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 Willow Springs Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
Kitchen sanitation and hand hygiene failures were observed when dust, debris, grease, and black buildup were found on kitchen surfaces and equipment, and wet plates were stacked in the warmer. Staff were also observed entering the kitchen and handling food-related tasks without washing hands, using paper towels to wipe the face after handwashing before putting on gloves, returning to the serving line with the same gloves after handling a dietary ticket, and touching a trash can lid after handwashing despite a foot pedal being available.
Staff failed to wear the required PPE for two residents on transmission-based precautions. An LPN provided bolus feeding care to a resident on EBP without a gown, despite signage requiring gloves and a gown for feeding tube care. In a separate observation, a CNA entered a room on droplet precautions without eye wear, even though the posted sign indicated gown, gloves, mask, and eye wear were required. The DON and IP stated staff were expected to follow the posted PPE guidance.
Staff failed to maintain a dignified dining experience by standing while assisting two severely cognitively impaired residents with meals. One resident’s tray had not arrived, and he/she reached for another resident’s food before a CNA provided yogurt and stood beside the resident while assisting with eating. An RN was also observed standing next to the other resident while helping with juice, despite staff and management stating residents should be assisted while seated beside them.
A resident receiving hospice for terminal lung cancer did not have a Significant Change MDS completed within the required 14-day timeframe after hospice election. The record showed hospice services began and the MDS was later signed as completed well after the deadline, and the MDSC, DON, and Regional MDS Coordinator all confirmed it was not done on time.
MDS prognosis coding was inaccurate for two residents receiving hospice services. In both cases, the MDS Coordinator coded the prognosis item as no while also coding hospice as yes, despite hospice records and physician documentation showing terminal illness or life expectancy of six months or less. The DON, Regional MDS Coordinator, and hospice staff confirmed the residents remained on hospice and that the prognosis coding should have matched the hospice status.
Two residents did not receive a baseline care plan within the required 48 hours after admission. One resident with muscle wasting, HF, and falls had the baseline care plan reviewed 13 days after admission, and another resident with trauma ischemic muscle, type 2 DM, and HTN had it reviewed five days after admission. The DON and SSD stated the baseline care plan should be discussed with the resident and family within 48 hours, and the facility policy required a baseline plan of care to meet immediate health and safety needs within that timeframe.
A resident receiving hospice services had no comprehensive person-centered care plan for hospice or terminal illness until much later than expected. Records showed hospice admission, a terminal lung cancer diagnosis, and an MDS indicating hospice status, while the MDSC, DON, RN, and Regional MDS Coordinator confirmed the care plan was not completed when hospice began.
An LPN administered a Jevity bolus feeding to a resident with a feeding tube without first verifying tube placement. The resident had diagnoses including stroke, dementia, aphasia, and a feeding tube, and the order required placement confirmation before feeding. The LPN said the step was forgotten and described checking placement by pulling back gastric residual. Facility policy required confirming tube placement before intermittent feeding.
Dusty Oxygen Concentrator Filter: A resident with COPD and atelectasis was observed using O2 via cannula connected to an O2 concentrator whose cabinet filter had a layer of dust and lint on repeated observations. The DON confirmed the lint should not have been there, and the resident had orders for intermittent O2 at 2 L/min PRN, plus weekly cleaning of the tubing, humidifier, and filter per facility policy.
Incomplete controlled substance logbook entries were found on two medication carts, Cedar Unit - High Side and Cedar Unit - Low Side. Multiple pages in the narcotic inventory logs were missing required details such as Rx number, Rx date, and/or label directions. An LPN stated nurses were responsible for completing the entries when receiving controlled substances from the pharmacy, but the entries were not verified as complete before medications were documented as removed. A consultant pharmacist audit also noted that the Cedar Unit controlled drugs logbook lacked complete Rx number, date, dose, amount received, and directions entries.
Expired OTC medications were found in the Cedar Unit High Side medication cart, along with unlabeled potassium chloride ER dose packs and a bottle of OTC Advil liquid gels labeled with the name of a discharged resident. In the Cedar Unit Low Side cart, a Mantoux test vial that required refrigeration was stored in a drawer without an open date, and the LPN could not say when it had been opened or how long it had been there. The DON stated that nurses and the Unit Manager were responsible for checking carts for expired medications and that expired medications must be removed from active supply and destroyed per policy.
