Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Runnells Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and a PEG tube reported that two female nurses pointed fingers and used swear words toward them during nighttime care, while denying rough physical treatment. The resident did not inform staff but told a family member, who then emailed the facility SW with concerns about rough care and verbal abuse. The SW did not review and elevate this email until returning to work several days later and was unable to confirm whether the allegations were investigated. The LNHA and Regional Clinical Director were not made aware of the alleged abuse until the SW later provided the email, despite facility policy requiring prompt reporting of suspected or alleged abuse.
A resident with multiple medical conditions was admitted and had medications reconciled by an LPN/UM who failed to verify that all pages of a multi-page medication list belonged to the correct individual, resulting in transcription of another resident’s psychotropic and cardiac medications into the new admission’s EMR and MAR. These incorrect medications, including furosemide, lithium ER, trazodone, clonazepam, and risperidone, were then administered over several days until the resident’s representative questioned the accuracy of the list and reported that the resident was not completing sentences. Review of records and staff interviews confirmed that the medications actually belonged to another resident and that the provider had been given inaccurate information when admission orders were obtained.
A resident with paraplegia, generalized weakness, incontinence, and a urinary catheter was transferred to a hospital for altered mental status, hypotension, diarrhea, and later admitted with septic shock, where the resident was identified as having Candida auris (CA). The IP stated the facility had the ability, PPE, and staff education to care for residents requiring Enhanced Barrier Precautions for CA. However, the DON and Admissions Director reported that, based on an internal corporate clinical capabilities list and an upper management decision that the facility was “not a C. Auris facility,” the resident was not allowed to return after hospitalization, resulting in a deficiency related to failing to ensure the transfer/discharge met the resident’s needs and preferences.
Surveyors identified that staff failed to consistently document care and services provided to two residents with severe cognitive impairment, including required behavior monitoring and two-hour safety rounds, as outlined in their care plans. Electronic records showed numerous missing entries for behavior and elimination monitoring, and facility leadership confirmed that these interventions were not documented as required by policy.
A resident with severe cognitive impairment was found with unexplained bruising on the right eye and arm. The facility investigated the incident but did not report it to the NJDOH as required, and failed to update the care plan to address the use of aspirin, the new bruising, or the resident's dementia. Facility policies for reporting and care planning were not followed.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss, but the facility failed to ensure accurate weight documentation and consistent monitoring of food intake. Weight records were incomplete or inaccessible in the eMR, and most shifts lacked documentation of meal consumption, despite care plan and policy requirements. Staff interviews confirmed that re-weights and intake monitoring were not properly recorded or available for review.
A CNA stood beside a blind resident and fed her breakfast while other residents were present, rather than assisting her in a dignified manner. In the same dining room, a hungry resident was given a bowl of hot cereal taken from another resident's tray without asking that resident if she was done eating. The DON agreed staff should not stand beside residents while helping them eat and that food should not be taken from one resident and given to another.
Failure to apply hand splints per the care plan was identified for a resident with TBI and bilateral hand contractures. Staff observed the resident with feet splints on but no hand splints, and documentation did not show hand splint use. CNAs, an LPN, the unit manager, and the DON stated they were unaware the resident was to wear hand splints or that the care plan was not being followed.
Improper glove use and hand hygiene were observed during meal service when a cook and two dietary aides handled ready-to-eat foods and food service items without changing gloves after touching other surfaces. One aide touched the inside of coffee cups and a heated cart with the same gloves, the cook handled sink surfaces, buns, and cooked foods without changing gloves, and another aide touched a cooler handle before preparing sandwiches. The FSD agreed the staff did not change gloves after contamination.
Improper glove use during resident care: A CNA and an LPN both used multiple layers of gloves while providing personal care and wound care to a resident. The CNA washed and dressed the resident while changing glove layers between tasks, and the LPN used four layers of gloves during wound care, removing pairs as she cleansed the wound and applied dressing materials. The IP stated this did not follow the facility’s glove policy, which requires hand hygiene after glove removal.
The facility failed to accurately code the MDS for two residents, leading to discrepancies in their medical records. One resident's use of antidepressant medication was not reflected, and another resident's multiple falls were not documented in the MDS. The errors were acknowledged by the facility's staff, who indicated that corrections would be made.
The facility failed to ensure that the primary physician conducted face-to-face visits and wrote progress notes at least once every sixty days for a resident with anxiety and depressive disorders. Instead, the NP conducted all visits within the specified period, with no documented evidence of the primary physician's involvement.
