Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Pine Acres Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Surveyors found that dependent, incontinent residents were not receiving timely incontinence care, with multiple residents observed in urine-saturated briefs and soiled underpads, and strong urine odors present on a nursing unit. Residents with conditions such as dementia, epilepsy, aphasia, diabetes, CHF, and hemiplegia—many with severe cognitive impairment and documented dependence on staff for personal hygiene—had care plans and facility policy requiring incontinence care every 2 hours and as needed, yet were left wet for extended periods, including one cognitively intact resident who removed a saturated brief independently after waiting without CNA assistance. Staff interviews revealed that CNAs were unable to provide 2-hourly incontinence care due to having assignments of 21 residents, and the staffing coordinator and leadership acknowledged that the unit was not staffed according to state-mandated CNA-to-resident ratios and that required staffing levels were not met.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in meeting their needs. One resident, with hemiplegia and hemiparesis, had a care plan that did not reflect their refusal to wear a right-hand splint. Another resident, with severe cognitive impairment, had a care plan that did not document the use of a physician-ordered resting hand splint at night. The facility's policy requires comprehensive care plans with measurable objectives, which was not followed.
A facility failed to follow proper hand hygiene and urinary catheter care protocols. A CNA did not perform hand hygiene after glove removal and washed hands for only eight seconds, contrary to guidelines. Additionally, a urinary catheter bag was improperly stored without a plastic bag, with exposed tubing. The facility's policies were not adhered to, as confirmed by staff.
The facility failed to notify CMS of a name change from 'Pine Acres Convalescent Center' to 'Pine Acres Rehab + Healthcare,' as observed by surveyors. The LNHA admitted that the necessary 855B form was not filed, and documents provided to surveyors reflected the unapproved name.
A facility failed to accurately complete the MDS for a resident with severe cognitive impairment, leading to a deficiency. The MDS incorrectly indicated that the resident did not receive antipsychotic medications, despite a physician's order for Risperdal, which was administered. The MDS Coordinator admitted to not coding the medication correctly, contrary to CMS RAI Manual guidelines.
Failure to Provide Timely Incontinence Care and Maintain Required Staffing Ratios
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to dependent residents on the first-floor nursing unit, resulting in multiple residents being found with saturated briefs, strong urine odors, and soiled underpads. During a unit tour, a surveyor detected a strong urine odor throughout the unit and observed a cognitively intact resident sitting in a wheelchair next to their bed with a urine-saturated adult brief lying on the bed. The resident reported that the brief had been there for 45 minutes and that they had removed it themselves because a CNA had not checked on them. This resident’s records showed diagnoses including pneumonia, generalized muscle weakness, and type 2 diabetes mellitus, with MDS documentation that they were frequently incontinent of bowel and bladder and required staff assistance for personal hygiene. The resident’s care plans directed staff to provide incontinence care throughout the shift and to check for incontinence throughout the shift, wash, rinse, and dry the perineum, and change clothing after incontinence episodes. During an incontinence tour of the first-floor east nursing unit with the LPN/unit manager, several additional residents who were dependent on staff for care were found with inadequate incontinence care. One resident with dementia, anxiety, and hypertension, and a BIMS score indicating severe cognitive impairment, was observed in bed with a brief that was saturated with urine; the LPN/unit manager confirmed the saturation. The MDS for this resident documented that they were always incontinent of bowel and bladder and required staff assistance for personal hygiene, and the care plan included interventions to provide incontinence care throughout the shift. Another resident with epilepsy, aphasia, and diabetes mellitus was observed in bed in a room with a strong urine odor; their brief was wet and the underpad was saturated with urine, which the LPN/unit manager confirmed. This resident’s MDS showed severely impaired cognitive skills, dependence on staff for personal hygiene, and that they were always incontinent of bowel and bladder, with a care plan directing staff to provide incontinence care every two hours and as needed. Further observations on the same tour revealed additional failures to provide timely incontinence care. One resident with seizures, hemiplegia, hemiparesis, and hypertension was found in bed in a room with a strong urine odor; when the LPN/unit manager exposed the resident’s brief, there was a second brief inserted inside the first, and both briefs and the underpad were saturated with urine. The MDS for this resident documented severely impaired decision-making, dependence on staff for personal hygiene, frequent bladder incontinence, and constant bowel incontinence, with a care plan instructing staff to provide incontinence care as needed. Another resident with dementia, congestive heart failure, and hypertension, and a BIMS score indicating severe cognitive impairment, was observed in bed with a brief saturated with urine; the LPN/unit manager confirmed the saturation. This resident’s MDS showed they were always incontinent of bowel and bladder and required staff assistance for personal care, and the care plan called for incontinence care every two hours and as needed. A further resident with hypertension and congestive heart failure, on oxygen via concentrator at 3 LPM, was also observed in bed with a brief saturated with urine, confirmed by the LPN/unit manager; this resident’s MDS showed severe cognitive impairment, dependence on staff for personal hygiene, and constant bowel and bladder incontinence, with a care plan directing staff to keep skin clean and dry and provide incontinence care throughout the shift and as needed. Interviews with staff revealed that incontinence care was not being provided every two hours as required by facility policy and resident care plans. The LPN/unit manager confirmed that the residents had not received timely and appropriate