Average — CMS composite of the measures below.
A standard survey is most likely before around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Jersey Extended Care during CMS and state inspections, most recent first.
Improper Storage of Food and Ice Scoop Utensils: The facility failed to store food and ice scoop utensils in a sanitary manner. A scoop was observed left inside a flour container, and ice scoops were repeatedly observed stored in a wash basin on top of an ice machine and horizontally within a cover rather than in a protected, inverted position. Staff confirmed residents used the ice machines each shift, and the DESM stated there was no specific log showing the ice scoop utensils were cleaned.
Failure to Complete Pre-Employment Reference Checks: The facility failed to follow its abuse screening policy by not documenting pre-employment reference checks for a housekeeper, a CNA, two RNs, and two LPNs before their start dates. Survey review of personnel files showed no evidence of the required screening, even though the DHR stated reference checks were completed before the first day of employment to screen for abuse history and related concerns.
A facility failed to keep multiple resident wheelchairs and one over-the-toilet commode clean, safe, and in good repair. Surveyors observed wheelchairs with heavy residue, dust, dirt, rust, and torn seating, and several residents said they did not know when the facility last cleaned their chairs or that they cleaned them themselves. Staff gave inconsistent statements about cleaning frequency, and the facility schedule showed monthly cleaning despite policy requiring cleaning and sanitation twice per month.
A resident’s Significant Change Comprehensive MDS was completed after the required timeframe. The MDSC said she was the only MDSC for two buildings and was out sick with no coverage, and the DON and RN/IP acknowledged that the assessment was completed late despite the expectation that MDSs be completed on schedule.
Late Quarterly MDS Assessments: The facility failed to complete Quarterly MDS assessments within the required timeframe for four residents. The MDSC stated she was the only MDSC for two buildings and was out sick with no coverage, and she confirmed the assessments were completed late. The DON and RN/IP acknowledged the assessments were overdue, and the facility policy required Quarterly assessments to be completed within 92 days of the prior assessment.
Late transmission of MDS assessments occurred for four residents when completed Quarterly and Annual MDSs were not sent to CMS within the required timeframe. The MDSC stated she was the only MDSC for two buildings and was out sick with no coverage, and she confirmed the assessments were transmitted late. The DON, RN/IP, and LNHA acknowledged the delay, and the facility policy required transmission within 14 days of completion.
Missing controlled substance documentation was identified when an LPN administered pregabalin and lacosamide to two residents but did not sign the declining inventory logs, even though both doses were documented in the eMAR. The LPN/UM and DON stated the administering nurse was expected to sign the narcotic log when the medication was removed from the cart, and the facility policy required controlled substances to be signed in the narcotic book.
An LPN left a resident’s refused polyethylene glycol solution on the bedside table during a med pass and left two blister packs of discontinued lisinopril unattended on top of the med cart while away from the cart. The LPN, LPN/UM, and DON all stated that medications should not be left at the bedside and must remain secured or under direct observation during administration.
CNA in-service training deficiency: The facility failed to ensure one CNA completed the required 12 hours of annual in-service education. Record review showed the CNA completed only 9.25 hours during the anniversary period, and the DON confirmed the CNA did not meet the annual training requirement. The facility policy stated CNAs must receive at least 12 hours of in-service training annually.
The facility failed to have a Surety Bond in place to protect resident personal needs account funds, affecting all residents with such funds. The LNHA initially provided a Commercial Crime Policy that did not cover resident funds, and a Surety Bond was only obtained after surveyor inquiry. The LNHA could not provide a prior bond or explain its absence before the surveyor's request.
The facility failed to maintain adequate RN staffing, with the DON serving as the only RN on duty on multiple occasions when the resident census exceeded 60. This occurred due to a staffing shortage after a weekend supervisor quit, leading to non-compliance with the facility's policy requiring RN services for at least 8 consecutive hours per day.
The facility failed to provide regular in-service education to CNAs based on job performance appraisals, with deficiencies identified for three CNAs. Performance appraisals showed a need for immediate improvement, but comments and goals were left blank, and no follow-up education was documented. The DON confirmed the lack of a policy on appraisals, leaving it to their discretion.
A survey revealed deficiencies in food handling and sanitation practices at a facility. A Dietary Aid was observed without a beard guard, and several food items, including hot dog buns, sandwiches, and iced tea, were improperly labeled or stored. A dented can of diced potatoes was also found in storage. These actions violated the facility's policies on food safety and sanitation.
Surveyors found a deficiency in the facility's management of resident smoking activities when a resident was observed smoking independently outside designated areas. The resident had signed a waiver releasing the facility from responsibility, but there was no specific policy supporting this practice. The care plan did not address the resident's ability to hold smoking materials, and the LNHA was unaware of a policy for residents holding lighters and smoking outside designated areas.
The facility failed to accurately report RN hours in their PBJ submission to CMS for a specific quarter. The report incorrectly showed 'No RN Hours' on several dates, despite the current DON and the President of Clinical Services working as RNs on some of those days. This was confirmed during an interview with the current DON, who assumed her role in April 2024.