A facility failed to administer medications according to standards when an LPN allegedly left Tramadol at a resident's bedside. The resident, who was cognitively intact and had multiple health issues, requested a CNA to hand them the medication after a shower. The facility's investigation concluded the LPN left the medication, although the LPN did not recall doing so. The facility's policy was not followed, as medications should not be left unattended at a resident's bedside.
The facility failed to meet the required CNA staffing ratios for 13 out of 14-day shifts, as mandated by New Jersey law. During the review period, the number of CNAs consistently fell short of the required number needed to care for the residents, indicating a systemic issue in maintaining staffing levels.
A resident with severe cognitive impairment experienced an unwitnessed fall, resulting in a delayed assessment and a right hip fracture. The LPN failed to follow protocol by not notifying an RN or documenting the incident. Additionally, another resident was found with a Wander Bracelet without a physician order or care plan documentation, contrary to facility policy. Interviews confirmed lapses in protocol adherence.
The facility consistently failed to maintain adequate CNA staffing levels, as required by New Jersey Department of Health guidelines, across several months. Interviews revealed that staff often had to manage more residents than recommended, and the facility struggled to meet staffing ratios, particularly during weekends. Despite efforts by the DON and other staff to address call-outs, the facility frequently fell short of the required staffing levels.
A facility failed to administer medications and enteral feedings within the required time frame for a resident with dysphagia and other conditions. The resident's treatments, including Apixaban and Metoprolol, were frequently delayed beyond the facility's policy of one-hour administration window. Staff interviews revealed a lack of adherence to procedures, and the Director of Nursing could not explain the delays, indicating oversight and documentation issues.
A facility failed to maintain and label respiratory equipment for a resident with respiratory failure and asthma. Observations revealed unlabeled and undated oxygen tubing and storage bags, despite physician orders and facility protocols requiring weekly changes and proper labeling. Interviews with staff confirmed the protocol, but it was not followed.
A resident receiving Seroquel for behavioral disturbances related to dementia was not monitored for target behaviors or side effects, contrary to facility policy. Despite the resident's severely impaired cognition and history of care rejection, there were no documented orders for such monitoring until prompted by a surveyor. The nursing staff and administration acknowledged the oversight, which led to the deficiency.
A resident's privacy was compromised during an incontinence care check when an LPN/UM failed to pull the privacy curtain. The resident, diagnosed with Diabetes, Depression, and Unspecified Epilepsy, was observed in bed with the head elevated. The LPN/UM could not explain why the privacy curtain was not used, leading to a deficiency in maintaining personal privacy.
The facility failed to maintain a clean and homelike environment on the Applewood Unit, with persistent strong odors of urine and feces noted by surveyors. Despite housekeeping efforts, the odors were attributed to dirty linens, which were picked up every 2 to 3 hours. Staff interviews confirmed the issue, and the facility's cleaning policy was reviewed.
A resident with severe cognitive impairment was mistakenly given an antibiotic not prescribed to them, due to a failure in following medication administration protocols. The facility's policy requires verification of the resident's identity and medication checks, but these were not adhered to, resulting in the error.
Kitchen sanitation and hand hygiene failures
Penalty
Summary
The facility failed to ensure the kitchen was clean, staff washed hands and wore gloves appropriately between task changes, and dishes were stacked dry. During an observation of the kitchen, dust and debris were visible on the top of the dishwasher, including a rusted spring and dirty knife, the tile wall next to the grill had dust and stains, the floor behind the oven and stove and under the three-compartment sink had a black substance, and the oven and stove top had built up grease and black debris. The plate warmers also had debris and dust on top of them, and plates in the warmer had water on them while stacked on top of each other. The Regional Dietary Director confirmed the areas were not clean and stated the water on the plates should not be there because it could carry bacteria and cause an infection. During later observations, the Regional Director of Dietary Services was seen bringing boxes of pasta into the prep area, taking plates of food to the dirty dishwasher area, and then pulling on the refrigerator handle without washing hands after entering the kitchen. The Food Service Director was observed washing hands, walking away with the paper towels, using the same towels to wipe his/her face, discarding them, and then putting on gloves before continuing to cook. A Dietary Aide took a dietary ticket in a gloved hand, returned to the serving line, and began setting up trays without changing gloves or washing hands. Another Dietary Aide washed hands, dried them, and then lifted the trash can lid with the hands even though the can had a foot pedal. The Regional Director of Dietary Services stated gloves should have been disposed of and hands washed before returning to the line, and that hands should have been washed again after wiping the face with the paper towel.