The facility failed to adequately monitor and document the target behaviors, interventions, and outcomes for a resident on psychotropic medications, leading to an incident of resident-to-resident abuse. The nursing staff did not understand how to properly use the Behavior Monitoring for Medication (BMFM) system, resulting in incorrect documentation.
Failure to Timely Review and Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the failure of the facility Social Worker (SW) to timely review and act upon an email reporting alleged verbal abuse and rough care toward a resident. The resident, who had a BIMS score of 10/15 indicating moderately impaired cognition and required staff assistance with ADLs, reported that on a nighttime occasion two female nurses, one with black hair and one with reddish dark hair, pointed their fingers and swore at them. The resident denied that staff were rough with PEG tube care or caused pain and stated that only swear words were used. The resident did not report the incident to staff but informed a family member the following day. The resident’s concerned contact (CC) sent an email to the facility SW describing care concerns, including allegations of rough care and staff cursing loudly at the resident. This email was sent on 4/10/26, but the SW, who was off until 4/14/26, did not review and bring the email forward until returning and mentioning it in a morning clinical meeting. The SW could not state whether the allegations were investigated. The LNHA and Regional Clinical Director reported that they were unaware of the alleged abuse until 4/16/26 when the SW handed the email to the LNHA. This sequence of events occurred despite the facility’s Abuse, Neglect, Misappropriation Prevention Policy requiring staff to report any suspected, actual, or alleged abuse, neglect, or mistreatment to a supervisor, department head, or the administrator.
Significant Medication Error from Incorrect Medication Reconciliation
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors during the admission and medication reconciliation process. A resident identified as having diagnoses including influenza, depression, cerebral infarction, hyperlipidemia, hypertension, and cardiac arrhythmia was admitted to the facility. An LPN/Unit Manager (LPN/UM) was responsible for reviewing the admission packet and reconciling the resident’s medications. While transcribing the medication list, which was on multiple pages, the LPN/UM did not verify that each page belonged to the correct resident and mistakenly used another resident’s medication list. As a result, medications prescribed for a different resident were entered into this resident’s electronic medical record and medication administration record (MAR). Review of the January MAR and order summary report for the admitted resident showed that several medications not ordered for this resident by the transferring facility were listed and administered. These included furosemide 20 mg daily, lithium carbonate ER 450 mg daily, trazodone 100 mg at bedtime, clonazepam 0.5 mg twice daily, and risperidone 3 mg twice daily. The transferring facility’s medication list for this resident did not contain any of these medications. Further review of records showed that these medications actually belonged to another resident with diagnoses including schizoaffective disorder, heart failure, and hypertension. The LPN/UM’s written statement confirmed that she failed to verify that each page of the multi-page medication list was for the correct resident, which led to entering the wrong medications and providing inaccurate information to the provider when obtaining verbal orders. The MAR documented that the wrong medications were administered over multiple days. Clonazepam and risperidone were given starting on the day of admission and continued on subsequent days; trazodone was administered at bedtime on several consecutive nights; and furosemide and lithium were administered daily on multiple mornings. The error was discovered only after the resident’s representative informed facility staff that the medications on the list were not accurate and reported that the resident was not completing sentences. The facility’s investigation, interviews with staff, and review of the medical record confirmed that the medication reconciliation process was not performed correctly, that the LPN/UM used another resident’s medication list, and that the attending physician had been provided with incorrect medication information when admission orders were obtained.
Removal Plan
- Assess and monitor the resident for any adverse reaction, including vital signs and level of consciousness; initiate and maintain neurological checks until the resident is sent out for further evaluation.
- Initiate an investigation into the incident and suspend the identified LPN/UM pending the outcome of the investigation.
- Audit all new admissions and re-admissions (including discharged medication reconciliation records) to ensure accuracy, proper transcription, physician orders, and compliance with the facility's admission protocol.
- Provide re-education for licensed nursing staff on the facility's admission process, medication reconciliation requirements, nurse accountability, and resident identification procedures.
- Educate licensed nursing staff on a protocol requiring two-nurse verification for transcription and review of hospital discharge medication lists and use of two resident identifiers prior to medication transcription and administration.
