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Birchwood Rehabilitation And Healthcare Center

205 Birchwood Ave, Cranford, NJ 07016 · For profit - Limited Liability company · 200 certified beds · (908) 272-6660 Medicare & Medicaid certified

Call the home — (908) 272-6660 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 25 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
570 South Ave E · (908) 603-4200 · Call to confirm hours
Pharmacy
501 Boulevard · (908) 276-8540 · Call to confirm hours
Grocery
735 Fairfield Ave · (908) 245-3600 · Call to confirm hours
Park
(908) 527-4900 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.3%8.7%15.4%better
Long-stay residents who lose too much weight1.0%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.2%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms18.0%12.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.3%2.3%3.3%better
Long-stay residents whose ability to walk worsened3.8%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.1%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine97.5%97.2%95.3%typical
Long-stay residents with pressure ulcers5.4%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control23.6%15.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.1%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine89.3%80.1%79.4%better
Short-stay residents rehospitalized after admission28.1%24.9%22.6%worse
Short-stay residents with an outpatient ER visit6.7%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.412.071.67better
Long-stay outpatient ER visits per 1,000 resident days0.911.111.80better

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.

68.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 358 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.4%U.S. median 51.5%
Got home and stayed home
8.5%U.S. median 10.7%
Went back to hospital
63.7%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 63.7% 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 182 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 0.28 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF68.4%CMS range 62.5–73.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.5%CMS range 6.6–11.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge56.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.9%CMS range 6.3–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.37
RN hours/ resident / day
0.97
LPN hours/ resident / day
2.01
Aide hours/ resident / day
3.35
Total nurse hours/ resident / day
0.37
RN hoursweekends
30.3%
Total nursing turnover
36.8%
RN turnover

How full it usually is: this home is certified for 200 beds and averages 185.3 residents a day — about 93% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 3.49 on weekdays — 14% thinner on weekends. RN hours go from 0.37 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% 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

