No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Runnells Center For Rehabilitation & Healthcare

40 Watchung Way, Berkeley Heights, NJ 07922 · For profit - Corporation · 300 certified beds · (908) 771-5700 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Oct 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$14,901 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,901 in federal fines (most recent 2026-02-04)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

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

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
1 Diamond Hill Rd · (908) 277-8880 · Call to confirm hours
Pharmacy
100 Connell Dr · (908) 469-0915 · Call to confirm hours
Grocery
404 Springfield Ave · (908) 464-8997 · Call to confirm hours
Park
Connell Dr · Typically dawn to dusk
Place of worship

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 5 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 improved from 3 to 5 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 rating5★
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 increased5.9%8.7%15.4%better
Long-stay residents who lose too much weight4.2%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.1%0.6%0.9%better
Long-stay residents with a urinary tract infection0.2%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms30.6%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 injury1.4%2.3%3.3%better
Long-stay residents whose ability to walk worsened2.7%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication26.8%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine93.1%97.2%95.3%typical
Long-stay residents with pressure ulcers4.7%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control16.6%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table25.9%12.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.6%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine70.4%80.1%79.4%worse
Short-stay residents rehospitalized after admission26.3%24.9%22.6%worse
Short-stay residents with an outpatient ER visit14.1%8.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.432.071.67better
Long-stay outpatient ER visits per 1,000 resident days0.911.111.80better

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.

60.0% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.0%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
61.9%U.S. median 56.6%
Met the expected recovery
0.19U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 61.9% 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 63 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 0.19 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF60.0%CMS range 51.2–67.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.5–13.210.7%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 discharge61.9%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 discharge39.7%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 discharge52.4%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 identified91.5%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 setting96.0%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 discharge91.3%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 stay1.1%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 worsened1.1%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 hospitalization6.7%CMS range 4.1–13.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 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

0.52
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.89
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.30
RN hoursweekends
36.2%
Total nursing turnover
42.1%
RN turnover

How full it usually is: this home is certified for 300 beds and averages 252.6 residents a day — about 84% occupied, or roughly 47 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.89 is at or above 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 3.87 hrs/resident/day on weekends vs 4.39 on weekdays — 12% thinner on weekends. RN hours go from 0.61 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%.

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

4
deficiencies at the latest standard inspection (2025-08-14)
3
at the previous standard inspection (2024-04-09)

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.

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-02-04 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #: 2728562, 2728912 Based on interviews, medical record review, and review of pertinent facility documents on 1/27/26, 2/2/26 and 2/4/26, it was determined that the facility failed to ensure that a resident was free from significant medication error. This occurred on 1/23/26, when a Licensed Practical Nurse Unit Manager (LPN/UM) incorrectly used a medication list belonging to another resident (Resident #6) to reconcile Resident #5's medications. Review of Resident #5's January 2026 Medication Administration Record (MAR) revealed incorrect medications were listed and the staff administered the wrong medications to Resident #5 on these dates as follows: -Furosemide (medication used to treat excess fluid in the body) 20 mg tablet daily (Administered on 1/24/26, 1/25/26, and 1/26/26).-Lithium Carbonate Extended Release (a mood stabilizer used to treat bipolar disorder) 450 mg tablet daily (Administered on 1/24/26, 1/25/26, and 1/26/26).-Trazodone (an antidepressant/anxiety) 100 mg tablet at bedtime (Administered on 1/23/26, 1/24/26, and 1/25/26).-Clonazepam (treats seizure…

    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 · D2026-04-17 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and review of pertinent facility documentations on 4/13/26, 4/16/26, and 4/17/26, it was determined that the facility Social Worker (SW) failed to review an electronic mail (email) message dated 4/10/26 about an alleged verbal abuse. The deficient practice was identified for 1 of 5 residents (Resident #1) reviewed for abuse and neglect and was evidenced by the following: A review of the Minimum Data Set (MDS), an assessment tool dated 2/25/26, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating the resident's cognition was moderately impaired. The MDS further revealed that the resident required assistance from staff for completion of their activities of daily living (ADLs). On 4/16/26 at 12:18 PM, the surveyor interviewed Resident #1 concerning the 4/9/26 incident. Resident #1 stated that it was nighttime and 2 female nurses, described as one with black hair and the other with reddish dark hair, pointed their fingers and swore at me. The resident denied staff being rough with their PEG tube cleaning or causing…