Failure to Readmit Resident With Candida auris Despite Facility Capability
Penalty
Summary
The deficiency involves the facility’s failure to allow a cognitively intact resident with an infectious diagnosis requiring Enhanced Barrier Precautions to return from the hospital, despite the facility’s ability to provide the necessary care. The resident had multiple diagnoses including compartment syndrome, paraplegia, generalized muscle weakness, and a need for assistance with personal care, and was frequently bowel incontinent with a urinary catheter. The resident was transferred to an acute care hospital for altered mental status, hypotension, and diarrhea, and was subsequently admitted for septic shock. While hospitalized, the resident was identified as positive for Candida auris (CA). The facility’s Infection Preventionist reported that cultures for CA were negative and stated that the facility had the ability to care for residents with CA, including having adequate PPE and staff education for contact isolation. Despite this, the DON stated that the facility was notified that the resident was positive for CA and that, based on an internal facility document and a decision made by upper management, the facility was “not a C. Auris facility” and therefore did not accept residents with CA. The DON described CA as highly contagious and cited this as the reason for not accepting the resident back. The Admissions Director reported that a family member informed her of the CA diagnosis and that she told the family the facility generally did not accept residents with CA, referencing a corporate-supplied clinical capabilities list that specified which conditions the facility could and could not manage. The facility’s refusal to readmit the resident, despite the Infection Preventionist’s statement that the facility could care for residents with CA and had appropriate resources, led to the identified deficiency related to ensuring transfers/discharges meet resident needs and preferences and preparing for a safe transfer/discharge.
Failure to Document Care and Services per Professional Standards
Penalty
Summary
The facility failed to ensure that staff consistently documented care and services provided to residents in accordance with professional standards, as required by the Nurse Practice Act and facility policy. Specifically, for two of three residents reviewed for accident/incident, there were significant gaps in documentation related to behavior monitoring and implementation of care plan interventions. For one resident with Alzheimer's disease, dementia, and diabetes, the care plan required monitoring for wandering behaviors and safety rounds every two hours. However, electronic documentation revealed numerous shifts with missing entries for behavior monitoring, and the Assistant Director of Nursing (ADON) confirmed that the required two-hour monitoring was not documented anywhere. Another resident, admitted with dementia and behavioral disturbances, was identified as high risk for falls and required two-hour rounding at night and toileting assistance prior to bed. Review of the electronic documentation system showed multiple shifts with missing entries for bowel and bladder elimination monitoring, as well as behavior monitoring. The ADON acknowledged that there was no documentation to support that the individualized care plan interventions were implemented for this resident. The facility's own policy required documentation of all pertinent psychosocial, medical, and nursing observations, including the plan of care and resident response. Despite this, the survey found repeated instances where required documentation was missing, and facility leadership could not provide evidence that care plan interventions were carried out as documented. This failure to maintain complete and accurate records constituted a deficiency in meeting professional standards of quality.
Failure to Report Injury of Unknown Origin and Update Care Plan
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey State Department of Health (NJDOH) and did not fully implement its policy for accidents and incidents by neglecting to thoroughly update the care plan after the event. A resident with severe cognitive impairment and dependent functional status was observed with unilateral bruising on the right eye and right arm. The incident was documented in the medical record, and witness statements were collected, but the event was not reported to the state as required. The Assistant Director of Nursing (ADON) confirmed that no reportable event was filed with the NJDOH, despite the facility investigating the bruises as being of unknown origin. The facility's investigation attributed the bruising to the resident's use of aspirin and underlying dementia, but did not establish a definitive root cause. Additionally, the care plan was not updated to include interventions related to the use of anticoagulants, the new bruising, or the resident's dementia diagnosis. The interdisciplinary team met to discuss the incident, but the care plan lacked specific focus and interventions addressing the identified issues. The facility's own policies required individualized interventions and reporting of such incidents, which were not followed in this case.
