Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Rose Garden Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was left unsupervised on an outdoor patio for nearly three hours in hot weather after being taken outside by a CNA who failed to notify other staff. The resident was not checked on by the assigned CNA or any other staff, and was later found by a visitor in distress with signs of heatstroke, dehydration, and second-degree burns, requiring hospital admission.
Kitchen sanitation and food storage deficiencies were identified when utensils were air-drying near a dusty fan, a manual can opener had heavy blackish buildup on a plastic insert, and a freezer lacked an internal thermometer. Staff also found unlabeled and undated potentially hazardous foods in a refrigerator, and 5-gallon water jugs were stored horizontally in dirty crates on the floor with exposed openings.
The facility used lemon-scented moist towelettes for resident hand hygiene before meals in the dining room, and staff stated these were the only supplies used. The towelettes were alcohol free, while the IP and ALNHA confirmed the facility was using them instead of alcohol-based hand wipes. The facility also failed to maintain EBP for a resident with a stage 3 sacral pressure ulcer: there was no EBP signage or PPE available near the room, and an LPN performed wound care wearing gloves but no gown, stating the gown was not used because no EBP sign was posted.
Failure to Document Non-Pharmacological Interventions Before Psychotropic Use: A resident with dementia and anxiety had reported afternoon/evening restlessness, pacing, and attempts to stand from a wheelchair, and staff described using redirection, food, toileting, activities, snacks, and folding clothes at times. However, the record did not document resident-specific non-pharmacological interventions before Zoloft and PRN Xanax were started, and the ICPs for dementia and behaviors contained only general interventions rather than individualized approaches.
MDS failed to accurately reflect a resident’s O2 use. A resident with pneumonia and COPD was observed on 2 L O2 via NC, and EMR documentation showed a physician order for PRN O2 and a nursing note indicating O2 was administered, but the quarterly MDS did not code O2 use. The MDS RN Coordinator confirmed the omission was an error in documentation.
Missing Person-Centered Pain Care Plan: A resident with right lower leg ulceration, pain, and recent surgery with skin graft had PRN opioid and acetaminophen orders, but no CPCCP for pain was in place after return from hospitalization. The resident reported ongoing pain needs, and the ALNHA acknowledged the care plan should have been present; the facility could not provide a policy for CPCCP development.
A resident with Alzheimer’s disease, HF, and DM had an ICP that was not revised to match current care. Staff observed chronic lower-extremity edema and use of compression stockings, and the MAR/TAR showed the stockings were applied in the AM and removed at HS, but the ICP still referenced furosemide even though it had been discontinued and did not include the stockings as an intervention. The LPN, RN/UM, ALNH Administrator, and DON confirmed the ICP was not resident-specific and should have been updated.
Unsafe Bed Halo Bar Condition: A resident with Alzheimer’s disease, muscle weakness, and severe cognitive impairment experienced a near-fall when a broken halo bar attached to the bed failed to lock into place. The accident investigation identified the halo bar as the contributing factor, and facility records showed no maintenance request was completed after the incident, despite the resident being on a fall-risk care plan and the halo bars being used as safety and mobility devices.
A resident with pneumonia and COPD was observed receiving O2 at 2 L via NC, but the MAR and nursing notes did not document the PRN O2 administration. An RN acknowledged giving the O2 for SOB but not signing it out, and the RN/UM and DON confirmed the care plan did not address the resident’s O2 use.
A resident with dementia and anxiety had confusion, sundowning, restlessness, pacing, wandering, and attempts to stand from a wheelchair, but the ICP contained only general dementia interventions such as simple instructions, a safe environment, and offering choices. Staff reported using redirection, food, toileting, occasional Xanax, and activity diversions, yet the care plan and progress notes did not document resident-specific triggers, calming techniques, or behavior interventions, and multiple leaders confirmed the dementia ICP lacked individualized interventions.
The facility failed to ensure the IP attended quarterly QAPI meetings and was included as a member of the QAA Committee. The IP stated she had never attended a QAPI meeting during her time in the role, and the ALNHA confirmed the IP was not a QAA member while the DON presented infection control information during QAPI meetings. Review of QAPI attendance sheets and the QAA member list showed the IP was absent from all reviewed meetings and not listed on the committee.