A resident's room was found infested with black flies, and the resident was addressed in an undignified manner by staff. The resident's urinary catheter was improperly placed on the bed, and the room had a noticeable urine odor. Despite the presence of flies, staff failed to maintain cleanliness, and an LPN used derogatory language towards the resident, violating the facility's dignity policy.
A resident's preferences for daily routine and personal belongings were not accommodated by the facility. Despite being cognitively intact, the resident's care plan lacked specific details about their preferences, and efforts to retrieve personal belongings from a previous facility were inadequate. The social worker's attempts to contact the previous facility were unsuccessful, and alternative communication methods were not pursued. The resident expressed dissatisfaction with their situation, including a preference for wearing personal clothing.
The facility failed to enforce its smoking policy, allowing two residents to hold their own cigarettes and lighters, contrary to the policy requiring smoking materials to be kept at the nurse's station. One resident was observed smoking outside the designated area, and staff interviews revealed inconsistencies in policy enforcement. The deficiency highlighted a lack of adherence to safety protocols intended to protect residents.
A resident's bathroom toilet remained non-functional for four days, filled with debris and lacking water. Despite awareness of the issue, the facility failed to log the repair need, and staff did not report the recurring problem of the resident flushing inappropriate items. Interviews with a CNA, LPN, Unit Manager, and Maintenance Director highlighted communication lapses and a lack of follow-through in addressing the issue.
Surveyors observed that the facility failed to maintain a clean and sanitary environment in resident rooms and common areas. In the Sub-Acute smoking courtyard, cigarette butts and empty packages were improperly discarded despite posted signs. A resident's room had a stained privacy curtain, soiled walls, a broken window blind, and flies, which the resident confirmed. These issues were reported to the LNHA, DON, and Interim Infection Preventionist nurse.
A facility failed to conduct a PASARR Level II assessment for a resident newly diagnosed with a mental illness. Despite a new diagnosis of depression and psychotic disorder, the facility did not initiate the required assessment. The Director of Social Services confirmed that a new psychiatric diagnosis should have triggered a Level II PASARR, but this was not done, contrary to the facility's policy.
A resident in an LTC facility did not receive timely incontinence care, leading to a deficiency. The resident, who was alert and cognitively intact, reported not receiving care since 3:00 AM, despite being soiled. The CNA assigned to the resident had not yet provided care by 9:24 AM, and the resident was found wearing two saturated briefs, contrary to facility protocol. The facility's policy required incontinence care every two hours, but the care plan did not specify frequency, resulting in the deficiency.
A facility failed to resolve conflicting physician orders for a resident's emergency treatment. The resident's records showed both a full code order and a DNR/DNI order, confirmed by the LPN Unit Manager and other staff. The facility's policy requires regular review of code status, which was not followed, leading to unresolved conflicting orders.
A facility failed to notify a physician of an abnormal HbA1C lab result for a resident with uncontrolled blood glucose, leading to a deficiency. Despite the result being highlighted in the electronic medical record, there was no documentation of physician notification. The resident had been hospitalized with multiple diagnoses, including acute kidney injury and dehydration. The DON stated that a nurse practitioner visited twice weekly, but the LPN confirmed the lack of notification. The Medical Director expected same-day notification of abnormal results.
A facility failed to obtain a Physician's Order for an orthotic device for a resident with multiple sclerosis and hemiplegia. The resident was observed with an orthotic near their right elbow, but no order was found in the records. Interviews with staff confirmed the absence of the required order, which was against the facility's policy requiring physician orders for such equipment.
A resident with respiratory failure was not receiving continuous oxygen as ordered, with the nasal cannula improperly stored and exposed. The facility's staff, including the DON and an LPN, acknowledged the oversight, which was contrary to the facility's oxygen administration policy.
A facility failed to properly don PPE and store respiratory equipment, leading to potential contamination. A resident's oxygen equipment was left exposed, and staff did not secure PPE gowns, causing them to drag on the floor. Despite previous training, staff did not follow proper procedures, as observed by surveyors.
A resident with complex medical conditions was discharged from an LTC facility without a comprehensive care plan or physician's order, despite needing assistance with daily activities. The discharge process lacked input from the interdisciplinary team and ignored family concerns about the resident's ability to care for themselves. The facility's discharge policy was not followed, and the discharge was reportedly driven by insurance coverage expiration.
The facility failed to maintain an operable resident call system, with multiple instances of malfunctioning call lights and delayed repairs, especially over weekends. A resident reported delayed staff response times, and the Maintenance Director acknowledged the issues but could not provide complete logs or confirm interim measures. The Director of Nursing lacked call bell audits, and the Administrator could not provide documentation of actions taken during the reported period.
Improper Storage of Food and Ice Scoop Utensils
Penalty
Summary
The facility failed to store utensils in a clean, dry location and failed to keep them covered or inverted to maintain sanitation. During observation in the kitchen, a white bin labeled flour with a clear top contained a white powder and a clear plastic scoop resting within the flour. When asked about this practice, the FSD stated the scoop should not be left in the flour and should be cleaned and placed in the drying area after use for sanitary reasons. The surveyor also observed ice scoop utensils stored unsafely on both units. On the C/D unit, a pink wash basin sat on top of the ice machine with a clear plastic scoop and a metal scoop inside it on multiple observations. On the A/B unit, a plastic ice scoop was resting within a protective hanger laid horizontally on top of the ice machine rather than hanging as designed. Staff interviewed confirmed residents were given ice from these machines each shift and as requested, and one LPN stated the scoops were kept in the basin because they did not fit in the hanger after the ice machine was changed. The DESM stated there was no specific log for cleaning the ice scoop utensils and could not provide evidence they were ever cleaned. The DON and LNHA acknowledged that scoop utensils should not be stored within the product, a wash basin, or horizontally within its cover.