2
deficiencies at the latest standard inspection (2025-12-11)
6
at the previous standard inspection (2024-08-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · E2025-12-11 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews and review of the facility policy, the facility failed to promote a dignified dining experience by serving resident meals on an overbed table in a small common area in front of the nurse's station for four residents (Resident (R)5 R23, R72 and R125) out of 21 residents residing in the memory care unit and reviewed for dignity while dining.Findings include:Observation of the evening meal on 12/09/25 at 05:30 PM in the Memory Unit revealed residents were seated in front of the Nurse's Station in a small common area that served as the dining room, activity room, and TV room. The room did not have a dedicated dining table or chairs to encourage or promote dignity during their meals. A Christmas movie was loudly playing on the television in the room during the evening meal. The following residents were observed: R5 was seated in a Geri chair in front of the nurse's station with his/her evening meal placed on an overbed table. The table was positioned in front of him/her and across the arms of his/her chair. The back of the resident's chair was not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and policy review, the facility failed to provide a homelike environment in good repair for six of 21 residents (Resident (R) 4, R5, R23, R72, R114 and R125) residing on the Memory Care Unit. Specifically, the facility failed to maintain cabinets, nightstands, windowsills, heating units, cubicle curtains, baseboards, bedroom doors and overbed table stands in good repair and safe operating condition. The failure to maintain an environment in good repair and homelike had the potential to affect the residents' psychosocial needs. Findings include:Observation of the Memory Care Unit on 12/08/25 at 11:13 AM revealed the following areas of concern:1.R4's room: the cover for the air conditioner/heating unit was missing; two of three drawers inside the closet were broken and would not close leaving the drawer partially open; laminate was missing from the edge of the windowsill; and half of the privacy curtain was not attached to the tract in the ceiling causing the curtain to touch the floor. 2.R5's room: The nightstand in the resident's room had three…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff followed physician dietary orders for one of five residents (Resident (R)146 reviewed of 30 sampled residents. This deficient practice has the potential for resident not to receive sufficient calories to prevent further nutritional problems. Findings include:Review of R146's admission Record in the Profile tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses of dementia and type II diabetes. Review of R146's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/12/25 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating severe cognitive impairment. Review of R146's Care Plan located under the Care Plan tab of the EMR dated 12/12/24, revealed R146 has a potential for nutritional problems with intervention to provide Ensure supplement as ordered. Review of R146's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of four residents (Resident (R)146 reviewed for side rails out of 30 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include Review of R146's admission Record in the Profile tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnosis of dementia. Review of R146's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/12/25 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating severe cognitive impairment. Review of R146's Care Plan located under the Care Plan 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-14 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #: NJ178726 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to sanitize and ensure that the frying pan was cleaned to prevent microbial growth. This deficient practice was evidenced by the following: On 11/14/24 at 11:36 a.m. the surveyor, who was accompanied by the Director of Food Services (DFS), observed in the kitchen, Dietary Aide (DA #2) washed a frying pan, rinsed, and then dipped the frying pan in the sanitizer for less than 3 seconds and removed and placed the frying pan on the side of the sink to drain. During an interview with the Director of Food Services (DFS) at 11:09 a.m., he stated that the sanitizing step should not be missed because it was the most important step, and it killed the bacteria and the germs. During an interview with DA #2 at 11:48 a.m., he stated that the frying pan should be sanitized for 20 seconds and that he did it for less than 20 seconds. DA #2 further stated it was important to disinfect the frying pan so that it does not have any germs, and that if there were…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to a.) store potentially hazardous foods (PHFs) in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: (PHFs) are foods that must be kept at certain temperatures to minimize the growth of pathogenic microorganisms that may be present in the food or to prevent the formation of toxins in the food. Generally, PHFs are moist, nutrient-rich and have a neutral ph.) On 7/24/24 at 10:05 AM in the presence of the Food Service Director (FSD) and the Administrator in training (AIT) the surveyor observed the following: 1. The surveyor and FSD went into the walk-in freezer, during observation it was noted that there were sheets of ice on the floor, icicles hanging from the ceiling, the condenser fans and food boxes. The kitchen supervisor was actively scraping the ice off the floor with a long-handled ice scraper. 