Barnegat Rehabilitation And Nursing Center
859 West Bay Ave, Barnegat, NJ 08005 · For profit - Limited Liability company · 115 certified beds · (609) 698-1400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,475 in federal fines (most recent 2024-11-01)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 21% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 fell from 3 to 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.3% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.4% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 12.1% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.0% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.7% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 33.7% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.3% | 5.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 21.8% | 15.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.6% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.5% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.2% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.6% | 8.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.33 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.46 | 1.11 | 1.80 | worse |
‡ 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.
61.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 207 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.1% 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 131 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.7%CMS range 54.5–70.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.6–12.9 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 51.1% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 53.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 43.5% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 10.0%CMS range 6.1–15.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 115 beds and averages 95.7 residents a day — about 83% occupied, or roughly 19 beds typically open. It usually has some room. 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.25 hrs/resident/day on weekends vs 3.90 on weekdays — 17% thinner on weekends. RN hours go from 0.43 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.
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
Deficiencies are more than at the previous inspection — worsening. 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.
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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2025-07-25 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ182922Based on interviews, medical record review, and review of other pertinent facility documents on 7/21/25, it was determined that the facility failed to implement their abuse policy by protecting Resident #4, as well as all residents from abuse, when on 1/25/25 at 8:40 PM, the Certified Nursing Aide (CNA #3) observed CNA #1 and CNA #2 physically abuse Resident #4 and CNA #3 did not report the incident until the next day, 1/26/25 at approximately 12:37 PM. On 1/25/25 at 8:40 PM, during the 3:00 PM to 11:00 PM shift (3-11), CNA #3 reported hearing screaming coming from Resident #4's room, and when she walked into the room, CNA #3 stated that she observed the resident sitting on their bed with CNA #1 trying to remove the resident's shirt and CNA #2 trying to put on a [NAME] coat (hospital gown). CNA #3 reported observing the resident yelling and being combative and spit at CNA #1, who appeared agitated from it and CNA #1 straddled the resident on the bed. CNA #3 reported that while resident laid…
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.
- Actual harm · Gcited before2023-08-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NJ # 164925 Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to ensure a resident (Resident #299) received adequate supervision to prevent an accident, specifically by a staff member operating a mechanical lift to transfer the resident from a bed to a wheelchair without another staff member as required resulting in the resident falling from the mechanical lift concluding in a fractured femur (thigh bone), head laceration, and a shoulder injury. The deficient practice was evident for 1 of 4 residents reviewed for Accidents. The deficient practice was evidenced by the following: A review of Resident #299's Minimum Data Set (MDS; an assessment tool) dated 5/31/2023 revealed under section C that he/she had a Brief Interview for Mental Status score of 11/15 indicating that he/she had moderate cognitive impairment. The MDS also revealed under section G, that he/she required total assistance to transfer from bed to wheelchair with two people providing support to physically assist. A review of Resident #299's…
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.
- Potential for harm · Fcited before2026-04-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation during food preparation in a safe and consistent manner designed to prevent food borne illness by cross contamination.This deficient practice was evidenced by the following:On 3/27/2026 at 10:18 AM, during a follow-up visit to the kitchen, the surveyor observed [NAME] #1 on the preparation (prep) table wearing disposable latex gloves with a hair cover. The surveyor observed the cook pull a plastic tape from a blue box on the table, go to the large grey trash bin, lifted the lid of the bin with their gloved right hand, threw the plastic tape in the trash bin, and returned the lid of the bin. Without washing hands and changing gloves, the cook opened the blue box on the table, took out several raw frozen fish fillets from the box, and placed them on a tray. Wearing the same gloves, the cook then went inside the walk-in freezer and took out another blue box and placed it on the prep table. The cook turned…
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.
- Potential for harm · Ecited before2026-04-01 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of other facility documents, it was determined that the facility failed to appropriate infection control practices specifically by failing to use personal protective equipment upon entering rooms that required it when performing patient care for 2 of 8 residents reviewed under enhanced barrier precautions (EBP) (Resident #10, #101). The deficient practice was evidenced by the following: On 03/26/2026 at 9:31 AM while touring the first floor, while outside of Resident # 10's room, the surveyor observed an orange sign outside the room door that revealed a stop sign symbol and the words, Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. At that time, 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.