Failure to Complete Pre-Employment Reference Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to follow its abuse screening policy by not completing reference checks on 6 of 107 employees before their start dates. The employees identified were a housekeeper, two RNs, two LPNs, and a CNA, each of whom had a documented start date but no evidence in the personnel file that a reference check had been completed prior to employment. During the survey, the Licensed Nursing Home Administrator and Director of Nursing were asked to provide personnel files for all new employees hired since the last standard survey. Review of those files showed no pre-employment reference check documentation for the six employees. The Director of Human Resources stated that reference checks were completed before the first day of employment to ensure the potential employee had nothing bad against them, such as abuse against a resident, and stated that if reference checks were not completed prior to the hire date, the employee would not be hired. The facility policy, revised 1/3/25, stated that potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property and that background, reference, and credential checks would be conducted and documented.
Soiled and Damaged Wheelchairs and Commode
Penalty
Summary
The facility failed to maintain a safe, comfortable, and home-like environment for residents who used wheelchairs and for a resident who used an over-the-toilet commode. During observation, a resident was seen seated in a wheelchair with a seat cushion that had a large amount of residue buildup on the sides and a rip along the right lateral side, and the wheelchair itself had a large amount of thick residue on the seat and frame. On follow-up, the wheelchair remained heavily soiled. Staff interviews reflected differing expectations for wheelchair cleaning, with one staff member stating wheelchairs were taken apart and cleaned two days per week, while others stated they should be cleaned every 2 weeks or as needed and kept clean and in good working condition. During an environmental tour, multiple residents were observed seated in wheelchairs that were dirty, rusty, or had residue buildup on the frame and wheels. One resident stated, "Look at this, I need a new seat, it's ripped," and the surveyor observed a large rip on the right side of the wheelchair seat. Other residents were observed in wheelchairs with rust, dust, dirt, and residue on various parts of the frame, wheels, and seat areas. Several residents stated they cleaned their own wheelchairs or could not recall the last time the facility cleaned them. The DESM accompanied the surveyor and confirmed the findings, stating he was disappointed in the condition of the wheelchairs because an employee was scheduled to work 2 days per week to clean them. The surveyor also observed an over-the-toilet commode in a resident's room with rust on the legs and arms. The RN/IP stated that wheelchairs should be cleaned every 2 weeks and as needed, and that cleaning was important so residents did not get sick and develop health concerns and spread viruses. The facility's wheelchair cleaning schedule for several months showed each wheelchair was scheduled for cleaning once per month, while the facility policy stated all resident wheelchairs must be thoroughly cleaned and sanitized twice per month, cleaned according to the posted schedule, and inspected for damage, loose parts, unsafe wheels, or malfunctioning brakes.
Late Completion of Significant Change MDS
Penalty
Summary
The facility failed to complete a Comprehensive MDS within the required timeframe for one resident reviewed for resident assessment. Resident #6 had a Significant Change in Status Comprehensive MDS with an ARD dated 10/6/25, but the assessment was not completed until 11/19/25. The report states that comprehensive assessments are required within 14 calendar days after admission, when there is a significant change in status, and at least once every 12 months, and that this assessment was completed after the required date. During interview, the MDSC stated she was the only MDSC for two buildings and was out sick during the timeframe, with no other employee covering for her. She said she sent a list of residents whose MDS assessments were due and that an RN such as the DON or RN/IP would sign the assessments before transmission to CMS. The DON and RN/IP both acknowledged the expectation that MDS assessments be completed in a timely manner, and the DON and LNHA later acknowledged that Resident #6's MDS assessment was completed late.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the Quarterly MDS within the required timeframe for 4 of 10 residents reviewed for resident assessment. Resident #5 had a Quarterly MDS with an ARD of 10/5/25 that was completed and accepted on 11/19/25. Resident #12 had a Quarterly MDS with an ARD of 10/14/25 that was completed and accepted on 11/19/25. Resident #18 had a Quarterly MDS with an ARD of 10/7/25 that was completed and accepted on 11/19/25. Resident #35 had a Quarterly MDS with an ARD of 10/13/25 that was completed and accepted on 11/19/25. During interview, the MDSC stated she was the only MDSC for two buildings and was out sick during that time with no other employee covering for her. She stated she normally sent a list of residents whose MDS assessments were due, and after completion an RN such as the DON or RN/IP would sign and transmit them to CMS. The MDSC confirmed the four residents' Quarterly MDS assessments were completed late. The DON stated she would expect the MDS to be completed in a timely fashion within the timeframe, and the RN/IP stated it was important to complete the MDS assessments as scheduled to capture an accurate assessment of the resident. The facility's MDS 3.0 Completion policy stated Quarterly Assessments were to be completed using the ARD no more than 92 days from the most recent prior quarterly or comprehensive assessment.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments within the required timeframe for 4 of 10 residents reviewed for resident assessment. The affected residents were Resident #2, #4, #8, and #11. Their assessments included a Quarterly MDS for Resident #2, an Annual MDS for Resident #4, a Quarterly MDS for Resident #8, and a Quarterly MDS for Resident #11. Each of these assessments was completed but not transmitted to CMS within the required 14 days after completion, with transmission and acceptance occurring weeks later. During interview, the MDS Coordinator stated she was the only MDSC for two buildings, was out sick during the relevant period, and no other employee covered her work. She confirmed that the assessments should be transmitted within 14 days after completion and acknowledged that the four residents' assessments were transmitted late. The DON and RN/IP stated they expected MDS assessments to be completed and transmitted within the required timeframe, and the DON and LNHA later acknowledged that the assessments were transmitted late. The facility's MDS 3.0 Completion policy stated that all assessments shall be transmitted to the designated CMS system within 14 days of completion.
