St Catherine Of Siena
7 Ryerson Avenue, Caldwell, NJ 07006 · Non profit - Corporation · 30 certified beds · (973) 226-1577 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- lower-than-typical staff turnover (10% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,171 in federal fines (most recent 2024-01-30)
- its payroll-based staffing 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 |
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 | 6.7% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.3% | 4.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.6% | 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 | 0.0% | 12.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 9.4% | 2.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.3% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.0% | 18.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.5% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 33.4% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.3% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.98 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.87 | 1.11 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. 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.
Staffing
How full it usually is: this home is certified for 30 beds and averages 25.9 residents a day — about 86% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 1.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.18 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 1.88 hrs/resident/day on weekends vs 1.95 on weekdays — 4% thinner on weekends. RN hours go from 0.59 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 10% is below 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
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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · F2025-01-07 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of facility provided documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received an annual performance review for 5 of 5 CNA files reviewed. The deficient practice was evidenced by the following: On 12/27/24 at 12:08 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual performance reviews that were done for 5 randomly selected CNAs. On 12/30/24 at 9:17 AM, the LNHA stated that the facility did not have any performance reviews for the 5 CNAs. She added that the Director of Nursing (DON) had the forms that were to be used but that she had not done the reviews yet. The facility did not provide any documented evidence that the 5 CNAs received an annual performance review. On 12/30/24 at 12:36 PM, in the presence of the survey team, the surveyor told the LNHA and DON the concern that the 5 CNAs did not have an annual performance review. On 12/31/24 at 10:44 AM, in the presence of the survey team and the LNHA, the DON stated that she had been at 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 · F2025-01-07 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
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 review of facility documentation, it was determined that the facility failed to ensure that a) Certified Nurses Aides (CNA) received 12 hours of mandatory in-service training for 5 of 5 CNAs reviewed (CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5); and b) CNA education included abuse and resident rights for 1 of 5 CNAs reviewed (CNA #1). This deficient practice was evidenced by the following: On [DATE] at 12:08 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was provided to 5 randomly selected CNAs. On [DATE] at 8:41 AM, the LNHA stated that the facility had a book of the education provided which were in person sessions with sign in sheets but that not everyone signed that they attended. She added that the facility did not use a computer-based education system and did not have an educator. On [DATE] at 9:11 AM, the LNHA provided the binder of inservice sign in sheets that the facility had done. The LNHA stated that capturing…
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 before2025-01-07 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 notify the resident's representative and the Office of the Ombudsman in writing for an emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, Resident #16, reviewed for hospitalization. On 12/31/24 at 8:15 AM, the surveyor observed Resident #16 during medication administration. The resident was seated in their wheelchair and was alert and oriented. A review of Resident #16's hybrid (paper and electronic) medical records revealed the following: A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (elevated blood pressure), depression (mental health condition that causes low mood and loss of interest in activities for a prolonged period) and history of urinary tract infection. A review of the Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/02/24, reflected that Resident #16…
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 · D2025-01-07 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, it was determined that the facility failed to provide the resident or resident representative appropriate written notification of the facility's bed hold and reserve payment policy upon transfer to the hospital for one of one residents (Resident #16) reviewed for hospitalizations. The deficient practice was evidenced by the following: On 12/31/24 at 8:15 AM, the surveyor observed Resident #16 during medication administration. The resident was seated in their wheelchair and was alert and oriented. A review of Resident #16's hybrid ( combination of paper and electronic) medical record revealed the following: A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypertension (elevated blood pressure), depression (mental health condition that causes low mood and loss of interest in activities for a prolonged period) and history of urinary tract infection. A review of the Discharge Minimum Data Set (MDS), an assessment tool used to…
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 before2025-01-07 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set ((MDS), an assessment tool used to facilitate the management of care), in accordance with federal guidelines for 3 of 12 residents, (Resident #23, Resident #28 and Resident #17) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 12/27/24 at 10:08 AM, the surveyor observed Resident #23 in their bed with their eyes closed. On 12/27/24 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who was the nurse providing care for Resident #23. LPN #1 stated Resident #23 was transitioning off a tube feeding (Enteral nutrition (EN), also called tube feeding, is a way of providing nutrition and fluids directly into the gastrointestinal (GI) tract through an enteral access device (feeding tube) that is placed with its tip in the stomach or small intestine) and is only receiving water flushes at this time. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-07 · 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, and record review, it was determined that the facility failed to administer oxygen (O2) therapy according to the physician's order for 1 (one) of 2 residents (Resident #22) reviewed for respiratory care. This deficient practice was evidenced by the following: On 12/27/24 at 10:05 AM, the surveyor observed Resident #22 in bed asleep, wearing a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) (NC) connected to an oxygen (O2) concentrator at four (4) liters per minute (lpm) on the regulator. On 12/27/24 at 10:25 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #22, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #22 was admitted with diagnoses that included but were not limited to malignant neoplasm (abnormal mass of tissue) of unspecified part of unspecified bronchus or lung. A review of the admission Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care…
