Average — CMS composite of the measures below.
The next survey window likely opens around January 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 The Center For Rehab & Nursing Washington Township during CMS and state inspections, most recent first.
Failure to Investigate Abuse Allegation: A cognitively impaired resident alleged that a nightshift CNA punched them, but the CNA who heard the allegation told an LPN and then did not report it further when the LPN said he did not want to get involved. The DON and LNHA were unaware of the allegation when interviewed, and no investigation had been started at that time. The resident had severe cognitive impairment and later stated they had received punches and that the incident should have been reported sooner.
Unsanitary dish handling and pantry conditions: A surveyor found dirty cups and a bowl with debris still present before meal service, and debris transferred from the cups onto a paper towel during inspection. In multiple pantry areas, the surveyor observed exposed glycerin swab sticks in a freezer, sticky debris on the floor and trash can lid, splatters on walls and pipes, loose trash and particles on the floor, and debris in steam trays. The FSD stated dishes must be thoroughly cleaned and that the swab sticks should not have been stored in the freezer, while the HKD said there was no formal pantry cleaning schedule.
A resident with chronic shoulder pain, osteoarthritis, and intact cognition received PRN oxycodone for documented pain scores that did not match the order for severe pain. MAR review showed repeated administrations at pain levels below severe, while the Consultant Pharmacist noted the mismatch multiple times and staff did not document action taken. Interviews showed staff understood severe pain as 7-10, but the DON stated there was no policy defining pain scale levels and the pain medication order did not include numeric pain guidance.
A cognitively impaired resident with a history of depression, anxiety, and severe cognitive impairment told a CNA that a night-shift CNA had punched them in the ribs. The CNA reported the allegation only to an LPN, who allegedly said he did not want to get involved, and the CNA did not escalate the report further, leaving the allegation undocumented in the record. When later interviewed, the resident stated they had received a couple of punches from a staff member and that the CNA knew who it was. Other staff described the resident as confused but not prone to false accusations. Facility leadership stated that all abuse allegations must be immediately reported up the chain of command for investigation and that accused staff should be removed from duty, but they were unaware of this allegation until informed by surveyors, indicating the facility’s abuse reporting policy was not followed.
Homelike Environment Not Maintained: Surveyors observed a cracked bedroom window, patched walls, stained ceiling tiles, cracks above doorways, debris on a shower bed, and stored items on the shower room floor on the 200 Unit, along with stained ceiling tiles on the hallway leading to the 300 Unit. The MD said several repairs were ongoing, including a delayed window replacement, and the HKD stated shower rooms were cleaned daily by housekeeping and after each resident use by nursing staff, but the shower room condition was not consistent with infection control standards or a homelike environment.
A cognitively impaired resident alleged that a staff member punched him/her in the side/back, but the allegation was not escalated after a CNA told an LPN and no further report was made. The resident had severe cognitive impairment on MDS, and staff interviews showed they knew abuse allegations should be reported immediately through the chain of command to the DON and LNHA. The facility’s policy required abuse allegations to be reported to the state within 2 hours, but the allegation was not reported to NJDOH within that timeframe.
Incomplete and Non-Specific Care Plan: A resident with spine fusion, bacterial pneumonia, osteomyelitis, and moderately impaired cognition had an ICCP that was not comprehensive or individualized. The plan listed vague or incomplete focuses such as infection, feeding tube use, impaired vision, hydration risk, toileting assistance, ADL deficits, falls, pain, and several medication-related therapies, but many entries lacked resident-specific details and included only generic interventions.
A resident with ESRD, dialysis dependence, and type 2 DM had ordered HD on M/W/F at 7:15 AM, plus insulin lispro, sevelamer, and timolol. The care plan did not address coordinating meds with dialysis, and MAR review showed multiple doses documented as not administered during dialysis times. Staff stated dialysis residents’ meds should be scheduled before or after dialysis, and the DON said the meds should be sequenced to when the resident was in the facility with MD approval.
A resident with atrial fibrillation, HTN, disorientation, and moderately impaired cognition had orders for Cardizem CD and Metoprolol, but the MAR showed multiple Code 9 entries for missed doses without a corresponding progress note explaining why the meds were not given. Staff, including an LPN, LPN/UM, and DON, stated that Code 9 should be accompanied by documentation of the reason the medication was withheld or not administered.
Failure to Report and Investigate Alleged Resident Abuse: A cognitively impaired resident told a CNA that a nightshift CNA punched the resident in the ribs, but the CNA only reported it to an LPN who said he did not want to get involved and no further report was made. The DON and LNHA later said they were unaware of the allegation, even though facility policy required abuse allegations to be reported to administration, investigated, and the resident protected during the investigation.
A resident with a sacral wound did not receive timely wound care due to a failure to transcribe a verbal order into the facility's system. The wound worsened, leading to hospital admission for debridement. Interviews confirmed that facility procedures for wound care orders were not followed, contributing to the deficiency.
The facility failed to provide a homelike environment by not ensuring adequate access to clean linens for residents. A surveyor observed a shortage of washcloths and towels in the 500 Unit, affecting 30 residents. Staff interviews revealed that linens were delivered late, and there were frequent complaints about the lack of linens. The DON and LNHA acknowledged the issue, with the DON attributing it to improperly labeled bins leading to discarded linens.
A facility failed to update a resident's care plan after a new wound was identified. The resident, admitted with conditions like anemia and muscle weakness, developed a skin tear in the sacral area. Although documented in progress notes, the care plan was not revised to include interventions for the wound. Interviews revealed a lack of understanding and adherence to the facility's policy on care plan updates.
A facility failed to secure a treatment cart and properly label a wound dressing during care for a resident. An RN left the treatment cart unlocked and unattended while performing wound care, and applied a dressing without initialing, dating, or timing it. Interviews confirmed the importance of these actions for safety and compliance with facility policies.
The facility was found deficient in food safety and storage practices, with observations of undated and expired food items, and incomplete temperature logs in the kitchen. The Dietary Director acknowledged the issues, which included expired bread and undated juice containers, contrary to the facility's food service policy.