incontinence care every two hours per facility policy. A 7 PM–7 AM LPN stated that CNAs should have provided incontinence care every two hours but suggested that the CNA had too many residents to accomplish this. The 11 PM–7 AM CNA confirmed that she was responsible for 21 residents and was only able to make rounds twice during her shift, stating it was not possible to provide incontinence care every two hours with that assignment. The staffing coordinator initially reported being unsure of state-mandated CNA-to-resident ratios and later confirmed not being aware of those ratios, and also stated they believed nurses could be counted as CNAs even if they were the only nurse on the unit. The Director of Operations acknowledged that the night shift CNA-to-patient ratio on the first floor was 1:21 instead of the required 1:14 and confirmed that the unit was not staffed in accordance with state regulations. The facility’s incontinence care policy stated that it is the policy of the facility to promote resident comfort by keeping residents clean and dry to prevent skin breakdown, and the DON confirmed that incontinence care should be provided by CNAs every two hours and as needed.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for two residents, leading to deficiencies in meeting their needs. For one resident, who was observed using their left hand due to weakness in the right hand, the care plan did not reflect their refusal to wear a right-hand splint. Despite the resident's intact cognition and a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, the care plan lacked documentation of the resident's refusal, which was confirmed by both a CNA and an LPN. Another resident, who had severe cognitive impairment and a physician's order for a resting hand splint at night, also had an incomplete care plan. The care plan did not document the use of the splint, despite observations and staff interviews confirming its application. The facility's policy requires comprehensive care plans to be developed within seven days of assessment, including measurable objectives and timetables, but this was not adhered to for these residents.
Deficiencies in Hand Hygiene and Urinary Catheter Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene practices, as observed during the care of a resident. A Certified Nursing Assistant (CNA) was seen touching a resident's blanket with clean gloves, then removing the gloves and discarding them without performing hand hygiene. The CNA then proceeded to another resident's room and performed hand hygiene for only eight seconds, contrary to the facility's policy and CDC guidelines, which require at least 20 seconds of handwashing. The Infection Preventionist confirmed that the CNA should have performed hand hygiene after glove removal. Another deficiency was observed in the care of a resident with an indwelling urinary catheter. The surveyor found a urinary catheter bag hanging on a rail in the bathroom without a plastic bag, and the catheter tubing was exposed and uncapped. The CNA responsible for the resident's care admitted to omitting the plastic bag and acknowledged that the urinary bag should not have been stored in that manner. The facility's policy requires the urinary bag to be cleaned, capped, and stored in a plastic bag when not in use. The facility's Infection Preventionist and other staff confirmed the improper handling of the urinary catheter bag. The facility's policy on the care and maintenance of the Foley drainage system was not followed, as the urinary bag was not properly stored, increasing the risk of contamination. The surveyor discussed these concerns with the facility's administration, but no further information was provided.
Failure to Notify CMS of Facility Name Change
Penalty
Summary
The facility failed to notify CMS and obtain authorization for a change in its facility name, as required by 42 CFR 424.516. Upon arrival, surveyors observed signage outside the facility displaying the name 'Pine Acres Rehab + Healthcare,' which did not match the CMS-licensed name 'Pine Acres Convalescent Center.' During the entrance conference, the surveyor noted that various documents and policies provided by the Licensed Nursing Home Administrator (LNHA) were titled 'Pine Acres Rehab + Healthcare,' and the facility's admission agreement and business cards also reflected this name. The LNHA explained that the facility's official name is 'Pine Acres Convalescent Center' and admitted that they had not filed the necessary 855B form with CMS to report the name change. A review of the facility's license, issued by the New Jersey Department of Health, confirmed that the licensed name was 'Pine Acres Convalescent Center.' This discrepancy between the facility's operating name and its licensed name constituted a failure to comply with federal and state regulations regarding provider enrollment and active status maintenance in the Medicare Program.
Inaccurate MDS Completion for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, leading to a deficiency in the management of care. The surveyor observed the resident, who was admitted with unspecified dementia and other behavioral disturbances, and reviewed their electronic medical record. The Admission MDS indicated a severe cognitive impairment with a Brief Interview for Mental Status score of 04 out of 15. However, there was a discrepancy in the MDS regarding the use of antipsychotic medication. The MDS incorrectly noted that the resident did not receive antipsychotic medications, despite a physician's order for Risperdal, an antipsychotic drug, which was administered on specific dates in July 2024. The part-time MDS Coordinator acknowledged the error, stating that the medication was not coded correctly in the MDS. The surveyor referenced the CMS Resident Assessment Instrument (RAI) Manual, which mandates that any medication classified as an antipsychotic must be recorded, regardless of its use. The survey team discussed the issue with the facility's administration, including the Licensed Nursing Home Administrator and Director of Nursing, but no further information was provided to address the discrepancy.
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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 Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Florham Park Rehabilitation And Healthcare Center | 1.3 mi | — | 0 | 0 |
| Cheshire Home | 1.3 mi | — | 8 | 0 |
| Chatham Hills Subacute Care Center | 1.7 mi | — | 17 | 0 |
| Morristown Post Acute Rehab And Nursing Center | 3.4 mi | — | 0 | 0 |
| Careone At Madison Avenue | 3.5 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.