Missing Controlled Substance Documentation
Penalty
Summary
The facility failed to accurately account for and document the administration of controlled medications on one of two medication carts reviewed. During a medication storage review, the surveyor observed that the individual resident Controlled Drug Record log for Resident #29 did not include the nursing administering signature for the 9:00 AM dose of pregabalin 100 mg, and the log for Resident #23 did not include the nursing administering signature for the 9:00 AM dose of lacosamide 200 mg. Both medications were identified as controlled substances, and the missing signatures were noted on the declining inventory logs for that morning dose. In interview, the LPN stated she administered both the pregabalin and lacosamide doses but did not sign the declining inventory logs for either resident, although both doses were documented as given in the eMAR. The LPN/UM stated the nurse administering the medication was expected to sign the narcotic declining inventory log when removing the medication from the cart. The DON stated nurses were to sign the declining inventory log as soon as the medication was taken from the cart to administer to the resident, and that there should not be any blanks on the narcotic declining inventory logs. The facility policy stated that if a medication is a controlled substance, the narcotic book is to be signed.
Unsecured Medications Left at Bedside and on Medication Cart
Penalty
Summary
The facility failed to keep medications secured and failed to ensure a refused medication was removed from a resident’s bedside. During a medication pass on 11/20/2025, an LPN prepared polyethylene glycol 3350 mixed with water and fluticasone-salmeterol inhaler medication for Resident #27. After the resident took two swallows of the polyethylene glycol solution and stated they did not want the rest, the LPN left the cup containing the remaining medication on the resident’s overbed bedside table while leaving the room with the resident’s breakfast tray and inhaler in hand. The surveyor observed the medication left unattended at the bedside until the LPN later returned, removed it, and discarded it. The surveyor also observed two blister packs of lisinopril 10 mg belonging to another resident left unattended on top of the medication cart while the LPN was in Resident #27’s room administering medication. The LPN stated she had removed the discontinued lisinopril from the cart drawer and placed it on top of the cart so she would remember to discard it. Interviews with the LPN/UM and DON confirmed that medications should not be left at a resident’s bedside and should remain secured in the medication cart or medication room when not under direct observation. The facility’s Medication Storage policy stated that during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area/cart.
CNA In-Service Training Deficiency
Penalty
Summary
The facility failed to ensure that one Certified Nursing Assistant (CNA #1) received at least 12 hours of mandatory in-service training annually. Review of the facility’s in-service education records for five randomly selected CNAs showed that CNA #1, hired on 6/30/15, completed only 9.25 hours of in-service training during the June 2024 through June 2025 anniversary period. During an interview on 11/25/25, the DON, in the presence of the LNHA and survey team, stated she was responsible for CNA in-service training and confirmed that CNA #1 did not meet the requirement for 12 hours of education from the date-of-hire anniversary date and also did not meet the 2024 calendar year requirement. The facility policy, Required Training, Certification and Continuing Education of Nurse Aides, dated 5/1/25, stated that the facility will provide at least 12 hours of in-service training annually and that documentation will be maintained in the employee’s personnel file.
Failure to Ensure Surety Bond for Resident Funds
Penalty
Summary
The facility failed to ensure a Surety Bond was in place to protect the personal needs account funds of residents. This deficiency affected all residents with personal needs funds held by the facility. The issue was identified when a surveyor requested a Surety Bond from the Licensed Nursing Home Administrator (LNHA) on two occasions, but the LNHA initially provided a Commercial Crime Policy that did not specify coverage for resident funds. A Surety Bond effective the same day was later provided, raising questions about its timing and the absence of a prior bond. Further investigation revealed that the facility's policy required proof of a Surety Bond or an acceptable alternative, such as a crime policy, which must designate an obligee and be managed by a third party. The LNHA was unable to provide a prior Surety Bond or explain why it was not in place before the surveyor's inquiry. The facility had no additional information to offer during the exit conference, and the LNHA could not address the actions of the previous owners regarding the bond.