A facility staff member failed to follow infection control practices by returning an opened pack of unused 4x4 gauze to the treatment cart after wound care, instead of discarding it. This was observed by a surveyor and confirmed by the RN involved, as well as the Infection Preventionist and DON, who reiterated the importance of discarding unused supplies to prevent cross-contamination.
The facility's wireless call bell system failed to alert staff effectively, leading to delayed responses to residents' needs. A resident with a fracture and other conditions reported a 50-minute delay in response, while another with COPD and anemia experienced similar issues. Staff interviews revealed that the system did not ring to work areas, requiring visual monitoring in hallways. The DON and LNHA confirmed the lack of a centralized alert system.
A facility failed to provide adequate nursing staff, resulting in delayed incontinence care for a resident. The resident was found with a saturated brief, and the CNA responsible had an excessive workload, including 13 residents needing significant assistance. Staffing records showed consistent deficiencies in meeting mandated ratios, impacting care quality. The DON acknowledged the shortfall, and the facility's staffing policy aimed to meet required ratios but fell short.
The facility failed to maintain safe food handling and sanitation practices, as observed in the kitchen and five pantries. Open food items were found in the walk-in freezer, and several pantries had issues such as missing thermometers, debris, and unlabeled resident food. Staff interviews revealed miscommunication regarding cleaning responsibilities, with discrepancies in who was responsible for cleaning various areas.
The facility failed to maintain a sanitary environment by not properly disposing of garbage in the dumpster area. Observations revealed debris and trash bags on the ground, contrary to the facility's policy. The FSD, FM, and LNHA acknowledged the issue, emphasizing the responsibility of maintenance, housekeeping, and dietary staff to keep the area clean to prevent pest infestations.
The facility failed to provide a dignified dining experience in one dining area, where two residents seated at the same table were not served their meals simultaneously. This led to one resident taking food from another's plate. The Registered Dietician and DON confirmed that meals should be served at the same time to maintain dignity, as per facility policies.
A facility failed to document a resident's life-sustaining treatment preference on the physician's orders. The resident, admitted with multiple diagnoses and an intact cognitive status, had no documented code status in their medical record. Interviews with staff revealed that the code status should have been determined upon admission, as per facility policy, but this process was not followed.
A facility failed to report an allegation of staff-to-resident abuse to the NJDOH and the Office of the Ombudsman in a timely manner. A resident with dementia and other conditions was allegedly emotionally abused by a CNA, as reported by the resident's family. The DON and staff did not follow proper reporting procedures, resulting in incomplete documentation and incorrect faxing of the report. The facility's policy requires immediate reporting of abuse allegations, which was not adhered to in this case.
A facility failed to conduct a thorough investigation into an alleged staff-to-resident abuse incident. A resident's family reported emotional abuse by a CNA, but the facility's investigation lacked comprehensive interviews and documentation, including missing statements from the involved CNA and the resident's roommate. The facility's policy requires thorough investigations, which was not adhered to in this case.
A facility failed to update a resident's care plan after the resident developed contractures. Despite therapy recommendations for daily range of motion (ROM) exercises, the resident's care plan did not reflect these needs. Interviews with staff revealed that the resident's contractures were not included in the care plan, and there were no physician orders or CNA instructions for ROM exercises. The Director of Nursing confirmed that the care plan should have been revised to include these details.
A resident with severe cognitive impairment and physical limitations did not receive proper nail care, resulting in a long, jagged fingernail on a contracted hand. Despite the care plan's directives and facility policy, staff were unclear about their responsibilities, leading to a lapse in care. Interviews revealed inconsistencies in understanding who was responsible for nail care, contributing to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses was not provided with meaningful activities reflecting their preferences. Despite a care plan indicating a preference for group activities, there was no documentation of participation or refusal in the past six months. On the survey day, the resident was found in bed during a scheduled activity, and the activity staff did not conduct the planned event. Staff interviews revealed a lack of coordination and documentation regarding the resident's activity participation.
A resident with multiple health issues, including a risk for skin integrity alteration, was found with an undocumented bandage on their forearm. The facility failed to notify the physician, obtain a treatment order, and document the injury, contrary to their policies. Staff interviews confirmed the lack of documentation and investigation.
A resident with severe cognitive impairment and a history of falls was observed without required floor mats on multiple occasions, despite physician orders and care plan interventions. Staff interviews confirmed the expectation for floor mats to be in place, but the facility lacked a policy and did not document the order in the treatment administration record.
A resident requiring CPAP therapy upon admission did not receive it until several days later due to communication failures and procedural oversights. The CPAP equipment was improperly stored, and the therapy was not included in the resident's care plan, contrary to facility policies.
The facility did not ensure the daily Nursing Home Resident Care Staffing Report was posted in an accessible location for residents and the public. The report was only available at the receptionist's desk in the front lobby, requiring a pass code for access to nursing units. The Director of Nursing and Licensed Nursing Home Administrator were unaware of the requirement for the report to be accessible without request, and the Staffing Coordinator confirmed limited posting locations. The facility's staffing policy lacked details on the required daily posting.
