceeding the 50 square feet threshold for requiring proper fire separation. The presence of these combustible materials, combined with the lack of a functioning self-closing door, constituted a failure to comply with the necessary fire safety standards, as outlined in the relevant sections of NFPA 101.
Plan Of Correction
12/31/24 Immediate Corrective Action: Inspection of all self-closing doors: A comprehensive inspection of all self-closing doors in hazardous areas (boiler rooms, electrical rooms, storage rooms, etc.) was conducted immediately by our maintenance team. Repairs or replacements: Any self-closing doors that are not functioning properly will be repaired or replaced immediately. This includes ensuring that the doors close automatically without obstruction and maintain the required fire-resistance rating. Basement activity storage door new closure was placed. See photo for reference. Identification of Non-Compliant Doors: We will identify and tag any doors that are not compliant and make necessary repairs, ensuring all doors in hazardous areas meet the required standards for self-closing and fire resistance. Systematic Changes to Prevent Recurrence: Routine Inspections and Testing: An annual inspection and testing program will be implemented for all self-closing fire-rated doors in hazardous areas. The program will include: - Verifying the proper operation of the door-closing mechanism. - Ensuring that doors are not obstructed and can close fully. - Checking that fire-rated doors are not damaged. The results of each inspection will be documented and kept on file for review. Long-Term Sustainability: Documentation and Tracking: A detailed log of all self-closing doors will be created, listing the location of each door, its inspection dates, and any repair or maintenance actions taken. Monitoring and Follow-Up: Ongoing Compliance: The facility will schedule annual internal inspections of self-closing doors in hazardous areas to ensure continued compliance. Reports will be reviewed by the facility's fire safety officer and any identified issues will be addressed promptly. The results of the findings will be addressed at the first quarter safety committee meeting and the first quarter QA meeting. Responsible Party: Maintenance Director: Oversees the inspection, repair, and ongoing monitoring of self-closing doors.
Failure to Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to follow fall prevention interventions as outlined in the individual comprehensive care plan (ICCP) for a resident identified as being at high risk for falls. The resident, who was admitted with diagnoses including Parkinson's disease and dementia, was observed in a reclining chair without the thick cushioned fall mat that was supposed to be placed next to their bed as per the care plan. The resident's ICCP included specific interventions such as keeping the bed in the lowest position and placing a thick floor mat and landing strips next to the bed. However, during an incident, these interventions were not in place, leading to the resident sustaining a hematoma and laceration after a fall. The investigation revealed that the bed was not in the lowest position at the time of the fall, and the floor mats were not in place, contrary to the care plan. The CNA responsible for the resident at the time was an agency staff member unfamiliar with the resident's specific needs. The Director of Nursing acknowledged that the care plan was not followed, and the Registered Nurse/Unit Manager emphasized the importance of adhering to the care plan to ensure the best outcomes for residents. The facility's policy required that interventions be implemented for residents with a high fall risk score, but this was not adhered to in this case.
Plan Of Correction
The root cause for this deficient practice was the nurse failed to properly oversee the agency aide assigned to resident #44 to ensure the appropriate interventions were in place when the resident was in bed. The nurse was re-educated on her responsibility to oversee the care provided by a CNA and to ensure the residents under her care have the appropriate safety interventions in place. All residents who are severely cognitively impaired, have a fall risk score above 10, and who have fall interventions of a low bed and floor mats, have the potential to be affected by this deficient practice. Residents Fall Risk Scores, BIMS scores, and Care Plans will be reviewed to identify residents at risk to ensure the information provided on the Resident Care Needs form is accurate. The unit managers/nursing supervisors will be educated on checking the daily staffing sheet to identify any agency staff assigned in the facility and will ensure they have received the Resident Care Needs form, which was created to easily and quickly be able to identify the care needs of residents. Licensed nursing staff will be re-educated on their responsibility to provide supervision and oversight to any CNA providing care to a resident under their care and to ensure all safety interventions are in place. A weekly Agency Staff Supervision form will be in the staffing office with the daily staffing sheets. The unit managers/nursing supervisors will complete this form daily. The form will be reviewed by the DON weekly x 12 weeks, then monthly x3 months to ensure agency staff have received the necessary information to provide safe resident care. The results of the reviews will be presented at the quarterly quality assurance meetings for the March and June meetings.
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What surveyors actually found near you
We read the 752 citations issued within 25 miles in the last 12 months — including the 21 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 Old Bridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Preferred Care At Old Bridge, Llc | 1.1 mi | ★★★★★ | 2 | 0 |
| Roosevelt Care Center At Old Bridge | 1.7 mi | ★★★★★ | 6 | 0 |
| Autumn Lake Healthcare At Old Bridge | 2 mi | ★★★★★ | 15 | 0 |
| Careone At East Brunswick | 4.8 mi | ★★★★★ | 0 | 0 |
| Complete Care At Madison, Llc | 4.9 mi | ★★★★★ | 14 | 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.