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 · D2025-01-07 · tag F0811 — isolatedEnsure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of pertinent facility documentation, the facility failed to ensure facility staff that were utilized to assist residents that needed to be fed were appropriately trained and evaluated as competent to be a paid feeding assistant. This deficient practice was evidenced by the following: On 12/27/24 at 10:01 AM, the surveyor entered Resident #12's room. The surveyor observed a staff member (SM) wearing gloves, holding a bowl and a spoon standing next to Resident #12's bed. After the surveyor introduced herself to Resident #12, the SM put down the bowl and spoon on the tray that was on the resident's over the bed table and wiped Resident #12's mouth with a napkin. The surveyor observed that the bedside table was next to the resident's bed and it was not positioned in front of the resident for the resident to feed himself/herself. The surveyor observed that the resident did not have any utensil in his/her hand. The surveyor observed the SM's badge which indicated the SM was a HHA (Home Health Aide). The surveyor asked the SM what she was doing…
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 · E2023-10-12 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 issue the proper required Skilled Nursing Facility Beneficiary Notices for 3 of 3 residents (#10, #28, #29) reviewed for facility change notifications. The deficient practice was evidenced by the following: On 10/5/23 at 09:00 AM, the facility presented the surveyor with a list of residents who were discharged from the facility within 6 months and should have received Beneficiary Notices. The surveyor reviewed 3 of the residents (Resident #10, #28, #29) which were discharged from a Medicare Part A stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. Resident #10 was admitted to the facility on [DATE]. The last documented covered day of coverage for Medicare Part A service was 5/3/23. The resident continued their stay in the facility. The facility did not present the resident or the Power of Attorney with the required Skilled Nursing Facility Advanced…
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 before2023-10-12 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 a significant change assessment was completed for 1 of the 13 residents (Resident #1). Resident #1 was noted with more than three areas of decline with Cognitive Patterns, Mood, Behavior, Health and Skin conditions, and Nutritional Status on the 8/7/23 Quarterly (Q) MDS (Minimum Data Set), an assessment tool used to facilitate the management of care. The deficient practice was evidenced by the following: On 10/04/23 at 11:10 AM, during the initial tour, the surveyor observed the resident lying in bed, alert and awake, able to answer some of the surveyor's inquiries. The surveyor observed the tray of covered food untouched on the overbed table. Resident#1 stated he/she did not want to eat breakfast and would eat lunch instead. Certified Nurse Assistant (CNA) #1, who worked in the facility for 22 years, noted that the resident sometimes does not eat breakfast. On 10/10/23 at 11:55 AM, the surveyor interviewed…
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 before2023-10-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to accurately complete portions of the Minimum Data Set (MDS), an assessment tool, to accurately reflect the residents' status as of the Assessment Reference Date (ARD) for 2 of 13 residents reviewed (Resident #24 and Resident #1). The deficient practice was evidenced by the following: 1. On 10/05/23 at 11:43 AM, the surveyor interviewed the Resident #24 in the resident's room. The resident was sitting on the wheelchair. The resident stated the last time they walked was about six months ago. The resident was able to move both of their arms and legs on command. On 10/05/23 at 11:56 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who has been working at the facility for 22 years. The CNA stated to the surveyor that the resident requires a Hoyer (mechanical lift) transfer and does not walk. On 10/05/23 at 12:25 PM, the surveyor interviewed the Registered Nurse (RN). The RN stated, the resident had orders for…
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 8 citations
- Potential for harm · D2023-10-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
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 develop a comprehensive, person-centered care plan for a resident with a clinical diagnosis of depression in accordance with federal guidelines. This deficient practice was identified for 1 of the 13 residents reviewed for behavioral-emotional investigation (Resident#20). The deficient practice was evidenced by the following: On 10/05/23 at 11:14 AM, the surveyor interviewed the resident, alert with forgetfulness. Resident #20 was observed talking about the parents and becoming emotional while wiping the tears from his/her eyes. The surveyor reviewed the hybrid medical record for Resident #20. The admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to Depression (long-term loss of pleasure and interest). A review of the quarterly MDS (QMDS) dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · 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 observation, interview, and record review and review of pertinent facility documentation, it was determined that the facility failed to update and revise a Care Plan to include a behavior for one (1) of 13 residents, (Resident #4), reviewed for care plans. This deficient practice was evidenced by the following: On 10/4/23 at 12:03 PM, the surveyor observed in the kitchen area of the dining room a sign which read ATTENTION . Don't EVER give [Resident #4] in room [redacted] knife's with meals. On 10/4/23 at 12:18 PM, the surveyor observed Resident #4 seated in a geri-chair ( a geriatric chair that is a large padded reclining chair designed to help with limited mobility) with his/her lunch tray on an overbed table in front of the resident. The lunch tray had a pureed lunch and there was a spoon and a fork provided. The resident stated that he/she had already eaten lunch. On 10/5/23 at 11:11 AM, the surveyor interviewed the Registered Nurse (RN) who provided medications for Resident #4. The RN stated that the resident was confused and had difficulty especially with short term…
