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Allendale Rehabilitation And Healthcare Center

85 Harreton Road, Allendale, NJ 07401 · For profit - Corporation · 120 certified beds · (201) 825-0660 Medicare & Medicaid certified

Call the home — (201) 825-0660 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609, F0610) — most recent Nov 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)
  • about 20% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
50 S Franklin Tpke · (201) 934-0043 · Call to confirm hours
Pharmacy
Walgreens1.1 mi
44 W Allendale Ave · (201) 327-4901 · Call to confirm hours
Grocery
10 Triangle Plz · (201) 995-6800 · Call to confirm hours
Park
E Main St · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.0%8.7%15.4%better
Long-stay residents who lose too much weight11.0%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.6%0.9%better
Long-stay residents with a urinary tract infection0.7%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms75.1%12.1%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.5%2.3%3.3%better
Long-stay residents whose ability to walk worsened4.5%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.2%18.8%18.9%typical
Long-stay residents given the seasonal flu vaccine98.8%97.2%95.3%typical
Long-stay residents with pressure ulcers4.9%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control10.7%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.8%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine93.8%80.1%79.4%better
Short-stay residents rehospitalized after admission22.7%24.9%22.6%typical
Short-stay residents with an outpatient ER visit7.7%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.052.071.67better
Long-stay outpatient ER visits per 1,000 resident days0.571.111.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 248 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.4%U.S. median 51.5%
Got home and stayed home
8.6%U.S. median 10.7%
Went back to hospital
81.0%U.S. median 56.6%
Met the expected recovery
0.12U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 81.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 126 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.4%CMS range 47.1–57.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.6%CMS range 6.4–11.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge81.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge73.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge73.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified91.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.0%CMS range 6.0–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.311.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.56
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.01
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.28
RN hoursweekends
44.3%
Total nursing turnover
35.7%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 105.4 residents a day — about 88% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.98 hrs/resident/day on weekends vs 3.65 on weekdays — 19% thinner on weekends. RN hours go from 0.68 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-11-25)
9
at the previous standard inspection (2024-06-21)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Fcited before2025-11-25 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and reviews of facility policies, the facility failed to ensure Infection Control measures were maintained 1. during incontinent care for one resident (Resident (R) 5) of one resident reviewed for incontinent care in a total sample of 29 residents, 2. during separation of clean and soiled laundry, and 3. in a water management program for Legionella bacteria. These failures placed residents at risk of cross-contamination of bacteria and increased health complications.Findings include: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R5 was admitted to the facility on [DATE] with a diagnosis of a non-traumatic brain injury. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/29/25 revealed R5 was assessed by staff to be severely impaired in cognition and was incontinent of bowel and bladder. During an observation on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure an abnormal involuntary movement scale (AIMS-a scoring system which uses a 0-4 rating scale for 12 items to assess the severity of the abnormal involuntary movements) was accurate and completed timely for three residents (Residents (R)10, R15, and R4) reviewed in a sample of29 residents. This failure placed residents at risk of not receiving care and services related to their psychiatric illnesses.Findings include: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, activity levels, ranging from manic highs to depressive lows), major depressive disorder, and anxiety disorder. Review of a significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-25 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure the admission PASARR (Pre-Admssion Screening and Resident Review-a mandatory review prior to admission to screen for mental illness and intellectual disabilities) was accurate for one resident (Resident (R)10) of two residents reviewed for PASARR in a total sample of 29 residents. This failure placed residents at risk of not receiving the appropriate mental health services.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, activity levels, ranging from manic highs to depressive lows), major depressive disorder, and anxiety disorder. Review of the 04/22/25 Level I PASARR located in the Miscellaneous tab of the EMR and completed by the hospital social worker, revealed that in Section II…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure hair washing was provided during showers for one resident (Resident (R) 49) of four residents reviewed for ADLs (Activities of Daily Living) in a total sample of 29 residents. This failure placed the residents at risk of a diminished quality of life.