Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Arbor At Laurel Circle during CMS and state inspections, most recent first.
The facility failed to follow its abuse prevention policy by not completing reference checks for 18 of 52 newly hired employees reviewed. Surveyors found no reference checks in the personnel files, while the HRS said reference checks were not done and the LNHA later acknowledged the policy included them but the records were unavailable. The DON stated reference checks were done, but the facility’s typed hiring process document said only background checks were completed.
Failure to change oxygen and nebulizer tubing weekly for a resident receiving continuous O2 and nebulizer care. A resident with CHF, hypoxemia, and HTN was observed with oxygen concentrator tubing and nebulizer tubing taped and dated beyond the weekly change interval. The RN and DON acknowledged the tubing should be changed weekly for infection control, and the facility policy required weekly changes of humidifier bottles and oxygen tubing.
A resident did not receive their prescribed anti-anxiety medication for 14 days due to a failure in communication and procedure at the LTC facility. The resident experienced agitation, anxiety, and insomnia, but the physician and family were not notified. Staff interviews revealed a lack of awareness and proper follow-up on the medication's unavailability.
The facility failed to maintain cleanliness in the food service pantry and storage room, with ants, flying insects, and debris observed. The FSS admitted to inadequate cleaning practices, and the LNHA acknowledged the concerns. The pantry and storage room had visible splatters, debris, and soiled equipment, potentially leading to foodborne illness.
The facility failed to conduct scheduled activities and meet residents' activity preferences, impacting their well-being. Observations revealed that activities like movies and bingo were not held, leaving residents without engagement. A resident with severe cognitive impairment was not provided with preferred activities, and there was no system to track participation. The Community Life Services staff acknowledged the lack of documentation and tracking processes.
Two residents with cognitive impairments and a history of falls were inadequately supervised in a LTC facility. Despite being at high risk for falls, interventions were not consistently implemented or revised. The facility lacked clear policies on supervision, leading to multiple unwitnessed falls and insufficient care plan updates.
The facility's QAPI program was found deficient due to its failure to self-identify concerns and maintain a data-driven approach. Issues such as adverse events, pest control, and kitchen sanitation were not adequately reviewed. The LNHA confirmed that these concerns were not addressed in QAPI meetings, which focused on limited areas without comprehensive oversight. Communication gaps led to unaddressed issues, and the facility's Quality Assurance Improvement Plan was not effectively implemented.
The facility failed to maintain effective pest control in the dining room, pantry, and food storage areas, with ants and flying insects observed. Inadequate cleaning was noted, with debris and splatters present. Pest control documentation revealed ongoing issues and structural concerns, but the LNHA did not acknowledge awareness of these issues during the survey.
A surveyor observed that a facility failed to maintain a clean and homelike dining environment. Issues included ants and flying insects in the pantry, splatters and debris on walls and floors, and visibly worn furniture. The dining room had dust, dead insects, a cracked ceiling, soiled rugs, and a dusty piano. The LNHA acknowledged these concerns.
A resident with a history of falls had their care plan inadequately updated, missing documentation of recent falls and interventions. Despite the resident's severely compromised cognition and dependency on staff, the care plan did not reflect the latest incidents or any new measures to prevent further falls. The DON acknowledged the lack of documentation and updates in the care plan.
A resident's respiratory care was compromised due to improper storage and labeling of oxygen and nebulizer equipment. An oxygen cylinder was found unsupported, and a nebulizer mask was improperly stored, with no 'oxygen in use' signs present. The resident had not used oxygen or received treatments for two weeks, despite having orders for such care. Facility policies on equipment storage and labeling were not adhered to.
The facility failed to ensure proper medication administration and vital sign monitoring, as observed during a survey. An RN administered insulin without priming the pen injector and did not obtain blood sugar levels immediately before administration. Additionally, the RN administered medications to residents without checking vital signs just prior, despite physician orders requiring specific parameters. The DON and LNHA acknowledged these deficiencies.
A facility failed to document non-drug interventions and the necessity for administering PRN Xanax to a resident with anxiety. Despite the resident's history of anxiety, the medication was not given for two months, and when administered, there was no documentation of target behaviors or symptoms. Staff acknowledged the lack of documentation, which was required by facility policy.