Failure to Use Required PPE for Isolation and EBP
Penalty
Summary
The facility failed to ensure staff donned appropriate PPE when entering a room for a resident on droplet precautions and when providing direct care to a resident on enhanced barrier precautions (EBP). One resident was admitted with diagnoses including stroke, non-Alzheimer’s dementia, aphasia, and a feeding tube, and had physician orders for bolus enteral feedings and medication administration through the feeding tube. During an observation, an LPN was seen administering a bolus feeding to this resident, who was on EBP, without wearing a gown. A sign outside the room indicated that staff and providers must wear gloves and a gown for high-contact resident care activities, including feeding tube care. When interviewed, the LPN stated the gown had been forgotten and acknowledged that staff were required to wear a gown and gloves whenever direct care was provided to a resident on EBP. A second resident had physician orders placing the resident in droplet isolation for flu. During an observation, a CNA entered the room wearing a gown, gloves, and a mask, but not eye wear, even though the posted sign for droplet precautions showed that eye wear was also required. The CNA confirmed the eye wear was not worn. The DON stated staff were expected to follow the sign and guidance for droplet isolation, and the IP stated all PPE indicated on the sign should be worn. Facility policy stated that appropriate PPE must be available and that the type of PPE required depends on the transmission-based precaution and task requirements.
Standing While Assisting Residents With Meals
Penalty
Summary
The facility failed to promote a dignified dining experience by standing while assisting two residents with meals on the Memory Care Unit. R42 was admitted with diagnoses including dementia with anxiety, aphasia, and dysphagia, and had a BIMS score of 3 out of 15 on the modified MDS, indicating severe cognitive impairment. R101 was admitted with diagnoses including Alzheimer's disease and aphasia, and had a BIMS score of 3 out of 15 on the quarterly MDS, also indicating severe cognitive impairment. During an observation of assisted dining, 15 residents were waiting for lunch and six staff members were present in the dining room. R42's lunch tray had not arrived when the meal cart for the dining room came, and R42 was observed reaching for R101's food because he/she had none. A CNA obtained yogurt for R42 and stood next to R42 while assisting him/her to eat. Later, an RN was observed standing next to R101 while assisting him/her to drink juice. When asked about the practice, the CNA and RN stated they should have sat with the residents, and the Unit Nurse Manager and Administrator stated staff are expected to sit next to residents when assisting them with meals. The facility policy stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example, not standing over residents while assisting them with meals.
Late Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment within 14 calendar days after a resident elected hospice benefits. Review of the RAI Manual showed that an SCSA is required when a terminally ill resident enrolls in hospice and remains in the nursing home, and that the ARD must be within 14 days of the effective date of the hospice election to support a coordinated plan of care between hospice and the nursing home. Resident 36 was observed receiving hospice services, and the record showed a physician order to admit the resident to hospice and hospice documentation indicating hospice services began for a terminal diagnosis of malignant neoplasm of the overlap site of bronchus and lung. The resident’s significant change MDS indicated hospice services, but the hospice section was not signed as completed by the MDS Coordinator until 09/24/25, which was 33 days after the hospice order/election date of 08/22/25. The MDS Coordinator confirmed the assessment was not completed within the required 14 days and stated it was missed. The DON and Regional MDS Coordinator also confirmed the assessment was not completed within the required timeframe.
MDS Prognosis Coding Did Not Match Hospice Status
Penalty
Summary
The facility failed to ensure that the MDS was accurate for two residents receiving hospice services. Review of the RAI Manual showed that Section J1400 Prognosis should be coded “yes” when the medical record includes physician documentation that the resident is terminally ill or when the resident is receiving hospice services. In both cases reviewed, the residents were documented as being on hospice, but the MDS was coded “no” for prognosis of less than 6 months while also coded “yes” for hospice services. For one resident, the record showed hospice admission in 2023, a care plan noting a terminal prognosis related to Alzheimer’s disease, and hospice physician documentation stating the resident was terminally ill with a life expectancy of six months or less. The quarterly MDS with an ARD in December 2025 was completed by the MDS Coordinator and coded “no” for terminal prognosis, even though hospice services were coded “yes.” The Hospice RN confirmed the resident had remained on hospice since admission, and the MDS Coordinator acknowledged the prognosis should have been coded “yes.” The DON and Regional MDS Coordinator also confirmed the coding was not accurate and should have matched the hospice status. For the second resident, the record showed hospice admission in August 2025, hospice physician certification that the prognosis was six months or less, and hospice narratives describing ongoing cognitive and functional decline, poor nutrition, and recent infections. Both the significant change MDS and the quarterly MDS were completed by the MDS Coordinator and coded “no” for terminal prognosis while also coded “yes” for hospice services. The Hospice Clinical Director confirmed the resident had remained on hospice, and the MDS Coordinator stated, “I just missed it,” while the DON stated her expectation was that the MDS be completed accurately.