2. In the walk-in freezer, the surveyor observed several boxes of opened, not labeled…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-06 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 assess for complications upon residents' return from the renal dialysis (RD) center for 2 of 5 residents (Resident #55 and Resident #146) reviewed for dialysis care. The deficient practice was evidenced by the following: 1. On 7/22/24 at 11:07, AM the surveyor observed Resident #55 lying in bed with the television on, wearing glasses, call light within reach. The resident stated, I go to dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) M-W-F, but I refused to go today because I don't feel good. I usually get my medication and meal before I leave for dialysis. I have my access on left arm and the nurses checks on this at times. A review of the medical record revealed the following information: The Resident #55 had a diagnosis of but not limited to end stage renal disease (esrd); dependence on renal dialysis. End stage renal disease is a medical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-06 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services by ensuring the accurate administration of a medication, Midodrine, (medication used to increase the blood pressure), according to the physician's order to meet the needs of the resident. The deficient practice was identified for one (1) of 34 residents, (Resident #55) reviewed for medication management. The deficient practice was evidenced by the following: On 7/22/24 at 11:07 AM, the surveyor observed the Resident #55 in the Unit 3 North Wing in their room, lying in bed with the television on, wearing glasses, and call light within reach. On 7/24/24 at 9:34 AM, the surveyor reviewed the electronic health records (EHR) for Resident #55 which revealed diagnosis that included but not limited to hypotension, the pressure of blood circulating around the body is lower than normal. Blood pressure (BP) is the pressure of blood on the walls of your arteries as your heart pumps blood around your body. A review of the Quarterly Minimum Data Sheet (MDS), an…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) minimize the potential spread of infection to residents during medication administration for 1 of 2 nurses observed during medication pass on 1of 2 units (Unit 3 Low side) and b.) follow Center for Disease Control recommendations and guidelines for Hand Hygiene. This deficient practice was evidenced by the following: On 7/24/24 at 7:56 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) prepare medication for administration to an unsampled resident in room [ROOM NUMBER]. The RN opened the drawer of the medication cart, retrieved the blister packs (multi-use medication packs), and removed the medications amlodipine besylate10mg tablet, colace 100mg tablet and doxazosin mesylate 2mg tablet. The RN administered the medications, returned to the medication cart, opened the drawer, removed the blister packs from the cart, and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint # NJ00167683 Based on observation and interview, it was determined that the facility failed to maintain the residents' environment and living areas in a sanitary and homelike manner. This deficient practice was identified for 1 of 5 nursing units observed for the facility environment task. This deficient practice was evidenced by the following: On 7/22/24 at 10:30 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/23/24 at 11:30 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/24/24 at 9:49 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/22/24 at 11:29 AM, the surveyor interviewed the porter who stated the floors are done daily. He also stated the rotunda was done already and that he has not done 400 wing yet. He further stated that he's usually the only porter and a floor tech works the weekends only. On 7/24/24 at 1:04 PM, the surveyor interviewed the Director of Housekeeping who stated that the procedure 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-08-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NJ 00167683 NJ 00172468 Repeat Deficiency Based on observation, interview, and record review it was determined that the facility failed to ensure the accurate assessment of residents using the Minimum Data Set (MDS) assessment tool. The deficient practice was identified for 3 of 34 residents (#94, 37, 586) reviewed for MDS accuracy and is evidenced by the following. 1. The surveyor observed Resident #94 on 7/23/24 at 11:58 AM, lying in bed with eyes closed. A review of the hybrid medical record revealed the resident was admitted with diagnoses including but not limited to cerebral infarction, gastrostomy, and seizure disorder. Wound Care Consultant reports from 5/6/24 through 7/22/24 documented chronic moisture associated skin damage (MASD) of the sacral area. Section M - Skin Conditions of the 7/14/24 annual MDS indicated the resident had no skin conditions (pressure ulcers, other ulcers, wounds and skin problems). Section M1040 - H MASD (incontinence associated dermatitis) was unchecked to indicate MASD was not present during the assessment reference date of 7/14/24. On 7/24/24 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan to address the anticoagulant medication prescribed for 1 of 3 residents (Resident # 115) reviewed for anticoagulant medications and evidence by the following: On 7/22/24 at 12:54 PM, the surveyor observed Resident #115 in room and the resident stated takes an anticoagulant medication. The surveyor reviewed the Electronic Medical Records for Resident # 115 that revealed the following: According to the admission Record indicated that Resident # 115 was admitted with diagnoses that included Atrial Fibrillation. According to the Physician's Order Summary Sheet, the resident had the following physician's order for by mouth administration of medications: -Apixaban Tablet (a medication which thins the blood and is used to reduce the risk of stroke and heart attack) 2.5 mg 1 tablet by mouth every two days. The surveyor reviewed the resident's care plans and observed that there was no care plan to address the care needs for Resident #115 with an anticoagulant. On…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint # 173271 Based on interview, record review and review of pertinent facility