    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 · D2026-02-04 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint # 2723777 Based on interviews and record review it was determined that the facility failed to allow a resident with an infectious diagnosis that required Enhanced Barrier Precautions to return after being hospitalized despite the facility's ability to provide that care. This deficient practice was identified for 1 of 2 residents (Resident #2) reviewed for discharges.This deficient practice was evidenced by the following:According to Resident #2's admission Record (AR), the resident was admitted with diagnoses including but not limited to: compartment syndrome (increased pressure in an area of the body that compromises blood flow and tissue function), unspecified, subsequent encounter; paraplegia (impairment or loss of motor and sensory function in the lower half of the body), unspecified; muscle weakness (generalized); and need for assistance with personal care. According to the Minimum Data Set (MDS), an assessment tool dated 12/27/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.…

    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 · Ecited before2025-10-31 · tag F0658 — failed to meet professional standards of care — pattern
    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

    Complaint # 2638227 Based on observation, interview, and record review it was determined that the facility failed ensure staff consistently documented care/services provided to residents in accordance with professional standard. This deficient practice was identified for 2 (two) of 3 (three) residents (Resident #1 and #3) reviewed for reviewed for accident/incident, and was evidenced as follows: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 a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing…

    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 · D2025-10-31 · 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

    Complaint #2585508 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey State Department of Health (NJDOH) an injury of unknown origin and implement facility's policy for accidents and incidents by not thoroughly updating the care plan after an assessment. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed for accident/incident, and was evidenced as follows: On 10/31/25 at 9:00 AM, during an interview with the surveyor, the Assistant Director of Nursing (ADON) informed the surveyor that there were no reportable events (report filed with the NJDOH) found on file for Resident #3.The surveyor reviewed the medical record for Resident #3. A review of the admission Record, (an admission summary) reflected the resident was admitted to the facility with diagnoses that included dementia (memory loss with cognitive decline) with other behavioral disturbances.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/8/25, reflected…

    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 · D2025-10-31 · 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

    Complaint # 2638227 Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure the accuracy of a resident's weight and monitor the resident's food intake in accordance with the resident's care plan. This deficient practice was identified for 1 of 3 closed records reviewed (Resident #1) and was evidenced by the following: The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included Alzheimer's disease, dementia (memory loss with cognitive decline) with psychotic disturbances, and type 2 diabetes (high blood sugar).A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/24/25, reflected a brief interview for mental status (BIMS) score of 2 out 15, which indicated a severely impaired cognition. Section E - Behavior reflected the resident had behavioral symptoms (such as hitting or scratching self, pacing,…

    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 · D2025-08-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, the facility failed to ensure three of three residents (Resident (R) 172, R204, and R218) rights to a dignified dining experience. The residents were unable to protect their right to dignity due to their impaired cognitive status creating the potential for feeling of embarrassment or frustration.Findings include:Review of R172's electronic medical record (EMR) annual Minimum Data Set (MDS), located under the MDS tab, with an Assessment Reference Date (ARD) of 06/10/25 revealed her Brief Interview for Mental Status (BIMS) score was nine out of 15, this score revealed she had moderate cognitive impairment.Review of R204's EMR revealed an annual MDS, located under the MDS tab, with an ARD date of 06/04/25 revealed his BIMS score was four out of 15, this indicated he had severe cognitive impairment.Review of R218's EMR quarterly MDS with a ARD of 08/05/25, located under the MDS tab, revealed her BIMS score was zero which indicated she had severe cognitive impairment.Observation on 08/12/25 at 9:20 AM in the 3W unit dining room,…