Baseline Care Plans Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to ensure that two sampled residents received a baseline care plan within 48 hours of admission. Resident R7 was admitted with diagnoses of muscle wasting, heart failure, and falls, and the Initial Navigation Guide Meeting note showed that the baseline care plan review was completed 13 days after admission. Resident R174 was admitted with diagnoses of trauma ischemic muscle, type two diabetes, and hypertension, and the Initial Navigation Guide Meeting note showed that the baseline care plan review was completed five days after admission. During interviews, the DON stated that the baseline care plan should be discussed with the resident and family and completed within 48 hours after admission. The SSD stated that social services and nursing meet with the family and/or residents within 48 hours to discuss the baseline care plan, but acknowledged that R7’s meeting was not completed within that timeframe. The SSD also reviewed R174’s meeting date and stated that the care plan should have been completed before the documented date. The facility policy titled Care Plan- Baseline stated that a baseline plan of care to meet the resident’s immediate health and safety needs is to be developed for each resident within 48 hours of admission.
Failure to Develop Timely Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan was developed for one resident receiving hospice services. The resident was observed in the room and confirmed to be on hospice. Records showed a physician order to admit the resident to hospice, hospice documentation indicating admission to hospice services with a terminal diagnosis of malignant neoplasm of overlap sites of bronchus and lungs, and an MDS showing the resident was receiving hospice services. The resident’s care plan, initiated later, included a terminal prognosis related to lung cancer, but the EMR contained no additional care plan implemented before that date regarding hospice services or the terminal diagnosis with measurable goals and interventions. During interviews, the Hospice Clinical Director confirmed the resident had been on hospice since the original admission date and had not come off hospice, while the MDS Coordinator, DON, RN, and Regional MDS Coordinator each confirmed the comprehensive care plan for hospice services was not developed or initiated until later.
Feeding tube placement not verified before bolus feeding
Penalty
Summary
The facility failed to ensure feeding tube placement was verified before administering a nutrition supplement for one of two residents reviewed with feeding tubes, Resident 89. R89 was admitted with diagnoses including stroke, non-Alzheimer's dementia, aphasia, and a feeding tube. The admission MDS showed a BIMS score of 14 out of 15, indicating R89 was cognitively intact. Physician orders directed bolus Jevity 1.5 feedings four times daily and required confirmation of placement before feeding, along with flushing instructions for medications and feedings. During a medication pass observation, an LPN administered a Jevity 1.5 bolus feeding without verifying tube placement first. When interviewed, the LPN stated he/she forgot to verify gastric tube placement and explained that placement was verified by pulling back gastric residual in a syringe. The ADON later reviewed the LPN's enteral tube feeding competency assessment dated 11/05/25, which indicated competency was demonstrated in enteral feedings following general guidelines. The facility policy titled Maintaining Patency of a Feeding Tube (Flushing) stated to confirm placement of the tube before intermittent feeding.
Dusty Oxygen Concentrator Filter
Penalty
Summary
The facility failed to ensure oxygen concentrator filters were clean and free of dust for one resident receiving oxygen therapy. During observations on 01/05/26 and 01/07/26, the resident was seen wearing an oxygen cannula connected to an O2 concentrator, and the cabinet filter had a layer of dust and lint on both occasions. During an observation and interview on 01/08/26, the DON was shown the filter and confirmed the lint should not have been there, stating the concentrators had just been serviced. The resident’s EMR showed an admission date of 11/26/25 with diagnoses of COPD and atelectasis, and physician orders included intermittent oxygen at 2 liters per minute as needed to keep saturation greater than 90%, along with orders to change oxygen tubing, humidifier, and clean the filter weekly and as needed for soiling or damage. The facility policy stated oxygen concentrator filters are to be washed every seven days with soap and water, rinsed, and squeezed dry.
