Atlas Rehabilitation And Healthcare At Daughters O
155 Hazel Street, Clifton, NJ 07011 · For profit - Limited Liability company · 210 certified beds · (973) 772-3700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 improved from 2 to 3 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 | 1.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.6% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 8.1% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.4% | 2.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 1.6% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.1% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 5.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.5% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.8% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 40.7% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.6% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.5% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.07 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.02 | 1.11 | 1.80 | better |
‡ 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.
56.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 235 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.7% 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 175 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.1%CMS range 49.0–61.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.0–13.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 81.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 78.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 69.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 4.7–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 210 beds and averages 200.1 residents a day — about 95% occupied, or roughly 10 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.02 hrs/resident/day on weekends vs 3.35 on weekdays — 10% thinner on weekends. RN hours go from 0.46 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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
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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-05-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the facility failed to sanitize glucometers between uses for one (Resident (R) 111) of two residents (R152 and R111) observed receiving blood glucose testing out of a total sample of 43 residents. The failure to sanitize glucometers between residents resulted in an Immediate Jeopardy (IJ) at F880-J: Infection Control due to the increased likelihood to cause serious harm due to the potential of cross-contamination of blood-borne pathogens. On 05/04/23 at 7:15 PM, the Administrator and Director of Nursing (DON) were notified of the IJ at F880-K: Infection Control. The Immediate Jeopardy began on 05/03/23 when the survey team identified glucometers were not being sanitized between uses for R111. The facility provided an acceptable Removal Plan which included retraining and ensuring competency of all Licensed Practical Nurses (LPN) and Registered Nurses (RN) on the use and sanitization of glucometers. Through interviews with facility staff, observations of glucose testing, and review of staff in-services, the survey team…
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 before2025-10-30 · 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
Complaint #185733 (397779)Based on interview, review of medical record, and other pertinent documentation, it was determined that the facility failed to ensure, a.) appropriate incontinence care was provided for 2 of 3 residents, (Residents #1 and #2) reviewed for quality of care and b.) meal trays delivered timely to residents in 1 of 1 nursing unit observed (2 [NAME] unit) in accordance with standard of clinical practice facility's practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint NJ#185733 (397779) Based on interview and record review, it was determined that the facility failed to maintain a complete record for 2 of 4 residents records reviewed (Residents #1 and #2). The deficient practice was evidenced by the following: 1. On 10/30/25 at 9:40 AM, both Surveyor #1 (S #1) and the Registered Nurse (RN) observed Resident #1 in the dining room seated in a wheelchair with other eight residents. The RN informed S #1 that Resident #1 was cognitively impaired, required extensive assistance with adls (activities of daily living), and incontinent of both bladder and bowel elimination. S #1 reviewed the medical records of Resident #1 and revealed: A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 9/9/25, revealed a brief interview for mental status (BIMS) score of 12 out of 15, which reflected that the resident's cognition was moderately impaired. Section H Bladder and Bowel reflected that resident always incontinent of urine and frequently incontinent of bowel. A review of 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 · Ecited before2025-02-18 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of 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 REPEAT DEFICIENCY Based on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 14 of 38 residents, (Residents #13, #18, #48, #60, #68, #77, #102, #103, #121, #162, #172, #175, #180, and #187), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following: 1. Surveyor#1 (S#1) reviewed the medical records of the following residents and their MDS and revealed: A review of Resident #18's comprehensive MDS (cMDS) with an assessment reference date (ARD) of 7/11/24, was completed on 7/18/24. A review of Resident #77's cMDS with an ARD of 10/31/24, was completed on 11/12/24. A review of Resident #162's cMDS with an ARD of 9/27/24, was completed on 10/9/24. A review of Resident #175's cMDS with an ARD of 11/20/24, was completed on 12/3/24. A review of Resident #180's cMDS with an ARD of 12/9/24,…