Failure to Accurately Monitor and Document Resident Weight and Food Intake
Penalty
Summary
The facility failed to ensure the accuracy of a resident's weight and to monitor the resident's food intake as required by the care plan. The resident, who had diagnoses including Alzheimer's disease, dementia with psychotic disturbances, and type 2 diabetes, was noted to have severely impaired cognition and behavioral symptoms. The resident's weight records showed a decline from 162 lbs to 147 lbs over several months, with one weight entry being crossed off by the Registered Dietician (RD) due to concerns about its accuracy. The RD did not document re-weights in the electronic medical record (eMR), and the re-weight information was not accessible to other staff, as it was kept in the RD's office and not entered into the eMR. Interviews with staff revealed that weights were obtained by CNAs and entered into a weight binder, with the RD providing lists of residents needing re-weights. However, the Assistant Director of Nursing (ADON) confirmed that these records were not part of the official medical record, and that weights and re-weights should have been available in the eMR for review by ancillary providers. This lack of documentation meant that weight variances were not thoroughly investigated or accessible to all relevant staff. Additionally, the care plan for the resident included monitoring oral intake as needed, but review of the electronic point-of-care system (POCS) showed significant gaps in documentation. For two consecutive months, the majority of shifts lacked documentation of the percentage of meals consumed by the resident, with only a small fraction of shifts having this information recorded. Facility policies required CNAs to monitor and document dietary intake for each meal, but this was not consistently done, contributing to the deficiency.
Failure to Maintain Dignity During Dining Assistance
Penalty
Summary
The facility failed to ensure three residents had a dignified dining experience. R172 had a BIMS score of 9 out of 15, indicating moderate cognitive impairment, R204 had a BIMS score of 4 out of 15, indicating severe cognitive impairment, and R218 had a BIMS score of 0, also indicating severe cognitive impairment. During observation in the 3W unit dining room, CNA2 was standing beside R172 and feeding her breakfast while other residents were present. R172 was blind and seated in a high-back wheelchair, and CNA2 fed her entire breakfast while standing. At the same observation, R204 was loudly saying he was still hungry, and CNA2 removed a bowl of hot cereal from R218's breakfast tray and gave it to R204 without asking R218 if she was done eating or still hungry. During interview, CNA2 stated she thought it was alright to give R218's cereal to R204 because the cover was still on it, but acknowledged she had not observed R218 at all times to know whether the cereal had been touched. The DON agreed staff should not stand beside a resident while helping them eat and confirmed that taking food from one resident's tray and giving it to another should not have been done.
Failure to Apply Ordered Hand Splints
Penalty
Summary
Failure to provide a resident with hand splints according to the care plan was identified for a resident admitted with traumatic brain injury and contractures of both hands. The resident's quarterly MDS documented persistent vegetative state, functional limitation in range of motion in all extremities, and total dependence on staff for personal care. The care plan dated 06/17/25 stated the resident was to continue wearing a left hand splint and right grip orthosis after morning care and have them removed before evening care, but the physician orders reviewed on 08/01/25 did not include an order for hand splints. Nursing notes from 07/01/25 through 08/12/25 did not document splint use, and two observations showed the resident sitting in her chair with feet splints on but no hand splints. The family member stated staff had not been placing the hand splints and wanted a device to prevent the resident's nails from rubbing and irritating her hands. CNAs and an LPNS stated they were not aware the resident required hand splints, and the unit manager and DON confirmed the resident needed a physician order for splints and that staff were not following the care plan. The Director of Rehabilitation stated the resident had splints on both hands during a recent quarterly assessment and had no decrease in ROM.
Improper Glove Use and Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper glove use and hand washing during meal service when one cook and two dietary aides handled ready-to-eat foods and other food service items without changing gloves after touching other surfaces. During observation in the kitchen, a dietary aide placed Styrofoam coffee cups on a tray with gloved hands, put fingers inside each cup, filled the cups with coffee, carried the tray to a heated cart, opened the cart with the same gloves, and then returned to fill another tray while again touching the inside of each cup without changing gloves. A cook was observed pureeing rice while wearing gloves and touching the three-compartment sink multiple times, then placing the rice in the steamtable, removing covers from other containers, handling hamburger and hot dog buns from a bag, and later dishing food and placing cooked hamburgers and hot dogs on buns with the same gloves. Another dietary aide, while wearing gloves, touched the walk-in cooler handle, retrieved cheese and ham, returned to the prep area, and then handled bread, cheese, and ham to prepare sandwiches. The Food Service Director agreed the cook and dietary aides had not changed gloves after touching other surfaces, and the facility policy stated gloves are a food contact surface that must be changed when contaminated or when interruptions occur.