A resident with pressure ulcers received wound care from an LPN who failed to follow proper hand hygiene protocols. The LPN did not consistently wash hands or use ABHR between glove changes, washing hands for only eight seconds instead of the required twenty. This deficiency was confirmed through interviews with the LPN, Infection Preventionist, and DON, highlighting a significant infection control concern.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to initiate and complete a thorough investigation after a cognitively impaired resident alleged staff-to-resident physical abuse. Resident #123 had diagnoses including insomnia, major depressive disorder, generalized anxiety disorder, and other symptoms involving cognitive functions and awareness, and the quarterly MDS dated 11/15/25 showed a BIMS score of 7 out of 15, indicating severe cognitive impairment. The resident’s care plan addressed cognitive loss, a right to a safe environment free from abuse, and resistive/noncompliant behaviors related to cognitive impairment. According to CNA #1’s statement and interview, Resident #123 reported that a nightshift CNA punched the resident in the ribs on 1/23/26 at 9:15 AM. CNA #1 stated she immediately told LPN #1, but he said he did not want to get involved. CNA #1 then did not report the allegation to anyone else. The resident later told the surveyor that they had received “a couple punches” and identified that CNA #1 probably knew who the perpetrator was. The resident also stated that the incident happened less than a month ago and that it would have been better if it had been reported earlier. When interviewed, the DON and LNHA stated they were not aware of the allegation and that an investigation had not yet been started at the time the surveyor raised the issue. The facility’s records reviewed by the surveyor did not include any abuse allegation in the progress notes from 1/20/26 through 2/3/26. Staff interviews showed that personnel understood allegations of abuse should be reported immediately through the chain of command, but that did not occur in this case. The report states the facility’s failure to implement its abuse policy by immediately investigating the allegation placed Resident #123 and all residents at risk for abuse and resulted in an Immediate Jeopardy situation.
Unsanitary dish handling and pantry conditions
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. During a spot-check of dishes in the large dining area before meal service, three 8 oz blue coffee cups and one black bowl were observed with debris inside. When the surveyor inspected the dishes with a paper towel, brown debris transferred from the coffee cups onto the towel, showing the items were not clean for service. Additional observations in multiple pantry areas showed unsanitary conditions and improper storage. In the 200 Unit pantry, an open package of lemon-flavored glycerin swab sticks was found exposed in the freezer, along with brown sticky debris, an open sugar packet, an open straw, and a trash can lid with brown sticky debris and loose trash exposed. In the 400 Unit pantry, the walls had splatters of brown debris and the steam trays contained white debris. In the 500 Unit pantry, the walls and pipes had splatters of brown debris, the floor had loose paper and particles, and there was a loose plastic cup, additional paper, white debris, a cabinet with brown sticky debris, and steam table trays with white debris. The Food Service Director stated that dishes should be thoroughly cleaned and that the glycerin swab sticks should not have been stored in the freezer. The Housekeeping Director stated housekeeping was responsible for cleaning pantry floors, walls, and trash, but there was no formal cleaning schedule for the pantries.
Pain Medication Administered Outside Ordered Pain Levels
Penalty
Summary
The facility failed to consistently administer pain medication according to the physician’s order and Consultant Pharmacist recommendations for one resident with chronic bilateral shoulder pain and osteoarthritis. The resident also had diagnoses of dementia with mild cognitive impairment, major depressive disorder, and anxiety disorder, and had a BIMS score of 15 out of 15, indicating intact cognition. The care plan identified oxycodone therapy for severe pain, and the physician order directed oxycodone 5 mg by mouth every 8 hours as needed for severe pain. Review of the MARs showed multiple administrations of oxycodone when the documented pain scores were 0, 2, 3, 4, 5, or 6, rather than severe pain. The Consultant Pharmacist repeatedly noted that documented pain levels of 0, 2, 3, and 4 did not match the PRN oxycodone indication of severe pain, and later noted that the resident had no PRN order covering moderate pain and that oxycodone had been administered for pain levels of 0 and 6. These recommendations were initialed by staff, but no action taken was documented in the reports reviewed. During interviews, an LPN stated that severe pain was 7 and above and commented that the order did not include a numeric pain scale related to severe pain. Another LPN stated that severe pain was 7 to 10 and that mild, moderate, and severe pain levels were expected to be included in pain medication orders. The DON stated there was no policy addressing pain levels with associated numerical ratings, and also stated that pain medication orders should define mild, moderate, and severe pain levels. Facility policy related to pain medication did not address or define pain scale levels.
Failure to Report and Act on Resident’s Allegation of Staff Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy after a cognitively impaired resident made an allegation of staff-to-resident physical abuse. The resident had multiple diagnoses including insomnia, major depressive disorder, generalized anxiety disorder, and cognitive impairment, with a BIMS score of 7/15 indicating severely impaired cognition. The resident’s care plan included interventions related to cognitive loss, the right to be free from abuse, and approaches for resistive or noncompliant behavior. Progress notes from 1/20/26 through 2/3/26 contained no documentation of any abuse allegation. During an interview, a CNA reported that approximately a week prior, the resident told her that a night-shift CNA had punched the resident in the ribs. The CNA stated she immediately informed an LPN, who allegedly responded that he did not want to get involved, and the CNA did not report the allegation to anyone else. The CNA believed the alleged perpetrator was another CNA who worked overnight and had previously received a written warning related to resident care. When interviewed, the resident initially had difficulty recalling the incident but then stated they had received a couple of punches from a staff member and indicated that the CNA probably knew who the perpetrator was. Other staff described the resident as confused but not known to make false accusations. Facility leadership, including the DON and LNHA, stated that staff were required to immediately report any abuse allegations to a supervisor so an investigation could be initiated and that staff accused of abuse should be suspended to protect residents. They reported being unaware of the allegation until informed by the surveyor and confirmed that the CNA should have reported the allegation beyond the LPN. Review of the facility’s Abuse Prevention Program policy showed requirements to protect residents from abuse, train staff on identification and reporting of abuse, and identify, assess, investigate, and report all possible incidents of abuse, which were not followed when the initial allegation from the resident was not promptly and fully reported or acted upon.