documentation it was determined that the facility failed to a.) thoroughly assess a skin discoloration that was identified on an admission assessment and, b.) implement a care plan for a resident identified as a high risk for skin breakdown. This deficient practice was identified for 1 of 4 residents (Resident #585) reviewed for pressure ulcers and was evidenced by the following: According to the admission Record, Resident #585 was admitted to the facility with the diagnoses which included but was not limited to; spinal stenosis cervical region, muscle wasting and atrophy and type two (2) diabetes mellitus. The admission Minimum Data Set (MDS), an assessment tool that facilitates a resident's care dated 3/29/24, reflected that the resident was frequently incontinent of bladder and bowel and required maximum assistance with activities of daily living (ADLs). The MDS also reflected that the resident was at risk for developing pressure ulcer and injuries and had no skin or ulcer injury treatments.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-06 · tag F0711 — isolated
    Ensure 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 observation, interview and record review, it was determined that the facility failed to ensure that the physician signed and dated monthly medication orders. The deficient practice was identified for 5 of 34 residents reviewed (#2, 84, 115, 32 and 33) and occurred over a 3 month period. The deficient practice was evidenced by the following. 1. A review of the hybrid medical record for Resident # 2 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 2. A review of the hybrid medical record for Resident # 84 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 3. A review of the hybrid medical record for Resident # 115 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 4. A review of the hybrid medical record for Resident #32 revealed the resident's physician had not hand signed or electronically signed the monthly…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-08-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous and dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during multiple kitchen tours and was evidenced by the following: On 7/12/2022 at 9:45 AM, the surveyor conducted an initial tour with the Food Service Director (FSD) and observed the following: A large ice machine with a brown and black substance along the entire baffle (device used to restrain the flow of ice or to prevent the spreading of ice in a particular direction) along with dripping condensation into the ice below. The FSD wiped the baffle with a paper towel which removed most of the substance. The FSD acknowledged it was not clean. FSD stated It should not be there, and I will shut it down. The shelf above the stove burners with crusted on drippings. When the surveyor asked what the shelf was used for? The FSD stated it is where…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-04 · tag F0637 — pattern
    Assess 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 that a significant change assessment was completed for Residents #66 and #140 for a total of two quarters. This deficient practice was identified for 2 of 2 residents reviewed, and was evidenced by the following: 1. On 7/12/22 at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident#66 was cognitively impaired and a wanderer. On that same date at 11:00 AM, the surveyor observed the resident standing in the nursing station with the LPN/UM. The resident was not able to respond appropriately to the surveyor's questions. Later on, the Certified Nursing Aide (CNA) came and accompanied the resident to be toileted by hand-held assistance while walking. The surveyor reviewed the medical records of Resident #66: The resident's admission Record (admission summary) disclosed that the resident had diagnoses which included, but were not…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow a Physician's Order (PO) for the use of Oxygen (O2) for 2 of 4 residents (Resident#150 and #678), b.) develop a care plan for the use of O2 for 2 of 4 residents (Resident#93 and #678), and c.) date and store the O2 cannula for 1 of 4 residents (Resident #93) reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 7/12/22 at 10:59 AM, the surveyor observed resident #150 in their bed with an oxygen nasal cannula (N/C; O2 tubing that is placed in the resident's nose) in place. The oxygen concentrator (a medical device that gives you extra oxygen) reflected the oxygen was set at 5 liters (L). The surveyor reviewed the medical records of Resident #150. The resident's admission Record (face sheet; an admission summary) indicated that the resident was admitted to the facility and had diagnoses that included but were not limited 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-04 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 provide pharmaceutical services in accordance with professional standards to assure that a.) a medications were available for administration during the medication administration observation for one (1) of four (4) residents (Resident #98) observed, b.) medications that were ordered by the physician were available for administration during the months of May, June and [DATE] for two (2) of five (5) residents, (Resident #12 and #93) who attended the resident council meeting and c.) a medication was removed from active inventory after being discontinued in [DATE] until surveyor inquiry for one (1) of five (5) medication carts inspected. 