A resident receiving IV cefazolin for an MRSA wound infection was not included on the facility’s monthly antibiotic roster used to monitor antibiotic use. The IP stated she kept antibiotic records but was not familiar with clinical criteria for identifying infections, and the consultant pharmacist and Medical Director said the SBAR form was the primary tool for tracking and managing antibiotic use.
Infection Preventionist Did Not Perform Required Infection Control Responsibilities. The IP stated she was not familiar with the facility’s clinical criteria for identifying infections, was not involved in the water management/treatment plan, and did not conduct regular surveillance in the kitchen or laundry areas. The ALNHA also stated the IP did not perform surveillance in those areas and instead did weekly rounds with the Maintenance Director. The facility policy for infection control rounds stated the rounds were to evaluate compliance with infection control policies and procedures throughout the facility.
Failure to offer pneumococcal vaccine on admission: A resident admitted for rehab had documentation showing conflicting immunization information, including a consent form indicating the pneumonia vaccine was desired and a nursing immunization record marked as up to date, while the IP stated the vaccine was only for LTC residents. The DON confirmed that all residents, including short-term rehab residents, should be offered the pneumonia vaccine, and the facility policy required it to be offered to every resident upon admission unless contraindicated or refused.
The facility failed to maintain sufficient nursing staff to meet resident needs, particularly on weekends and night shifts. Residents reported missed care, and staffing records confirmed consistent CNA shortages. Staff interviews highlighted frequent call-outs and unmet staffing plans, contributing to inadequate care.
The facility failed to handle potentially hazardous food safely, as observed by a surveyor. Expired syrup bottles and improperly stored frozen hash browns and French fries were found in the kitchen. The facility's policy requires proper labeling and dating of food items, which was not followed, leading to the removal of these items by the Food Service Director.
The facility failed to issue the required beneficiary notices for two residents, using admission agreements instead of the CMS-10055 form. The AIT admitted awareness of the correct form but stated the facility was waiting for instructions to change their practice, despite the issue being questioned annually during surveys.
A facility failed to follow a physician's order for weekly weights for a resident with surgical aftercare needs and major depressive disorder. The MAR lacked documentation for specific dates, indicating non-compliance. Interviews with staff revealed inconsistencies in the process of obtaining and documenting weights, with the DON citing staffing challenges as a factor. Facility policies emphasized the need for proper documentation and execution of orders, which was not adhered to in this instance.
A resident with chronic respiratory conditions and a PRN oxygen order was not consistently monitored for SPO2 levels, as required by the facility's policy. Despite having an order to administer oxygen if SPO2 fell below 92%, there were no documented SPO2 readings from June 2023 until April 2024, except for a few entries. The facility's DON confirmed the lack of monitoring and acknowledged the need for regular SPO2 checks as per the physician's order.
A facility failed to follow infection control protocols for respiratory equipment for two residents. One resident's nasal cannula tubing was not changed weekly as required, and another resident's nasal cannula was found in a trash can, with a nebulizer mask left exposed. Staff interviews confirmed these lapses, despite the facility's policy to change and cover equipment regularly.
Resident Left Unattended Outdoors Resulting in Heatstroke and Burns
Penalty
Summary
A cognitively impaired, aphasic resident with multiple serious medical conditions, including Alzheimer's disease, brain and colon cancer, and a history of traumatic brain injury, was left unattended on an outdoor patio for approximately two hours and forty minutes during a period of heat and sun exposure. The resident required maximal staff assistance for mobility and activities of daily living and was unable to communicate effectively. After being transported to the patio in a wheelchair by a CNA following lunch, the resident was not monitored or checked on by any staff, and the CNA failed to inform other staff members of the resident's location. During this period, the assigned CNA did not check on the resident or account for their whereabouts, and no other staff intervened. The resident was eventually discovered by another resident and a visitor, slumped over in the wheelchair, with hot, dry skin and an elevated temperature. Emergency services were called, and the resident was transferred to the hospital, where they were diagnosed with heatstroke, dehydration, acute kidney injury, elevated troponin, and second-degree burns (sunburns with blisters) on multiple body areas. Hospital records documented the resident's acute distress, altered mental status, and multiple metabolic complications resulting from the prolonged heat exposure and lack of monitoring. Facility records and staff interviews confirmed that there was no policy in place at the time regarding resident supervision outdoors, and staff failed to follow basic protocols for communication and resident safety. The assigned CNA was unaware of the resident's location for an extended period, did not perform required rounds, and failed to provide necessary care such as hydration, toileting, and skin protection. The lack of monitoring and communication directly resulted in the resident's serious medical deterioration and hospital admission.