The facility failed to provide residents with hand hygiene opportunities during meal delivery, as observed by a surveyor. CNAs delivered meals without offering sani-wipes or hand sanitizers, despite using ABHR for their own hand hygiene. The DON confirmed that the practice of providing sani-wipes on trays was discontinued post-COVID, contributing to the deficiency.
Failure to Complete Required Reference Checks for New Hires
Penalty
Summary
The facility failed to implement its abuse prevention policy by not completing reference checks for 18 of 52 newly hired employees reviewed since the prior survey. During the review of employee files on 1/13/2026, surveyors found no reference checks in the records for Employee #1 through Employee #18, with dates of hire ranging from 10/18/2024 through 10/21/2025. The facility’s Abuse Prevention Policy, revised 11/2017, stated that prior to a new employee starting work, the community would initiate a reference check from previous employer(s) in accordance with community policy and NJAC 8:39-9.3(b). During interviews, the HRS stated reference checks were not done because, from past experience, people can lie and background checks take care of that, although he said the facility does do employment verification. The DON stated reference checks were absolutely done by the HRS and said the facility would know if a potential new employee was a good performer because the HRS calls for a reference. The LNHA initially stated the facility would follow up, then later stated the facility policy does not speak to reference checks and provided a typed Hiring Process document stating, “We only do background checks. We do not do reference checks.” After the survey team presented the Abuse Prevention Policy, the LNHA acknowledged that the policy included reference checks and that the requested reference checks for the 18 employees were not available.
Failure to Change Oxygen and Nebulizer Tubing Weekly
Penalty
Summary
The facility failed to change respiratory equipment in a manner to prevent contamination for infection control for Resident #23. During an initial tour, the surveyor observed the resident seated in a wheelchair in the bedroom with an oxygen concentrator and nasal cannula tubing attached with clear tape dated 12/5, and a nebulizer machine on the bedside table with tubing also taped and dated 12/5. The resident stated they used oxygen at all times. The resident’s record showed diagnoses including chronic diastolic congestive heart failure, hypoxemia, and hypertension, and the most recent MDS indicated a BIMS score of 9 out of 15, reflecting moderately impaired cognition. The resident had physician orders for continuous oxygen at 3 liters per minute via nasal cannula and for oxygen tubing to be changed weekly every Wednesday night shift. The RN stated that oxygen tubing and nebulizer tubing should be changed weekly by the nurse and dated when changed, and that the tubing should not remain on the oxygen concentrator past 7 days. The DON stated staff were expected to check the oxygen and nebulizer tubing daily, ensure the devices were functioning properly, and change the tubing weekly for cleanliness and sanitation. When shown the tubing observed during the tour, the RN and DON acknowledged that both were dated 12/5 and should have been changed weekly. The DON later confirmed in the presence of facility leadership and the survey team that the tubing should be changed weekly and stated it had been missed. The facility policy stated that humidifier bottles and oxygen tubing are to be changed weekly to reduce the risk of nosocomial infections.
Failure to Administer Anti-Anxiety Medication
Penalty
Summary
The facility failed to thoroughly review the hospital discharge summary and communicate the recommendations for an anti-anxiety medication to the physician, resulting in a resident not receiving the prescribed medication for 14 days. The resident, who had a history of falling, anxiety disorder, chronic heart failure, and muscle weakness, was admitted to the facility with a hospital discharge summary that included an order for Clonazepam to be administered nightly. However, the medication was not administered from December 5 to December 19, 2023, as the order was not properly communicated to the pharmacy, and the medication was marked as unavailable. During this period, the resident experienced changes in behavior, including agitation, anxiety, insomnia, and wandering at night. Despite these changes, there was no documented evidence that the physician or the family was notified about the lack of medication administration. The facility's staff failed to follow up on the medication's unavailability, and the physician was not informed of the resident's condition or the medication error. Interviews with facility staff revealed a lack of communication and proper procedure in handling the medication order. The Licensed Practical Nurse who admitted the resident was unaware of the medication not being administered, and the Director of Nursing was only made aware of the issue after the surveyor's inquiry. The facility did not conduct a proper investigation into the medication error, and there was no evidence of a timely response to rectify the situation.
