Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Village Point during CMS and state inspections, most recent first.
An orientee LPN, while paired with preceptors, twice failed to verify resident identity and administered medications prescribed for one resident to another. In one shared room, a cognitively intact resident stated the roommate’s name, and the LPN did not check the ID band, resulting in administration of diabetes, reflux, and mood-stabilizing meds intended for the roommate. On another occasion, the LPN was told to give meds to a specific roommate but instead gave a regimen including Jardiance, Metoprolol, Protonix, PreserVision, and Eliquis to the wrong roommate, who had different active orders and later developed hypotension and hypoxia requiring hospital admission. Facility policy required verification of the “five rights” and prohibited giving one resident’s meds to another, yet the orientee was allowed to pass meds independently, and the orientation checklist for the LPN was blank.
A resident with MS and severe cognitive impairment was care planned for a two-person Hoyer transfer, but staff did not follow that plan during multiple transfers. CNA statements conflicted, surveillance footage did not support the reported Hoyer use with two staff, and the hospice aide confirmed transfers were done without the required second person.
Failure to Provide Scheduled Showers: Two residents who required substantial to maximum assistance with bathing did not receive showers per their care plans and shower schedules. One resident reported getting only one shower a week instead of two, and documentation showed multiple entries for "sink" rather than showers. The other resident reported receiving only one shower in 11 days; the shower log showed two refusals and one shower, while the DON stated there was no clear nursing follow-up to ensure showers were completed or properly documented.
An LPN identified bruising, swelling, and oozing on a resident’s leg, but the resident’s record did not show timely physician notification, a documented assessment, or pain documentation before the resident was later sent to the hospital with a tibial fracture. The facility also missed multiple ordered doses for another resident’s meds, including vitamin supplements, potassium citrate, diltiazem ER, Myrbetriq, and cinacalcet, because the meds were not reordered or available on hand, and staff noted the resident’s meds were not always given on time.
Incomplete documentation for UTI evaluation and antibiotic use: A resident admitted with a hip fracture and prior indwelling catheter had an abnormal urinalysis, a urine culture showing bacteria, and an order for Cipro for a UTI, but the EMR lacked documentation of the resident’s symptoms or the reason the UA was obtained. The DON stated there was no note regarding UTI signs and symptoms, and the skilled nursing documentation only showed the antibiotic was checked without a narrative explaining why the resident was on an antibiotic.
Significant Medication Errors by Orientee LPN Due to Resident Misidentification and Lack of Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically involving a nurse trainee (LPN #1) who administered wrong medications to two residents while on orientation with preceptors. On one occasion, LPN #1 entered a shared room occupied by Resident #2 and another resident and asked Resident #2 to state their name. Resident #2 responded with the roommate’s name, and LPN #1 did not verify the resident’s identity by checking the identification band or otherwise confirming identity as required by facility policy. As a result, Resident #2 received medications that were prescribed for the roommate, including Farxiga 10 mg, Protonix 40 mg, and Depakote 125 mg. Resident #2 later confirmed that the nurse did not check their identification band or name before administering the medications. A second significant medication error occurred when LPN #1, still in orientation, was assigned with a preceptor (LPN #2) during a day shift. The preceptor instructed LPN #1 to independently administer medications to Resident #1, who shared a room with Resident #3. LPN #1 went into the room and administered medications intended for Resident #1 to Resident #3 instead. The medications given in error to Resident #3 included Jardiance 10 mg, Metoprolol succinate 100 mg, Protonix 40 mg, PreserVision (Areds) 4296 mcg/90 mg/226 mg, and Eliquis 2.5 mg, all of which were ordered for Resident #1. A CNA present in the room questioned whether LPN #1 was going to administer medications to Resident #1 and then informed LPN #1 that the person who had just received the medications was actually Resident #3, not Resident #1. LPN #1 acknowledged that she did not follow the facility’s medication policy. Resident #3’s medical record showed active orders for a different medication regimen, including Keppra, Metformin, Amiodarone, Lipitor, Methimazole, a multivitamin, Sitagliptin, Vitamin D, and Metoprolol 25 mg, and the resident had diagnoses including muscle weakness, diabetes mellitus, acute respiratory failure, and epilepticus, with intact cognition (BIMS 13/15). After receiving the wrong medications, Resident #3 developed low blood pressure (80/50) and symptoms of hypoxia and required transfer to the emergency room and hospital admission. Resident #1, for whom the medications were actually prescribed, had a separate set of diagnoses including unspecified dementia, chronic kidney disease, overactive bladder, major depression, and a cardiac pacemaker, and was moderately cognitively impaired (BIMS 10/15). The facility’s medication administration policy required that medications be administered as prescribed and that the individual administering medications verify the right resident, right medication, right dose, right time, and right method, and explicitly prohibited administering a medication ordered for one resident to another. The survey also revealed that the orientation checklist for LPN #1 was blank and that preceptors acknowledged they did not remain with the orientee during medication passes, despite the orientee being in training and identified as not safe to pass medications independently.