Removal Plan
- Checks were implemented on all outdoor areas (patio, courtyard, entrance), checks recorded on log sheets
- Notifications to NJDOH, Ombudsman Office and facility administrative staff were sent
- Patio keypad was changed to locked
- All employees at the facility were educated on Resident Safety/Heat Advisory
- CNA #1 received inservice/education on Resident Safety
- CNA #2 received inservice/education on Resident Safety, knowing your assigned resident's whereabouts, making rounds on assigned residents and received a suspension
- A facility wide inservice on the new Outdoor Resident Policy was initiated with Resident Safety/Updated Log Sheets
- Camera installation on the patio was completed
- Checks remain on all outdoor areas recorded on log sheets
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to ensure that washed utensils were dried in a manner that would prevent contamination from foreign substances and the development of food-borne illness. During a kitchen tour with the Food Service Director, dinner knives, forks, and teaspoons were observed in perforated plastic flatware containers air-drying by a standing fan that had dust buildup on the back grills. The Food Service Director stated the fan had been cleaned the previous night. The surveyor also observed a manual can opener with a blue plastic slide bar insert that had a heavy buildup of blackish unidentified substance, and the Food Service Director stated the blue plastic insert could not be cleaned and a new one had been ordered. The facility also failed to maintain kitchen equipment in a sanitary manner and to properly store, label, and date potentially hazardous foods. In the first-floor pantry, a reach-in freezer had no internal thermometer and contained six cups of ice cream. The same refrigerator contained an unlabeled and undated chicken soup in a covered Pyrex container, along with an undated box of two cannoli and a box of two puff pastries. In the hallway near the kitchen, three 5-gallon jug water containers were stored horizontally in blue plastic crates in direct contact with the floor, with the mouthpiece and neck exposed and the crates showing heavy buildup of dirt and dust. The Food Service Director stated the water jugs should not be there and would be relocated.
Inadequate Hand Hygiene Supplies and Failure to Use EBP for a Resident With a Stage 3 Sacral Wound
Penalty
Summary
The facility failed to provide appropriate hand hygiene products for residents during mealtime in two dining room observations. In the 1st floor Tea dining room, the Assistant Activities Director provided residents with lemon-scented moist towelettes for hand hygiene before lunch, and stated that these were the facility’s usual supplies for resident hand hygiene prior to meals. The towelettes were observed to be alcohol free. In a separate lunch observation in the Tea dining room, Helping Hand staff and a CNA assisted residents in wiping their hands with the same lemon-scented moist towelette packs before eating, and staff stated these were the only supplies used to clean residents’ hands before meals. During interviews, the Infection Preventionist stated that the facility provides lemon-scented towelettes to residents during mealtimes and was unsure whether they contained alcohol. The Assistant Licensed Nursing Home Administrator also stated that lemon-scented moist towelettes were currently used for resident hand hygiene prior to meals and that the facility planned to purchase alcohol-based hand wipes in the future. A facility policy titled Resident Health Program stated that residents should be educated on proper hand hygiene, including washing hands with soap and water, using alcohol-based sanitizer rub, and using the wipes provided with meals. The facility also failed to implement and maintain Enhanced Barrier Precautions for Resident #114, who had a stage 3 sacral pressure ulcer and malnutrition. The resident’s room had no EBP signage inside or outside the room and no PPE supplies were immediately available near the room during multiple observations. When the resident’s sacral wound was treated, the LPN wore gloves but did not wear a protective gown, and stated that a gown was not used because there was no EBP sign at the doorway. The resident’s record showed a stage 3 sacral wound with treatment orders for cleansing with normal saline, applying Manuka honey ointment, and covering with a dry dressing, and the facility’s EBP policy stated that gown and glove use applies to residents with wounds or indwelling medical devices when Contact Precautions do not otherwise apply.