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to maintain a homelike environment that was clean, safe, and sanitary on the 200 and 300 units. On the 200 Unit, the surveyor observed a cracked bedroom window in one room that allowed air to pass through, multiple patched areas on the walls, a brown-stained drop ceiling tile in the hallway, cracks above the shower room and nursing supplies room entrance doors, white debris on a shower bed, and stored items on the shower room floor including uncovered pillows, plastic-wrapped pillows, a black metal device, and an air-pressure mattress pad. The surveyor also observed a piece of wall paint ripped away near the sink by the soap dispenser in the shower room. On the hallway leading to the 300 Unit, the surveyor observed two brown-stained drop ceiling tiles with white material coming through them. The Maintenance Director stated that the cracks above doorways were recurring settled cracks, that the spackling in the room and hallways was related to planned painting, that wall damage in the shower room resulted from relocating hand sanitizer dispensers, and that repairs had been underway for one to two months. He also stated that a replacement window for the room had been ordered six months earlier but was delayed due to financial approval and partial vendor payment, and that the delivered window had incorrect measurements. The Housekeeping Director stated that housekeeping cleaned shower rooms daily and nursing staff cleaned them after each resident use, and the report stated the shower room condition was not consistent with infection control standards and did not meet the requirements for a homelike environment.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report within two hours to the NJDOH an allegation of abuse after a cognitively impaired resident reported that a staff member punched him/her in the ribs/side/back. Resident #123 had diagnoses including insomnia, major depressive disorder, generalized anxiety disorder, and other symptoms involving cognitive functions and awareness, and the quarterly MDS dated 11/15/25 showed a BIMS score of 7 out of 15, indicating severely impaired cognition. The care plan addressed cognitive loss, dignity and respect, and resistive/noncompliant behavior related to cognitive impairment. According to CNA #1’s written statement and interview, the resident reported the allegation to her on 1/23/26 at 9:15 AM. CNA #1 stated she immediately told LPN #1, but he said he did not want to get involved, and she did not report the allegation to anyone else. The resident later told the surveyor that CNA #1 knew about the incident and that, if it had been reported earlier, it would have been better. Other staff interviewed stated that allegations of abuse should be reported immediately through the chain of command to the supervisor, DON, and LNHA. The DON and LNHA stated they were unaware of the allegation until the surveyor informed them during the investigation, and they verified that CNA #1 should have reported it to a supervisor. The facility’s Abuse Investigation and Reporting policy stated that alleged abuse must be reported immediately, but not later than two hours if the allegation involves abuse, and that the Administrator or designee reports to the state licensing/certification agency. The deficiency was based on the facility’s failure to ensure the allegation was reported to NJDOH within the required timeframe.
Incomplete and Non-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for one resident reviewed for care plans. The resident had diagnoses including fusion of the spine, bacterial pneumonia, and osteomyelitis of the vertebra, and the comprehensive MDS dated 11/16/25 showed a BIMS score of 11 out of 15, indicating moderately impaired cognition. The resident was also taking an antibiotic medication. On 1/29/26, the resident was observed sitting in the room and stated being on a long-term antibiotic and having no concerns. Review of the individualized comprehensive care plan showed multiple incomplete and nonspecific focuses and interventions. The care plan listed an incomplete focus of infection without identifying the type of infection and included only one intervention to administer medication per physician order. Additional care plan entries were also incomplete, including need for feeding tube/potential for complication of feeding tube use, impaired vision, risk for alteration in hydration, toileting assistance, ADL self-care deficit, risk for falls, pain, anticoagulant therapy, anticonvulsant therapy, endocrine system, and diuretic therapy. Several of these entries lacked resident-specific details, and some interventions were limited to generic statements such as diet type, total dependence for toileting, extensive assist with ADLs and bed mobility, and administering pain medication per physician orders.
Missed Medication Administration During Dialysis Schedule
Penalty
Summary
The facility failed to adjust medication administration times to accommodate a resident’s scheduled dialysis treatments. The resident had diagnoses including end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus, and the comprehensive MDS indicated intact cognition with a BIMS score of 15 out of 15 and that the resident received dialysis treatments. The individualized care plan identified the resident’s need for dialysis related to renal failure, but it did not include interventions to coordinate the medication schedule with dialysis times. The resident was ordered hemodialysis by wheelchair on Monday, Wednesday, and Friday with pickup at 7:15 AM, along with insulin lispro with meals, sevelamer with meals, and timolol eye drops twice daily. Review of the January and February 2026 MARs showed multiple instances in which these medications were documented as not administered during the resident’s dialysis dates and times. Staff interviews confirmed that dialysis residents’ medications were supposed to be scheduled before or after dialysis so doses would not be missed, and that if a medication time conflicted with dialysis, the nurse should notify the supervisor, ADON, or physician to have the schedule adjusted. The DON stated the medications should be sequenced to when the resident was in the facility with physician approval, but the MARs showed the medications were still documented as not administered during dialysis times.
Missing Documentation for Withheld Medications
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when the facility failed to document a rationale for medications that were not administered for one resident. The resident had diagnoses including atrial fibrillation, hypertension, and disorientation, and the admission MDS showed a BIMS score of 8 out of 15, indicating moderately impaired cognition. The care plan identified cardiac disease related to hypertension, atrial fibrillation, and congestive heart failure, with interventions to administer medications per physician orders. The resident had physician orders for Cardizem CD 120 mg daily and Metoprolol Succinate ER 50 mg daily for hypertension. The MAR showed Code 9 entries for both medications on multiple dates, and for Metoprolol on additional dates. The corresponding progress notes did not include a rationale for why the medications were not administered. Staff interviews confirmed that Code 9 was used when a medication was not available, refused, or possibly held for low blood pressure, and that a progress note should be written to explain why the medication was not given. The DON acknowledged that a progress note should have been written when Code 9 was used and stated the facility did not have a policy reflecting the specific codes used during medication administration.