Incomplete Controlled Substance Logbook Entries on Two Medication Carts
Penalty
Summary
The facility failed to implement processes for receiving controlled substances on two of three medication carts observed, Cedar Unit - High Side and Cedar Unit - Low Side. On the Cedar Unit - High Side cart, the controlled substance inventory log sheets in the medication cart logbook were missing required information on multiple pages, including the Rx number, Rx date, and/or the controlled substance label directions. On the Cedar Unit - Low Side cart, the controlled substance inventory log sheets were also missing required information on multiple pages, including the Rx number, Rx date, and/or the controlled substance label directions. During interview, an LPN stated that nurses who received narcotics and controlled substances from the pharmacy were responsible for transcribing the resident's name, prescribing doctor, medication directions, Rx number, and Rx issue date onto the inventory sheet, and that the consultant pharmacist checked the logbooks during on-site audits. The LPNs stated they did not ensure the inventory sheets were complete before documenting removal of controlled medications. The DON stated that nurses and the Unit Manager were responsible for overseeing procedures to prevent drug diversion by monitoring the inventory log sheets and narcotic count, and that the consultant pharmacist audited the medication carts every two to three months. A consultant pharmacist audit dated 12/10/25 documented that the Cedar Unit controlled drugs logbook did not have complete Rx number, date, drug, dose, amount received, and directions entries.
Expired and Improperly Labeled Medications Found in Medication Carts
Penalty
Summary
Expired medications were found stored in two of three medication carts during observation of medication storage and labeling. In the Cedar Unit High Side medication cart, the LPN observed expired OTC medications including Zinc 50 mg tablets with an expiration date of 08/2025 and an open date of 10/06/24, Dairy Aid tablets with an expiration date of 08/2025 and an open date of 11/20/24, Folic Acid 800 mcg tablets with an expiration date of 09/2025, Fish Oil 1000 mg softgels with an expiration date of 12/2025, and Fish Oil 1200 mg softgels with an expiration date of 11/2025. During the same observation, four Potassium chloride ER 10 mEq tablets in daily dose packs were not labeled for an individual resident, and one bottle of OTC Advil liquid gels had a resident's name written on it even though that resident had been discharged from the facility. In the Cedar Unit Low Side medication cart, a vial of Tuberculin Purified Protein Derivative (Mantoux) Test dose that must remain refrigerated was stored in the top drawer, and the box stated to discard opened product after 30 days, but there was no open date. The LPN stated the Mantoux test should be dated and refrigerated and could not state when the vial was opened or how long it had been in the cart. The DON stated that nurses and the Unit Manager were responsible for checking medication carts for expired medications and removing them, that OTC and prescription medications should be checked for expiration before administration, and that all expired medications must be removed from active supply and destroyed in accordance with facility policy.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications according to acceptable standards of nursing practice for one resident. The incident involved a Licensed Practical Nurse (LPN) allegedly leaving medications at the bedside of a resident who was cognitively intact and had multiple diagnoses, including cellulitis, hypertension, heart failure, depression, and acute kidney failure. The resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The medication in question was Tramadol, prescribed as needed for pain. On the day of the incident, a Certified Nursing Assistant (CNA) informed the resident that their medication was on the bedside table after the resident returned from a shower. The resident requested the CNA to hand them the medication, which the CNA did. The facility's investigation concluded that the LPN left the medication at the bedside, although the LPN did not recall doing so. The Assistant Director of Nursing (ADON) confirmed that the expectation was for nurses to ensure residents took their medications before leaving the room, as leaving medications unattended could pose a risk. Interviews with the Assistant Director of Nursing, the LPN, and the Director of Nursing (DON) revealed that the facility's policy was not followed, as medications should not be left unattended at a resident's bedside. The DON stated that the investigation could not confirm what medication was left at the bedside, and the resident was transferred to the hospital shortly after the incident. The facility's policy required that medications be administered in accordance with prescriber's orders and that nurses should return to administer medications if a resident is not available during the initial medication pass.