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R49 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, and anxiety disorder. Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/06/25 revealed R49 had a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated R49 was severely impaired in cognition and required moderate assistance with bathing/showering. Review of the 09/29/23 ADL Self Care Performance Care Plan located in the Care Plan tab of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to provide timely repositioning for one (Resident (R)5) of two residents reviewed for positioning in a total sample of 29 residents. This failure placed the resident at risk of skin breakdown.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] with diagnoses that included non-traumatic brain injury, aphasia (language disorder caused by damage to the parts of the brain that control language, speech and understanding language), and respiratory failure. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/29/25 revealed R5 had a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated R5 was severely impaired in cognition, had no pressure ulcers, and was always incontinent of bowel and bladder. Review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility policy, the facility failed to utilize the physician ordered hand splints or a hand roll for two of two residents (Residents (R) 5 and R81) reviewed for contractures in a total sample of 29. This failure placed the residents at risk of further decreased range of motion (ROM) and worsening contractures (a condition of shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints.)Findings include:1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] with a diagnosis that included a non-traumatic brain injury. Review of the Order Summary located in the Orders tab of the EMR revealed an order dated 08/27/25 to Apply bilateral hand splints for 4 hours twice daily. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of four residents (Resident (R)68) reviewed for side rails out of 29 sampled residents. The lack of alternate side rail measures and proper assessment/consent increased the potential for restraint or side rail entrapment. Findings include: Review of R68's admission Record in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnosis of muscle weakness. Review of R68's admission Minimum Data Set (MDS) assessment under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/16/25 revealed a Brief Interview for Mental Status (BIMS), score of eight out of 15 indicating severe cognitive impairment. This MDS revealed that R68 was able to self-transfer. Review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-06-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/13/24 at 9:15 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: Upon entering the kitchen the surveyor observed the FSD and Dietary Aide #1 (DA#1) both wearing earrings that hung more than one inch (in) from their earlobes. The FSD acknowledged both she/he and DA#1 were wearing jewelry that was prohibited in the kitchen area. On 6/17/24 at 9:04 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a kitchen policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, with a revised date of November 2022. Under the policy interpretation and implementation section it states, Fingernails/Jewelry, 17. Jewelry will be kept to a minimum. Hand jewelry and wrist jeweler are covered with gloves…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NJ#162614 Based on observations, interviews, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to report as required to the New Jersey Department of Health (NJDOH) within two hours an allegation of abuse for one (1) of two (2) residents (Resident #156) reviewed for abuse. This deficient practice was evidenced by the following: On 6/13/24 at 11:20 AM, the surveyor reviewed a Reportable Event Record (RER) for a resident to resident abuse that indicated the RER was submitted to the NJDOH by the facility's Administrator at that time, on 3/20/23. A review of the RER included the following: Today's Date: 3/20/23 Date of Event: 3/18/23 Time of Event: 11:00 PM The section that the facility can document if the incident was a significant event and if the event was called in was blank. Further review of the RER indicated that Resident #156 was hit by an unsampled resident on 3/18/23. On 6/13/24 at 12:30 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the facility's complete documentation of the RER…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-21 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, it was determined that the facility failed to provide the resident or resident representative appropriate written notification of the facility's bed hold and reserve payment policy upon transfer to the hospital for two (2) of two (2) residents (Resident #69 and #85) reviewed for hospitalizations. The deficient practice was evidenced by the following: 1. A review of Resident #69's hybrid (combination of paper and electronic) medical record revealed the following: Resident #69's two discharge assessment-return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, reflected that the resident was transferred to the hospital. A review of Resident's hybrid medical record did not include a written notification of the facility's bed hold policy to the resident or resident representative (RR) prior to the transfer to the hospital. On 6/14/24 at 10:24 AM, the surveyor interviewed the Business Office Manager (BOM) regarding the facility's written notification of the bed hold policy process. The BOM stated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-06-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for three (3) of twenty four (24) residents, Resident #69, Resident #105 and Resident #306 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 6/13/24 at 10:31 AM, Surveyor #1 (S#1) observed Resident #69 seated in a wheelchair calling for the nurse. The Licensed Practical Nurse (LPN) stated to the surveyor that Resident #69 had just returned from dialysis. On 6/13/24 at 01:00 PM, S#1 reviewed Resident #69's medical record. A review of Resident #69's admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-21 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for one (1) of one (1) resident (Resident #3) reviewed for PASRR. This deficient practice was evidenced by the following: On 6/13/24 at 10:20 AM, the surveyor observed Resident #3 lying in bed in their room. The resident was alert and oriented. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #3 which revealed the following: According to the admission Record (AR, an admission summary), Resident #3 had diagnoses that included but were not limited to, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety disorder, major depressive disorder, and paranoid schizophrenia (a type of delusion that usually involves persecution). Further review of the AR revealed the diagnosis of paranoid schizophrenia had an onset date of 01/18/23 during the stay of the resident at the facility. A quarterly Minimum Data Set (qMDS) assessment, a tool used…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-21 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to accurately: a) documenting medication administration for one (1) of 24 residents, Resident #18, reviewed for insulin medications, b) complete dialysis post assessment forms for one (1) of one (1) resident, Resident #69, reviewed for dialysis, and c) complete behavior monitoring sheets for one (1) of five (5) residents, Resident #50, reviewed for unnecessary medications. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and review of facility policies, it was determined that the facility failed to identify and accurately address an Enteral Feeding (EF) order discrepancy. This deficient practice was identified for one (1) of two (2) residents reviewed for EF (Resident #27). The deficient practice was evidenced by the following: On 6/13/24 at 10:24 AM, the surveyor interviewed Resident #27 in the resident's room. The resident stated he/she does not take eat by mouth and receives a tube feeding (TF, an EF, is a way of delivering nutrition directly to stomach or small intestine). On 6/14/24 at 9:04 AM, the surveyor reviewed Resident #27's hybrid (paper and electronic) medical record which revealed the following: Resident #27's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: dysphagia (difficulty swallowing) following cerebral infarction, encounter for attention to gastrostomy and unspecified severe protein-calorie malnutrition. The Minimum Data Set…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-21 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to clarify medication route for a resident during the monthly medication (med) reviews for one (1) of six (6) Residents, Resident #27. The deficient practice was evidenced by the following: On 6/13/24 at 10:24 AM, the surveyor interviewed Resident #27 in the resident's room. The resident stated he/she does not take any medications (meds) by mouth. On 6/14/24 at 9:04 AM, the surveyor reviewed Resident #27's hybrid (paper and electronic) medical record which revealed the following: Resident #27's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: dysphagia (difficulty swallowing) following cerebral infarction, encounter for attention to gastrostomy and unspecified severe protein-calorie malnutrition. The Minimum Data Set (MDS), an assessment tool used for the management of care dated 4/05/24, documented the resident had a Brief Interview for Mental Status (BIMS) and scored a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-21 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of pertinent facility provided documentation, it was determined that the facility failed to ensure that the employed designated Infection Preventionist (IP) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role for one (1) of one (1) employee reviewed for IP. This deficient practice was evidenced by the following: On 6/14/24 at 12:10 PM, the surveyor reviewed the facility provided signed job description for the IP which listed the date of hire as 6/10/21. The IP's job description included the following Educational and Certification Requirements: The IP's job description included the following acknowledgement that was signed by the IP and dated 6/10/21: I have read this job description and fully understand that the requirements set forth therein have been determined to be essential to this position (unless otherwise noted in Column 2). I hereby accept the position of Infection Preventionist and agree to perform the tasks outlined in this job…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-21 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    COMPLAINT # NJ171657 Based on interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for one (1) of two (2) residents reviewed, Resident # 157. This deficient practice was evidenced by the following: On 6/17/24 at 12:10 PM, the surveyor in the company of another surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Regional Director of Operations/Registered Nurse (RDoO/RN) who explained that the investigation involves a look back of 48 hours, including statements from staff who cared for the resident. The surveyor reviewed the medical records of Resident #157 and revealed the following: The admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to essential (primary) hypertension (elevated blood pressure), unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life),…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-11 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the interview and record review, it was determined that the facility failed to assure the Licensed Nursing Home Administrator (LNHA) attended the quarterly Quality Assurance (QA) meetings. This was identified for 2 of the 3 QA meetings reviewed. This deficient practice was evidenced by the following: On 10/07/22 at 10:27 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the sign-in sheets for the last three QA meetings and showed the following: 1/27/22 (1st Quarterly QA Meeting)=attendees included an Infection Preventionist Nurse (IPN), Medical Director (MD), and the Director of Nursing (DON). 4/6/22 (2nd Quarterly QA Meeting)=attendees included IPN, LNHA, and the DON. 7/7/22 (3rd Quarterly QA Meeting)=attendees included IPN and DON. According to the above three quarters QA meetings sign-in sheets, the LNHA did not attend the 1st and 3rd quarters QA meetings. In addition, the above sign-in sheets revealed that the MD did not attend the 2nd and 3rd quarters QA meetings. On 10/07/22 at 9:57 AM, the surveyor interviewed the LNHA regarding concerns…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined that the facility failed to accommodate a resident's need and provide a functioning air conditioner. This deficient practice was identified for Resident # 75, 1 of 18 residents reviewed for the accommodation of needs, and was evidenced by the following: On 9/28/22 at 12:29 PM, during an initial tour of the facility, the surveyor met with resident #75, who was in the bed. During the interview, the resident told the surveyor that he/she had no air conditioning throughout the summer. Resident #75 said that the Certified Nursing Assistants (CNAs) and the nurses were also complaining about the heat in the room. On that same date and time, the surveyor asked the resident if anyone was notified such as maintenance and Resident #75 said yes and was told that a new air conditioner was ordered but it never arrived. The resident showed the surveyor a fan that he/she had to have family bring in to help tolerate the heat. The surveyor reviewed Resident #75's medical record. The admission Record (admission summary or Face sheet)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined that the facility failed to develop a comprehensive person-centered care plan to include resident preferences for 1 of 3 residents, Resident #4, reviewed for the resident council meeting and was evidenced by the following: On 9/29/22 at 10:30 AM, the surveyor conducted a Resident Council Meeting at the facility. Three residents attended the meeting that included Resident #4. On 9/29/22 at 11:21 AM, following a resident council meeting, Resident #4 stated that there was an incident a month and a half ago that happened between the resident and the nurse. The resident stated that he/she did not like the nurse. The resident further stated that the incident was reported to the previous Licensed Nursing Home Administrator (LNHA) and the Social Worker (SW). The resident indicated it was investigated. On that same date and time, the resident informed the surveyor that the involved nurse still works in the facility, but no longer was taking care of the resident since the incident. Then, the resident told the surveyor that the nurse was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 4 medication carts inspected. This deficient practice was evidenced by the following: On 10/03/22 at 11:33 AM, the surveyor inspected the South Middle med cart in the presence of a Registered Nurse (RN). The surveyor observed two opened boxes of Ipratropium bromide/ Albuterol Solution 0.5-2.5, 3 ml vials (Medication for breathing) that belong to two residents, Residents#72 and #183 that were discharged from the facility. The surveyor interviewed the RN who stated that both residents were discharged from the facility and were not able to tell the surveyor when they will be returning to the facility. The RN also stated that all medications belonging to residents who were discharged from the facility should be removed from active medication stock. On 10/03/22 at 1:45 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Regional RN no further information was provided by the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) that staff handle clean linens and towels appropriately to prevent contamination and b.) all staff entering the building were screened for Covid-19 signs and symptoms in accordance with the facility policy Covid-19 Employee Screening and Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22, reflected 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic . Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria .2) symptoms of COVID-19 . 