Failure to Report and Investigate Alleged Resident Abuse
Penalty
Summary
The LNHA failed to ensure staff and facility leadership followed the abuse reporting and investigation policies after a cognitively impaired resident alleged that a nightshift CNA punched the resident in the ribs. The report states that the resident, Resident #123, told CNA #1 about the alleged physical abuse, and CNA #1 then told LPN #1, who said he did not want to get involved. CNA #1 did not report the allegation to anyone else after that response. The surveyor interviewed Resident #123, who initially said they could not recall the incident, then stated, "I can't honestly say, too much time has gone by, but I did get a couple punches from her." CNA #1 later provided a written statement confirming that the resident reported the allegation on 1/23/26 at 9:15 AM and that she reported it to LPN #1, but no further report was made. The DON and LNHA stated they were unaware of the allegation when interviewed and acknowledged that abuse allegations were supposed to be reported immediately so an investigation could begin and the accused staff member could be suspended to protect residents. The facility's abuse policies required all allegations of abuse to be reported to administration, thoroughly investigated, and reported within required timeframes. The Abuse Prevention Program and Abuse Investigation and Reporting policies both stated that administration would identify and assess possible abuse incidents, investigate and report allegations, and protect residents during investigations. The LNHA stated his responsibilities included managing the facility, ensuring staff education was completed, and ensuring policies and procedures were followed, but the allegation involving Resident #123 was not reported to administration and no investigation was initiated when the allegation was first made.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to obtain a Physician's Order for a wound care recommendation, which resulted in the worsening of a pressure ulcer for a resident. The resident, who was cognitively intact and admitted with conditions including anemia, depression, and muscle weakness, developed a skin alteration in the sacral region. Despite a verbal order for wound care being received by an LPN, it was not transcribed into the facility's electronic system, Point Click Care (PCC), as required by the facility's policy. Consequently, there was no documented wound care order in place from the time the skin alteration was identified until the wound worsened. The resident's sacral wound was initially identified on 01/23/2025, and a wound consult on 01/28/2025 noted the wound's size and condition. However, the wound care recommendations were not implemented, and the wound progressed in size by 02/04/2025. The resident complained of pain in the sacral area, and although the dressing was changed, there was no evidence of consistent wound care being provided. It was not until 02/05/2025 that a formal wound care order was documented, but by then, the resident required hospital admission for wound debridement. Interviews with the LPN, DON, and the resident's Physician confirmed that the facility's procedures for wound care orders were not followed. The LPN admitted to not entering the verbal order into PCC, and the DON acknowledged that the absence of a treatment order could lead to the worsening of the wound. The Physician emphasized the importance of immediate implementation of wound care orders to prevent deterioration. The facility's policies on wound care and documentation were not adhered to, contributing to the deficiency.
Facility Fails to Provide Adequate Linens for Resident Care
Penalty
Summary
The facility failed to maintain a homelike environment for residents by not providing adequate access to clean linens. During a tour of the 500 Unit, the surveyor observed a significant shortage of washcloths and towels in the linen rooms, with only a few washcloths available for 30 residents. Interviews with staff, including a housekeeper and a CNA, revealed that linens were delivered late, and there were frequent complaints from residents about the lack of linens. The CNA reported having to cut bath blankets to provide care due to the shortage of washcloths and towels. The Director of Nursing acknowledged the issue, attributing it to improperly labeled bins in the soiled linen room, which led to staff discarding linens. The Housekeeping Director also recognized that the PAR levels for linens were low and needed adjustment. The Licensed Nursing Home Administrator was aware of the linen shortage and had ordered more linens, but the problem persisted, as evidenced by the surveyor's observations and staff interviews. The deficiency was further corroborated by Resident Council Meeting Minutes, which documented ongoing resident complaints about the lack of linens.
Failure to Update Care Plan for Resident's New Wound
Penalty
Summary
The facility failed to update and revise a resident's care plan for a newly identified wound. Resident #4, who was admitted with diagnoses including anemia, depression, and muscle weakness, was found to have a skin tear in the sacral area on 01/23/2025. Despite the wound being documented in the progress notes and wound care recommendations being provided, the care plan was not updated to reflect this new condition. The care plan initially noted the resident was at risk for skin integrity issues due to fragile skin and immobility, but it did not include interventions for the actual wound. During interviews, the Resource Nurse/Registered Nurse was unable to explain the importance of the care plan or who was responsible for updating it. The Director of Nursing confirmed that the care plan should have been updated with the new wound information and that the interdisciplinary team is responsible for such updates. The facility's policy requires care plans to be revised as new information about residents becomes available, but this was not followed in the case of Resident #4.
Failure to Secure Treatment Cart and Properly Label Wound Dressing
Penalty
Summary
The facility failed to ensure that the treatment cart was secured during a wound care observation and did not adhere to professional standards of clinical practice by not initialing, dating, and timing a dressing before applying it to a resident. During the observation, a Registered Nurse (RN) parked the treatment cart outside the resident's room, performed hand hygiene, donned clean gloves, and gathered supplies before entering the room to perform wound care. The treatment cart was left unlocked and unattended, out of the RN's line of sight, while the RN was in the resident's room. No residents were observed in the hallway near the treatment cart at that time. After completing the wound care, the RN applied a clean dressing to the resident's wound without initialing, dating, or timing it. Interviews with the RN, Resource Nurse, and Director of Nursing (DON) confirmed the importance of locking treatment carts to prevent residents from accessing potentially harmful items and the necessity of initialing, dating, and timing dressings to inform staff of the last dressing change. The facility's policies on Storage of Medications and Wound Care were not followed, as they require compartments containing drugs and biologicals to be locked when not in use and dressings to be initialed, dated, and timed before application. These deficiencies were identified for one resident observed for wound care.
Deficiency in Food Safety and Storage Practices
Penalty
Summary
The facility failed to ensure proper food safety and storage practices, as evidenced by several observations during a survey. The surveyor, along with the Dietary Director (DD), noted that food items in the kitchen were not properly dated, and some were past their use-by dates. Specifically, an unopened loaf of rye bread and an opened gluten-free bread were found with expired use-by dates, and a bag of English muffins lacked any labeling or expiration date. Additionally, the temperature log for the walk-in refrigerator was incomplete, with a missing entry for the PM temperature on a specific date. Further inspection of the walk-in refrigerator revealed undated opened juice containers, including a pitcher of orange juice and two bottles of cranberry juice. The DD acknowledged that all food and juice items should have been dated upon opening and agreed that expired items should have been discarded. The facility's food service policy mandates that food be clearly marked with the date it should be consumed or discarded, and the DD's job description includes monitoring food preparation and storage to ensure compliance with health and sanitation regulations.