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 · E2025-02-18 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and review of other facility documentation, it was determined that the facility failed to ensure that the physicians must review the residents' total program of care including medications and treatments, and write, sign, and date progress notes at each visit. This deficient practice was identified for 14 of 35 residents, (Residents#10, #13, #16, #18, #50, #60, #68, #102, #103, #121, #131, #149, #175, and #180), reviewed for physician services. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:49 AM, Surveyor #1 (S#1) observed Resident #18 in the activity room behind the 1 East nursing station seated in a wheelchair with other residents. The surveyor reviewed the medical record of Resident #18 and revealed: A review of the admission Record (AR, an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; effusion of left knee (swollen joint), essential hypertension (elevated blood pressure), and lymphedema (most common manifestation of lymphedema is soft tissue swelling). A 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 · D2025-02-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 review of other pertinent facility documents, it was determined that the facility failed to a.) treat each resident with respect and dignity in a manner that promotes their quality of life during breakfast and b.) provide privacy during med administration for 1 of 6 residents, (Resident #39), observed during medication pass administration. This deficient practice was evidenced by the following: On 2/10/25 at 8:44 AM, during the medication administration pass observation, the surveyor observed the Licensed Practical Nurse (LPN), prepared medications (meds) for Resident #39, and brought them inside the dining area in the 2 East unit. The surveyor observed that there was a total of five residents inside the dining area eating their breakfast including Resident #39. The LPN also checked Resident #39's blood pressure inside the dining room. After the LPN administered the meds, the surveyor interviewed the LPN outside the dining room. The surveyor asked the LPN if it was appropriate to administer and check the blood pressure of the resident inside 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 · D2025-02-18 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure a licensed staff credentials were verified upon hire. This deficient practice was identified for 1 of 9 newly hired licensed staff reviewed. This deficient practice was evidenced by the following: On [DATE] at 1:30 PM, the surveyor reviewed ten randomly selected new employee files. The review for license verification/renewal for one of the new licensed employees, Social Worker (SW), revealed no license in her employee file. On [DATE] at 12:19 PM, the surveyor requested from the Regional Nurse, the SW's license. The Regional Nurse stated, She works full time as a SW. I think something with pending status on her license, the License Nursing Home Administrator (LNHA) will come in and give more information. On [DATE] at 12:56 PM, the LNHA provided the surveyor a New Jersey Division Consumer Affairs license verification printout dated [DATE] at 9:14 AM, which revealed license…
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 · D2025-02-18 · 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 the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold notices for 1 of 1 resident, (Resident #175), reviewed for hospitalizations. This deficient practice was evidenced by the following: On 2/7/25 at 11:33 AM, the surveyor observed Resident #175's outside door with a posted sign for Enhanced Barrier Precautions (EBP are measures implemented in healthcare settings to prevent the transmission of infections, particularly in situations where standard precautions alone may not be sufficient) and the resident was not inside the room. On that same date and time, the Certified Nursing Aide (CNA) informed the surveyor that the resident was in therapy. The surveyor reviewed the medical records of Resident #175 and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; urinary tract infection site…
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 · D2025-02-18 · 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 observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for 1 of 38 residents, (Resident #18), reviewed for Minimum Data Set (MDS). This deficient practice was evidenced by the following: According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2024 showed: An SCSA must be completed within 14 days of determining a significant change from baseline. The resident's condition is not expected to return to baseline within two weeks. Comparison with the most recent comprehensive and quarterly assessments is crucial. Criteria for SCSA include two areas of decline or improvement, or IDT (Interdisciplinary team) recommendation. Documentation of criteria met is essential in the resident's medical record. Required for various scenarios like hospice enrollment, a consistent pattern of changes, etc. On 2/7/25 at 11:49 AM, the surveyor observed Resident # 18 in…
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 · D2025-02-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documentation, 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, for 2 of 38 residents, (Residents #18 and #190), reviewed for MDS accuracy. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:49 AM, the surveyor observed Resident #18 in the activity room behind the 1 East nursing station seated in a wheelchair with other residents. The surveyor reviewed the medical records of Resident #18 and revealed: A review of the admission Record (AR, an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; effusion of left knee (swollen joint), essential hypertension (elevated blood pressure), and lymphedema (most common manifestation of lymphedema is soft tissue swelling). A review of the quarterly MDS (qMDS) with an assessment reference date (ARD) of 10/4/24, revealed a brief interview for mental status (BIMS) score of 6 of 15,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-18 · 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
Complaint#: NJ175914 Based on observations, interviews, review of medical records, and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical and psychosocial needs. This deficient practice was identified for 4 of 38 residents (Residents #111, #172, #180, and #442), reviewed for a care plan. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:26 AM, the surveyor interviewed Resident #111 who was seated in a wheelchair, and stated that they had just returned from a physical therapy (PT)session. Resident #111 further stated that they had several falls and that they banged up knee and it was still bruised maybe because of diabetes. The surveyor observed a Fall Risk wrist band on Resident #111's wrist and that the resident's bed was low to the ground. On 2/11/25 at 10:37 AM, the surveyor interviewed Resident #111's Licensed Practical Nurse #1 (LPN#1) regarding the process for fall risk assessment and falls. LPN#1 stated that a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2025-02-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure that a.) the monthly Psychoactive Review (behavior monitoring) was done routinely and accurately and b.) identified behaviors were discussed with the interdisciplinary team for 1 of 5 residents, (Resident #175), reviewed for unnecessary medications, according to the standard of clinical practice and facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized…
