Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Skilled Nursing At Fellowship Village during CMS and state inspections, most recent first.
Kitchen sanitation and food storage deficiencies: Surveyors observed a can-opener blade with missing areas and congealed residue, cutting boards with deep etching and discoloration, scoops stored in food containers instead of on the hook, multiple frozen foods left unsealed and exposed to air and frost, and 6 trash cans without appropriate covers in several kitchen areas. The FSD acknowledged the concerns, and the RDM stated the can-opener blade should be changed regularly and equipment should be hand scrubbed before high temp washing.
Failure to provide documented medically-related social services for a resident transitioning from rehab to LTC. A cognitively intact resident with repeated falls and depression said they had not discussed their LTC plan of care and did not know if the facility had a SW. Record review found a discharge-focused care plan was discontinued when the resident became LTC, with no other active SW interventions located, and the SW and DON could not identify documentation of resident or family discussions in the EMR.
Missing consent for psychoactive medications: The facility failed to document informed consent for psychoactive drug therapy for two residents. One resident with severe cognitive impairment was receiving Risperidone and Venlafaxine, and the consent form in the admission packet was not signed until after surveyor inquiry. Another resident with dementia, COPD, CHF, and DM2 was receiving Mirtazapine, but the psychoactive medication consent form in the admission packet was left blank, and staff interviews confirmed the admission paperwork was not completed.
Missing Pre-Employment Screening for Newly Hired Staff: The facility failed to follow its abuse prevention, hiring, and employment history check policies by not documenting a criminal background check for a Homemaker and not documenting reference checks for a CNA before employment began. Survey review of personnel files showed the required screening was absent, and the HR Recruiter stated the facility normally obtains two references and completes background checks before the first day of hire.
A resident admitted with dementia, anxiety, COPD, CHF, and DM2 was observed on O2 and receiving insulin, but the baseline care plan was not completed or provided with signatures. Record review showed the paper baseline care plan summary was left blank except for the date, and staff interviews confirmed the admission paperwork and baseline care plan were missed.
A facility failed to update care plans for two residents after changes in status and orders. One resident had dysphagia, a feeding tube, and an order for pleasure feeds, but the care plan still reflected NPO and tube feeding only. Another resident's care plan still listed a cervical collar and RUE sling even though both orders had been discontinued, and an LPN acknowledged the items were old and no longer reflected the resident's current condition.
A resident with muscle weakness, left hemiparesis, and impaired left wrist ROM was observed wearing a left wrist brace and had another brace in the room, but the EMR did not show a physician order or wearing schedule for the device. The RN/CN stated there was no order for the brace and that it was not care planned, while the OT said no wearing schedule had been established and she thought the brace was a doctor’s order. The resident’s record also noted contracture, continued brace use, and risk for skin breakdown.
Improper Storage of Urinary Catheter Drainage Bag: A resident with a suprapubic catheter had a bedside drainage bag observed hanging on a bathroom handrail with the uncapped tube tip on the floor. The CNA stated she removed the night bag, washed it, and hung it on the rail for reuse, while the RN, IP, and DON all confirmed the tubing tip should not have been on the floor because it was an infection control issue. The resident had orders for catheter care, a bedside drainage bag at night, and a leg bag during the day, but the care plan did not include a focus or intervention for changing or disposing of the drainage bag per facility policy.
A facility failed to follow its flu and pneumococcal vaccine policies for three residents by not consistently documenting education, risks/benefits discussion, and refusals in the chart. One resident had incomplete and unsigned admission vaccination forms despite EMR refusals for both flu and pneumococcal vaccines; an LPN said the paperwork was started but not completed, and the DON acknowledged the forms were not signed or verified. For two other residents, the EMR noted vaccine refusals and education, but the hard charts contained blank or incomplete consent forms, including one resident with dementia and another with a BIMS of 14.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
Kitchen equipment was observed in an unclean and unsafe condition during a surveyor tour of the kitchen. The can-opener blade had areas missing and a congealed orange residue in the top left corner, and the Food Service Director acknowledged that the blade had not been changed. Cutting boards, including 4 green and 8 white plastic boards, were observed with deep etching and black/brown discoloration. The Food Service Director acknowledged the concerns and stated the boards went through the high temperature wash machine, but could not identify the discoloration. Food storage and garbage handling were also observed to be out of compliance with sanitary practices. In the dry storage area, 2 containers of sugar and white rice had scoops stored in the product instead of on the hook within the container. In the freezer, multiple food items, including vegetable burgers, okra, pumpkin, macadamia cookies, and link sausage, were open to air and not sealed or stored in containers with tight fitting lids. The surveyor also observed 6 trash cans without appropriate covers in multiple kitchen areas, and the FSD acknowledged the concerns. The LNHA, DON, IP, RDON, and VPCO later acknowledged that the equipment should be cleaned, maintained, and lidded to prevent injury or cross contamination, and the RDM stated the can-opener blade should be changed regularly and equipment should be hand scrubbed before high temperature washing.