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 · D2023-10-12 · 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 follow monitoring guidelines during medication administration in accordance with acceptable standards of clinical practice. The deficient practice was identified for one (1) of two (2) nurses, who administered medications to one (1) of seven (7) residents (Resident #5) and 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. On 10/11/2023 at 8:28 AM, the surveyor observed a Registered Nurse (RN) preparing to administer 11 medications to…
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 · F2022-10-06 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and facility policy review, the facility failed to ensure that the designated individual responsible for the infection control program was certified in infection prevention. This failure has the potential to affect all 23 current residents at the facility, new admissions, and the potential to have missed opportunities for prevention of the spread of the COVID-19 virus, or other infections among residents and staff. Findings include: 1. During an interview on 10/03/22 at 9:30 AM, the Administrator and Director of Nursing (DON) stated the facility did not have a specified staff member as the Infection Preventionist (IP). The Administrator stated they have an IP consultant (IPC) who was certified, and the IPC comes to the facility at least once a week or more often if needed. During an interview on 10/05/22 at 2:00 PM, with the DON and IPC, the IPC stated she was at the facility .on average 8 hours a month . but will visit more when needed. The IPC stated she was certified in IP and confirmed the DON has not completed any infection control (IC) certification courses.…
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 before2022-10-06 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 staff interview and record review, the facility failed to notify their designated State Ombudsman for hospital transfers, or discharges, for two (Resident (R) 11 and R24) of two residents reviewed for hospitalizations or discharges, resulting in the potential for hospital transfers and unplanned discharges by the facility to go unnoticed by the State Ombudsman. Findings include: 1. Review of R11's admission Record, undated, in the Electronic Medical Record (EMR) under the Profiles tab, indicated the facility admitted the resident on 08/13/22. R11 was hospitalized on [DATE]. Review of the Progress Notes in the EMR for R11 revealed R11 was transferred to the hospital on [DATE] at 2:26 PM for .poor intake for a few days and her risk of dehydration and cardiac issues . R11 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. Review of R11's Progress Notes in the EMR revealed no documentation which indicated the State Ombudsman was notified of the hospital transfer. 2. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-06 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for one of 12 residents (Resident (R) 25) reviewed for MDS accuracy in a total sample of 12 residents. This deficient practice increased the potential for missed opportunities of care or services. Findings include: 1. Review of R25s admission Record, undated and located in the electronic medical record (EMR) under the Profile tab, indicated an admission date of 02/01/22, and diagnoses of; dementia, acute on chronic congestive heart failure (CHF), and hypertension. Review of R25's Progress Notes, located in the EMR under the Progress Notes tab, revealed R25 was placed on Hospice services on 09/06/22. R25 passed away on 09/16/22. Review of R25's completed, and accepted, MDS located in the EMR under the MDS tab, revealed no significant change MDS was completed when R25 was placed on Hospice services on 09/06/22. During an interview on 10/04/22 at 4:00 PM the Director of Nursing (DON) stated she was the responsible person for completing .nursing related MDS…
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 · D2022-10-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 policy review, the facility failed to ensure staff monitored and documented ordered blood pressure (BP) readings for one of one resident (Resident (R) 11) reviewed for medications. This failure had the potential for R11 to receive unneeded or missed blood pressure medications. Findings include: 1. Review of R11's admission Record undated, located in the resident's electronic medical record (EMR) under the Profile tab, indicated a current admission date to the facility of 08/13/22, with diagnoses of; dementia, atrial fibrillation (rapid heartbeat), and hypertension. According to the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/22, revealed R11 had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Review of the September 2022 monthly Pharmacy Recommendations provided by the Director of Nursing (DON) for R11 revealed on 09/06/22, the pharmacist identified .Hold parameters ordered to be monitored for this resident [R11] and recorded 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.
- No harm found · C2022-10-06 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interviews, the facility failed to ensure that staffing information was prominently posted in an area that was readily assessable to residents and visitors daily. This had the potential to affect all residents and visitors of the facility. Findings include: 1. Observation on 10/03/22 at 10:28 AM, revealed the daily staffing information was not posted on the unit. On 10/05/22 at 10:28 AM, an interview with the Director of Nursing (DON) revealed that the nurse staffing is located at the back of the nursing station on the counter. However, it did not contain the daily census and was not visible to residents and families. The DON stated, We used to have it posted on the bulletin board. The last time the state was here, they told us it no longer had to be posted and we removed it from the bulletin board. NJAC 8:39-41.2
“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
$16,171 in federal fines across 4 penalties.
- $9,116 — penalty dated 2024-01-30
- $2,117 — penalty dated 2023-11-13
- $1,764 — penalty dated 2023-11-06
- $3,174 — penalty dated 2023-10-17
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| RAMM, LUELLA | Individual | CORPORATE OFFICER | since 05/01/2020 |
| WITTLER, JUDITH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| SCHLAM, EVERETT | Individual | ADP OF THE SNF | since 05/01/2025 |
CMS files one row per role, so the 4 rows in the source record cover these 3 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.
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 $90K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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 315471. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-07, 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.