Failure to Document Non-Pharmacological Interventions Before Psychotropic Use
Penalty
Summary
The facility failed to document non-pharmacological interventions used to manage a resident’s behaviors before administering psychotropic medications. Resident #37 was admitted with diagnoses including dementia with other behavior disturbance, anxiety disorder, hypothyroidism, and hypertension. The quarterly MDS dated 8/15/25 showed short- and long-term memory deficits, severe impairment in decision making, moderate assistance needed with ADLs, and no behaviors documented. During observation on 9/11/25, the resident was sitting quietly in the hallway in front of the nurse’s station, in no distress, clean, and appropriately dressed, and could not be interviewed because of cognitive deficits. Staff interviews described the resident as confused, needing supervision and direction, and at times sundowning, pacing the hallways in a wheelchair, yelling, trying to stand up, and not returning when redirected. The LPN stated the resident was redirected with guiding, food, and toileting and was given Xanax at times for restlessness, but not all the time. The LPN/UM stated the resident was calm in the morning but restless in the afternoon and early evening, and that staff would sometimes let the resident pace, activities would try to read with the resident, take the resident outside, provide snacks, or have the resident fold clothes. The psychiatrist’s consultation on 7/9/25 documented reports of increased anxiety, restlessness, and frequent attempts to stand up after dinner, and Sertraline was started for anxiety. Review of the record showed no documented behavior notes or non-pharmacological interventions before Zoloft was started on 7/9/25, and no behavior monitoring documented after the medication was administered. The ICP dated 5/12/25 for dementia and the ICP dated 7/23/25 for behaviors did not contain resident-specific interventions addressing wandering, pacing, standing from the wheelchair, or other listed behaviors. The care plans contained general interventions such as using simple words, maintaining a safe environment, encouraging activities, orienting to surroundings, and administering medications as ordered, but no documented resident-specific non-pharmacological approaches. Facility leadership, including the DSW, DON, AA, LPN/UM, and MD, confirmed there were no documented non-pharmacological interventions initiated prior to psychotropic drug use and that the care plan did not address resident-specific behavioral interventions.
MDS Failed to Accurately Reflect O2 Administration
Penalty
Summary
The facility failed to accurately code a resident’s O2 administration on the quarterly MDS for one resident reviewed. The resident was admitted with diagnoses including pneumonia and COPD, and the quarterly MDS dated 8/15/25 reflected a BIMS score of 8/15, indicating moderate cognitive impairment, along with moderate assistance needed for all activities of daily living. However, the MDS did not reflect that the resident was receiving O2. During the initial tour on 9/11/2025, the surveyor observed the resident lying in bed on O2 at 2 liters via nasal cannula. Review of the EMR showed a physician order dated 5/27/25 for O2 at 2 liters via nasal cannula PRN for pulse oximetry less than 91% on room air or visible shortness of breath, and a nursing progress note dated 8/14/25 documented that the resident was in fact administered O2 at 2 liters. The MDS RN Coordinator confirmed that the progress note showed O2 use during the look-back period and stated the MDS should have been modified to include that the resident was on O2 when the assessment was completed, identifying the omission as an error in documentation.
Missing Person-Centered Pain Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for pain for Resident #129 that included measurable objectives and timeframes. The resident was admitted with diagnoses including atherosclerosis with ulceration to the right lower leg and pain in the right leg, and the annual MDS dated 07/22/2025 showed a BIMS score of 15 out of 15, indicating intact cognition. Section J of the MDS indicated the resident received as-needed pain medication and non-medication interventions for pain management. On 09/11/2025, the surveyor observed the resident lying in bed with the head of the bed elevated to approximately 45 degrees. The resident reported having undergone surgery on the lower right leg on 09/04/2025, including a skin graft for a painful wound, and stated that pain medication had been received at about 6:00 a.m. with plans to ask for additional medication later. Physician orders dated 09/09/2025 and 09/10/2025 included oxycodone and acetaminophen for severe, moderate, and mild pain, but the resident did not have a Comprehensive Person-Centered Care Plan for pain. During interview, the Assistant Licensed Nursing Home Administrator stated the resident had been hospitalized and returned on 09/09/2025, had previously had a pain care plan, and acknowledged that one should have been in place upon return. The facility was unable to provide a policy regarding development of a CPCCP.