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…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to: a.) appropriately perform hand hygiene during the medication pass observation for 1 of 5 nurses, and during incontinence care for 1 of 3 residents (Resident #158), b.) appropriately don (put on) Personal Protective Equipment (PPE) prior to entering and while providing care to residents on Transmission Based Precautions (TBP), c.) appropriate clean multi-use resident equipment, d.) follow appropriate sequential infection control practices when providing care to residents on TBP, and e.) follow the Center for Disease Control (CDC) guidelines and facility policies and procedures to prevent the spread of infection to residents. This deficient practice was identified for, (Resident #93, #158, #678) and on two out of five nursing units (unit three and five). This deficient practice was evidenced by the following: 1. On 7/14/22 at 9:06 AM, the surveyor observed Licensed Practical Nurse#1 (LPN#1) assisting Resident#149 to be wheeled outside the room…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-04 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the interview, and review of medical and facility policy, it was determined that the facility failed to provide information in a manner easily understood by the resident or resident representative about the right to formulate an Advanced Directive (AD). This deficient practice was identified in 1 of 3 residents reviewed for AD (Resident #150) and evidenced by the following: During an interview of the surveyor on 7/15/22 at 11:11 AM, Resident #150 stated that he/she does not recall if staff offered them AD information. The surveyor reviewed the electronic Medical Record (eMR) for Resident #150. The resident's admission Record (face sheet; an admission summary) indicated that the resident was admitted to the facility and had diagnoses that included but were not limited to; acute respiratory failure with hypoxia (an absence of oxygen in the tissues of the body to sustain bodily functions), unspecified protein-calorie malnutrition, muscle wasting and atrophy (the wasting, thinning, or loss of muscle tissue), tracheostomy (a surgically created opening into the trachea 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-04 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 3 of 35 residents reviewed (Resident #66, #149, and #167) as evidenced by the following: 1. On 7/12/22 at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident#66 was cognitively impaired and a wanderer. On that same date at 11:00 AM, the surveyor observed the resident standing in the nursing station with the LPN/UM. The resident was not able to respond appropriately to the surveyor's questions. During the observation the surveyor could not observe a wander guard on the resident. The surveyor reviewed the medical records of Resident #66: The resident's admission Record (admission summary) disclosed that the resident had diagnoses which included, but were not limited…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-04 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, it was determined that the facility failed to clarify a physician order for 1 of 3 residents (Resident #63) reviewed for code status according to professional standards 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 otherwise legally authorized physician or dentist. 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 licensed practical nurse is defined as performing tasks…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-04 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order (PO) for a right-hand grip splint. This deficient practice was identified for 1 of 3 residents (Resident #73) reviewed for limited range of motion (ROM). This deficient practice was evidenced by the following: On 7/12/22 at 11:30 AM, the surveyor observed the resident awake, dressed, and seated in a wheelchair in the rotunda area. The resident's right hand was observed contracted with no device in use. The resident was alert, and able to answer questions appropriately. Later that same day at 01:00 PM, the surveyor observed the resident out of bed seated in a wheelchair in their room with no device in use. On 7/13/22 at 11:50 PM, the surveyor observed the resident awake, out of bed and seated in a wheelchair. The resident was self-propelling back to their room. There was no right-hand grip splint in use. At that same time, the surveyor interviewed the resident's assigned Certified Nursing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly label an opened Blood Glucose test strip, b.) identify, and dispose of an expired biological in 1 of 5 medication carts and 1 of 2 medication rooms inspected. This deficient practice was evidenced by the following: On [DATE] at 9:41 AM, the surveyor inspected wing three (3) medication (med) room in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed one box of Sterile 0.9% NaCl (Sodium Chloride) solution for inhalation dated [DATE]. The surveyor interviewed LPN #1 who stated that the med room is inspected by the Unit Manager (UM) who is away on vacation. LPN #1 also acknowledged the expired Sterile Sodium Chloride for inhalation should not have been in the med room. He further stated that he would remove the expired item from the med room and give it to a UM. On [DATE] at 11:47 AM, the surveyor inspected wing four (4) South med cart in the presence of LPN…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-04 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to safety store Oxygen (O2) equipment in a resident's private room. This deficient practice was identified for one of six resident's reviewed, (Resident #678) for respiratory care and was evidenced by the following: On 7/12/22 at 11:25 AM, the surveyor observed Resident #678 laying in bed in their room. At that time, the surveyor attempted to interview the resident and the resident responded with yes or no answers. The surveyor observed a free standing, portable O2 cylinder in the upright position in the resident's room to the left of the resident's nightstand while facing the head of the resident's bed. The portable O2 cylinder was not observed to be stored in a container. The surveyor further observed that the gauge on the portable O2 cylinder read that it was full. On 7/14/22 at 10:26 AM, the surveyor observed the resident in their room lying in bed watching television. The surveyor observed the portable O2 cylinder in the upright position in the same…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 →