Sanitation Deficiencies in Food Service Areas
Penalty
Summary
The facility failed to maintain the remote healthcare food service pantry area and adjacent storage room in a clean and sanitary manner, which could potentially lead to foodborne illness. During a survey, an ant was observed crawling up the wall in the kitchen, and several small flying insects were present in the pantry. The Food Service Supervisor (FSS) acknowledged an ant issue and mentioned that pest control had been notified and had sprayed for ants. However, the surveyor noted splatters on the walls and crumbs and debris on the floor behind equipment and in corners, indicating inadequate cleaning practices. The FSS admitted that a deep cleaning, including moving mobile equipment, had not been performed since he assumed his role. Additional observations included debris in the crevice of a grooved cutting board attached to the steam table, a red bucket lodged behind a metal table with debris on the lower shelf, and splatters on the wall. The adjacent storage room also contained debris on the floor and in corners, with splatters and stains on the walls. Flying insects were present, and boxes of cold cereal and sugar packets were stored on a metal shelf. An open cart used for resident trays was cracked and had visible debris, and a black insulated food transportation cart outside the pantry door was visibly soiled. The Licensed Nursing Home Administrator (LNHA) acknowledged these concerns during the survey.
Failure to Conduct Scheduled Activities and Meet Resident Preferences
Penalty
Summary
The facility failed to ensure that scheduled activities were conducted and that residents received their identified activity preferences, which are crucial for their physical, mental, and psychosocial well-being. This deficiency was observed on two units, where activities such as an evening movie and bingo were scheduled but not conducted. The surveyor noted that residents were left without engagement, with some sitting idle in common areas, and there was a lack of nursing presence to facilitate these activities. Resident #34, who has severe cognitive impairment and a history of dementia, depression, muscle weakness, and lack of coordination, was observed to be without direction or engagement in activities. Despite having a care plan that included specific activity preferences such as balloon volleyball, listening to stories, and pet care, there was no evidence that these preferences were being met. The resident was seen wandering and asking for guidance, indicating a lack of structured activity support. The Community Life Services Manager and Director acknowledged the absence of a system to track and quantify resident participation in activities. They admitted to relying on attendance records, which were not available for review, and there was no documented process to ensure that resident care plans were updated or that activities were conducted as scheduled. The facility's failure to provide scheduled activities and track resident engagement highlights a significant gap in meeting the residents' needs for enrichment and interaction.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to consistently implement and revise fall prevention interventions for residents at risk for falls, specifically for two residents. Resident #9, who has dementia and other cognitive impairments, experienced multiple falls over a period of time. Despite being identified as high risk for falls, the facility did not consistently follow through with interventions such as ensuring supervision in common areas and maintaining a clutter-free environment. The resident was often found unsupervised in the dayroom, and the care plan was not updated after each fall to include necessary supervision. Resident #34, also with severe cognitive impairment and a history of falls, was left unsupervised in the dayroom on multiple occasions. The facility's incident reports documented several unwitnessed falls, and there was a lack of staff supervision noted in these reports. The care plan for Resident #34 did not adequately address the need for supervision, and the facility lacked a clear policy on what constituted appropriate supervision levels for residents at risk of falls. The Director of Nursing (DON) acknowledged the deficiencies in the facility's fall prevention process, including the absence of a policy defining supervision levels. The facility's fall policy required assessments and care plan adaptations based on residents' conditions, but these were not consistently implemented. The lack of staff presence in common areas and failure to update care plans after falls contributed to the ongoing risk of falls for these residents.
Deficient QAPI Program and Oversight in LTC Facility
Penalty
Summary
The facility was found to have a deficient Quality Assurance Performance Improvement (QAPI) program, as it failed to effectively self-identify concerns and maintain a data-driven approach. The survey revealed that the facility did not adequately review adverse events such as medication errors and falls, nor did it ensure effective pest control and kitchen sanitation. Additionally, scheduled activity programs were not consistently conducted. The Licensed Nursing Home Administrator (LNHA) confirmed that these issues were not addressed in the QAPI meetings, which only focused on limited areas such as infection control, antibiotic stewardship, and falls without a comprehensive review of significant events or root cause analyses. The LNHA admitted that the process for determining what should be reviewed in QAPI was based on input from department heads, which led to gaps in communication and oversight. For instance, pest management and kitchen sanitation issues were not appropriately addressed or brought to the Quality Assurance Committee. The QAPI minutes and improvement activity progress forms provided by the LNHA did not include significant concerns such as hand hygiene, activities, and cleanliness of the kitchen. The facility's Quality Assurance Improvement Plan from 2019 outlined guidelines for governance and leadership, but these were not effectively implemented, as evidenced by the lack of monitoring and feedback systems for adverse events and other critical areas.