Failure to Provide Documented Social Work Services for Resident Transitioning to LTC
Penalty
Summary
Medically-related social services were not provided for a resident who had transitioned from rehabilitation to long-term care. Resident #16, who had diagnoses including repeated falls and depression and was cognitively intact with a BIMS score of 15 out of 15, told the surveyor they had fallen and been injured, had needed rehabilitation, and had lived in the facility for a long time. The resident also stated they used to live in an apartment and wished they could return, preferred to stay in their room, chose not to socialize with other residents, did not know whether the facility had a social worker, and could not recall discussing their plan of care or transition to long-term care with anyone. Record review showed a care plan focus initiated for support with a safe discharge plan to return home, but it was cancelled on 1/9/26 with the note, "Resident is now a LTC resident... Discontinue treatment plan." The surveyor could not locate other current or active social work focus areas or interventions. The DON reviewed the record and could not explain the social work note, and the SW could not locate documentation of conversations with the resident or family in the EMR at the time of the survey. Although the SW stated she saw the resident weekly and was familiar with them, the record contained limited social service documentation, and several care plan meeting summaries and a social service note were entered or signed only after surveyor inquiry.
Missing consent for psychoactive medications
Penalty
Summary
The facility failed to obtain documented consent for psychoactive medication therapy for 2 of 5 residents reviewed for unnecessary medications. For one resident, the record showed diagnoses including anxiety disorder, unspecified dementia, depression, and unspecified psychosis, with a BIMS score of 0 indicating severe cognitive impairment. The resident was receiving Risperdal and Effexor XR, and the care plan identified psychoactive medication use and the need to monitor for adverse effects. The admission packet contained a Consent for use of Psychoactive Medication Therapy form that had been filled out with the resident’s information and medications, but it was not signed until the date of surveyor inquiry. Surveyor review and staff interviews confirmed that the consent form for this resident had been left unsigned during the original admission period. An RN stated that the facility confirms consent during admission with a form in the admission packet and acknowledged that the form had been signed the previous day after consent was obtained by phone. The RN/UM stated that consent should be obtained upon admission for residents receiving psychoactive medications, even if they were already taking them, and acknowledged that the form had been signed after survey inquiry. The DON also acknowledged that the consent form had been left blank during the resident’s original admission and was signed after the surveyor asked for it. For the second resident, the record showed diagnoses including dementia, anxiety disorder, COPD, CHF, and type 2 diabetes mellitus, with a BIMS score of 15 indicating cognitive intactness. The resident was receiving oxygen, insulin, and Mirtazapine for depression. The admission packet contained a two-page Consent for use of Psychoactive Medication Therapy form that had no information completed, with the consent statement, signature lines, and telephone consent section all left blank. A note in the packet stated that the resident representative would return the next day to sign documents, but the record did not show that the consent was completed. Staff interviews confirmed the omission: the assigned LPN stated the paperwork should have been completed but was not, the RN/UM stated the facility missed it and the whole packet was not signed, and the DON acknowledged that the consent should have been completed and documented.
