Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Complete Care At Green Knoll during CMS and state inspections, most recent first.
The facility failed to inform residents about how to file anonymous grievances. During interviews, residents expressed their lack of knowledge about anonymous grievance filing, and staff confirmed that no explanation was provided. The facility's grievance policy did not address anonymous filing, and there was no method in place for it.
The facility failed to provide written notice of their bed hold policy and costs when residents were transferred to the hospital. This deficiency affected five residents, as there was no documented evidence of the required information being provided. Staff interviews revealed a lack of awareness and understanding of the official policy, leading to potential confusion or distress for residents and their representatives.
The facility failed to serve food at a palatable temperature, affecting several residents who reported the food was consistently cold and tasteless. Observations showed that food temperatures were not monitored throughout the meal service, resulting in significant temperature drops by the time meals were served. The facility's policy required hot foods to be served at a minimum of 135 degrees F, but the test tray showed temperatures well below this standard.
A resident was mistakenly dropped off at their personal residence instead of the facility after an appointment due to an address error. Additionally, two residents were transferred without gait belts, contrary to safe practices. Staff reported that gait belts were not commonly used unless approved by therapy, despite facility policy requiring safe handling evaluations.
A facility failed to ensure a resident received alternative measures and informed consent before installing bed rails. The resident, with intact cognition, had no documented alternatives or consent for bed rail use. Interviews revealed staff did not adhere to protocols, with unfilled consent forms and uncertainty about alternatives. The DON acknowledged incomplete QAPI efforts and inconsistent consent practices.
The facility failed to properly label medication containers, leading to a risk of residents receiving incorrect medications. Observations revealed that medication carts contained boxes of slow-release iron pills and Alaway eye drops labeled only with room numbers, lacking specific resident names. Staff confirmed that all medications, including OTCs, should be labeled with the resident's name, as per facility policy.
Failure to Inform Residents About Anonymous Grievance Filing
Penalty
Summary
The facility failed to provide information on how to file an anonymous grievance for six residents reviewed for the grievance process. During a resident group interview, all six residents expressed that they were unaware of how to file an anonymous grievance, stating that they were only informed about filing grievances through the social worker, but not anonymously. The review of Resident Council meeting minutes from January to September revealed no mention of anonymous grievance filing. Interviews with the Social Services staff and the Administrator confirmed that residents were not informed about the process for filing anonymous grievances. The Social Services staff mentioned that she regularly checked in with residents about grievances but did not explain the anonymous filing process. The Administrator also acknowledged the lack of explanation and stated that there was no existing method for filing anonymous grievances in the facility. The facility's grievance policy emphasized the right to voice grievances without interference or reprisal but did not address anonymous grievance filing.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written notice of their bed hold policy and the cost of a bed hold when residents were transferred to the hospital. This deficiency was identified for five residents who were hospitalized, as there was no documented evidence that the facility provided the required information to the residents or their representatives. The absence of this information had the potential to cause confusion or distress regarding the cost to hold a room and whether or not a resident would be able to return to the facility after hospitalization. For Resident 119, the facility did not provide a bed hold letter for two hospitalizations, and the letters that were found did not include the cost after the ten-day hold period or confirm the resident's ability to return. Similarly, for Residents 87, 83, 29, and 67, there was no documented evidence of written information regarding the facility's bed hold policy being provided at the time of transfer. Interviews with staff revealed a lack of awareness and understanding of the official policy, with the Administrative Receptionist admitting to sending out notices without being familiar with the policy details. The facility's policy, updated in January 2024, required that written information be provided to residents or their representatives before a transfer to the hospital or therapeutic leave, specifying the duration of the bed-hold policy, the reserve bed payment policy, and conditions for returning to the facility. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation and communication with the residents' representatives regarding the bed hold policy and associated costs.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was at a palatable temperature, affecting five of six residents reviewed for palatability. Residents reported that the food was consistently cold and tasteless, and these concerns had been raised in monthly council meetings without any observed changes. Observations revealed that food temperatures were not monitored throughout the meal service, leading to significant temperature drops by the time meals were served to residents. During the meal service, the food temperatures on a test tray were significantly below the facility's policy requirements, with chicken at 130.3 degrees F, potatoes at 113.3 degrees F, and broccoli at 112.8 degrees F. The facility's policy required hot foods to be held and served at a temperature of at least 135 degrees F. The Dietary Manager acknowledged the significant temperature drops and stated that the facility used heated pellets intended to maintain temperatures for up to 20 minutes. However, the food temperatures did not meet the desired range, indicating a failure in maintaining the required standards.