Deficient Pest Control and Sanitation in Dining and Kitchen Areas
Penalty
Summary
The facility failed to maintain an effective pest control program in the healthcare dining room, attached meal service pantry, and food storage area. During an observation on September 10, 2024, the surveyor noted an ant crawling up the wall in the kitchen and several small flying insects in the pantry. The Food Service Supervisor acknowledged the ant issue and mentioned that pest control had been notified and had sprayed for ants. However, the surveyor also observed splatters on the walls, crumbs, and debris on the floor behind equipment and in corners, indicating inadequate cleaning. The adjacent storage room also had debris on the floor, splatters on the walls, and flying insects, with food items stored on a metal shelf. Dead insects were found on the window sill and multiple insects on the wall molding in the main healthcare dining room. The surveyor reviewed the pest control documentation, which revealed ongoing issues with ants and small flies, and noted structural and sanitation concerns that had been previously identified by the pest control company. These included an improperly sealing exit door, unclean floor drains, standing water, and wet areas conducive to pest breeding. Despite these documented issues, the Licensed Nursing Home Administrator did not provide additional information or acknowledge awareness of the concerns during the survey. The facility did not offer further information during the exit conference regarding the pests observed during the survey.
Facility Fails to Maintain Clean and Homelike Dining Environment
Penalty
Summary
The facility failed to maintain the healthcare dining room in a clean and homelike manner, as observed by a surveyor. During a meal preparation observation in the healthcare pantry on the 2nd floor, the surveyor noted an ant crawling up the wall and several small flying insects in the pantry. The Food Service Supervisor (FSS) acknowledged an ant issue and mentioned that pest control had been notified and had sprayed for ants. Additionally, the surveyor observed splatters on the walls and crumbs and debris on the floor behind equipment and in corners. The adjacent storage room also contained debris, splatters, and stains on the walls, with flying insects present. Boxes of cold cereal and sugar packets were stored on a metal shelf, and a soiled dustpan was found on the floor next to a plunger and broom. Upon exiting the pantry into the main healthcare dining room, the surveyor observed dust and debris on the window sill with several dead insects, multiple insects stuck to the wall molding, and visibly worn table and chair legs. A visible crack in the painted ceiling above the resident meal tables was noted, approximately one foot long. Two rugs outside the pantry door were visibly soiled with debris, and there were stains and debris on the floor, including white splatter-type stains under the resident dining tables. Additionally, a black piano in the dining room was visibly dusty. The Licensed Nursing Home Administrator (LNHA) was shown these concerns and acknowledged them.
Failure to Update Care Plan for Resident with Multiple Falls
Penalty
Summary
The facility failed to revise a resident-centered ongoing care plan for a resident who experienced multiple falls. This deficiency was identified during a survey when it was observed that the care plan for a resident, who had a history of falls, was not updated to include the most recent fall incidents on 08/09/2024 and 09/03/2024. The care plan also lacked documentation of any new interventions following these falls. The resident, who had severely compromised cognition and was dependent on staff for daily activities, had a history of falls documented in the medical record, but the care plan did not reflect the latest incidents or any adjustments made to address them. The Director of Nursing acknowledged the oversight, stating that while falls should be documented in the care plan, the dates of the falls were not typically listed, only the interventions. However, there was no documentation of the interventions being offered or implemented, such as the use of a reclining chair, which the resident reportedly refused. The lack of updated information and documentation in the care plan was confirmed by the Director of Nursing, who admitted that the care plan was not revised to include the resident's two most recent falls.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, leading to potential infection and injury risks. During an observation, a surveyor found an oxygen cylinder in a canvas carrier, unsupported and not in a cylinder holder, with oxygen tubing wrapped around it and a label dated from two weeks prior. There was no 'oxygen in use' sign on the door or over the bed. Additionally, a nebulizer machine was observed on the resident's bedside table with a mask wrapped in a paper towel, lacking a label. The resident reported not using oxygen or receiving breathing treatments for at least two weeks. Interviews with the Unit Manager and Director of Nursing revealed that the oxygen tank should not have been present, and the tubing should have been stored properly. The nebulizer mask and tubing were also expected to be labeled and stored in a bag. The medical record indicated that the resident had orders for oxygen and nebulizer treatments, which had been discontinued or completed prior to the observation. The facility's policies required proper labeling and storage of respiratory equipment, but these were not followed, and there was no policy provided for the proper storage of oxygen tanks.