1. On 10/04/22 at 12:40 PM, in the presence of a second surveyor it…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-11 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a safe and sanitary environment in the folding and laundry rooms in accordance with the facility's policy. This deficient practice was evidenced by the following: On 10/06/22 at 9:10 AM, two surveyors interviewed Laundry Aide #1 (LA#1) who was in the room with folded and stacked linens. She informed the surveyors that the room was the folding area, where they folded the clean linens. The surveyors observed a table in the room. LA#1 stated that they utilized the table for folding the clean linens. On that same date and time, during the interview of the surveyors, LA#2 entered the room. LA#1 and #2 stated that the folding room was a clean room. Furthermore, the surveyors observed the folding room with folded and stacked linens on the folding table, metal wall-mounted shelves, and 4-tier metal shelves cart. There was a capped half-full bottle of water on the folding table, touching the clean folded and stacked linens. LA#1 and #2 stated that the bottle did not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 86 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Avalon Rehabilitation And Healthcare CenterHamilton, NJ 1 of 5Bay Harbor Post Acute Healthcare CenterSalisbury, MD 1 of 5Blueberry Hill Rehabilitation And Healthcare CtrBeverly, MA 1 of 5Canterbury Rehabilitation And Healthcare CenterRichmond, VA 1 of 5Cape Cod Post Acute CareBrewster, MA 1 of 5Crest Pointe Rehabilitation And Healthcare CenterPt Pleasant, NJ 1 of 5Highland Park Rehabilitation And Healthcare CenterChelsea, MA 1 of 5Mount Holly Rehabilitation & Healthcare CenterLumberton, NJ 1 of 5Nashua Post Acute CareNashua, NH 2 of 5Arbor Ridge Rehabilitation And Healthcare CenterWayne, NJ 2 of 5Atlantic View Post AcuteNewport News, VA 2 of 5Bayview Rehabilitation and Healthcare CenterNorth Kingstown, RI 2 of 5Collingswood Rehabilitation And Healthcare CenterRockville, MD 2 of 5Elmhurst Rehabilitation and Healthcare CenterProvidence, RI 2 of 5Graduate Post AcutePhiladelphia, PA 2 of 5Heritage Hills Nursing & Rehabilitation CenterSmithfield, RI 2 of 5Laurel Brook Rehabilitation And Healthcare CenterMount Laurel, NJ 2 of 5Lawrence Rehab & Hcc/The Meadows At LawrenceLawrenceville, NJ 2 of 5Lawrence Rehabilitation HospitalLawrenceville, NJ 2 of 5Lighthouse Rehabilitation And Healthcare CenterRevere, MA 2 of 5Lincolnwood Rehabilitation and Healthcare CenterNorth Providence, RI 2 of 5North End Rehabilitation And Healthcare CenterBoston, MA 2 of 5Orchard Hill Rehabilitation And Healthcare CenterTowson, MD 2 of 5Palm Springs Post AcuteChelmsford, MA 2 of 5Riverview Healthcare CommunityCoventry, RI 2 of 5Roosevelt Rehabilitation And Healthcare CenterPhiladelphia, PA 2 of 5Southampton Rehabilitation And Healthcare CenterRichmond, VA 2 of 5Springfield Rehabilitation And Healthcare CenterSpringfield, PA 2 of 5West Chester Rehabilitation And Healthcare CenterWest Chester, PA 2 of 5Westgate Hills Rehab & Healthcare CtrBaltimore, MD 2 of 5Willow Brook Rehabilitation And Healthcare CenterWilmington, MA 2 of 5YORK Post AcuteYorktown, VA 3 of 5Alexandria Rehabilitation And Healthcare CenterAlexandria, VA 3 of 5Aspen Hill Rehabiliation & Healthcare CenterHaverhill, MA 3 of 5Belmont Bay Rehabilitation And Healthcare CenterWoodbridge, VA 3 of 5Brighton Post Acute CareBrighton, MA 3 of 5Cambridge Rehabilitation And Healthcare CenterMoorestown, NJ 3 of 5Capitol Rehabilitation And Healthcare CenterHarrisburg, PA 3 of 5Chelsea Rehabilitation And Healthcare CenterGoochland, VA 3 of 5Exton Post AcuteExton, PA

Showing 40 of 86; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
TD BANK N.A.Organization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTERESTsince 08/04/2021
BRADFORD, CHRISTINEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2024
HARMAN, DINAIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 08/04/2021
SCHAFFER, YERACHMIELIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 11/18/2024
VIROJA, YOGESHIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 08/04/2021
POSEN, MINDEEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2023
MARQUIS LIMITED LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2025
RELIANT PRO REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2025
SAWHNEY, JATINDERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/24/2025
FLAGLER, OSHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/24/2025
KAHANOW, AVIVAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/24/2025
LEVOVITZ, TZVIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/18/2025
ROKEACH, FRAIDEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/24/2025
ROKOWSKY, YITZCHOKIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/24/2025
ALLENDALE REAL PROPERTY LLCOrganizationADP OF THE SNFsince 08/04/2021
NFR 2020 IRRV TROrganizationADP OF THE SNFsince 08/04/2021
QUINTO NEXGEN LLCOrganizationADP OF THE SNFsince 08/04/2021
RSBRMK HOLDINGS LLCOrganizationADP OF THE SNFsince 08/04/2021
SK NEXGEN TROrganizationADP OF THE SNFsince 08/04/2021
TRYKO NEXGEN HOLDINGS LLCOrganizationADP OF THE SNFsince 08/04/2021
UAK 2020 IRRV TROrganizationADP OF THE SNFsince 08/04/2021
UKR NEXGEN LLCOrganizationADP OF THE SNFsince 08/04/2021
YK NEXGEN TROrganizationADP OF THE SNFsince 08/04/2021
YR NEXGEN TROrganizationADP OF THE SNFsince 08/04/2021

CMS files one row per role, so the 35 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

13 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$16.2M
Net patient revenuemost recent cost report
+5.3%
Operating marginrevenue minus expenses
$3.0M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 44%Medicare 31%Other / private 25%

This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$445per resident / day
operating cost
$13,519per month
≈ monthly operating cost
$470per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315497. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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