RatingThis homeChain avg
Overall 5 of 53.6+1.4 vs chain
Health inspection 4 of 53.1+0.9 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 28 homes this chain runs (chain average 3.6★, per CMS)
2 of 5Atlas Post Acute At Woodbury Country ClubWoodbury, NJ 2 of 5Haverhill Rehabilitation And Healthcare CenterHaverhill, MA 2 of 5Port Rehabilitation And Healthcare CenterNewburyport, MA 2 of 5Rossville Rehabilitation And Healthcare CenterBaltimore, MD 2 of 5The Elms Rehab And Healthcare Center Of CranburyCranbury, NJ 2 of 5Village Green Rehabilitation And Healthcare CenterBristol, CT 2 of 5Wynwood Rehabilitation And Healthcare CenterCinnaminson, NJ 3 of 5Atlas Rehabilitation And Healthcare At Daughters OClifton, NJ 3 of 5Atlas Rehabilitation And Healthcare At WashingtonSewell, NJ 3 of 5Masconomet Rehabilitation And Healthcare CenterTopsfield, MA 3 of 5Nemasket Rehabilitation And Healthcare CenterMiddleborough, MA 3 of 5Oak Knoll Rehabilitation And Healthcare CenterFramingham, MA 3 of 5Roland Park Rehabilitation And Healthcare CenterBaltimore, MD 4 of 5Atlas Rehabilitation And Healthcare At MaywoodMaywood, NJ 4 of 5Cedar Grove Respiratory And Nursing CenterWilliamstown, NJ 4 of 5Hathorne Hill Rehabilitation And Healthcare CenterDanvers, MA 4 of 5Meadowbrook Respiratory And Nursing CenterMatawan, NJ 4 of 5Mystic Meadows Rehabilitation And Nursing CenterLittle Egg Harbor Tw, NJ 4 of 5Shrewsbury Rehabilitation And Nursing At SouthgateShrewsbury, MA 4 of 5Sippican Rehabilitation And Healthcare CenterMarion, MA 4 of 5Suffield House Rehabilitation And Healthcare CenteSuffield, CT 4 of 5Towson Rehabilitation And Healthcare CenterTowson, MD 5 of 5Atlas Rehabilitation & Healthcare At West DeptforWest Deptford, NJ 5 of 5Bride Brook Rehabilitation & Nursing CenterNiantic, CT 5 of 5Manchester Rehabilitation And Healthcare CenterManchester, CT 5 of 5Pendleton Rehabilitation And Nursing CenterMystic, CT 5 of 5Vernon Rehabilitation And Healthcare CenterVernon, CT 5 of 5Waterfront Rehabilitation And Healthcare CenterRaritan, NJ

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

Who owns this facility

Owner / managerTypeRoleShareSince
CRANFORD HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2022
COPPER NJ TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
GOLD NJ TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
MALT FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
NJ MAZEL PARENTCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
NJ NOBLE PARENTCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
SGS 2010 FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
SILVER NJ TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
TYH 2017 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
MEISNER, ROBERTIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2022
GOLDBERGER, SHLOMOIndividualW-2 MANAGING EMPLOYEEsince 08/01/2022
BAK, PINCHOSIndividualCORPORATE OFFICERsince 08/01/2022

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

Follow the money — this home’s finances

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

$23.2M
Net patient revenuemost recent cost report
+11.0%
Operating marginrevenue minus expenses
$1.3M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 15%Other / private 17%

This home reported $1.3M 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

$322per resident / day
operating cost
$9,784per month
≈ monthly operating cost
$362per day
avg. revenue, all payers

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

What families pay in NJ

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315091. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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