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 Willow Springs Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
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.
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.
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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 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 | — | 0 | 0 |
| Preferred Care At Wall | 3.1 mi | — | 0 | 0 |
| Crest Pointe Rehabilitation And Healthcare Center | 3.9 mi | — | 10 | 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.