Failure to Follow Hoyer Transfer Care Plan
Penalty
Summary
The facility failed to implement R112’s care plan related to transfers using a mechanical full-body Hoyer lift and two staff members. R112 was admitted with diagnoses including multiple sclerosis and vascular dementia with behavioral disturbances, had a BIMS score of 3 indicating severe cognitive impairment, and was totally dependent on one to two staff members for all ADLs including transfers. The comprehensive care plan stated that the resident was a two-person assist via Hoyer lift and that staff would ensure transfers to and from bed were completed with two persons. The facility investigation found that on 12/21/24 and 12/22/24 the resident’s care plan was not followed on three occasions. CNA1 initially gave conflicting statements about how the resident was transferred, including stating that she and CNA3 used the Hoyer lift, then stating she transferred the resident on her own. Surveillance footage was reviewed and did not show the Hoyer lift or CNA3 entering the resident’s room during the time CNA1 described. The investigation also found that the hospice aide stated she used the Hoyer lift both days without a second person because she could not find anyone, and later confirmed she did not use two persons when transferring R112 per the care plan.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure ADLs were provided for two residents who required substantial to maximum assistance with showering. R2 was cognitively intact with a BIMS score of 15 and had a care plan noting right leg weakness, generalized weakness, and impaired mobility, with staff assistance for care daily and as needed. R2 told the surveyor he was only getting one shower a week and thought he was supposed to get two. The shower documentation from 07/01/25 through 07/22/25 showed R2 received only three showers, with no refusals documented, while "sink" was documented 26 times. R2's CNA care plan indicated showers were his preference on Mondays and Thursdays on the 3:00 PM to 11:00 PM shift with one staff assist. R76 was also cognitively intact with a BIMS score of 15 and required substantial to maximum assistance with showering due to weakness and impaired mobility. R76 stated he had not received more than one shower in the last 11 days. His CNA care plan identified a preference for showers on Mondays and Thursdays on the 3:00 PM to 11:00 PM shift with one staff assist. The shower sheet showed two refusals, one when he went to the hospital and one when he returned, and one shower on 07/15/25. A CNA stated R76 had received bed baths during the first two to three weeks because of pain, and the DON stated there did not seem to be follow-up by nursing to ensure showers were done or documented to show why a shower was not done; the DON also stated that "sink" meant a clean-up and was not considered a shower.
Delayed Response to Change in Condition and Missed Medication Doses
Penalty
Summary
The facility failed to provide timely assessment, physician notification, and medical care for a resident with severe cognitive impairment, multiple sclerosis, and vascular dementia after staff identified bruising, swelling, and oozing on the resident’s right lower leg. An LPN documented that she observed bruising and swelling on the right lower front leg, asked the resident about a fall, applied ice, and attempted to locate the supervisor, but there was no documented evidence that the physician was notified, that a skin assessment was completed, or that pain was assessed and documented at that time. The resident’s record also did not show documentation of the resident’s condition after the finding was reported or of any pain intervention by that nurse. The facility investigation and subsequent nursing note documented that the resident later had bluish discoloration and edema of the right lower leg, pain with palpation and movement, and was transferred to the hospital for right lower extremity pain, edema, and bruising. Hospital records showed the resident arrived with a discolored and swollen knee and right lower extremity, and imaging suggested a proximal tibial fracture. Interviews with facility staff reflected uncertainty about the event, including that the unit manager did not recall being informed, the previous administrator could only guess the transfer was non-emergent, and the DON stated the LPN should have notified the physician and completed a documented assessment when the change in condition was identified. The facility also failed to ensure another resident received medications as ordered. The resident had diagnoses including hypertension, renal insufficiency, atrial fibrillation, overactive bladder, and primary hyperparathyroidism, and the MAR showed multiple missed doses across several months for medications including ergocalciferol, potassium citrate-citric acid, pyridoxine, Myrbetriq, diltiazem ER, and cinacalcet. The MAR entries stated the medications were not administered because the pharmacy was called and the medication was being delivered, and pharmacy order details showed several orders were placed the same day the dose was missed or after the facility had already run out. The resident stated that medications were not always given on time because they ran out due to poor planning, and staff interviews indicated the medications should have been reordered earlier or obtained from stock, but were not.
Incomplete Documentation for UTI Evaluation and Antibiotic Use
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate for one resident, R5, who was admitted with diagnoses including a right hip fracture with hip replacement. R5’s care plan identified a potential for infection and urinary retention related to an indwelling bladder catheter, with interventions for catheter care, assessment for bladder distention and fullness, monitoring urine appearance, and consultation with the MD regarding continued catheter need. The physician order showed the indwelling urinary catheter was removed, and later a urinalysis report in the hard chart showed an abnormal result with bacteria in the urine, followed by an order for Cipro for a UTI. The EMR did not contain documentation of what symptoms R5 was having or the reason the urinalysis was obtained. The skilled nursing documentation showed the antibiotic was checked, but there was no narrative explaining why R5 was on an antibiotic. During interview, the DON stated she did not find a note regarding the signs and symptoms of the UTI and acknowledged that there should have been a progress note in the EMR. The DON also reported that RN 2 stated the resident had complained to the doctor about cloudy urine.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monroe Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cranbury Center | 3.2 mi | ★★★★★ | 10 | 2 |
| Careone At East Brunswick | 4.2 mi | ★★★★★ | 0 | 0 |
| The Elms Rehab And Healthcare Center Of Cranbury | 4.4 mi | ★★★★★ | 15 | 1 |
| Gardens At Monroe Healthcare And Rehabilitation, T | 4.6 mi | ★★★★★ | 0 | 0 |
| Excel Care At Manalapan | 5.3 mi | ★★★★★ | 24 | 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.