Infection Control Breach During Wound Care
Penalty
Summary
The facility staff failed to maintain appropriate infection control practices during a wound care observation. Specifically, a Registered Nurse (RN) completed a wound care treatment and improperly returned an opened pack of unused 4x4 gauze to the treatment cart instead of discarding it. This action was observed by a surveyor and confirmed during an interview with the RN, who acknowledged that the opened gauze should have been discarded to prevent cross-contamination. Further interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the facility's policy requires unused treatment supplies to be discarded after use. Both the IP and DON emphasized the importance of not returning opened supplies to the treatment cart to prevent the potential spread of infection. The facility's policy, revised in January 2025, outlines the need for an Infection Control Program to prevent disease transmission, which was not adhered to in this instance.
Deficient Call Bell System Delays Resident Assistance
Penalty
Summary
The facility failed to ensure that their wireless call bell system effectively communicated calls directly to the staff, resulting in delayed responses to residents' needs. Resident #1, who was admitted with a fracture, sarcoidosis, and hypertension, reported that it took staff 50 minutes to respond to their call light. The surveyor confirmed this delay by observing the call bell light still on without an audible sound after 14 minutes. Resident #1 mentioned that this was a recurring issue and had been reported to the nurse. Resident #3, with chronic obstructive pulmonary disease, anemia, and hyperlipidemia, also experienced delays in call light responses. The resident stated that staff sometimes never responded to the call light, and this issue was reported to the charge nurse. Similarly, Resident #7, who had diabetes, morbid obesity, and a history of falls, reported that staff took more than ten minutes to respond to call bells, particularly during the evening shift. Interviews with staff, including CNAs, LPNs, and RNs, revealed that the call bell system did not ring to staff work areas, and staff had to visually monitor the lights in the hallways. The system's design required staff to be present in the hallways to notice the call lights, as there was no centralized alert system. The Director of Nursing and the Licensed Nursing Home Administrator confirmed the lack of a centralized call bell system, and the facility's policy emphasized the need for prompt responses to call bells.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by the inability to provide timely incontinence care to a resident. On a specific day, a resident was observed lying in bed with a saturated incontinence brief that had leaked onto the cloth underpad. The resident's family member noted that the resident was usually washed, dressed, and in their wheelchair by that time. The assigned LPN and CNAs confirmed the saturated condition of the brief. The CNA responsible for the resident explained that she had to prioritize getting rehabilitation residents ready for therapy, which delayed her usual morning routine with the resident. The staffing issues were further highlighted by the CNA's workload, which included 13 residents, many of whom required total assistance with activities of daily living (ADLs) and feeding. The facility's staffing records revealed consistent deficiencies in CNA staffing over several weeks, failing to meet the New Jersey mandated staffing ratios. The Director of Nursing acknowledged the staffing shortfall and confirmed that the CNA should not have been assigned 13 residents, as it exceeded the mandated ratio of one CNA for every eight residents on the day shift. The facility's staffing policy, revised in December 2023, outlined the requirement to meet federal, state, and local staffing requirements, including specific staff-to-resident ratios. Despite efforts to manage staffing levels based on census and resident care needs, the facility consistently fell short of the required staffing ratios, impacting the quality of care provided to residents. The surveyor's interviews with the staffing coordinator and DON revealed attempts to address staffing challenges, but the facility continued to experience deficiencies in meeting the mandated staffing levels.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by the surveyor in the kitchen and five pantries designated for resident food. In the walk-in freezer, a box of French toast and a box of veggie burgers were found open to the air, which the Food Service Director acknowledged should have been closed and wrapped. Additionally, the 200-unit pantry's freezer lacked a thermometer and had dark dust-like debris, while the 100-unit pantry's freezer also had debris and the microwave contained dried food particles. The 300-unit pantry's freezer was missing a thermometer, had ice buildup, and contained an unlabeled pint of ice cream with ice buildup on the container. Further observations revealed that the 400-unit locked pantry had a stainless-steel sink with dried food particles and dust-like debris, and the water machine outside had white debris on the grate. The 500-unit locked pantry had food particles outside the microwave and liquid on the refrigerator's bottom tray. Interviews with staff, including the Housekeeping Supervisor and Food Service Director, indicated miscommunication regarding cleaning responsibilities, with discrepancies in who was responsible for cleaning various areas, including the stainless sinks, refrigerators, and freezers. The facility's policy required all foods in refrigerators or freezers to be covered, labeled, and dated, and for refrigerators to have working thermometers, but no policy was provided for cleaning the pantry area.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to maintain a sanitary environment by not properly disposing of garbage and refuse in the dumpster area. During an initial kitchen tour, the surveyor observed debris, trash, and leaves around the enclosed dumpster area, which included four blue dumpsters and one black dumpster for used oil. Five black trash bags were found lying directly on the ground next to the first dumpster, and one black trash bag was lying next to the third dumpster. The trash company driver stated that he had moved the bags to access the dumpster, and the Food Service Director (FSD) acknowledged that there should be no debris or trash bags outside the dumpster area. The FSD indicated that maintenance, housekeeping, and dietary staff were responsible for cleaning the area to prevent pest or rodent infestations. Further interviews revealed that both maintenance and dietary staff were responsible for keeping the dumpster area clean, as confirmed by the Facility Manager (FM). The Licensed Nursing Home Administrator (LNHA), along with the Director of Nursing (DON) and the survey team, also stated that leaving trash bags on the ground was unacceptable. The facility's policy on garbage disposal, reviewed and revised in March 2024, mandates that containers and dumpsters be kept covered when not being loaded and that the surrounding area be kept clean to minimize debris accumulation and insect or rodent attraction. The policy also specifies that garbage should not accumulate or be left outside the dumpster.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents, as observed in one of the six dining areas, specifically the activities room. During the observation, two residents were seated at the same table, but only one had received their lunch tray. The delay in serving the second resident led to the resident taking food from the other resident's plate. This incident was witnessed by a surveyor and involved intervention by an LPN. The Registered Dietician and the Director of Nursing both acknowledged that residents seated at the same table should be served simultaneously to maintain dignity and respect. The facility's policies on Dining Room Services and Resident Rights emphasize treating residents with dignity and respect during mealtimes. However, the failure to serve meals simultaneously resulted in a breach of these policies. The Director of Nursing and the Licensed Nursing Home Administrator confirmed that the resident who was not served on time usually ate in the main dining room, but due to its unavailability, was rerouted to the activities room, leading to the oversight. This deficiency was identified as a failure to honor the residents' rights to a dignified existence and self-determination.