    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 · Dcited before2025-08-14 · 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, and record review, the facility failed to ensure that one of one residents (Resident (R) 16) reviewed with contractures out of 35 sample residents received a splint on her hands per the care plan. Failure to use the hand splints has the potential for the resident to develop skin breakdown in the palms of her hands.Findings include:Review of R16's Face Sheet located in the electronic medical record (EMR) under the admission tab documented that the resident was admitted to the facility on [DATE] with diagnoses of traumatic brain injury (TBI) and contracture of muscle of right and left hands.Review of R16's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/11/25 located in the resident's EMR under the MDS tab revealed the resident had persistent vegetative state (a severe brain disorder where a person is awake but unaware of themselves or their surroundings), functional limitation in range of motion bilaterally in upper and lower extremities, and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-14 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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, and policy review, the facility failed to ensure proper glove use and hand washing was used during one of one meal services observed. One of one cook (Cook (C) 1) and two of three dietary aides (DA) (DA2 and DA4) touched ready-to-eat foods and the inside of coffee cups without performing hand hygiene when moving between tasks. The failure to ensure proper hand washing and glove use could contaminate the food served to the residents.Findings include:Observation on 08/13/25 at 10:30 AM in the kitchen revealed DA4 placing Styrofoam coffee cups with his gloved hands onto a tray. He put his fingers inside of each cup as he placed the cup on the tray. DA4 then filled a large pitcher with coffee and filled each coffee cup. When DA4 had filled the tray of coffee cups with coffee he carried it to a heated cart. DA4 opened the cart with the same gloves and then returned to fill another tray, again touching the inside of each cup. DA4 never changed his gloves during this process.Observation on 08/13/25 at 10:45 AM in the kitchen revealed C1 had gloves on and…

    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 · Dcited before2025-08-14 · 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 observation, interview, and policy review, the facility failed to ensure one of one Licensed Practical Nurse (LPN) (LPN 4) and one of one Certified Nursing Assistant (CNA) (CNA 13) used proper glove technique when providing wound care and personal care for one of one residents (Resident (R) 18) observed for wound care of 35 sample residents. This practice placed the resident at an increased risk for infections.Findings include:Observation on 08/12/25 at 10:34 AM of CNA13 as she provided personal care to R18. CNA13 entered R18's room and washed her hands and then put on a protective gown and two pairs of gloves. CNA13 retrieved her cell phone from the supply cart outside of the door and looked at her phone while a basin was filled with soapy water. R18 was handed a soapy washcloth, and he washed his own face. CNA13 took another cloth and washed his chest, abdomen, underarms, hands, and back. CNA13 then dried those areas with a towel, applied lotion and deodorant. CNA13 then provided perineal care to the front and used a towel to wash his legs. CNA13 removed the first layer…

    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 · D2024-04-09 · 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 NJ #165993 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 2 of 35 residents, Resident #200 and #655 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 4/02/24 at 09:33 AM, the surveyor interviewed Resident #200 in their room. Resident #200 stated they take an antidepressant medication and have for a few years. On 4/4/24 at 9:10 AM, the surveyor reviewed Resident #200's hybrid (paper and electronic) medical records. The admission Record (AR) documented the resident had diagnoses that included but were not limited to, adjustment disorder with depressed mood, schizoaffective disorder depressive type, bipolar disorder, and generalized anxiety disorder. A review of a Annual MDS assessment, dated 1/22/24, indicated in Section N-Medications, under N0415. High-risk Drug…

    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
Show the remaining 16 citations
  • Potential for harm · D2024-04-09 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 ensure that the primary physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 1 of 35 (Resident #658) reviewed for physician visits and was evidenced by the following: On 4/4/24 at 12:40 PM, the surveyor reviewed the closed paper and electronic medical record for Resident #658. The admission Record (a summary of important information about a resident) documented that Resident #658 had diagnoses that included but were not limited to, generalized anxiety disorder and major depressive disorder. A review of physician progress notes revealed the following: On 9/12/22, a medical visit note was completed by the resident's primary physician. On 10/4/22, a medical visit note was completed by the Nurse Practitioner (NP). On 11/1/22, a medical visit note was completed by the Nurse Practitioner (NP). On 11/28/22, a medical visit note was completed by the Nurse Practitioner (NP).…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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