Missing Pre-Employment Screening for Newly Hired Staff
Penalty
Summary
The facility failed to implement its abuse prevention policy by not completing required pre-employment screening for newly hired staff reviewed since the prior survey. During the entrance conference on 3/30/26, the surveyor requested all newly hired employee files for active and inactive employees from 11/4/24 to the current date. Review of personnel records showed that Employee #4, a Homemaker with a hire date of 5/5/25, had no evidence of a background check prior to the start of employment, and Employee #5, a CNA with a hire date of 8/26/25, had no evidence of reference checks prior to the start of employment. The facility’s Selection and Hiring Policy, Employment History Checks policy, and Abuse Prevention policy all stated that applicants must complete criminal background checks and reference verification before hire or before beginning work, with at least two references obtained prior to making an offer of employment. On 4/2/26, the HR Recruiter stated that the facility normally receives two reference checks prior to hire and that background checks are completed prior to the first day of hire. The LNHA and DON were informed of the concerns, and the LNHA stated there was no additional information to present regarding the missing background check and reference checks.
Baseline Care Plan Not Completed or Signed for New Admission
Penalty
Summary
The facility failed to ensure that a written baseline care plan was completed and provided to the resident and/or resident representative within 48 hours of admission for one resident. Resident #61 was admitted with diagnoses including dementia, anxiety disorder, COPD, CHF, and type 2 diabetes mellitus. On the initial tour, the resident was observed in a reclining chair wearing oxygen via nasal cannula at 2 liters per minute and stated that, so far, the care was good. Record review showed the resident’s admission summary and MDS documented cognitive intactness, oxygen use, insulin, and an antidepressant. The individual comprehensive care plan included a focus for subacute care related to respiratory distress, DM2, and CHF, and a separate focus for antidepressant medication related to depression. However, the care plan did not include a focus or intervention for oxygen use or for receiving insulin. The progress notes showed that the admission packet was reviewed with the resident and that a call was made to a representative who would come the next day to sign necessary documents. The paper chart contained a two-page Client’s Baseline Care Plan Summary dated 3/13/2026, but no other information was completed on it. There was no signature from the resident, the resident representative, or the nurse completing the form. Staff interviews confirmed the baseline care plan was not completed and not signed. The LPN stated she started the admission paperwork and left a sticky note indicating the representative would return the next day, while the RN/UM and DON acknowledged that the baseline care plan should have been completed and signed but was not.
Care plans not updated for changed resident status and orders
Penalty
Summary
The facility failed to update the individualized comprehensive care plan for two residents after changes in their conditions and orders. For one resident, the record showed dysphagia, a feeding tube, and physician orders for a regular mechanical soft diet with nectar/mildly thick consistency and pleasure feedings on request only. The care plan still reflected NPO status and tube feeding dependency, but did not include the pleasure feeds that had been initiated and documented in the MAR and speech therapy communication form. For the second resident, the care plan continued to list interventions for a cervical collar and a sling to the right upper extremity even though the physician orders for both items had been discontinued months earlier. The resident was observed sitting, standing, and moving arms and legs without assistance, and stated they took care of themselves for dressing, bathing, and other ADLs. The nurse reviewing the care plan acknowledged that the collar and sling were old items and that the resident had not changed, but the care plan had not been updated to reflect the discontinued orders. The DON stated that care plans are initiated on admission and updated as the resident's condition changes, and that they are reviewed by the clinical team at least quarterly. The facility policy stated that the comprehensive care plan will be reviewed and revised or updated as necessary when a resident experiences a status change, and that the care plan will be updated with new or modified interventions accordingly. The surveyor determined that the care plans for these two residents were not updated to reflect the current orders and resident status.
Missing Order for Resident’s Wrist Brace
Penalty
Summary
The facility failed to obtain a physician’s order for a left wrist splint and/or brace for Resident #70. During observation, the resident was in bed wearing a left wrist brace, and the resident representative stated the brace was removed to wash the resident’s left hand and that the left wrist had no function and needed support to keep it straight. A blue brace was also observed on the windowsill, and the representative stated it was used on the left arm at night to keep it straight. Review of the medical record showed diagnoses including muscle weakness, cognitive communication deficit, and dermatitis. The MDS dated 3/19/26 indicated a BIMS score of 14 out of 15 and impairment on one side, upper extremity. The ICCP dated 3/20/26 did not include a focus area or intervention for use of a left arm/wrist/hand splint. The OT plan of care signed 3/20/26 documented impaired left wrist ROM and that the resident was wearing a splint with the wrist in neutral position with forearm supination. A provider follow-up note dated 3/27/26 stated the resident had left hemiparesis, left upper extremity weakness, contracture, and to continue brace and OT, with risk for skin breakdown. The Order Summary Report did not show a physician’s order for a splint or brace to the left hand, wrist, or arm, or for a placement/removal schedule. The RN/CN stated the brace had been present on admission, was worn at all times, and was removed for skin checks, but also stated there was no order for the brace and that it was not care planned. The PT stated she had only seen the wrist immobilizer and had not seen anything about a second brace. The OT stated the wrist brace came from the hospital, no wearing schedule had been established, and she thought it was a doctor’s order. The DON stated therapy should enter the order after evaluation, nursing would approve it, and if a resident had a brace upon admission, the admitting physician would accept that order until therapy saw the resident.