Inadequate RN Staffing and DON Role Misuse
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. This deficiency was identified during a review of the Nurse Staffing Reports and Payroll Based Journal (PBJ) Reports, which revealed that the DON worked as the only Registered Nurse (RN) on several days when the resident census exceeded 60. Specifically, on multiple occasions in May and June 2024, the facility had only one RN on duty during the day shift, despite having a census ranging from 90 to 100 residents. The Human Resource Director confirmed that the DON covered these shifts due to a staffing shortage after a weekend supervisor quit. Further investigation into the PBJ Report for the fiscal year quarter 2, 2024, showed that the facility triggered for no RN hours on several dates, with the previous DON working as the only RN on days when the census was over 60. The facility's policy requires the utilization of RN services for at least 8 consecutive hours per day, 7 days per week, which was not adhered to. Interviews with the DON and the Vice President of Clinical Services (VPCS) revealed a lack of clarity and planning regarding RN coverage, contributing to the deficiency.
Deficiency in CNA In-Service Education and Performance Appraisals
Penalty
Summary
The facility failed to provide regular in-service education to Certified Nurse Aides (CNAs) based on their job performance appraisals. This deficiency was identified for three out of ten CNAs reviewed. The performance appraisals for these CNAs revealed scores indicating a need for immediate improvement in areas such as Adaptability, Leadership, and Dependability. However, the comments and goal sections of these appraisals were left blank, and there was no documentation of any follow-up education or training provided to address these deficiencies. The Director of Nursing (DON) acknowledged that the appraisals were incomplete and confirmed that there was no formal training on how to complete them. Interviews with the DON and the Vice President of Clinical Services (VPCS) revealed that the facility lacked a policy on employee job performance appraisals, leaving it to the discretion of the DON. The facility's assessment indicated that training and education should be provided whenever an area of concern is identified, but this was not followed. The DON's job description included responsibilities for evaluating work performance and implementing discipline, but these duties were not adequately fulfilled, as evidenced by the lack of documented follow-up on the CNAs' performance issues.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies related to food handling and sanitation practices during a survey conducted on June 13, 2024. A Dietary Aid was observed preparing food without wearing a beard guard, which is against the facility's policy requiring all kitchen staff to wear proper attire to prevent food contamination. Additionally, an opened package of hot dog buns was found without an opened date and use by date, contrary to the facility's policy that mandates dating of opened food items. A can of diced potatoes with a dent on the seam was also found in the dry storage area, which should not have been used according to the facility's food purchasing policy. Further observations revealed multiple instances of improperly labeled food items in the walk-in refrigerator. Ten prepared salami sandwiches, fifteen dessert cups of diced pineapple, three pitchers of iced tea, a plate of leftover cheese ravioli, and leftover sautéed spinach were all found without proper labeling of preparation and use by dates. The facility's policy requires all time and temperature control for safety foods to be labeled, covered, and dated when stored. These deficiencies indicate a failure to adhere to the facility's food safety and sanitation policies, potentially compromising food safety.
Deficiency in Smoking Policy Management
Penalty
Summary
The deficiency in the facility was identified when surveyors observed a resident, identified as Resident #25, walking alone around the building's perimeter and smoking a cigarette. The resident was found to have signed a waiver releasing the facility from responsibility for any injuries sustained while outside the building. This waiver was created by the Director of Nursing (DON) and the previous administrator, allowing certain residents to come and go freely, despite the facility's policy against residents holding their own smoking materials and lighters. The waiver was not supported by a specific policy, and the facility's smoking policy did not account for residents smoking outside designated areas. The resident's medical records indicated a history of encephalopathy, major depressive disorder, and hemiplegia, but also showed that the resident was cognitively intact with a perfect score on the Brief Interview for Mental Status. The care plan for the resident included a focus on smoking, stating that the resident was an independent smoker who did not require direct supervision. However, the care plan did not address the resident's ability to hold smoking materials and lighters or the implications of smoking around the building. The facility's smoking assessment confirmed the resident's capability to handle smoking materials independently, but there was no care plan related to the waiver or the resident's independent smoking activities. The Licensed Nursing Home Administrator (LNHA) was interviewed and acknowledged his responsibility for ensuring compliance with facility policies, including the smoking policy. However, he was unaware of a specific policy regarding residents holding lighters and smoking outside designated areas. The LNHA admitted that a handful of residents were allowed to smoke independently outside, but there was no formal policy or procedure to manage this practice. The lack of a clear policy and the use of an informal waiver system led to a deficiency in the facility's management of resident smoking activities, potentially affecting the safety of all residents.
Inaccurate RN Hours Reporting in PBJ
Penalty
Summary
The facility failed to submit accurate Registered Nurse (RN) hours in their Payroll-Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 2, covering January 1 to March 31, 2024. Specifically, the report inaccurately reflected 'No RN Hours' on several dates, including January 27, January 28, February 24, February 25, March 10, March 23, and March 24. Upon review, it was found that on January 27 and 28, the facility's current Director of Nursing (DON), who was not yet promoted to the DON role, worked as an RN. Additionally, on March 23 and 24, the President of Clinical Services served as the RN. This discrepancy was confirmed during an interview with the current DON, who stated she assumed her role in April 2024. The facility's policy mandates the submission of timely and accurate staffing data through the CMS PBJ system, which was not adhered to in this instance.