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 · D2025-02-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a) the resident's current active care plan (CP) contained the interventions that were implemented after each resident's fall, in order to prevent any additional falls; and b) ensure a fall risk assessment was done quarterly in accordance with their facility policy for 1 of 2 residents reviewed for accidents/falls (Resident #111). The deficient practice was evidenced by the following: On 2/7/25 at 11:26 AM, the surveyor interviewed Resident #111 who was seated in a wheelchair. Resident #111 stated that they had just returned from a physical therapy session. Resident #111 stated that they had several falls and that they banged up knee and it was still bruised maybe because of diabetes. The surveyor observed a Fall Risk wrist band on Resident #111's wrist and that the resident's bed was low to the ground. On 2/11/25 at 9:58 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) to provide any incidents or investigations…
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 · D2025-02-18 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 monitor enteral tube feeding administration to assure the total volume (TV) administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 resident, (Residents #172), reviewed for enteral tube feeding. This deficient practice was evidenced by the following: On 2/7/25 at 10:45 AM, the surveyor observed Resident #172 lying in bed with the head of the bed elevated and their eyes were closed. The resident had enteral feeding equipment and supplies at the bedside. On 2/11/25 at 9:05 AM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #172. A review of the admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, cerebral infarction (stroke), dementia, type 2 diabetes mellitus, and gastrostomy (tube that is inserted through the abdominal wall into the stomach to provide nutrition, fluids, and medication). A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-18 · 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
REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to, a.) maintain the necessary respiratory care and services of residents and b.) develop an individualized care plan in accordance with professional standards of practice for one 1 of 4 residents, (Resident #187), reviewed for respiratory care. This deficient practice was evidenced by the following: On 2/7/25 at 11:00 AM, the surveyor observed the Resident #187 sitting on the bed, nebulizer (neb) machine on top of the bedside table, mask in the drawer and not in the bag. The resident stated they placed the neb in the drawer and did not put it back in the plastic bag. The plastic bag was dated 2/1/25. The resident stated, I had an infection before, not now. I use that for breathing. A review of the admission Record (an admission summary) revealed diagnoses which included but not limited to; encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft, and pneumonia…
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 · D2025-02-18 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to, a.) ensure a resident's medication, blood sugar check, and times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 2 of 3 residents (Residents #77 and #121) and b.) clarify duplicate orders for 1 of 3 residents, (Resident #77), reviewed for dialysis, according to facility's policy and standard of clinical practice. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or…
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 · D2025-02-18 · tag F0732 — isolatedPost nurse staffing information every day.
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 pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 2 of 7 days in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: 1. On 2/7/25 at 8:47 AM, upon entry to the facility, Surveyor #1 (S#1) observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main lobby. The NHRCSR posted was dated 2/6/25 for the [7:00 AM to 3:00 PM] day shift. There was no NHRCSR for 2/7/25 posted. On 2/7/25 at 9:20 AM, S#1 interviewed the receptionist by the main lobby, who stated, I am responsible for posting the staffing. I know it's the wrong date, I was waiting on the Staffing Coordinator (SC) to come in, she's running late. She will usually give me the numbers and I will correct it on the paper. I am the one printing out the staffing. On 2/11/25…
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 · D2025-02-18 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident's dietary preferences were honored for 1 of 1 resident, (Resident #48), reviewed for food concerns. This deficient practice was evidenced by the following: On 2/7/25 at 10:41 AM, the surveyor observed Resident #48 lying in their bed with the head of the bed elevated. The resident was alert, and verbally responsive. Resident #48 expressed concerns with their meals. The resident stated that they selected from a menu the food items they wanted and did not get what was requested most of the time. The resident further explained that if they received a food item they did not request, the staff would call the kitchen, and the resident would just get what's available .whatever they have left at the time. Resident #48 stated they did discuss with kitchen and registered dietician (RD) about not getting food items requested and the issue still occurs. On 2/11/25 at 9:35 AM, the surveyor reviewed the paper chart and electronic medical record…
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 before2025-02-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