Plan Of Correction
All residents had potential to be affected. 1. Resident #1 no longer resides at the facility. The DON re-educated LPN #1 on 11.25.24 on the facility's medication administration policy including but not limited to ensuring meds are taken before leaving the resident and that medications are not left at the bedside. No further variances were noted. CNA#1 on 11.25.24 was educated to immediately notify the supervisor if medications are noted at the bedside. 2. Rounds were made on current residents on 12.3.24 by the DON with no medications noted at resident beside. On-going rounds continued. 3. Licensed Nurses were re-educated on 11.25.2024 on the facility's medication administration policy including but not limited to ensuring meds are taken before leaving the resident and that medications are not left at the bedside. Facility staff were educated on 11.25.2024 on notifying the nursing supervisor immediately if medications are noted at bedside. 4. The Director of Nurses/designee will conduct 3 rounds on each floor weekly to validate no medications are left at the bedside. Variances will be addressed. In addition, 3 medication pass competencies will be completed to validate that the medication administration process is in compliance with professional standards. These audits will be conducted weekly x 4 weeks, then monthly x 2 months. The findings of the audits will be submitted by the Administrator to the QAPI Committee for review and recommendation monthly for 3 months or ongoing until compliance is sustained.
Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates a minimum of one Certified Nurse Aide (CNA) for every eight residents during the day shift. This deficiency was identified during a review of staffing records for the period from November 24, 2024, to December 7, 2024. During this time, the facility was consistently understaffed on 13 out of 14-day shifts, with the number of CNAs falling short of the required number needed to adequately care for the residents. For instance, on November 24, 2024, the facility had 14 CNAs for 143 residents, whereas at least 18 CNAs were required. Similar deficiencies were noted on other days, such as November 25, 2024, with 13 CNAs for 143 residents, and December 2, 2024, with 12 CNAs for 134 residents. This pattern of insufficient staffing was observed throughout the reviewed period, indicating a systemic issue in maintaining the mandated staffing levels, which had the potential to affect all residents in the facility.
Plan Of Correction
No residents were identified. Residents of the facility have the potential to be affected. The Director of Nursing, Staffing Coordinator, and Administrator will meet daily during the week to review recruitment efforts, staffing for the next day, and staffing for the upcoming week. The facility has developed a Culture Committee focused on recruitment and retention of staff along with customer service and the employee experience. The facility has implemented the Care Champion Program to mentor new employees, which has been proven to raise retention rates. The facility participates in an interdisciplinary Quality Care Resource call to review open positions, recruitment tactics, and changes to improve outcomes. The facility has implemented a multifaceted approach for recruitment and retention of employees, including job fairs, flexible scheduling, increased utilization of PRN staff, implementation of OnShift, multimedia advertisements, partnership with schools, sign-on bonuses, referral bonuses, pick-up shift bonuses, a boomerang campaign to rehire staff that have resigned, rate adjustments, benefit adjustments, contract staff utilization, and text message campaigns. An ongoing staffing analysis is reviewed by shift to determine the amount of direct care staff and licensed nursing staff required by regulatory requirements to meet the care needs of the residents based on the daily census. This analysis is used to ensure additional staff are scheduled to cover call outs. Vacancy and retention rates are analyzed weekly by the DON and Staffing Coordinator to identify additional hiring to ensure care needs and regulatory requirements are met. The staffing schedule was reviewed by the DON, DON consultant, Administrator, and the Staffing Coordinator to identify by shift the required number of direct care and licensed nursing staff based on current and projected census. Innovative scheduling is being used to ensure adequate licensed nursing staff meet the regulatory requirements and resident care needs based on acuities. The facility has agreements with CNA programs/schools to utilize the facility as a clinical site for their students. A QAPI root cause analysis was conducted, including direct care and licensed nurses from all shifts, to identify internal and external barriers to attract new staff. Assignments were reviewed to assure residents with high acuities are equally distributed on direct care staff assignments. Performance evaluations are completed, and targeted education is provided to staff to ensure they feel competent in their role to enhance job satisfaction. Job applications are readily available at the reception desk to ensure individuals looking for a job can be provided with an application immediately, and an interview can be coordinated that same day to expedite hiring. The administrator/designee will review the minutes from the resident council to determine whether any concerns regarding care and services are identified monthly for two months and then quarterly. The results of Resident Council minutes, as well as recruitment data, will be reviewed by the Administrator or designee at the quarterly QAPI meeting. These audits will be conducted weekly for 4 weeks, then monthly for 2 months. The findings of the audits will be submitted by the Administrator to the QAPI Committee for review and recommendation monthly for 3 months or ongoing until compliance is sustained.