Insect Infestation and Dignity Violation
Penalty
Summary
The facility failed to maintain a resident's room and environment free of insects and did not address the resident in a dignified manner. This deficiency was observed in the case of Resident #55, who was found in a room with a noticeable urine odor and black flies present. The resident's urinary catheter was lying on the bed, and the resident confirmed awareness of the flies. During multiple observations, surveyors noted the presence of flies on the bedspread, remote, and meal tray lid. The Licensed Practical Nurse Unit Manager acknowledged the uncleanliness and presence of flies but claimed not to have seen them before. Additionally, the staff's interaction with Resident #55 was undignified. An LPN referred to the resident in a derogatory manner, calling the resident a "dirty old [gender redacted]" and described the resident as noncompliant. This behavior was witnessed by surveyors and confirmed by the Director of Nursing, who acknowledged it as a dignity issue. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by the disrespectful language used by the LPN and the failure to maintain a clean and dignified environment for the resident.
Failure to Accommodate Resident Preferences and Needs
Penalty
Summary
The facility failed to accommodate the preferences of a resident, identified as Resident #12, regarding their daily routine and personal belongings. During an initial tour, the resident expressed a desire to get out of bed at a specific time, which was not honored by the facility. The resident was observed in a hospital gown and expressed distress over not being able to contact their family and retrieve personal belongings from a previous facility. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident's care plan did not specify their preference for getting out of bed, and their personal needs were not adequately addressed. The facility's social worker attempted to contact the previous facility to retrieve the resident's belongings but was unsuccessful and did not pursue alternative communication methods, such as sending a letter. The social worker also failed to escalate the issue to the facility's administrator for further guidance. The resident continued to express dissatisfaction with their situation, including a preference for wearing personal clothing rather than a hospital gown. The facility did not provide documentation of efforts to address the resident's concerns until prompted by the survey team, indicating a lack of proactive measures to ensure the resident's rights and preferences were respected.
Failure to Enforce Smoking Policy for Resident Safety
Penalty
Summary
The facility failed to adhere to its smoking policy, resulting in a deficiency related to the safety of residents who smoked and held their own cigarettes and lighters. This issue was identified for two residents. Resident #22, who had intact cognition and was admitted with diagnoses including respiratory failure and alcohol abuse, was observed holding their own cigarettes and lighter in their room. Despite the facility's smoking policy requiring all smoking paraphernalia to be kept at the nurse's station, the resident stated that the facility was aware of their possession of these items. Interviews with staff, including the Smoking Aide, Licensed Nursing Home Administrator (LNHA), Social Worker (SW), and Licensed Practical Nurse (LPN) Unit Manager, revealed inconsistencies in the enforcement of the smoking policy, with some staff incorrectly believing that alert residents could hold their own smoking materials. Resident #25 was observed smoking outside the designated smoking area, walking around the building with a personal lighter. The resident's care plan indicated they were an independent smoker who did not require direct supervision, but it did not specify that they could hold their own smoking materials. The resident confirmed they smoked a pack of cigarettes a day and kept a personal lighter. The facility's smoking policy, which was confirmed by the LNHA, stated that residents were only permitted to smoke in designated areas and that all smoking products should be lit by a smoking monitor or designated staff member. The deficiency was further highlighted by the lack of adherence to the facility's smoking policy, which was intended to ensure the safety of residents. The policy required a smoking monitor to observe all smokers and prohibited residents from holding their own lighters. However, both residents were found to be in possession of lighters, and staff interviews revealed a lack of consistent understanding and enforcement of the policy. This failure to follow the established smoking policy posed a potential safety hazard for the residents involved.
Failure to Maintain Sanitary and Functional Toilet
Penalty
Summary
The facility failed to maintain a sanitary and functional toilet in a resident's bathroom for four days. On multiple occasions, the surveyor observed the toilet in the resident's room filled with brown debris and paper products, with no water present in the bowl. The resident confirmed that the toilet had been non-functional for several days, and the facility was aware of the issue. Despite this, the toilet was not listed for repair in the maintenance log, and no work order was generated until a separate issue with a paper towel dispenser was addressed. Interviews with facility staff, including a CNA, LPN, Unit Manager, and Maintenance Director, revealed a lack of communication and follow-through regarding the toilet's condition. The CNA and LPN acknowledged the recurring issue of the resident flushing inappropriate items, such as paper towels, leading to frequent clogs. However, neither reported the recent clogging incident. The Unit Manager confirmed that all repair needs should generate a work order, but this was not done for the toilet. The Maintenance Director admitted that a toilet should not remain clogged for four days, recognizing it as an inconvenience and unhealthy for the resident.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms and common areas, as observed by surveyors. In the Sub-Acute smoking courtyard, cigarette butts were scattered throughout the lawn area surrounding the gazebo, on top of a garbage can, and partially filled an open bucket on the ground, which also contained empty cigarette packages. Despite signs instructing proper cigarette disposal, these items were improperly discarded. In a resident's room, the surveyor noted several deficiencies, including a stained privacy curtain, soiled walls, a broken window blind, and the presence of flies. The resident confirmed the presence of flies in the room. These observations were reported to the LNHA, Director of Nursing, and Interim Infection Preventionist nurse.