- Potential for harm · D2026-04-01 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility provided documentation, the facility failed to ensure that a resident did not self administer medication without an assessment, interdisciplinary care team meeting determination, a physician's order, or care plan intervention for 1 of 3 residents (Resident #28) reviewed for the Medication Administration task.This deficient practice was evidenced by the following:During observation of medication administration on 03/27/2026 at 9:33 AM, Resident #28 told Licensed Practical Nurse (LPN) #1 that they had already administered their eye drops. Resident #28 stated, I have them in my drawer; I do it myself. When the LPN asked, You give yourself the eye drops? the resident confirmed. The surveyor then asked the LPN whether Resident #28 self medicated their eye drops, and the LPN stated, Yes.A review of Resident #28's admission Record revealed diagnoses including, but not limited to, Alcohol Abuse with Withdrawal Delirium, Attention Deficit Hyperactivity Disorder, and Post Traumatic Stress Disorder.A review of the physician's orders…
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.
- Potential for harm · D2026-04-01 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, it was determined that the facility failed to ensure that the results of the most recent survey were readily accessible to residents and the public.The deficient practice was evidenced by the following:On 03/26/2026 at 09:52 AM during the initial tour, the surveyor observed the State Survey Binder located in the lobby of the facility. At that time, the surveyor did not observe any Life Safety Code Statement of Deficiencies (CMS-2567) from previous surveys within the binder.On 03/31/2026 at 12:00 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) replied I will check after the surveyor asked if there is a reason the Survey Binder does not include any Life Safety Code Statements of Deficiencies.On 04/01/2026 at 10:25 AM during an interview with the surveyor, the LNHA said that the Life Safey Code Statement of Deficiencies is now included in the Survey Binder.N.J.A.C. S 8:39-13.1(a)
- Potential for harm · D2026-04-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 of 2 units (First and Second Floor). This was evidenced by: On 03/26/2026 at 10:06 AM, Surveyor #1 observed the first-floor shower room. In the first shower stall, on the bottom left corner, Surveyor #1 observed black discoloration and several chipped tiles. During an interview on 03/30/2026 at 11:15 AM, the Assisitant Director of Nursing (ADON) stated that housekeeping was responsible for the major cleaning of the shower room. Surveyor #1 and the ADON reviewed the shower room together. The ADON acknowledged that the shower tiles need attention. During the initial tour on 03/26/2026 at 9:26 AM, the surveyor observed room [ROOM NUMBER]A. At that time, the surveyor observed that the wallpaper was ripped behind the bed. The surveyor then observed room [ROOM NUMBER]. At that time, the surveyor observed, below the window, that there was a gap…
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.
- Potential for harm · D2026-04-01 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent 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
Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility did not ensure a residents medication regimen was free from unnecessary psychotropic medications. Specifically, a psychotropic medication ordered for an extended duration lacked documented clinical rationale in the resident's record. The deficient practice was identified for 1 of 5 residents (Resident #41) reviewed for unnecessary medications.This deficient practice was evidenced by the following:On 03/26/2026 at 12:43 PM, the surveyor observed Resident #41 walking the facility halls speaking incoherently to themselves. A review of the Electronic Medical Record (EMR) under Diagnoses revealed that Resident #41 was diagnosed with but not limited to generalized anxiety disorder and unspecified dementia (a decline of cognitive function).A review of Resident #41's Minimum Data Set (MDS; an assessment tool used to facilitate the management of care) dated 03/11/2026, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15,…
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.
- Potential for harm · D2026-04-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 ensure that the Minimum Data Set (MDS) assessment was accurate by relying solely on an initial assessment performed by a Licensed Practical Nurse (LPN) without further RN clinical verification for 1 of 1 resident (Resident # 36) reviewed for assessment accuracy.The 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 case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for 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.
- Potential for harm · Dcited before2026-04-01 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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, review of medical records and other facility documentation, it was determined that the facility failed to ensure that nursing assessments for falls were completed by a Registered Nurse (RN) and fall care plans were formulated and evaluated for effectiveness by an RN, in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents (Resident #10) reviewed for accidents.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 case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New…
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.
- Potential for harm · D2026-04-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to ensure that appropriate incontinence care was provided for a resident who was dependent on staff for toileting hygiene and incontinence care. This deficient practice was identified for 1 out of 3 residents (Resident #70) reviewed for bladder and bowel incontinence. The deficient practice was evidenced by the following:On 3/26/2026 at 9:40 AM, during the initial tour of the facility, the surveyor observed a malodorous smell on the first-floor unit hallway across the room of Resident #70. The surveyor observed Certified Nursing Assistant #1 (CNA #1) 1 enter Resident #70's room.On 3/26/2026 at 9:56 AM, the surveyor observed the door to the resident's room open. From the hallway, the surveyor observed CNA #1 fixing Resident #70's hair. When CNA#1 exited the room, the surveyor asked the CNA how many residents were in their assignment. CNA #1 stated they have 16 residents in their assignment. The surveyor entered the room of Resident #70. 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.