Deficiencies in Fall Assessment and Elopement Prevention
Penalty
Summary
The facility failed to assess a resident in a timely manner after an unwitnessed fall, which resulted in a significant injury. Resident #534, who had severe cognitive impairment and was independent with walking, fell in front of the nursing station. The fall was reported by a CNA to an LPN, who did not follow the facility's policy for unwitnessed falls. The LPN failed to notify an RN supervisor for a full assessment, did not document the incident, and did not inform the resident's family or primary medical doctor. As a result, the resident was not properly assessed until the following day, when severe pain and a right hip fracture were identified, leading to hospitalization. Additionally, the facility did not ensure proper documentation and physician orders for the use of a safety device intended to prevent elopement. Resident #107, who had severe cognitive impairment and was at risk for elopement, was observed with a Wander Bracelet. However, there was no physician order or care plan documentation for the device. The facility's policy required a physician order and care plan update when a Wander Bracelet was recommended, but this was not followed. Interviews with facility staff revealed a lack of adherence to established protocols for both fall assessment and elopement prevention. The DON confirmed that the LPN should have notified an RN for assessment and reported the fall immediately. Similarly, the absence of a physician order and care plan for the Wander Bracelet was acknowledged by the LPN/UM, who indicated the need to address the oversight.
Consistent Understaffing in Nursing Facility
Penalty
Summary
The facility failed to maintain sufficient nursing staff on a 24-hour basis to meet the needs of its residents, as evidenced by multiple instances of understaffing across several months. The Nurse Staffing Reports revealed consistent deficiencies in the number of Certified Nursing Assistants (CNAs) available during day shifts, with the facility often falling short of the required staffing ratios as per New Jersey Department of Health guidelines. For example, on numerous occasions, the facility had significantly fewer CNAs than the required number, impacting the care provided to residents. Interviews with staff and residents highlighted the impact of this understaffing. A resident mentioned that the facility seemed short-staffed on weekends, while a CNA reported having a heavy workload, often caring for more residents than the recommended ratio. The Director of Human Resources acknowledged the challenge of meeting staffing requirements, especially when faced with call-outs, and admitted that the facility did not always meet the staffing ratio requirements. The Director of Nursing (DON) confirmed the staffing patterns and ratios used by the facility, which were intended to align with state guidelines. However, the DON also noted that despite efforts to meet these requirements, the facility struggled to maintain adequate staffing levels, particularly during weekends. The DON and other staff members, including the Assistant Director of Nursing and Unit Managers, were expected to assist when necessary, but the facility still faced challenges in maintaining the required staffing levels consistently.
Failure to Administer Medications and Enteral Feedings Timely
Penalty
Summary
The facility failed to ensure that medications, treatments, and enteral feedings were administered within the required time frame, consistent with professional standards and facility policy. This deficiency was identified for one resident who required enteral feeding and various medications administered via a PEG tube. The resident's medical history included conditions such as retention of urine, symbolic dysfunctions, and dysphagia, necessitating careful and timely administration of prescribed treatments and feedings. The Medication Administration Audit Report revealed multiple instances where medications and enteral feedings were administered two or more hours late. Specific medications such as Apixaban, Metoprolol, and Phos-NaK, among others, were frequently delayed. The facility's policy required medications to be administered within one hour of the prescribed time, yet this was not adhered to, and there was no documentation in the progress notes to explain the delays or notify the physician and family. Interviews with facility staff, including LPNs and the Director of Nursing, highlighted a lack of adherence to the facility's policies and procedures. Staff acknowledged the importance of timely administration but failed to provide reasons for the delays. The Director of Nursing was unable to explain why the medications and feedings were documented as late, indicating a gap in oversight and documentation practices. The facility's policies on enteral nutrition and medication administration emphasized the need for timely and accurate administration, which was not followed in this case.