    Complaint NJ #165993 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behaviors for the number of episodes, behavioral interventions, and its outcomes for the use of psychotropic medications (mood altering medications) in accordance with facility policy. This deficient practice was identified for one (1) of six (6) residents (Resident #656) reviewed for abuse in a resident-to-resident interaction, and was evidenced by the following: A review of the reportable event record/report (FRI; Facility Reported Incident) that was called in on 7/23/23 at 1:10 PM. The FRI occurred on 7/23/23, at approximately 11:22 AM, and was reported an incident of a resident-to-resident abuse. The event description included the following: At around 11:22 AM on 7/23/23, the Licensed Practical Nurse (LPN) was in the hallway by her medication cart when she witnessed Resident #656, and Resident #657 passed each other on opposite sides of the hallway. The LPN witnessed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-01-19 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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

    Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) document and carry out a Physician's Order (PO) for a urine and stool culture within an appropriate time frame and b.) notify the resident's physician that staff was unable to obtain the urine and stool sample. This deficient practice was identified for 1 of 35 residents, (Resident #84) reviewed for quality of care and was evidenced by the following: On 1/05/22 at 11:44 AM, the surveyor was approached by an alert and oriented resident, Resident #34 who was the roommate of Resident #84. Resident #34 stated that his/her roommate was recently admitted to the hospital. Resident #34 stated that he/she was very close with his/her roommate and they looked after one another like family. Resident #34 further stated that his/her roommate, Resident #84 had become delirious in the middle of the night and when that happened, the resident was sent out to the hospital by facility staff. The surveyor reviewed the medical record for Resident #84. A review of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-19 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    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

    Based off observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) place a splinting device on a resident who had a Physician's Order (PO) for one and b.) maintain accurate and consistent accountability for the use of the splinting device for the months of November 2021, December 2021, and January 2022. This deficient practice was identified for 1 of 4 residents, (Resident #43) reviewed for position and mobility. The deficient practice was evidenced by the following: On 01/04/22 at 10:02 AM, the surveyor observed Resident #43 glide to the front of the nurse's station on the 3 [NAME] unit in his/her motorized wheelchair. The surveyor further observed that the resident had a splinting device secured around on his/her left hand. The surveyor attempted to interview the resident; the resident softly told the surveyor his/her name. On 01/05/22 at 12:21 PM, The surveyor observed the resident lying in bed in his/her room. The surveyor observed a trapeze bar over the resident's bed. The surveyor further observed…

    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 · E2022-01-19 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide 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

    Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) receive a Physician's Order (PO) for a change in a resident's dialysis schedule and b.) plot medications to be administered according to the resident's dialysis schedule. This deficient practice was identified for 1 of residents, (Resident #15) reviewed for dialysis and was evidenced by the following: On 1/04/22 at 10:26 AM, the surveyor observed Resident #15 lying in bed. The resident closed his/her eyes when the surveyor entered the resident's side of the room. The surveyor asked the resident if he/she went to dialysis and the resident stated, no. The surveyor did not attempt to further interview the resident because the resident's body language indicated that he/she did not want to further communicate with the surveyor. The surveyor reviewed the medical record for Resident #15. A review of the resident's admission Record (an admission Summary) reflected that the resident resided at the facility for approximately half a year and had…

    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 · E2022-01-19 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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 provide appropriate pharmaceutical services which included ensuring accurate administering and reconciliation of all drugs, in accordance with professional standards. This deficient practice was identified for 3 of 4 residents (Resident #47, #156 and #812) during the medication administration observation with 2 of 2 nurses during the medication observation pass. 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…

    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 · Ecited before2022-01-19 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    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 documentation, it was determined that the facility failed to ensure that a physician's order was clarified with the physician to prevent an antipsychotic medication (Zyprexa) being administered in excess of the recommended manufacturer's total daily dosage and increased the antipsychotic dosage by doubling the total daily dose from 12/22/21 to 1/5/22 (fifteen days). This deficient practice was identified for 1 of 5 residents (Resident #70) reviewed for unnecessary medications and the evidence was as follows: On 1/3/22 at 12:30 PM, the surveyor observed Resident #70 walking in the hallway. The resident was dressed and appeared groomed. The resident informed the surveyor that he/she was walking to their room. The surveyor reviewed the medical record for Resident #70. A review of the admission Record face sheet (an admission summary) reflected that the resident was re-admitted to the facility in October 2021 with diagnoses which included schizoaffective disorder (a mental health condition including…

