Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Careone At Holmdel during CMS and state inspections, most recent first.
The facility failed to maintain the required emergency water supply, initially having only 132 gallons instead of the needed 258 gallons for its residents. The FSD miscounted the water cases, and additional water was ordered during the survey. Facility policies and contracts required a three-day supply, but these were not met initially.
A resident admitted with a community-acquired pressure ulcer did not have their wounds measured or documented upon admission, and a physician's order for wound care was delayed. Facility staff interviews revealed that the protocol for wound assessment and treatment was not followed, leading to a delay in care.
A facility failed to obtain, record, and monitor weights for a resident on admission, readmission, and weekly as required. The resident, with diagnoses including dysphagia and GERD, had severely impaired cognition. Despite the care plan's focus on nutritional status, weights were not documented due to the resident's refusal and lack of follow-up by staff. Interviews revealed shared responsibility among staff for obtaining weights, but the facility's protocol was not followed.
A facility failed to obtain a physician order to maintain and discontinue a peripheral IV access after completing IV antibiotic treatment for a resident. The resident, admitted with multiple diagnoses, was observed with a heparin lock despite the completion of antibiotics. Records showed no physician order for flushing the line, and staff interviews revealed a lack of clarity on protocols for maintaining and removing peripheral lines. The facility's policy lacked guidance on peripheral line flushes and discontinuation, leading to the deficiency.
A resident with severe cognitive impairment was administered Midodrine despite physician's orders to hold the medication if systolic blood pressure (SBP) was above 100. The medication was given on four occasions when the SBP exceeded this threshold, as identified in the electronic Medication Administration Record (eMAR). The LPN acknowledged the error, which was contrary to the facility's medication administration policy.
A resident with a history of bipolar disorder and peripheral vascular disease sustained a serious laceration to the left lower leg, requiring hospital treatment. The incident was unwitnessed, and the resident, with moderately impaired cognition, could not explain the cause. The facility failed to report the injury to the NJ DOH within the required 2-hour timeframe, as the DON focused on patient care and staff interviews, delaying notification. The facility's policy mandates immediate reporting for serious injuries, which was not adhered to in this case.
A CNA failed to wear appropriate PPE, specifically eye protection, while exiting a resident's room under COVID-19 isolation precautions. Despite signage and training indicating the need for goggles or a face shield, the CNA wore regular eyeglasses, which do not provide adequate protection. The facility's IPN confirmed the deficiency, noting that the CNA had been trained and marked competent in PPE use.
The facility failed to maintain a designated qualified Infection Prevention and Control Nurse from December 2023 to February 2024. During this period, the DON assumed the responsibilities of the Infection Preventionist without the necessary certification, contrary to facility policy. The facility did not have a full-time IPN in the building after the previous IPN left, and the new IPN only completed training in February 2024. This gap in compliance occurred during a COVID-19 outbreak, underscoring the need for a qualified infection preventionist.
Deficiency in Emergency Water Supply Maintenance
Penalty
Summary
The facility failed to maintain the required emergency water supply for its residents in the event of a loss of normal water supply. During a survey, it was observed that the facility, which was licensed for 120 beds and had a census of 86 residents, only had 22 cases of water, each containing six one-gallon bottles, totaling 132 gallons. This was insufficient to meet the requirement of one gallon per person per day for three days, which would require 258 gallons. The Food Service Director (FSD) initially miscounted the number of cases, stating there were 22 cases when there were actually 36 cases, totaling 216 gallons. Additional water was ordered during the survey, but the initial deficiency was acknowledged by the Licensed Nursing Home Administrator (LNHA). The facility's policies and contracts indicated that a three-day supply of water should be maintained, with specific guidelines for emergency situations. However, the facility did not have the required amount of water on hand initially, and there was confusion regarding the responsibility for ordering and maintaining the emergency water supply. The Director of Maintenance (DM) stated that he did not order the water and that it was the FSD's responsibility. The facility's contract with a food service vendor also outlined the need for maintaining an inventory of bottled water, but the facility did not meet these requirements at the time of the survey.