Failure to Maintain and Label Respiratory Equipment
Penalty
Summary
The facility failed to provide necessary care and maintenance of respiratory equipment for a resident with respiratory needs. During multiple observations over several days, the surveyor noted that the oxygen tubing and the storage bag for a resident were not labeled or dated as required. The resident had been admitted with diagnoses including respiratory failure with hypoxia and asthma, and there was a physician's order for continuous oxygen administration at 2 liters per minute via nasal cannula. The order also specified that the oxygen tubing, humidifier, and filter should be changed weekly and labeled accordingly. Interviews with facility staff, including an LPN, the Infection Preventionist, and the Director of Nursing, confirmed that the facility's protocol required weekly changes of respiratory equipment on the Friday night shift, with documentation in the electronic record and proper labeling. However, the observations indicated that these procedures were not followed, as the equipment was neither labeled nor dated. The facility's policy on oxygen administration, revised in 2010, also emphasized the need to verify physician orders and follow protocol for oxygen administration, which was not adhered to in this case.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that specific target behaviors were monitored prior to the administration of an anti-psychotic medication for a resident who had been receiving Seroquel since May 2024. The resident, who was admitted with diagnoses including heart failure, chronic kidney disease, restlessness, agitation, and dementia, had a severely impaired cognition score and exhibited behaviors of care rejection. Despite these conditions, there was no documented order to monitor the behaviors associated with the use of Seroquel or the potential side effects of the medication. Observations and interviews revealed that the nursing staff, including LPNs and the Unit Manager, were not documenting the presence or absence of behaviors or side effects related to the use of Seroquel. The staff acknowledged that there should have been orders for monitoring these aspects, but they were not in place until the surveyor's inquiry prompted a new order. The facility's policy required monitoring for target behaviors and side effects, but this was not adhered to in the case of the resident. The Assistant Director of Nursing confirmed that monitoring should have been in place from the initiation of the Seroquel order to ensure the resident was not taking medications unnecessarily or experiencing unnecessary side effects. The Director of Nursing also acknowledged the lack of orders for behavior and side effect monitoring, which was contrary to the facility's policy and regulatory requirements. This oversight led to the deficiency identified by the surveyors.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during an incontinence care check. This deficiency was identified during a surveyor's observation of a Licensed Practical Nurse/Unit Manager (LPN/UM) who did not pull the privacy curtain while attending to a resident. The resident, who was in bed with the head elevated at 45 degrees, was admitted with diagnoses including Diabetes, Depression, and Unspecified Epilepsy. During an interview, the LPN/UM was unable to provide a reason for not pulling the privacy curtain, which compromised the resident's privacy.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the Applewood Unit, as evidenced by persistent strong odors of urine and feces. During a survey conducted on two separate days, the surveyor noted a strong urine odor upon entering the unit, despite the presence of housekeeping staff actively cleaning. On one occasion, a strong feces odor was also detected, although no dirty linens were observed on the cart, and incontinence care was not being provided at that time. Interviews with staff revealed that the Licensed Practical Nurse/Unit Manager (LPN/UM) acknowledged the presence of the urine odor and attributed it to dirty linens, which were reportedly picked up by laundry every 2 to 3 hours. The LPN/UM stated that the unit was cleaned in the morning, with floors and rooms cleaned twice per shift. The Housekeeping Director (HD) confirmed that rooms were cleaned twice a day and that Certified Nursing Assistants (CNAs) were responsible for changing linens. The HD was made aware of the odor issue by a nurse. The facility's policy on cleaning schedules was reviewed, indicating that cleaning schedules are developed to maintain a safe, clean, and comfortable environment.
Medication Error Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving Resident #19. The resident, who was severely cognitively impaired with a BIMS score of 0/15, was mistakenly administered an antibiotic that was not prescribed to them. This error occurred during a medication pass on the Applewood Unit, as documented in an incident report dated November 1, 2022. The resident's medical history included major depressive disorder, constipation, unspecified dementia, abnormal gait, and dysphagia, and they had no known allergies. The error was acknowledged by the staff member involved, who stated that they administered the wrong medication and were subsequently educated on the seven rights of medication administration. The facility's policy, revised in April 2019, emphasizes the importance of verifying the resident's identity and checking the medication label three times to ensure the correct administration. Despite these guidelines, the error occurred, and the surveyor was unable to interview the nurse responsible for the mistake. The Regional Director of Specialty Program highlighted the expectation for nurses to follow physician orders and regulations during medication administration.
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 379 citations issued within 25 miles in the last 12 months — including the 14 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 Brick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Laurelton, Llc | 1 mi | ★★★★★ | 1 | 1 |
| Complete Care At Brick Llc | 1.2 mi | ★★★★★ | 14 | 0 |
| Concord Healthcare & Rehabilitation Center | 2.6 mi | ★★★★★ | 6 | 0 |
| Preferred Care At Wall | 3.1 mi | ★★★★★ | 0 | 0 |
| Crest Pointe Rehabilitation And Healthcare Center | 3.9 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Willow Springs Rehabilitation And Healthcare Ctr.
100% money-back within 48 hours.
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.