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to document a resident's life-sustaining treatment preference on the physician's orders, which was identified during a survey. The deficiency was noted for a resident who was admitted with multiple diagnoses, including heart failure and chronic kidney disease. Despite having an intact cognitive status, as indicated by a BIMS score of 13 out of 15, there was no documented evidence of the resident's code status in their medical record. This oversight was confirmed by a Registered Nurse (RN) who acknowledged the absence of the code status in the electronic medical record and expressed uncertainty about how it was missed. Interviews with facility staff, including the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), revealed that the resident's code status should have been determined upon admission as part of the facility's admission process. The facility's policy required the Social Services Director or designee to inquire about any written advance directives prior to or upon admission. However, the process was not followed, resulting in the lack of a documented code status for the resident. The DON explained that if a Provider Orders for Life-Sustaining Treatment (POLST) form was not available upon admission, it should be confirmed during a care conference with the Interdisciplinary Team (IDT), and a physician order should be written accordingly.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman in a timely manner, as required by state and federal regulations and the facility's own policy. This deficiency was identified during a review of a case involving a resident with multiple diagnoses, including dementia and major depressive disorder, who was alleged to have experienced emotional abuse by a Certified Nursing Assistant (CNA). The incident was reported by the resident's family member, who claimed that the CNA was rude and asked them to leave the room during care, leading to the CNA walking out when the family refused. The Director of Nursing (DON) and other staff members failed to follow proper procedures for reporting the incident. The Reportable Event Record/Report (RER/R) was not completed correctly, as it lacked the date and time the incident was reported to the NJDOH. Additionally, the RER/R was faxed to an incorrect number, and there was no evidence that the NJDOH received the report. The facility also did not provide documentation that the Office of the Ombudsman was notified of the incident. The DON admitted to human error in the reporting process and was unsure of the specific time frame required for reporting such incidents. The facility's policy mandates that all allegations of abuse must be reported immediately, or within two hours if the incident involves abuse, and within 24 hours if it does not involve abuse or serious bodily injury. The policy also requires that the findings of abuse investigations be reported to the appropriate agencies. However, the facility failed to adhere to these requirements, as evidenced by the lack of timely notification to the NJDOH and the Office of the Ombudsman, and the absence of a completed investigation report submitted within the required time frame.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of staff-to-resident abuse, as required by their policy. The incident involved a resident with intact cognition, who was reported by their family to have experienced emotional abuse by a CNA. The family alleged that the CNA was rude and did not provide timely care, which left the resident tearful. Despite the family’s report, the facility did not document a comprehensive investigation, including interviews with all potential witnesses such as the resident's roommate. The facility's documentation was incomplete, as evidenced by the absence of a statement from the CNA involved, despite it being referenced in the investigation report. The Director of Nursing (DON) acknowledged the missing statement and attempted to rectify this by contacting the CNA after the event. However, the investigation did not include interviews with the resident, the resident's roommate, or other staff members who might have witnessed the incident, which was contrary to the facility's policy. The facility's policy mandates a thorough investigation of abuse allegations, including interviews with all relevant parties and documentation of findings. However, the investigation into this incident was insufficient, as it lacked comprehensive interviews and documentation. The failure to adhere to the policy resulted in an incomplete understanding of the events and potentially compromised the resident's right to be free from abuse and neglect.
Failure to Revise Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan after the resident developed contractures. The deficiency was identified during a survey when a resident was observed with a contracted left hand. The resident's medical record indicated diagnoses of unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness. The Minimum Data Set (MDS) assessment revealed impaired range of motion (ROM) in both upper and lower extremities, but the resident's Individualized Comprehensive Care Plan (ICCP) did not reflect these impairments or include interventions to address or prevent further reduction in ROM. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Director of Rehab (DOR), revealed that the resident had been seen by Occupational Therapy (OT) and Physical Therapy (PT) earlier in the year. The therapies had provided education to staff on the importance of ROM exercises, and recommendations were made for daily ROM exercises to be incorporated into the resident's care. However, the ICCP was not updated to include these recommendations, and there were no physician orders or CNA instructions for ROM exercises in the resident's records. Further interviews with nursing staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that contractures should be included in the resident's care plan to ensure proper care. The DON acknowledged that the ICCP should have been revised to include the resident's contractures and therapy recommendations. The facility's policies on ROM exercises and comprehensive care plans emphasized the need for ongoing assessments and updates to care plans as residents' conditions change, which was not adhered to in this case.
Failure to Provide Adequate Nail Care to Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was unable to perform activities of daily living (ADL) due to severe cognitive impairment and physical limitations. The resident, diagnosed with unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness, was observed with a contracted left hand and a long, jagged fingernail on the left middle finger. The resident's care plan included interventions for nail care, specifying that nails should be checked and trimmed on bath days and as necessary. However, there was no documentation of the resident refusing nail care, and the facility staff were unclear about their responsibilities regarding nail care. Interviews with facility staff revealed inconsistencies in understanding who was responsible for nail care. A CNA stated that activities staff were responsible, while the Activities Director indicated that their staff only painted nails and did not trim them. The DON confirmed that CNAs were responsible for filing nails and should notify a nurse if a resident refused care. Despite these protocols, the resident's left-hand fingernails remained untrimmed, indicating a lapse in care. The facility's policy on nail care emphasized the importance of regular cleaning and trimming to prevent injury, yet this was not adhered to, as evidenced by the resident's condition.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful activities that reflected the preferences of a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness, was dependent on staff for all activities of daily living. The resident's care plan indicated a preference for group activities, yet there was no documentation of the resident's participation or refusal of activities in the past six months. On the day of the survey, the resident was observed lying in bed during a scheduled activity time, and the activity staff did not show up to conduct the planned activity. The Activities Director admitted to not being present for the activity and acknowledged that the resident would benefit from attending activities for social stimulation. Despite the resident expressing a desire to attend an activity when asked, there was no prior documentation of refusals or attempts to engage the resident in activities. Interviews with staff revealed a lack of coordination and communication regarding the resident's participation in activities. CNAs and LPNs were unclear about their responsibilities in encouraging and documenting the resident's involvement in activities. The facility's policy emphasized the importance of tailoring activities to residents' interests and maintaining records of participation, but these practices were not followed, leading to the deficiency.