    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 · E2022-01-19 · tag F0836 — pattern
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility provided documentation, the facility failed to a.) ensure that incontinence care was provided in a timely manner for 1 of 10 residents (Resident #43) reviewed for incontinence care, b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 23 of 23-day shifts and 1 of 14 overnight shifts reviewed and c.) ensure call bells were answered timely for 1 of 35 residents (Resident #154) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10…

    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 · Ecited before2022-01-19 · tag F0880 — failed to prevent and control infections — pattern
    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 observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility staff failed to a.) appropriately don (put on) and doff (remove) Personal Protective Equipment (PPE), in accordance with Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting a resident's room who was on Transmission Based Precautions (TBP) due to being a Person Under Investigation (PUI) for 1 resident on 1 of 5 units, (Resident #20), b.) appropriately perform hand hygiene and wear PPE at the appropriate time on 1 of 5 units by staff in the nursing department and recreation department, and c.) appropriately disinfect multiuse medical equipment for 1 of 4 nurses during the medication pass. These deficient practices were evidenced by the following: CDC COVID-19 Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 9/10/2021, Managing Residents with Suspected or Confirmed SARS-CoV-2 Infection…

    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 · D2022-01-19 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based off observation, interview, and record review it was determined that the facility failed to maintain respect and dignity for a resident prior to providing incontinence care. This deficient practice was identified for one of three residents, (Resident #43) reviewed for respect and dignity and was evidenced by the following: On 01/10/22 at 10:17 AM, the surveyor walked by Resident #43's room and observed the resident's Certified Nursing Aide (CNA) in the room with the resident. Resident #43's bed was closest to the door in the room. The surveyor observed that the door to the resident's room was open, the resident's privacy curtain was drawn open, and the resident's genital area was exposed. The surveyor observed a white sheet placed just below the resident's genitals. At that time, the surveyor made the CNA aware that incontinence care was going to be observed. The CNA walked out of the room to gather supplies. The resident remained uncovered with his/her genitals exposed. The CNA did not close the door to the resident's room or pull the privacy curtain before exiting 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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

    Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) maintain a resident's motorized wheelchair in a clean and sanitary manner and, b.) maintain a resident's tube feeding pole in a clean and sanitary manner. This deficient practice was identified on 1 of 5 nursing units, 3 West, for 1 of 35 residents reviewed, (Resident # 42) for cleanliness of wheelchairs, and for 1 of 5 residents reviewed, (Resident #15) who were receiving artificial nutrition via a tube feeding. The deficient practice was evidenced by the following: 1. On 01/04/22 at 10:02 AM, the surveyor observed Resident #43 glide up to the front of the nursing station while seated in his/her motorized wheelchair. The surveyor observed that the residents motorized wheelchairs was covered in yellow, brown, and white caked on dust and debris. The resident spoke very softly and was able to tell the surveyor his/her name. On 01/05/22 at 12:21 PM, the surveyor observed the resident laying in bed in his/her room. The surveyor exited the resident's room and…

    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 · Dcited before2022-01-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow physician's orders by administering as needed narcotic pain medications based on pain scale parameters for the prescribed tramadol and oxycodone in accordance with professional standards of practice. This deficient practice was identified for 1 of 2 residents (Resident #154) reviewed for pain. 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 a licensed or otherwise legally authorized physician or dentist.…