- Potential for harm · D2026-04-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
Based on observation, interview, review of medical record and other pertinent facility documentation, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased range of motion (ROM) after discharge from therapy. This deficient practice was identified for 1 of 1 resident (Resident #25) reviewed for position and mobility.This deficient practice was evidenced by the following: On 3/26/2026 at 10:07 AM, the surveyor observed Resident #25 in bed. The surveyor observed the resident's right fingers flexed with short nails visible. The surveyor asked the resident if they could open their right hand. The resident's right fingers were observed with little movement but remained flexed. The surveyor observed the skin on the right palm dry under the nails with no redness. The surveyor asked the resident if the staff apply anything on their right hand. The resident…
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.
Show the remaining 14 citations
- Potential for harm · Dcited before2026-04-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 provided information, it was determined that the facility failed to ensure that a resident at risk for elopement had complete and accurate physician orders and consistent monitoring of a wander guard device following readmission from the hospital. The deficient practice was identified for 1 of 1 Resident (Resident # 52) reviewed for elopement. This deficient practice was evident by the following:During the initial tour on 03/26/2026 at 10:23 AM, the surveyor observed Resident #52 in bed with a wander guard device (a device that may trigger an audible sound when the wearer passes through an exit doorway) on the right ankle.A review of Resident #52's admission Record showed diagnoses including dementia, major depressive disorder, and Alzheimer's disease. The resident's Care Plan, initiated on 01/15/2024, identified a risk for elopement with an intervention for the resident to wear a wander Guard.A review of the Physician Order Summary revealed…
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.
- Potential for harm · Dcited before2026-04-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter (tube inserted in the bladder to drain urine) drainage bag was secured in a manner to prevent contamination and provide appropriate and sufficient services based upon current standards of practice and the resident's comprehensive care plan to document urinary output in the Treatment Administration Record (TAR). The deficient practice was identified for 1 of 1 resident (Resident # 3) investigated for Urinary Catheter or UTI.The deficient practice was evidenced by the following:On 03/27/2026 at 9:31 AM, the surveyor observed Resident #3 seated in a wheelchair in the dining room, the urinary drainage bag was observed below the resident's wheelchair in direct contact with the floor. On the same day at 9:33 AM, during an interview with the surveyor, Certified Nurse Aide (CNA) #1 stated that urinary drainage bags should be stored below the waist and should not make contact with the floor. A review of the electronic…
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.
- Potential for harm · D2026-04-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice specifically by leaving a nasal cannula out of a bag, exposed to air and not having a physician's order for oxygen administration. The deficient practice was identified for 1 of 1 (Resident # 12) residents reviewed for Respiratory Care. The deficient practice was evidenced by the following:On 03/26/2026 at 9:47 AM, during the initial tour, the surveyor observed Resident #12 in their room. At that time, the surveyor observed a nasal cannula (tube that delivers oxygen through the nares) resting on top of an oxygen concentrator and a nebulizer (machine that aerosolizes medication for inhalation) mask stored in the resident's bedside table. The nasal cannula and nebulizer mask were not in a bag and were exposed to air. At that time, during an interview with the surveyor, Certified Nurses Aide (CNA) #1 stated, that was not the way…
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.
- Potential for harm · D2026-04-01 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 provided information, it was determined that the facility failed to ensure that a resident (Resident #2) with a prescribed fluid restriction had monitoring orders in place and documented intake as required for 1 of 1 resident reviewed for dialysis. This deficient practice was evidenced by the following: On 03/27/2026 at 09:19 AM, the surveyor observed Resident #2 in bed with a cup on the bedside table. Resident #2 voiced no concerns at that time. A review of Resident #2's admission record revealed diagnoses including, but not limited to, End Stage Renal Disease (kidneys do not function properly).A review of the electronic medical record showed that Resident #2 was admitted to the hospital on [DATE] for hyperpotassemia (elevation of potassium in the blood) and was readmitted to the facility on [DATE].A review of the March 2026 Medication Administration Record (MAR) revealed a previous order for a 1000 milliliter (mL) fluid restriction (660 mL…
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.
- Potential for harm · D2026-04-01 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 and record review, it was determined that the facility failed to ensure Licensed Practical Nurse staff practiced within their professional scope of practice. The facility permitted Licensed Practical Nurses (LPNs) to independently conduct initial nursing assessments and initiate resident care plans without Registered Nurse (RN) coordination or oversight. The deficient practice was identified for 1 of 1 resident (Resident # 36) reviewed under the Competent and Sufficient Nursing Staff. The 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 case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing,…
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.