Improper glove use during resident care
Penalty
Summary
The facility failed to ensure proper glove technique during personal care and wound care for one resident who was observed receiving both types of care. During personal care, a CNA entered the resident’s room, washed her hands, put on a protective gown and two pairs of gloves, retrieved her cell phone from the supply cart, and continued care while looking at the phone. She provided bathing and perineal care, removed one layer of gloves, then used another washcloth to cleanse the resident’s bottom before removing the remaining gloves and washing her hands. During wound care, an LPN placed dressing supplies on the wound cart, left to retrieve additional supplies, then entered the room, washed her hands, put on four layers of gloves and a protective gown, and placed a barrier on the overbed table. She removed the first pair of gloves and cleansed the wound twice with wound cleanser and gauze, removed the second pair of gloves and applied Triad paste with her gloved hand, then covered the wound with a border dressing. The CNA and LPN both stated that using multiple gloves was how they had been taught or that it saved time, while the Infection Preventionist stated the practice did not follow the facility’s glove policy and that one pair of gloves should have been used with hand hygiene between each glove change.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their medical records. For Resident #200, the MDS did not reflect the use of an antidepressant medication, despite the resident's admission record and physician's orders indicating the use of Sertraline HCL for depression. The MDS Coordinator acknowledged this as a data entry error and stated that the MDS assessment would be corrected. The facility's policy requires the MDS Coordinator to ensure appropriate edits are made before transmitting MDS data, which was not followed in this case. For Resident #655, the MDS did not accurately reflect multiple falls that occurred within the assessment period. The resident's medical records and incident reports documented falls on several occasions, but the quarterly MDS indicated no falls. The MDS Coordinator stated that the MDS Nurse responsible for completing that section should have included the data. The facility's policy mandates that all MDS assessments be completed and transmitted accurately, which was not adhered to in this instance. Both deficiencies highlight a failure in the facility's process for ensuring accurate MDS coding, which is crucial for the management of resident care. The inaccuracies in the MDS assessments for both residents were acknowledged by the facility's staff, who indicated that corrections would be made following the surveyor's findings.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the primary physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days. This deficiency was identified for one resident who had diagnoses including generalized anxiety disorder and major depressive disorder. The review of the resident's medical records revealed that the primary physician did not visit and examine the resident at least every 60 days, as required. Instead, the Nurse Practitioner (NP) conducted all the visits within the specified period, with no documented evidence of the primary physician's involvement. Interviews with the VP of Clinical Services and the Director of Nursing (DON) confirmed that the primary physician should have conducted face-to-face visits at least every 60 days when alternating with an NP. The NP also confirmed that she visited the residents monthly and that the primary physician was required to visit quarterly. Despite these acknowledgments, there was no additional information provided by the facility to demonstrate compliance with the required physician visit schedule. The facility's policy also stipulated that after the first ninety days, the primary physician's visits should not exceed every sixty days, which was not adhered to in this case.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor the target behaviors for the number of episodes, behavioral interventions, and their outcomes for the use of psychotropic medications in accordance with facility policy. This deficiency was identified for one resident who was involved in a resident-to-resident interaction that resulted in abuse. The incident occurred when a Licensed Practical Nurse (LPN) witnessed the resident strike another resident twice in the face. The resident had a history of unspecified dementia with behavioral disturbances and major depressive disorder, and was on medications including Ativan and Depakote for anxiety and mood stabilization, respectively. The review of the resident's medical records and electronic Medication Administration Record (eMAR) for June and July 2023 revealed that behaviors were documented without specifying whether they were for anxiousness or explosive aggressive behavior. Additionally, the documentation lacked details on the number of episodes, non-pharmacological interventions, and the outcomes of these interventions. This was a significant oversight as the facility's policy required detailed behavior monitoring to manage problematic behaviors appropriately. Interviews with the Director of Nursing (DON) and the President of Clinical Services confirmed that the nurses did not understand how to properly use the Behavior Monitoring for Medication (BMFM) system. The DON acknowledged that the order was for behavior monitoring, not just the administration of medication, and that the documentation on the BMFM was incorrect. This lack of proper documentation and understanding among the nursing staff contributed to the failure in adequately monitoring and managing the resident's behaviors, leading to the incident of resident-to-resident abuse.
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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 Berkeley Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Berkeley Heights | 1.3 mi | ★★★★★ | 8 | 0 |
| Mcauley Hall Health Care Cente | 1.7 mi | ★★★★★ | 14 | 0 |
| Continuing Care At Lantern Hill | 1.8 mi | ★★★★★ | 4 | 1 |
| Spring Grove Rehabilitation And Healthcare Center | 2.6 mi | ★★★★★ | 18 | 0 |
| Aristacare At Norwood Terrace | 3 mi | ★★★★★ | 0 | 0 |
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