    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 · D2022-01-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 documentation, it was determined that the facility failed to obtain the appropriate physician orders for the care of a resident with a tracheostomy (an opening surgically created through the neck into the trachea). This deficient practice was identified for 1 of 1 residents (Resident # 210) reviewed for respiratory care. This deficient practice was evidenced by the following: On 1/3/22 at 1:00 PM, the surveyor observed Resident # 210 inside his/her room. The resident was observed with a tracheostomy. The resident was able to speak. The tracheostomy dressing was clean and intact. On 1/4/22 at 10:45 AM, the surveyor observed the resident in his/her room. The resident did not wish to speak with the surveyor. The surveyor reviewed the medical record for Resident #210. A review of the resident's admission Record reflected that the resident had diagnoses which included but were not limited to malignant neoplasm of check mucosa, cellulitis of face, malignant neoplasm of accessory sinus, unspecified, squamous…

    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 · D2022-01-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 ensure that all medications were administered without error of 5% or more. During the medication observation on 1/6/22 and 1/10/22, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 33 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.06 %. This deficient practice was identified for 1 of 4 residents (Resident #47), that were administered medications by 1 of 2 nurses and was evidenced by the following: 1. On 1/6/22 at 11:03 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor. The surveyor observed the Licensed Practical Nurse (LPN) preparing to administer ten (10) medications to Resident #47 which included polyethylene glycol 3350 powder (Clearlax; a laxative medication to relieve constipation) 17 grams (GM). The LPN stated that Clearlax was an over the counter (OTC)…

    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 · D2022-01-19 · 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, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) identify and remove expired medications from an active medication cart and b.) maintain a completed temperature log for a medication storage refrigerator. This deficient practice was identified for 1 of 5 observed medication carts (2 East) and 1 of 3 observed medication storage rooms (3 West) and was evidenced by the following: 1. On 1/10/22 at 9:53 AM, the surveyor interviewed the Licenced Practical Nurse/Unit Manager (LPN/UM) regarding the process for checking medication storage. The LPN/UM stated that the nurses and her were responsible for checking medication storage to ensure there were no expired medications or items. The LPN/UM further stated that expired medications and items were given back to central supply to discard. On 1/10/22 at 10:01 AM, the surveyor in the presence of a second surveyor and LPN #1 inspected medication cart two (2) on 2 East. The cart contained the following expired medications: geri-tussin 11/21 house…

    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 · D2022-01-19 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 facility documentation, it was identified that the facility failed to maintain a functioning call bell system. This deficient practice was identified on 2 of 5 nursing units (3 [NAME] and 3 East) and for 2 of 35 residents (Resident #27 and Resident #38) reviewed and was evidenced by the following: 1. On 1/5/22 at 11:39 AM, the surveyor observed Resident #38 seated in a wheelchair in his/her room. The resident stated that his/her call bell had not been working for a couple of days and the facility gave him/her a tap bell to use. The surveyor observed the tap bell on the residents overbed table. On 1/6/22 at 12:07 PM, the surveyor stood outside of Resident #38's room and observed the call bell light blinking over the door to the residents room. On 1/6/22 at 12:09 PM, the surveyor observed the resident and his/her friend in the resident's room. The resident's friend stated that they had called the maintenance department to notify them that 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.

    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

$14,901 in federal fines across 1 penalty.

  • $14,901 — penalty dated 2026-02-04

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 THE ROSENBERG FAMILY — 16 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 2 of 52.7-0.7 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 15 homes this chain runs (chain average 2.7★, 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 / managerTypeRoleShareSince
ROSENBERG, AVRAHAMIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/30/2023
ROSENBERG, ESTHERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 11/30/2023
ROSENBERG, JONATHANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 11/30/2023
ROSENBERG, MOSHEIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/30/2023
ROSENBERG, ZVIIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/30/2023
RUNNELLS PROPERTY LLCOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 11/30/2023
STERN, SAMUELIndividualCORPORATE OFFICER; ADP OF THE SNFsince 08/01/2022
GARRETT, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/23/2025
JAIN, DONEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023

CMS files one row per role, so the 17 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$30.2M
Net patient revenuemost recent cost report
-11.7%
Operating marginrevenue minus expenses
$4.1M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 92%Medicare 5%Other / private 3%

About 92% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $4.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$342per resident / day
operating cost
$10,387per month
≈ monthly operating cost
$306per 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 315009. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, 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.

What to do next