Deficiencies in Medication Administration and Vital Sign Monitoring
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, as evidenced by improper administration techniques for insulin pen injectors and failure to obtain vital parameters just prior to medication administration. During a medication administration observation, a registered nurse (RN) was observed administering insulin to a resident without priming the insulin pen injector as per manufacturer specifications and without obtaining the resident's blood sugar level immediately before administration. The RN admitted to not being aware of the specific instructions for using the insulin pen injector and had not received any in-service training on the technique. Additionally, the RN was observed administering medications to several residents without obtaining vital signs immediately before administration, despite physician orders requiring specific vital parameters to determine whether to administer the medications. The RN stated that she obtained vital signs during her rounds at the beginning of her shift, which was not in compliance with the facility's policy that required vital signs to be taken as close to the administration time as possible. The Director of Nursing (DON) acknowledged that the policy did not specify a timeframe but expected vital signs to be taken immediately before medication administration. The surveyor's interviews with the Assistant Director of Nursing (ADON) and the Consultant Pharmacist (CP) revealed that there was a lack of in-service training on medication administration and insulin pen injector techniques. The CP confirmed that vital signs should be obtained just before administering medications, especially when there are hold parameters in the physician's orders. The DON and the Licensed Nursing Home Administrator (LNHA) acknowledged the deficiencies and the need for immediate vital sign checks before medication administration.
Failure to Document Non-Drug Interventions and PRN Medication Necessity
Penalty
Summary
The facility failed to document attempted non-drug interventions and the necessity for administering a PRN psychotropic medication, Xanax, for a resident. The deficiency was identified during a survey when it was observed that there was no documentation of target behaviors or symptoms that warranted the administration of Xanax on a specific date. Additionally, there was no record of any non-drug interventions being attempted prior to the administration of the medication. The resident involved had a history of anxiety, depression, and unspecified psychosis, and was prescribed Xanax on a PRN basis for anxiety. Despite the prescription, the medication was not administered for two months prior to the incident, and when it was given, there was no documentation to support the decision. Interviews with staff revealed that the resident could be confused and anxious but was often calmed by non-drug interventions such as redirection or a call from family. The facility's policy required documentation of symptoms or complaints for which a PRN medication was administered, but this was not adhered to in this case. The Director of Nursing and other staff acknowledged the lack of documentation and the need for it, but no additional documentation was provided to the surveyors. The facility's failure to document the necessary information led to the identification of this deficiency.
Inadequate Hand Hygiene Practices During Meal Delivery
Penalty
Summary
The facility failed to adhere to proper infection control and hand hygiene practices during meal delivery, as observed by a surveyor. On multiple occasions, Certified Nursing Assistants (CNAs) delivered meals to residents without providing them with opportunities to cleanse their hands. This was observed during breakfast and lunch meal deliveries, where no sani-wipes or hand sanitizers were offered to the residents. The CNAs used Alcohol-Based Hand Rub (ABHR) for their own hand hygiene but did not extend this practice to the residents. An interview with a resident confirmed the absence of hand hygiene opportunities before meals. Further investigation revealed that the CNAs were unaware that the wipes available in the storage room were not suitable for hand cleansing, as they were intended for cleaning the perineal area. The facility's handwashing policy, dated 2001, emphasizes the importance of hand hygiene in preventing healthcare-associated infections, and staff are regularly trained on this. However, the Director of Nursing (DON) acknowledged that the practice of providing sani-wipes on meal trays had been discontinued after COVID, which contributed to the deficiency.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 737 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bridgewater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| N J Eastern Star Home | 1 mi | ★★★★★ | 16 | 0 |
| Complete Care At Green Knoll | 1.9 mi | ★★★★★ | 16 | 0 |
| Waterfront Rehabilitation And Healthcare Center | 2.2 mi | ★★★★★ | 13 | 0 |
| Bridgeway Care And Rehab Center At Bridgewater | 2.2 mi | ★★★★★ | 3 | 1 |
| Careone At Somerset Valley | 4.1 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 July 2026) and official state health department websites.