Failure to Document and Treat Pressure Ulcer on Admission
Penalty
Summary
The facility failed to document the measurement of a pressure ulcer and obtain a physician's order for wound care for a resident admitted with a community-acquired pressure ulcer. This deficiency was identified for a resident who was admitted with diagnoses including venous insufficiency, an unstageable pressure ulcer on the right heel, and peripheral vascular disease. Upon admission, the resident's evaluation indicated a stage 3 pressure ulcer on the sacrum and right buttock, but no measurements were documented. The care plan included interventions for skin breakdown, but a physician's order for wound treatment was not obtained until several days after admission. Interviews with facility staff, including the wound care LPN, LPN/Unit Manager, and Director of Nursing, revealed that the protocol for wounds identified on admission was not followed. The protocol required a full-body assessment, measurement, and documentation of wounds, and obtaining physician orders for treatment immediately. The facility's policies also outlined these steps, but they were not adhered to in this case, resulting in a delay in wound care treatment for the resident.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to obtain, record, and monitor weights for a resident on admission, readmission, and weekly as per professional standards of practice. This deficiency was identified for a resident who was admitted with diagnoses including dysphagia, depression, and GERD. The resident's comprehensive admission MDS indicated severely impaired cognition, and the care plan included a focus on nutritional status with interventions such as obtaining weights. However, the physician's orders for January and February did not include an order to obtain weights, and the resident's most recent weight was not documented in the resident evaluations completed by nursing on admission. The facility's protocol required weights to be obtained on admission, readmission, and weekly for four weeks, but this was not followed. Interviews with the LPN/UM, RD, and DON revealed that the responsibility for obtaining weights was shared among staff, but the resident's weight was not obtained due to the resident's refusal and lack of documentation. The RD attempted to address missing weights by contacting the family and using hospital weights, but the facility's policy on monitoring and documenting weights was not adhered to, leading to the deficiency.
Failure to Discontinue Peripheral IV Access After Antibiotic Treatment
Penalty
Summary
The facility failed to obtain a physician order to maintain peripheral intravenous (IV) access and to discontinue the peripheral IV access after the completion of an IV antibiotic treatment for a resident. This deficiency was identified for a resident who was observed with a heparin lock in the left antecubital space, despite the completion of IV antibiotic treatment. The resident was admitted with multiple diagnoses, including sepsis, cellulitis, urinary tract infection, and pneumonia, and had received IV medications during their stay. The review of the resident's records revealed that there was no physician order to flush the heparin lock, and the peripheral line remained in place even after the completion of the IV antibiotics. The care plan indicated a focus on potential complications at the IV insertion site, but the interventions included flushing IV lines per physician orders, which were not present. Progress notes documented that the peripheral line was intact and easy to flush, but there was no documentation of a physician order for maintaining the line or for its removal after the antibiotics were completed. Interviews with facility staff, including an LPN, LPN/Unit Manager, and the Director of Nursing, revealed a lack of clarity and adherence to protocols regarding the maintenance and removal of peripheral lines. The LPN was unsure of how long a peripheral line should remain in place, and the LPN/UM acknowledged that the heparin lock should not remain at the same site for more than 72 hours. The DON confirmed that the peripheral line should have been removed after the completion of IV antibiotics and that there should have been a physician order for flushes. The facility's policy did not include protocols for peripheral line flushes and discontinuation, contributing to the deficiency.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to a physician's orders for the administration of blood pressure medication for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including peripheral vascular disease and heart failure, had a physician's order for Midodrine to be administered three times a day, with specific instructions to hold the medication if the systolic blood pressure (SBP) was greater than 100. However, the medication was administered on four occasions when the resident's SBP exceeded this threshold. The deficiency was identified through a review of the electronic Medication Administration Record (eMAR) for February and March 2024, which showed that the medication was given despite the SBP being above 100 on specific dates. The Licensed Practical Nurse (LPN) acknowledged the error upon review of the records in the presence of the surveyor. The facility's policy for administering medications, which requires adherence to prescriber orders and verification of vital signs, was not followed in this instance.