COMPLAINT #: NJ173918 Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 4 of the 38 residents reviewed, (Residents #131, #162, #175, and #493). This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:47 AM, the surveyor observed Resident #162 seated in a wheelchair outside their room with a right leg prosthesis in use. The surveyor reviewed the medical records of Resident #162, and revealed the following: The admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dehiscence of amputation stump (a rare medical condition where the surgical incision site from a previous amputation reopens or separates, exposing the underlying tissues and bones), acquired absence of right leg below the knee, encounter for orthopedic aftercare following surgical amputation, and type 2 diabetes…
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 before2025-02-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene, use of personal protective equipment (PPE) practices, and use of disinfecting wipes for 3 of 6 staff (1 Certified Nursing Aide and 2 Nurses) and b.) ensure that the COVID-19 infection precaution was posted and ensure the physician order for transmission based precautions (TBP) was followed for 1 of 1 resident, (Resident #292), and follow appropriate infection control practices, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical…
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 · D2025-02-18 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ183033 Based on interviews, medical record reviews, and review of other pertinent facility documents, it was determined that the facility failed to ensure that the physician was consulted and notified immediately of resident's change in condition and follow the facility's policy and protocol with regard to notification of changes. This deficient practice was identified for 1 of 3 residents, (Resident #443), reviewed. This deficient practice was evidence by the following: A review of the admission Record (an admission summary) revealed that Resident #443 was admitted to facility with diagnoses which included but were not limited to; Parkinson's Disease without dyskinesia, without mention of fluctuations, other Alzheimer's Disease, multiple myeloma (a cancer of plasma cells, a type of white blood cell that normally produces antibodies) not having achieved remission, type 2 diabetes mellitus without complications, nonrheumatic aortic (valve) insufficiency, aneurism of the ascending aorta, without…
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 · D2023-10-20 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # 165432 Based on interview, record review, and facility policy review, the facility failed to report an injury of unknown origin to the state survey agency for one (Resident (R) 9) of 12 sampled residents reviewed for abuse. Findings Include: Review of R9's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed R9 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance and mood disturbance, repeated falls, muscle weakness, and age-related osteoporosis. Review of R9's Care Plan, located under the Care Plan tab of the EMR and dated 10/02/22, revealed, R9 is using a psychotropic medication Seroquel to manage target symptoms of fighting and being combative during care. It was recorded R9 had behavioral issues of hitting and pushing on tables. Review of R9's quarterly Minimum Data Sheet (MDS), with an assessment reference date (ARD) of 06/21/23 and located under the MDS tab of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 164077 Based on resident and staff interview and medical record review, the facility staff failed to administer physician ordered medications as scheduled for one (Resident (R) 6) of 12 sampled residents. Findings included: Review of R6's Face Sheet, located in the electronic medical record (EMR), revealed R6 was admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia of the left side, diabetes mellitus, and depression. Review of R6's annual Minimum Data Set (MDS), located in EMR, revealed R6 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R6's Physician's Orders and Medication Administration Records (MARS), located in the EMR, revealed R6 was to receive the following medications: Prandin, an antidiabetic medication - one milligram (mg) orally twice daily; Baclofen, a muscle relaxant - 10 mg orally twice daily; Carbamazepine, an anticonvulsant - 200 mg orally twice daily; Gabapentin,…
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 · E2023-05-05 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation on 05/01/23 at 1:35 PM, R2 was lying in bed and R2 had facial hair on her upper lip. R2 said she could not talk as she couldn't hear. During an observation on 05/01/23 at 3:45 PM, R2 was observed in bed with facial hair on her upper lip. On 05/02/23 at 11:52 AM, R2 was observed seated in the dining room. R2 was observed to have facial hair on her upper lip. During an observation on 05/02/23 at 1:00 PM, R2 was observed in the dining room with facial hair on her upper lip. 05/03/23 at 9:19 AM, R2 was observed with facial hair on her upper lip. Review of R2's Face Sheet, located in the EMR under the Resident tab, revealed an admission date of 05/24/18 with medical diagnoses that included spondylosis (degenerative changes in spine). Review of R2's annual MDS, located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 02/15/23 revealed R2 required extensive physical assistance of one person for her personal hygiene needs. Review of R2's Care Plan, located in the EMR under…
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 before2023-05-05 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of 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 interviews, record reviews, and review of the facility's policy, the facility failed to provide timely Minimum Data Set (MDS) data submission in one (Resident (R) 343) of six residents reviewed for MDS transmission out of a total sample of 43 residents. Findings include: Review of R343's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R343 was admitted to the facility on [DATE]. R343's admitting diagnoses included Huntington's disease (a progressive neurodegenerative disease), malignant neoplasm (cancer) of brain, dementia with agitation, anxiety disorder, a cardiac pacemaker, malnutrition, and repeated falls. Review on 05/02/23 of R343's MDS with an Assessment Reference Date (ARD) of 04/23/23, located under the MDS tab, indicated this MDS was not complete due to the majority of the MDS sections being colored red (in process) instead of green (completed). Review on 05/03/23, of R343's MDS indicated the majority of the MDS sections were colored yellow (in…