- Potential for harm · Dcited before2024-11-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 pertinent documentation it was determined that the facility failed to ensure the resident's environment is free of accident hazards by failing to use bilateral floor mats as ordered. The deficient practice was identified for 1 of 5 residents (Resident # 31) reviewed under Accidents. The deficient practice was evidenced by the following: A review of Resident # 31's comprehensive Minimum Data Set, dated [DATE] revealed that Resident # 31 had a fall prior to admission. A review of Resident # 31's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Mats at the bedside while in bed every shift for safety. The order became active on 09/21/2024. A review of Resident # 31's Treatment Administration Record for October of 2024 revealed the order for, Mats at the bedside while in bed every shift for Safety was indicated as administered for each shift up until the time of surveyor review. A review of Resident # 31's Care Plan…
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.
- Potential for harm · D2024-11-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications for 2 out of 3 medication carts inspected. This deficient practice was evidenced by the following: On 10/30/2024 at 10:06 AM, in the presence of the Licensed Practical Nurse (LPN)# 1, the surveyor inspected the medication cart on the second floor labeled the high side cart for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed 8 Xanax (a narcotic medication used to treat anxiety) 5mg (milligram) in the blister pack in the narcotic box, but the Controlled Drug Sheet (CDS) documented 9 were left. LPN #1 stated that he forgot to sign that out this morning, and that he should have signed it out the minute he gave it. On 10/30/2024 at 10:15 AM, in the presence of LPN# 2 the surveyor inspected the medication cart on the first floor labeled low side cart 2 for storage and labeling…
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.
- Potential for harm · Dcited before2024-11-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically by failing to wear a gown when providing wound care. The deficient practice was identified for 1 of 2 (Resident # 27) residents reviewed for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 27's physician's orders located in the Electronic Medical Record (EMR) revealed that he/she was receiving Santyl External Ointment (topical ointment enzyme that breaks down collagen) applied to the left trochanter wound topically every day shift for healing. The order further revealed to cleanse with acetic acid 0.25%, pat dry, apply santyl, calcium alginate, and cover with a [clean dry dressing]. A review of Resident # 27's diagnoses located in the EMR, revealed a diagnosis of but not limited to a pressure ulcer on the left hip. On 10/25/2024 at 12:36 PM, with permission from Resident # 27, the surveyor observed his/her wound care provided 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.
- Potential for harm · Ecited before2023-08-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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, medical record review, and review of other facility documentation, it was determined that the facility failed to maintain an indwelling urinary catheter in a manner that would limit the potential to cause a Urinary Tract Infection (UTI) for 3 of 3 residents reviewed for indwelling urinary catheters (Resident #199, #79, and #20). This deficient practice was evidenced by the following: On 07/25/2023 at 10:23 AM, during the initial tour of the facility, the Surveyor #1 observed Resident #199 lying in bed. Surveyor #1 observed Resident #199's catheter bag suspended from bed frame and no privacy bag/cover was in place. Urine was visible, however Resident #199's catheter drainage bag was obscured from view on this observation due to their privacy curtain preventing observation from the common hallway outside the room. On 07/27/2023 at 8:38 AM, Surveyor #1 observed Resident #199 lying in bed eating breakfast. Surveyor #1 observed Resident #199's catheter bag lying on floor. The catheter…
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.
- Potential for harm · Ecited before2023-08-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 07/25/2023 from 9:15 to 9:41 AM, the surveyor, accompanied by the Account Manager (AM), observed the following in the kitchen: 1. In the walk-in refrigerator a plastic pan on top of a wheeled cart contained sliced pears. The pan was covered with plastic wrap and dated 7/21. The AM removed the pears to the trash. 2. During the observation of the walk-in freezer it was noted that the walk-in floor was covered with unidentified debris and ice chunks. When interviewed the AM stated that the freezer is on the cleaning schedule and is generally cleaned on delivery day. 3. A stack of four (4) 1/4 pans on the middle shelf of the pan rack were stacked on top of each other. The surveyor removed the top 1/4 pan on the stack and observed a wet, watery substance on the base of the 1/4 pan below.…
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.