ICP Not Updated to Reflect Current Edema Management
Penalty
Summary
The facility failed to update and revise the interdisciplinary care plan for a resident with Alzheimer’s disease, heart failure, and diabetes mellitus so that it accurately reflected current care. The resident’s quarterly MDS dated 8/4/2025 showed a BIMS score of 8/15, indicating moderate cognitive impairment, and the resident required maximum assistance with activities of daily living. During observation on 9/11/2025, the resident was seen sitting in the dayroom with edema of the lower extremities and wearing compression stockings, but was unable to provide details about them during interview. Review of the medical record showed a physician order dated 1/29/2025 for knee-high compression stockings to be applied in the morning and removed at bedtime, and the September 2025 TAR showed staff were documenting application and removal of the stockings. The care plan dated 3/02/2020 and reviewed 8/4/2025 still identified decreased cardiac output and stated the resident would be free of complications such as edema, fluid overload, and shortness of breath, but it continued to reference furosemide even though the medication had been discontinued on 12/10/2024 and did not include the compression stockings as an intervention. On 9/15/2025, the resident was again observed with compression stockings on both lower extremities, and the CNA and LPN confirmed the stockings were applied every morning and removed at night for chronic non-pitting edema. The RN/UM, ALNH Administrator, and DON all confirmed the care plan should have been revised to include the compression stockings and remove the discontinued diuretic medication.
Unsafe Bed Halo Bar Condition
Penalty
Summary
The facility failed to ensure that the resident’s environment was free of possible hazards when Resident #128’s right halo bar, a safety and mobility device attached to the bed, was broken and failed to lock into place during a near-fall incident out of bed. The accident investigation identified the broken halo bar as the contributing factor, and the resident was documented as having diagnoses including Alzheimer’s Disease and muscle weakness, with a Significant Change MDS dated 10/30/2024 showing a BIMS score of 2 out of 15, indicating severe cognitive impairment. The resident’s comprehensive care plan dated 09/18/2024 identified a high risk for falls and the need for preventative measures to reduce the likelihood of falls. Facility documentation showed work requests for loose halo bars submitted by nursing on 09/25/2024 and 10/18/2025, but there was no maintenance request submitted or completed on 10/11/2024 for Resident #128’s halo bar after the near-fall incident. During interview, the Assistant Licensed Nursing Home Administrator stated that the halo bars were used as safety devices to help prevent falls and assist with mobility and repositioning in bed, and she was unsure why maintenance did not complete a facility-wide audit of halo bars after the incident.
Failure to Document PRN Oxygen Administration and Care Plan Oxygen Use
Penalty
Summary
The facility failed to document the administration of oxygen for a resident with diagnoses including pneumonia and COPD, and failed to include oxygen use on the resident’s interdisciplinary care plan. The resident’s quarterly MDS dated 8/15/2025 showed a BIMS score of 8/15, indicating moderate cognitive impairment, and the resident required moderate assistance with all aspects of ADLs. On 9/11/2025, the surveyor observed the resident lying in bed on oxygen at 2 liters via nasal cannula, but the resident was sleeping and not observed to be short of breath at that time. Review of the physician’s order dated 5/27/2025 showed oxygen at 2 liters via nasal cannula PRN for pulse oximetry less than 91% on room air or visible shortness of breath. However, the MAR for 9/11/2025 did not show documentation that oxygen had been administered, and the nursing progress notes for that date also lacked documentation of oxygen administration. The surveyor later observed the resident again on oxygen at 2 liters via nasal cannula, and an RN confirmed the resident was receiving oxygen but acknowledged that it was not signed out on the MAR. The RN stated she had administered the PRN oxygen when the resident was short of breath but did not document it on the MAR. The RN/UM confirmed that the MAR did not show oxygen administration and that the care plan did not document the resident as being on oxygen continuously or intermittently. The DON stated that oxygen should have been care planned and that nurses were responsible for signing out oxygen when administered. The facility policy on oxygen administration required documentation of the resident condition, oxygen administered, SpO2 testing, and response to therapy, and the care plan policy stated that care plans should address the resident’s needs and be updated with changes in condition.