Failure to Conduct PASARR Level II Assessment for New Psychiatric Diagnosis
Penalty
Summary
The facility failed to conduct a new Preadmission Screening and Resident Review (PASARR) Level II assessment for a resident who was newly diagnosed with a mental illness. This deficiency was identified during a survey when it was found that a resident, who had previously been assessed with a negative Level I PASARR indicating no mental illness, was later diagnosed with depression and a psychotic disorder. Despite this new diagnosis, the facility did not initiate a Level II PASARR assessment as required. The Director of Social Services, who started working at the facility in February 2024, acknowledged during an interview that a new psychiatric diagnosis should have prompted an interdisciplinary conference and a request for a Level II PASARR. However, no such assessment was completed for the resident following the diagnosis of psychosis in December 2023. The facility's policy, implemented in January 2024, mandates that any resident with a newly evident serious mental disorder should be referred for a Level II review, which was not adhered to in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence and personal hygiene care for a resident, leading to a deficiency in activities of daily living. The resident, who was alert and cognitively intact, reported that incontinence care was not provided in a timely manner. The resident was last assisted with incontinence care at 3:00 AM and had not received care by 9:24 AM, despite being soiled and requesting to be changed. Upon observation, the resident was found wearing two saturated incontinent briefs, which was against the facility's protocol. The Certified Nursing Aide (CNA) assigned to the resident confirmed that she had not yet provided incontinence care to the resident and had a total of 10 residents on her assignment, seven of whom required total assistance. The CNA stated that she would complete her first round of care by 11:00 AM. The Unit Manager and the surveyor observed the resident with double briefs, which was not the facility's practice, and the issue had been addressed earlier in the year with staff in-service training. The facility's protocol required incontinence care every two hours and as needed, but the care plan for the resident did not specify the frequency for incontinence care. The resident's care plan included a focus on maintaining dignity by being clean, dry, odor-free, and well-groomed. The facility's policy emphasized providing necessary services to maintain good nutrition, grooming, and personal hygiene for residents unable to carry out activities of daily living. Despite these protocols, the resident did not receive timely care, resulting in the deficiency.
Conflicting Code Status Orders for a Resident
Penalty
Summary
The facility failed to identify and resolve conflicting physician orders regarding emergency treatment for a resident. The resident's electronic medical record contained a full code order with a start date of May 2, 2024, and a DNR/DNI order with a start date of January 29, 2024. Additionally, the resident's POLST dated October 3, 2022, indicated a do not attempt resuscitation and do not intubate order. This discrepancy in the resident's code status was confirmed during an interview with the LPN Unit Manager, who acknowledged the conflict and stated that the order should not indicate a full code. Further interviews with the Director of Nursing, Licensed Nursing Home Administrator, and Interim Infection Control Preventionist confirmed that the resident should not have both full code and DNR/DNI status. The facility's policy on POLST/Advanced Directive, dated November 13, 2023, requires a review of code status on a quarterly basis or upon significant change with the resident or healthcare representative. This policy was not adhered to, resulting in the conflicting orders remaining unresolved in the resident's medical record.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure a system was in place to review and notify physicians of laboratory values, resulting in a deficiency for one resident. The resident, who was observed in bed and responding to questions, had been discharged to the hospital with diagnoses including acute kidney injury, altered mental status, dehydration, hypernatremia, Diabetes Type 2, and a urinary tract infection. A Nutrition Note indicated the resident was on a no concentrated sweets puree diet, with varying intake and an uncontrolled blood glucose level, as evidenced by an HbA1C of 11.8%. This laboratory result was highlighted as abnormal in the electronic medical record. Despite the abnormal HbA1C result, there was no documentation indicating that the physician was notified. The Director of Nursing stated that a nurse practitioner visited the facility twice weekly to complete progress notes. However, during an interview, the Licensed Practical Nurse Unit Manager confirmed that there was no record of the physician being informed of the abnormal lab result. The Medical Director stated that he should be notified of abnormal laboratory values on the same day they are received, which did not occur in this instance.
Failure to Obtain Physician's Order for Orthotic Device
Penalty
Summary
The facility failed to obtain a Physician's Order for an orthotic device for a resident who was reviewed for positioning and mobility. The resident, who was admitted with diagnoses including multiple sclerosis, cerebral infarction, and hemiplegia, was observed with an orthotic device near their right elbow. Despite the occupational therapy discharge summary recommending a right elbow extension orthotic, the Order Summary Report did not include an order for this device. Interviews with the President of Clinical Services and a Licensed Practical Nurse confirmed that there should have been a physician's order for the orthotic device. The facility's policy on Range of Motion, Splinting, and Bracing, which requires a physician's order for such equipment, was not followed. This oversight was identified during a survey, highlighting a deficiency in the facility's compliance with their own policies and state regulations.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to adhere to physician orders for continuous oxygen administration for a resident, leading to a deficiency. The surveyor observed that the resident, who was diagnosed with conditions including diffuse traumatic brain injury, dementia, and respiratory failure, was not receiving the prescribed oxygen therapy. On two separate occasions, the resident was found without the nasal cannula in place, and the oxygen equipment was improperly stored, with the nasal cannula exposed to the environment. The resident's medical records indicated a requirement for continuous oxygen at 2 liters per minute, which was not being followed. The Director of Nursing and the Licensed Practical Nurse Unit Manager acknowledged the oversight when it was brought to their attention. The facility's oxygen administration policy, which was last revised in 2010, was not being followed, as evidenced by the lack of proper oxygen delivery and equipment handling. The deficiency was identified during a survey, and the facility's existing policy was the only guideline available at the time of the incident.