- Potential for harm · D2023-08-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to revise a care plan for a resident who transitioned from intravenous antibiotics to oral antibiotics. This deficient practice was identified for 1 of 25 sampled residents, (Resident # 69) and was evidenced by the following: A review of the admission Record revealed Resident #69 was admitted to the facility with diagnoses including but not limited to: Right Hip Replacement and Methicillin Susceptible Staphylococcus Aureus Infection (MSSA) (is an infection caused by a type of bacteria commonly found on the skin). A review of the admission Minimum Data Set, an assessment tool used to facilitate resident care dated 04/12/2023, revealed a Brief Interview for Mental Status of 15/15 indicating Resident #69 was cognitively intact. A review of section N revealed the resident received 7 days of antibiotic therapy. A review of the Order Summary Report (OSR) dated 05/01/2023 revealed a physician order for start date of Daptomycin Intravenous Solution…
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.
- Potential for harm · Dcited before2023-08-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
2. According to the admission Record, Resident # 28 was admitted to the facility with diagnoses including but not limited to: Hypothyroidism (means that the thyroid gland can't make enough thyroid hormone to keep the body running normally). A review of the Consultant Pharmacist (CP) report dated 05/10/2023 revealed a note to the physician to Consider ordering TSH- last noted 7/22 in medical record. A handwritten note indicated TSH ordered 5-15-22. A review of the lab results for the TSH dated 05/15/2023 revealed Results 0.04 with a Ref (reference range) 0.3-4.2 A review of the progress notes dated 05/15/2023 through 05/31/2023 did not include documentation that the physician was notified of the abnormal lab results. A review of the Order Summary Report (OSR) with active orders as of 07/01/2023, revealed a physician order for TSH (Thyroid Stimulating Hormone) (blood test to check your thyroid hormone level) one time only ordered on 06/06/2023 and scheduled for 07/10/2023. A review of the lab results for the TSH dated 07/10/2023 revealed results of 0.12 with a Ref (reference range)…
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.
- Potential for harm · D2023-08-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 pertinent facility documentation it was determined that the facility failed to A.) limit the timeframe for a PRN (as needed) psychotropic medication, which was not an antipsychotic medication, to 14 days, unless a longer timeframe was deemed appropriate by the attending physician or the prescribing practitioner and B.) provide a clinical reason or a clinically pertinent rationale for administering a PRN (as needed) psychotropic medication and failed to monitor and accurately document the resident's response to the medication. The deficient practice was identified for 2 of 5 residents (residents #47, #66) reviewed for Unnecessary Medications. The deficient practice was evidenced by the following: 1.) A review of Resident #47's quarterly Minimum Data Set (MDS) an assessment tool dated 06/23/2023, revealed that Resident #47 had a brief interview for mental status score of 1 indicating that he/she had severe cognition impairment. The MDS further revealed that Resident…
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.
- Potential for harm · Dcited before2023-08-08 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to implement appropriate infection prevention and control practices during medication administration specifically by a staff member lathering with soap and water for less than twenty seconds and by a staff member administering eye drops to a resident without wearing gloves. The deficient practices were identified for 2 of 2 nurses during the Medication Administration task. On 07/26/2023 at 8:20 AM, during medication administration, the surveyor observed Licensed Practical Nurse (LPN #1) finish administering medications to a resident. At 8:27 AM, the surveyor observed LPN #1 enter the bathroom in the residents room with the door open. The surveyor observed LPN #1 turn on the faucet, use the soap dispenser to apply soap to her hand, wet both hands with running water, and began lathering her hands outside of the water. The surveyor used the Department of Health issued computer clock to determine that LPN #1 lathered her hands for 7 seconds. On 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.
“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.
- 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.
Fines & penalties
$13,475 in federal fines across 1 penalty.
- $13,475 — penalty dated 2024-11-01
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CONTINUUM HEALTHCARE — 13 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 12 homes this chain runs (chain average 2.5★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| BRUCKSTEIN, DANIEL | Individual | DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 04/03/2025 |
| BARNEGAT REAL PROPERTY LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE HOLDINGS LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 10/03/2019 |
| CONTINUUM HEALTHCARE I INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/02/2025 |
| EXECUCARE ASSOCIATES | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/15/2025 |
| LESHKOWITZ & COMPANY LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| TWOMAGNETS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/26/2025 |
| DORN, CHERYL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/01/2022 |
| FRISCH, ARTHUR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2023 |
| GANDHI, DHIREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/26/2013 |
| LITMAN, WARREN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2024 |
| MANDELBAUM, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2019 |
| STONEBRIDGE HEALTHCARE MEMBER I LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE MEMBER II LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE MEMBER III LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
| BRUCKSTEIN, ROBERT | Individual | ADP OF THE SNF | since 10/03/2019 |
CMS files one row per role, so the 26 rows in the source record cover these 16 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.
9 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.
This home reported $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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
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
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.
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 315222. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, 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 →
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