Incomplete Dementia Care Plan With No Resident-Specific Behavior Interventions
Penalty
Summary
The facility failed to develop an individualized comprehensive assessment and care plan with resident-specific interventions for a resident diagnosed with dementia and anxiety, and failed to follow its dementia care policy. The resident’s diagnoses included dementia with other behavior disturbance, anxiety disorder, hypothyroidism, and hypertension. The quarterly MDS dated 8/15/2025 indicated short- and long-term memory deficits, severe impairment in decision making, moderate assistance with ADLs, and no behaviors documented. During observation and staff interviews, the resident was described as confused, requiring supervision and direction, and needing assistance with washing, dressing, and tray setup. Staff reported sundowning, restlessness, pacing in a wheelchair, wandering, trying to stand up from the wheelchair, yelling, and needing redirection with guiding, food, toileting, and occasional Xanax. The LPN/UM and other staff stated the resident was calm in the morning but restless in the afternoon and early evening, and that staff sometimes had to sit with the resident or use activities such as reading, going outside, snacks, or folding clothes as diversion. The ICP dated 5/12/2025 had a dementia focus, but the interventions were general and not resident specific, including simple words or instructions, maintaining a safe environment, offering two choices, and evaluating the medication regimen. The psychiatric evaluation dated 9/3/2025 documented anxiety, dementia, and behaviors occurring after dinner, including restlessness, trying to stand from the wheelchair, and wandering looking for the resident’s daughter. Staff, including the DSW, DON, AA, and LPN/UM, confirmed there were no documented interventions on the ICP to address the resident’s specific behaviors, triggers, calming techniques, or activity interventions, and the SW acknowledged there was no documentation in the progress notes or dementia ICP regarding those behaviors.
QAPI Committee Missing Required Infection Preventionist Member
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) was present for quarterly QAPI meetings and failed to include the IP as a member of the QAA Committee. During interview, the IP stated that she had worked at the facility for the past two and a half years in her current role and had never attended a QAPI meeting, explaining that she provided infection control information to the DON, who then presented it during the QAPI meetings. The ALNHA stated that the IP did not attend QAPI meetings and was not a member of the QAA committee, and that the DON presented infection control information during the meetings. Review of the facility’s 2025 quarterly QAPI attendance sheets for meetings held on 01/28/2025, 04/25/2025, and 07/29/2025, along with the list of QAA committee members, showed that the IP did not attend any of the QAPI meetings and was not listed as a member of the QAA committee. The facility policy dated 04/01/2025 stated that the facility would develop a QAPI plan in accordance with Federal Guidelines.
Antibiotic Roster Missed Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to consistently implement its Antibiotic Stewardship Program because its monthly antibiotic roster for 08/2025 did not include a resident who had received IV antibiotics during that month. The resident was admitted with diagnoses including infection following a procedure at the lumbar spine surgical site and MRSA infection. The resident’s admission MDS dated 08/06/2025 showed a BIMS score of 15 out of 15, and Section O indicated the resident had received IV medication. The comprehensive care plan dated 07/28/2025 identified that the resident was receiving IV antibiotic therapy for an MRSA wound infection. The resident’s physician orders dated 08/03/2025 included cefazolin 2 grams in 50 milliliters of dextrose IV piggyback every 8 hours for a total of 142 doses. During interviews, the IP stated she kept detailed records for residents receiving antibiotics but was not sure what clinical criteria the facility used to diagnose infections and was not familiar with established clinical criteria used to identify infections in LTC facilities. The Assistant Licensed Nursing Home Administrator stated that if the resident had received IV antibiotics, the resident should have been included on the monthly antibiotic roster. The consultant pharmacist and Medical Director stated that the facility used the SBAR form as the primary tool for tracking and managing antibiotic usage, while the facility policy required a monthly infection control report with quantitative and qualitative rationale for antibiotic use, effectiveness, and adverse side effects.
Infection Preventionist Did Not Perform Required Infection Control Responsibilities
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) actively performed responsibilities in accordance with the designated role for implementing programs and activities to prevent and control infections. During interview, the IP stated she was not sure what specific criteria the facility used for diagnosing infections and said she would need to follow up to determine that information. She also stated she was not familiar with established clinical criteria used to identify infections in LTC facilities, was not involved in the facility’s water management or treatment plan because those responsibilities were handled by maintenance, and did not conduct regular surveillance in the kitchen or laundry areas, entering those areas only if she needed something. The Assistant Licensed Nursing Home Administrator stated she was unsure what clinical criteria the facility used to identify infections, confirmed that the IP did not conduct surveillance in the kitchen or laundry areas, and said the IP instead did weekly rounds throughout the facility every Monday with the Maintenance Director. The facility policy titled Infection Control Rounds stated that infection control rounds are intended to evaluate compliance with infection control policies and procedures throughout the facility and that collected data are to be used for staff education and improving resident care and facility practices.