Improper Storage of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain infection control standards for a resident with a suprapubic catheter when the resident’s urinary catheter drainage bag was observed attached to a bathroom handrail with the uncapped tube tip resting on the floor. During the initial tour, the surveyor observed the drainage bag in that condition, and the same condition was observed again later that morning. When the surveyor accompanied the RN to the bathroom, the RN confirmed the tube tip should not have been on the floor for infection control and stated it should have been placed in a plastic bag. The resident involved had diagnoses including urinary retention, BPH with lower urinary tract symptoms, and obstructive and reflux uropathy. The resident’s MDS reflected an indwelling catheter and moderately impaired cognition. The physician’s orders included suprapubic catheter care every shift, a bedside drainage bag to be applied when in bed every evening shift, and a leg bag to be applied when out of bed every day shift. The resident’s care plan included infection related to use of the suprapubic catheter and a focus on the indwelling suprapubic catheter, but it did not include a focus or intervention for changing or disposing of the urinary drainage bag as per facility policy. Interviews with staff showed that the CNA assigned to the resident removed the night bag, washed it, and hung it on the handrail by the toilet so it could be reused. The CNA stated she had done this before depending on how soiled the drainage bag was and acknowledged it should have been stored in a plastic bag for infection control. The IP and DON both stated the drainage bag tubing tip should not have been on the floor because it was an infection control issue, and the IP stated the CNA should have removed and discarded the drainage bag after finishing care. Facility policy stated leg bags may be worn during the day but need to be removed and discarded, with a new bedside drainage bag placed at night, and another policy stated the drainage bag should not be placed on the floor.
Vaccination Education and Refusal Documentation Not Completed
Penalty
Summary
The facility failed to implement its influenza and pneumococcal vaccination policies for three residents reviewed for immunizations. The report found that eligible residents were not consistently educated on the benefits and potential side effects of the flu and pneumococcal vaccines, and that refusals and education were not properly documented in the medical record as required by facility policy. For one resident, the EMR showed refusal of the 2025-2026 influenza vaccine and PCV 21 pneumococcal vaccine, but the paper chart contained incomplete vaccination consent forms. The flu vaccine declination form was not signed by the resident, the resident representative form was blank, and the pneumonia vaccination consent form had the resident’s name marked with a check and the word “verbally” written next to “Do not give consent,” but the signature line was blank. The assigned LPN stated she started the admission packet, wrote a note that the representative would return the next day to sign documents, and acknowledged the paperwork should have been completed but was not. The DON reviewed the packet and acknowledged the vaccination paperwork was not signed by the resident or verified by the nurse. For another resident, the EMR documented that pneumococcal immunization was refused by family with education and risk-versus-benefit discussion noted, but the hard chart contained a blank pneumonia vaccination consent form. For a third resident, the EMR documented refusal of the influenza vaccine with education and risks/benefits noted, but the hard chart contained flu vaccine consent forms that were signed by the resident and representative without any consent or declination indicated. The resident had diagnoses including dementia and a BIMS score of 11, while the other reviewed resident had a BIMS score of 14 and diagnoses including muscle weakness, cognitive communication deficit, and asthma.
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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 Basking Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Green Knoll | 4.7 mi | ★★★★★ | 16 | 0 |
| The Arbor At Laurel Circle | 5.5 mi | ★★★★★ | 8 | 0 |
| Waterfront Rehabilitation And Healthcare Center | 6 mi | ★★★★★ | 13 | 0 |
| Bridgeway Care And Rehab Center At Bridgewater | 6 mi | ★★★★★ | 3 | 1 |
| Careone At Somerset Valley | 6 mi | ★★★★★ | 0 | 0 |
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