Improper PPE Use and Oxygen Equipment Storage
Penalty
Summary
The facility failed to appropriately don Personal Protective Equipment (PPE) and store respiratory equipment to prevent contamination and exposure to the environment. On June 13, 2024, a surveyor observed a staff member assisting Resident #42, who was wearing a nasal cannula attached to a portable oxygen tank set at 2 liters per minute. The following day, the surveyor noted that the resident's portable oxygen tank was left on the back of a recliner chair in the hallway, with the nasal cannula tubing exposed to the environment and not in a protective covering. Additionally, the resident was found in bed without the oxygen tubing in a protective covering, and it was in direct contact with a mechanical lift pad. The Director of Nursing (DON) and a Licensed Practical Nurse Unit Manager (LPN UM) acknowledged the resident was not receiving continuous oxygen as ordered. The LPN UM donned a PPE gown but failed to secure the tie around her waist, resulting in the gown dragging on the floor while she attended to the resident. Similarly, two Certified Nursing Assistants (CNAs) arrived to assist the resident and also failed to properly secure their PPE gowns, which were observed falling down and dragging on the floor during their tasks. The facility's policies on oxygen administration and PPE use were reviewed, revealing that the oxygen administration policy did not include guidelines for storing oxygen delivery equipment. The PPE policy outlined the proper procedure for donning gowns, which was not followed by the staff. Despite previous in-service training on PPE, staff members failed to adhere to the correct procedures, leading to potential contamination risks.
Inadequate Discharge Planning for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to adequately plan and execute the discharge of a resident, identified as Resident #194, who had multiple complex medical conditions including hypertension, pulmonary emboli, deep vein thrombosis, pneumomediastinum, multiple hemorrhagic strokes, and a history of intravenous drug use. The resident was discharged without a comprehensive care plan addressing their discharge needs, despite requiring assistance with activities of daily living such as bed mobility, transfer, and toileting. The discharge planning process was incomplete, lacking a physician's order and failing to incorporate input from the interdisciplinary team or the resident's family, who had expressed concerns about the resident's ability to care for themselves independently. Interviews with facility staff revealed significant lapses in the discharge process. The Licensed Practical Nurse Unit Manager acknowledged that discharge planning should begin upon admission and involve all care team members, but this was not done for Resident #194. The nurse responsible for completing the discharge paperwork was unfamiliar with the resident's care and was only present for one day, leading to incomplete documentation. Additionally, the Director of Nursing admitted that the discharge summary was incomplete and that there was little she could do as she was not the physician. The facility's policy on discharge planning, which requires an interdisciplinary approach and input from all relevant parties, was not followed. The policy mandates that discharge plans be initiated within seven days of admission and that a physician's order is necessary for discharge, neither of which were adhered to in this case. The resident's representative reported that the discharge was prompted by the expiration of health insurance coverage, despite the resident's ongoing need for assistance, highlighting a failure to prioritize the resident's care needs over administrative concerns.
Deficient Call System Maintenance and Response Delays
Penalty
Summary
The facility failed to maintain an operable resident call system, as evidenced by multiple instances of malfunctioning call lights across different units. During a survey, a resident reported that while the call light was functional, staff response times were delayed, sometimes taking up to 30 minutes. Maintenance logs revealed numerous entries indicating broken or non-functional call lights on two of the four units, with repairs often delayed, especially over weekends when no maintenance service was available. The Maintenance Director acknowledged these issues but could not provide logs for the unit where the complaint originated, nor could he confirm if alternative measures were implemented during the downtime. The surveyor's investigation highlighted a significant delay in addressing a call light issue on Unit AB, which took seven days to repair. The Maintenance Director admitted that the system was defective and could not be repaired immediately, but he was unable to provide details on interim measures or whether the Department of Health was notified. The Director of Nursing was unable to provide any call bell audits, indicating a lack of proactive monitoring of the call system's functionality. The facility's policies on maintenance inspections and call light accessibility were reviewed, revealing that routine inspections and immediate corrective actions were required but not consistently implemented. The Administrator, who was not employed during the period of the reported issues, stated that the protocol for a defective call light system involved notifying the state and providing residents with alternative alert methods, but no documentation was available to confirm these actions were taken. The facility's inability to provide comprehensive documentation on how the call light issues were addressed further underscores the deficiency.
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What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bridgeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Preferred Care At Cumberland | 2.7 mi | ★★★★★ | 1 | 0 |
| Big Oak Rehabilitation And Healthcare Center | 6.5 mi | ★★★★★ | 8 | 0 |
| Millville Center | 9.4 mi | ★★★★★ | 2 | 2 |
| New Jersey Veterans Memorial Vineland | 11.3 mi | ★★★★★ | 2 | 1 |
| Bishop Mccarthy Center For Rehab & Healthcare | 11.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.