Failure to Offer Pneumococcal Vaccine on Admission
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccination was offered to a resident upon admission. Resident #87 was admitted with diagnoses including a displaced fracture of the left lower leg and encounter for orthopedic aftercare, and the most recent MDS dated 7/22/2025 showed a BIMS score of 12 out of 15, indicating moderately impaired cognition. The MDS also indicated that the pneumococcal vaccine was offered but declined. However, the resident's Immunization Consent form dated 7/16/2025 showed that the pneumonia vaccine was desired, and a handwritten note on the printed copy stated that the resident had received the pneumonia vaccine previously in 2024, which was not identified in the electronic medical record. The resident's Nursing Immunization Record, created on 7/16/2025 and completed on 7/2/25, indicated that the resident's pneumococcal vaccination was up to date. During interview, the Infection Preventionist stated she oversaw immunization consents and said the resident was admitted for short-term rehabilitation and that the pneumococcal vaccine was only admitted to long-term care residents. The DON later confirmed that all residents, both long-term care and short-term rehabilitation, should be offered the pneumonia vaccine and that it was one of the questions asked during admission. The facility's undated policy stated that the pneumococcal vaccine shall be offered to every resident upon admission unless medically contraindicated or refused.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff on a 24-hour basis to meet the needs of residents, as evidenced by multiple observations and interviews. During an initial tour, residents reported a shortage of nurses and aides, particularly on weekends, which affected their care. For instance, one resident mentioned not receiving a bed bath due to staffing shortages. The Resident Council Meeting further highlighted concerns about inadequate staffing, especially at night, with residents noting that staff breaks seemed to coincide, leaving them without necessary care. The facility's staffing records from two separate periods revealed consistent deficiencies in CNA staffing during day shifts and occasional shortages during evening and overnight shifts. For example, during a two-week period in July and August 2023, the facility was deficient in CNA staffing for all 14 day shifts, with similar issues noted in April 2024. Interviews with staff, including a Registered Nurse and a CNA, confirmed these challenges, citing frequent call-outs and insufficient staffing levels, particularly on weekends. The facility's staffing plan, as outlined in the Facility Assessment, was not being met, as confirmed by the Director of Nursing. The plan detailed specific staffing levels for different shifts and floors, but the DON acknowledged that these levels were not consistently achieved, especially on weekends when Unit Managers were not present. This discrepancy between the staffing plan and actual staffing levels contributed to the deficiency in providing adequate care to residents.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by a surveyor in the presence of the Food Service Director (FSD). In the dry storage room, seven bottles of Smucker's Breakfast syrup were found, six of which had expired. The FSD removed these expired syrups from storage. Additionally, in the walk-in freezer, a plastic bag containing frozen hash brown potatoes was covered in ice and lacked any dates, leading to its disposal by the FSD. Furthermore, a box of frozen French fries was found with the bag opened and exposed to air, which was also discarded by the FSD. The facility's policy on Dating and Labeling, established in December 2022, requires all food items stored outside their original containers to be labeled and dated with an expiration date of five days unless otherwise specified. The policy mandates that all kitchen staff are responsible for labeling items as they are opened and stored, with verification by prep cooks and cooks at the end of each service day. The observed deficiencies indicate a failure to adhere to this policy, as evidenced by the presence of expired and improperly stored food items.
Failure to Issue Required Beneficiary Notices
Penalty
Summary
The facility failed to issue the required beneficiary notices for two residents reviewed for Beneficiary Protection Notification. For both residents, the Skilled Nursing Facility Beneficiary Protection Notification Review indicated that their last covered Medicare day was 02/29/2024, and they remained in the facility. The facility claimed to have provided a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 to both residents. However, when the surveyor requested copies of these forms, the Administrator in Training (AIT) provided copies of the residents' signed Admission Agreements instead. During interviews with the surveyor, the AIT admitted that the facility uses section 5 of the admission agreement as the SNFABN instead of the CMS-10055 form. The AIT acknowledged awareness of the CMS-10055 form but stated that the facility was waiting to see if they would be instructed to change their practice. The AIT further clarified that although this issue is questioned every year during surveys, it has never been formally identified as a deficiency until now.