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin that resulted in serious bodily injury to the New Jersey Department of Health (NJ DOH) within the required 2-hour timeframe. This incident involved a resident with a history of bipolar disorder, peripheral vascular disease, recurrent depressive disorder, anxiety disorder, and a laceration to the left lower leg. The resident was found bleeding profusely from a large laceration on the left lower leg, which required immediate medical attention and resulted in the resident being sent to the hospital for treatment, including 20 stitches. The incident was unwitnessed, and the resident, who had moderately impaired cognition, was unable to explain how the injury occurred. The facility's Director of Nursing (DON) reported the incident to the NJ DOH and the Ombudsman's office, but not within the required 2-hour timeframe. The DON acknowledged that the focus was on patient care and staff interviews to ensure accurate reporting, which delayed the notification to the authorities. The facility's policy on reporting abuse, neglect, exploitation, or injury of unknown source requires immediate reporting to the administrator and state officials, defined as within two hours for incidents involving serious bodily injury. The DON admitted to not being familiar with the specific reporting timeframes and recognized that the incident should have been reported sooner. The Licensed Nursing Home Administrator (LNHA) also confirmed that the incident should have been reported within 2 hours, as per the facility's policy.
Failure to Adhere to PPE Protocols for COVID-19 Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) to prevent the potential spread of COVID-19 on the North unit. This deficiency was observed when a Certified Nursing Assistant (CNA) exited a resident's room without wearing goggles or a face shield, despite the presence of a sign indicating the need for droplet/contact precautions, which included eye protection. The CNA was wearing regular eyeglasses, which do not provide adequate protection against exposure to respiratory secretions. The resident in question was on isolation for COVID-19, as indicated by the sign on the door and confirmed by the CNA. The facility's Infection Preventionist Nurse (IPN) confirmed that the CNA was not following the required precautions, as eyeglasses are not sufficient for eye protection. The CNA had previously been marked as competent in donning PPE, including goggles or a face shield, and had received in-service training on COVID-19 infection control and PPE. The facility's policy on droplet precautions also specified the need for gloves, gown, and goggles if there is a risk of spraying respiratory secretions. Despite these measures, the CNA did not adhere to the required PPE protocols, leading to the deficiency.
Failure to Maintain Qualified Infection Preventionist
Penalty
Summary
The facility failed to maintain a designated qualified Infection Prevention and Control Nurse from December 1, 2023, to February 18, 2024. During this period, the Director of Nursing (DON) assumed the responsibilities of the Infection Preventionist (IP) without having the necessary certification in infection control. The facility's policy requires that the infection prevention control program be coordinated by a certified infection preventionist, which was not adhered to during the transition period. The DON was performing dual roles, managing both the duties of the DON and the IP, which is against the facility's policy that mandates a full-time IPN with no other responsibilities. The deficiency was further evidenced by the fact that the facility did not have a designated full-time IPN in the building after the previous IPN left on November 30, 2023, until a new IPN assumed the role on February 18, 2024. The new IPN had only completed the necessary training on February 19, 2024, indicating a gap in compliance with the state directive requiring facilities to have trained individuals in infection prevention and control. During this period, the facility experienced a COVID-19 outbreak, which the DON managed without the required infection control certification, highlighting the critical need for a qualified infection preventionist in the facility.
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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 Holmdel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Bayshore Llc | 2.7 mi | — | 2 | 0 |
| Meadowbrook Respiratory And Nursing Center | 2.8 mi | — | 0 | 0 |
| Anchor Care And Rehabilitation Center | 3.6 mi | — | 0 | 0 |
| Complete Care At Madison, Llc | 4.1 mi | — | 14 | 0 |
| De La Salle Hall | 4.1 mi | — | 1 | 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 August 2026) and official state health department websites.