Deficiencies in Resident Safety and Transfer Practices
Penalty
Summary
The facility failed to ensure the safety of a resident during transport to an outside appointment. A resident with severe cognitive impairment and mobility issues was mistakenly dropped off at their personal residence instead of being returned to the facility. This error occurred because the transportation company was provided with the resident's personal address instead of the facility address. The incident was not immediately noticed, and the facility only contacted the transportation company after realizing the resident had not returned. Additionally, the facility did not ensure safe resident transfers for two residents who required assistance. One resident, who had hemiplegia and moderately impaired cognition, was transferred by two CNAs without the use of a gait belt, which is contrary to safe transfer practices. The CNAs used their arms and the resident's clothing to assist with the transfer, and it was noted that gait belts were not available on the floor. Another resident, with severely impaired cognition, was transferred by a CNA without locking the wheelchair brakes and without using a gait belt. The facility's staff, including CNAs and LPNs, reported that gait belts were not commonly used unless approved by therapy. The facility's policy on safe resident handling was not adhered to, as the interdisciplinary team is supposed to evaluate and assess each resident's mobility needs and perform lifting and transferring according to the resident's care plan. The Rehabilitation Director indicated that gait belts should be used unless a resident can transfer with minimal assistance and respond well to verbal cues. However, this practice was not followed, leading to unsafe transfer methods being used for residents.
Failure to Obtain Informed Consent and Explore Alternatives for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident received alternative measures and informed consent with explained risks and benefits prior to the installation of bed rails. The resident, identified as R30, was admitted with diagnoses including vascular dementia, depression, bipolar disease, muscle weakness, and anxiety. The resident's Minimum Data Set (MDS) assessment indicated intact cognition with a BIMS score of 13 out of 15. Despite this, the facility did not document any alternative measures before installing the bed rails, nor did they obtain informed consent for their use. Interviews with facility staff revealed a lack of adherence to protocols regarding bed rail use. An LPN admitted that alternatives were not tried before using side rails for the resident, and informed consent forms were found unfilled and unsigned. Another LPN was unsure about what alternatives could have been used and stated that the decision to use side rails was binary. The Director of Nursing acknowledged that informed consent was not consistently obtained and that a Quality Assurance and Performance Improvement (QAPI) initiative had been implemented but was incomplete. The QAPI did not address the lack of exploring alternatives prior to bed rail use.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of medication containers, which led to a potential risk of residents receiving incorrect medications. During an observation, it was found that medication cart one on the second floor contained boxes of slow-release iron pills labeled only with room numbers 223 and 224, without specifying whether they were for bed A or B. This lack of specific labeling could result in the wrong resident receiving the medication. A registered nurse confirmed that the boxes should have included the resident's name, not just the room number. Additionally, medication cart two on the second floor was found to have a bottle of Alaway eye drops labeled only with a room number and no resident name. An LPN was unsure if the eye drops required a name since they were over-the-counter (OTC) medication. However, the Director of Nursing confirmed that all medications, including OTCs, should be labeled with the specific resident's name. The facility's policy on labeling medication containers, updated in January 2024, requires that labels for OTC drugs include the resident's name, indicating a failure to adhere to this policy.
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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 Bridgewater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waterfront Rehabilitation And Healthcare Center | 1.2 mi | — | 13 | 0 |
| Bridgeway Care And Rehab Center At Bridgewater | 1.2 mi | — | 3 | 1 |
| The Arbor At Laurel Circle | 1.9 mi | — | 8 | 0 |
| N J Eastern Star Home | 2.9 mi | — | 16 | 0 |
| Skilled Nursing At Fellowship Village | 4.7 mi | — | 12 | 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.