Failure to Document Weekly Weights as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order for weekly weights for a resident, leading to a deficiency in meeting professional standards of quality. The resident, who was admitted with diagnoses including surgical aftercare following digestive system surgery and major depressive disorder, had a physician order for weekly weights to be taken on Mondays before breakfast. However, a review of the Medication Administration Records (MAR) for March and April 2024 revealed that the weights for March 25 and April 15 were not documented, indicating that the weights were not completed as ordered. Interviews with facility staff, including an LPN, the Unit Manager, and the Director of Nursing, revealed inconsistencies in the process of obtaining and documenting weights. The LPN stated that weights are usually done by CNAs, while the Unit Manager confirmed that the MAR was blank for the specified dates and acknowledged that if there is no documentation, the weight was not done. The Director of Nursing noted that due to staffing challenges, nurses are responsible for weighing residents and ensuring documentation in the MAR. The facility's policy on weight monitoring and physician's orders emphasized the need for documentation and execution of orders, which was not followed in this case.
Failure to Monitor SPO2 for Resident with PRN Oxygen Order
Penalty
Summary
The facility failed to consistently assess or measure blood oxygen saturation (SPO2) for a resident with an order for PRN supplemental oxygen use. This deficiency was identified during a survey when an oxygen concentrator was observed in the resident's room but was not in use. The resident, who had diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and congestive heart failure, had a physician's order to administer oxygen if SPO2 dropped below 92%. However, there was no evidence of regular SPO2 monitoring in the resident's medical records for March and April 2024. The surveyor's review of the electronic medical record revealed that the resident had an active order from June 2023 for PRN oxygen administration if SPO2 fell below 92%. Despite this, there were no documented SPO2 readings from June 2023 until April 2024, except for a few entries in early June 2023 and late April 2024. The facility's Director of Nursing (DON) confirmed the absence of SPO2 monitoring records for the specified period and acknowledged that the physician's order required regular SPO2 checks to determine the need for oxygen therapy. Interviews with facility staff, including the Unit Manager/Registered Nurse, indicated a lack of clarity regarding the facility's policy for PRN oxygen use and SPO2 monitoring. The facility's policy required daily SPO2 checks for residents on PRN oxygen, but this was not adhered to for the resident in question. The DON admitted that the policy had been revised after COVID-19, but the requirement for daily SPO2 checks remained unchanged. This oversight led to the deficiency in providing appropriate respiratory care for the resident.
Infection Control Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols concerning respiratory equipment for two residents. For one resident, the nasal cannula tubing was observed with a date indicating it had not been changed for over two weeks, despite physician orders requiring weekly changes. Interviews with nursing staff confirmed that the tubing should be changed weekly, but it was not done, leading to a lapse in infection control practices. Another resident was found with a nasal cannula draped over a trash can while receiving oxygen therapy, and a nebulizer mask was left exposed on a bedside table. The facility's policy mandates that respiratory equipment should not touch the floor and should be covered when not in use. Interviews with nursing staff revealed that the resident often played with their equipment, but the staff acknowledged that the equipment should not have been left in such conditions. Both residents had significant respiratory diagnoses, including chronic obstructive pulmonary disease and pneumonia, which necessitated careful management of their respiratory equipment. The facility's failure to follow its own policies and physician orders for changing and storing respiratory equipment contributed to the deficiencies observed by the surveyors.
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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 Toms River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Bey Lea, Llc | 0.9 mi | ★★★★★ | 13 | 0 |
| Hampton Ridge Healthcare And Rehabilitation | 1.3 mi | ★★★★★ | 9 | 0 |
| Childrens Specialized Hospital Toms River | 1.3 mi | ★★★★★ | 0 | 0 |
| Complete Care At Green Acres | 1.8 mi | ★★★★★ | 0 | 0 |
| Complete Care At Shorrock | 2.8 mi | ★★★★★ | 9 | 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.