Failure to Document and Report Resident's Skin Injury
Penalty
Summary
The facility failed to notify the physician of an injury sustained by a resident, obtain a physician's order for a wound treatment, and document a skin assessment in accordance with the facility policy and professional standards of nursing practice. This deficiency was identified for a resident who was observed with a bandage on their right lower forearm, which was not dated, and a dried red substance on their pillow. The resident reported that the bandage was applied by an unknown staff member after they scratched themselves. The resident's medical record review revealed multiple diagnoses, including repeated falls, multiple fractures, cancer, chronic obstructive pulmonary disease, and a pressure ulcer. The resident's comprehensive care plan indicated a risk for skin integrity alteration due to impaired mobility, with interventions including weekly body audits and reporting changes to the medical doctor. However, there was no documented evidence of the resident's forearm skin alteration in the progress notes or skin assessments. Interviews with facility staff, including a CNA, RN, and the DON, confirmed that the bandage was not documented, and no wound investigation or treatment order was obtained. The facility's policies on accidents, incidents, and documentation require prompt investigation, documentation, and communication of changes in a resident's condition, which were not followed in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that floor mats were in place for a resident who was at risk for falls. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed on multiple occasions without floor mats on either side of the bed, despite having physician orders and care plan interventions for floor mats to be placed on both sides of the bed. The resident had a history of rolling out of bed and sustaining a head injury, which was documented in the progress notes and incident report. Interviews with facility staff, including a hospice aide, certified nursing assistant, licensed practical nurses, and the director of nursing, confirmed that floor mats should have been in place while the resident was in bed to prevent injury from falls. The facility was unable to provide a policy related to the use of floor mats, and the treatment administration record for the relevant month did not include the physician order for the floor mat, indicating a lapse in following the prescribed care plan and physician orders.
Failure to Provide and Manage CPAP Therapy for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required a CPAP machine upon admission. The resident, who had a history of obstructive sleep apnea among other medical conditions, did not receive CPAP therapy until several days after admission, despite the need being documented in the Admission Notification form and physician's progress notes. The delay in providing the CPAP was due to a breakdown in communication and procedure, as the Admission Notification form did not reach the admitting nurse, and the discharge summary did not include the CPAP requirement. Additionally, the facility did not store the CPAP equipment according to professional standards. The CPAP mask was observed on multiple occasions to be improperly stored, either uncovered on the nightstand or hanging and touching the floor. This improper storage was confirmed by nursing staff, who acknowledged that the mask should be cleaned and stored in a bag when not in use. Furthermore, the resident's comprehensive care plan did not include the CPAP therapy, which is a critical component of the resident's care needs. The omission was confirmed by the nursing staff and the Director of Nursing, who stated that the CPAP should have been included in the care plan to ensure all staff were aware of the resident's needs. The facility's policies on Durable Medical Equipment and comprehensive care planning were not adhered to in this case.
Failure to Post Daily Staffing Report Accessibly
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report was posted and displayed in a location that was readily accessible to both residents and the general public. This deficiency was observed across all five nursing units. On a specific date, the surveyor noted that the staffing report was only posted on the receptionist's desk in the front main lobby, which required a pass code to access the nursing units. During a subsequent inquiry, the Director of Nursing stated that the report was posted at both facility entrances, but the Licensed Nursing Home Administrator was unaware of the requirement for the report to be accessible without request. The Staffing Coordinator confirmed that the report was only posted in the front and rehab lobbies, not on the nursing units. Additionally, the facility's staffing policy, reviewed in December 2023, did not include details about the required daily posting of the staffing report.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during a wound treatment for a resident. The resident, who had a history of osteomyelitis, diabetes mellitus with chronic kidney disease, muscle weakness, and pressure ulcers, was observed receiving wound care from an LPN. The LPN did not consistently perform hand hygiene between glove changes, which is a critical step in preventing infection. Specifically, the LPN did not wash hands or use alcohol-based hand rub (ABHR) after doffing gloves and before donning new ones, which is against the facility's hand hygiene policy. The resident's medical record indicated the presence of a Stage 4 pressure ulcer on the sacral region and a Stage 2 pressure ulcer, both of which required specific wound care treatments as per physician orders. During the wound care observation, the LPN was seen preparing and applying treatments such as Medihoney and Santyl without following proper hand hygiene protocols. The LPN washed hands for only eight seconds on two occasions, which is below the required minimum of twenty seconds as per the facility's policy. Interviews with the LPN, the Infection Preventionist, and the Director of Nursing confirmed the deficiency in hand hygiene practices. The facility's policy mandates hand washing for at least twenty seconds, especially after removing gloves and before handling clean or soiled dressings. The failure to adhere to these protocols was identified as a significant infection control concern, as it could lead to cross-contamination and compromise resident safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,260 citations issued within 25 miles in the last 12 months — including the 16 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sewell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlas Rehabilitation And Healthcare At Washington | 1.6 mi | ★★★★★ | 0 | 0 |
| Elmwood Hills Healthcare Center Llc | 3.7 mi | ★★★★★ | 1 | 1 |
| United Methodist Communities At Pitman | 3.8 mi | ★★★★★ | 4 | 0 |
| Advanced Subacute Rehabilitation Center At Sewell | 4.8 mi | ★★★★★ | 2 | 0 |
| Laurel Manor Healthcare And Rehabilitation Center | 6.7 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.