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 · D2023-05-05 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure a hearing aid was in place in one of 43 sampled residents (Resident (R) 2) in order to maintain her hearing abilities. This deficient practice created a potential for a lack of communication to occur. Findings include: Review of R2's undated electronic medical record (EMR) Face Sheet, under the Profile tab, revealed R2 was admitted to the facility on [DATE]. Review of R2's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicative of intact cognition. On the same annual MDS, R2 was able to hear with minimal difficulty if hearing aid used. Review of R2's EMR Orders tab for current physician's orders included an order, dated 12/03/2020, for right hearing aid accountability every shift. Review of R2's EMR Care Plan tab revealed a Care Plan, dated 03/16/23. The Care Plan stated R2 has a communication problem r/t…
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 · D2023-05-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of policy, the facility failed to consistently provide daily range of motion (ROM) services for one (Resident (R) 126) of two residents sampled for limited ROM out of a total sample of 43 residents. This failure had the potential for the resident to lose mobility and independence. Findings include: Review of the admission Record, located in the Profile tab of R126's electronic medical record (EMR), documented an admission date of 05/04/21. R126's diagnoses included hemiplegia and hemiparesis (paralysis and weakness) following a cerebral infarction (stroke) affecting his right side. Review of R126's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R126 was cognitively intact. Review of R126's Care Plan, last updated on 03/20/23, revealed that R126 was to have restorative nursing active ROM to both upper (arms) and lower extremities (legs) of two sets with ten repetitions. Review of R126's May 2023…
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 before2023-05-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility policy, the facility failed to obtain physician orders and develop a care plan with interventions for one of two residents (Resident (R) 292) reviewed for oxygen therapy from a total sample of 43 residents. Findings include: Observation on 05/02/23 at 9:57 AM revealed R292 in bed receiving morning care. R292 was wearing a nasal cannula with an oxygen concentrator at bedside. There was a portable tank of oxygen observed on the back of R292's wheelchair. Observation 05/03/23 at 3:07 PM revealed R292 sitting up in her wheelchair with nasal oxygen in place. The oxygen concentrator for set two liters per minute. The humidifier jar had a date of 05/03/23. Review of R292's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/23, located in the electronic medical records (EMR) MDS tab, assessed R292 had Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition Further review of this MDS for special treatments and procedures documented that R292 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.
- Potential for harm · D2023-05-05 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure a medication regimen review was completed by a pharmacist at least once a month in one resident (Resident (R) 150) out of five residents reviewed for unnecessary medications out of a total sample of 43 residents. Findings include: Review of R150's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R150 was admitted to the facility on [DATE]. R150's admitting diagnoses included heart disease, left above the knee amputation, aortocoronary bypass graft, long term use of insulin, anxiety disorder, and major depressive disorder. Review of R150's EMR under the Orders tab indicated R150's ordered medications included: metformin hcl (hydrochloric acid) oral tablet 500 milligrams (mg) one tablet two times day; Percocet oral tablet, one tablet every six hours for phantom pain; alprazolam tablet 0.5 give one tablet by mouth every eight hours as needed for anxiety for 14 days; abilify oral tablet…
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 · D2023-05-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, the facility failed to ensure psychotropic medication efficacy was monitored for one of five residents (Resident (R) 15) reviewed for unnecessary medications. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of medication. Findings include: Review of R157's printed admission Record, from the electronic medical record (EMR) Profile tab, showed an admission date of 08/03/22 with medical diagnoses that included major depressive disorder, unspecified psychosis (out of touch with reality) not due to a substance or known physiological condition, and Alzheimer's dementia. Review of R157's printed Order Summary, from the EMR Orders tab, showed the following orders: atypical antipsychotic quetiapine 12.5 milligrams (mg) daily at bedtime for psychosis, with an order to monitor behavior for efficacy; an antidepressant medication Remeron 15mg at bedtime for depression, with an order to monitor behavior for efficacy; and a mood stabilizing medication valproic acid 125mg every…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ATLAS HEALTHCARE — 29 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 3.1 | -1.1 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 28 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NJ MAZEL PARENTCO 2 LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 06/23/2022 |
| NJ NOBLE PARENTCO 2 LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 06/23/2022 |
| COPPER NJ TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/23/2022 |
| GOLD NJ TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/23/2022 |
| MALT FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/23/2022 |
| SGS 2010 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/23/2022 |
| SILVER NJ TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/23/2022 |
| TYH 2017 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/23/2022 |
| MEISNER, ROBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/23/2022 |
| BAK, PINCHOS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/23/2022 |
CMS files one row per role, so the 11 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% 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 $1.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 315021. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-18, 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.