Grove Park Healthcare And Rehabilitation Center
101 North Grove Street, East Orange, NJ 07017 · For profit - Individual · 185 certified beds · (973) 672-1700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — 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 (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $50,642 in federal fines (most recent 2026-02-21)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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 2 to 4 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 | 2.3% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.7% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.4% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.4% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.8% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.7% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.6% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.6% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.9% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.1% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.8% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.1% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.66 | 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.
Met the expected recovery: 86.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 61 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.8–16.5 | 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 | 86.9% | 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 | 80.3% | 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 | 70.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.3% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 92.6% | 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 | 0.0% | 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.6%CMS range 3.8–14.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.36 | 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 185 beds and averages 171.6 residents a day — about 93% occupied, or roughly 13 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.549 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.50 on weekdays — 14% thinner on weekends. RN hours go from 0.63 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Kcited before2026-02-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) all emergency equipment was readily available at bedside for residents with tracheostomies (a surgical opening in the neck to provide an airway and remove secretions from the lungs), b.) staff were trained to use the emergency tracheostomy equipment, and c.) the primary care nurses were aware of the residents' inner cannula sizes for their tracheostomies. This deficient practice was identified for 2 of 3 residents reviewed for tracheostomy (Resident #6 and Resident #174). 1.Resident #174 was admitted to the facility on [DATE], and had a tracheostomy (trach). Observations and interviews on 02/17/26, revealed that emergency trach supplies were not being kept at Resident #174's bedside and readily available for use. There was no obturator (a device that fits inside the trach tube to guide it during insertion) in Resident #174's room, and staff were unable to locate any extra ones…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policies, the facility failed to ensure that three residents (R4, R62, and R175) out of a sample of 36 were treated with dignity and respect. Specifically, R4 was not permitted to go out on a pass without an escort even though the resident was their own responsible party. R62's Do Not Resuscitate (DNR) wristband was not removed at the time of admission and could be observed by residents and visitors. R175 was denied the ability to leave the facility due to a past positive drug test and was not informed that he/she could refuse to submit to a drug screening. In addition, facility staff entered R175's room without knocking or announcing themselves. These failures resulted in actual and potential impacts on residents' dignity, autonomy, and rights.Findings include:1. Review of R4's Face Sheet located in the Electronic Medical Record (EMR) revealed the most recent admission date of 08/09/25, with diagnoses of paraplegia and muscle weakness. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and policy review, the facility failed to ensure a resident's rooms was clean and in good repair creating a homelike environment for one resident (Resident (R)83) of 175 residents in the facility. Failure to provide a homelike environment has the potential to affect the resident's quality of life.Findings include:Review of R83's admission Record located under the admission tab of the Electronic Medical Record (EMR) revealed R83 was admitted to the facility with diagnoses of dementia, major depressive disorder, and anxiety disorder. Review of R83's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 02/03/26, with a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R83's cognition was severely impaired. Review of R83's care plan initiated on 08/15/24, located under the Care plan tab revealed that R83 had a focus that R83 was at risk for changes in mood related to dementia with interventions in place, to assess for physical/environmental changes that may precipitate change in mood.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-21 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 written transfer notice that contained all required information and the bed hold notice was provided for one of four residents (Resident (R)174) and/or their resident representatives (RR) reviewed for hospital transfer out of 36 sample residents. This failure had the potential to result in the resident and their RR to not have the knowledge of where and why a resident was transferred, the bed hold policy and/or how to appeal the transfer, if desired.Findings include:Review of R174's undated Face Sheet in the electronic medical record (EMR) indicated R174 was originally admitted to the facility with diagnoses of chronic respiratory failure, tracheostomy status, and persistent vegetative state. Review of R174's Nursing Progress Notes located under the Progress Note tab in the EMR indicated on 02/07/26 at 1:10 PM, . Resident family member did ask the nurse that Resident responsible party [sic]. have instructed we send resident to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-21 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on, record review, interviews, policy review, the facility failed to provide training for three nurses (Licensed Practical Nurse (LPN)1, LPN2 and Registered Nurse (RN)3) to have the knowledge and competency to care for three of three residents (Resident (R)6, R174 and R199) with a tracheostomy. This failed practice had the potential to cause harm to the residents that had a tracheostomy. Findings include:During an interview on 02/17/26 at 2:06 PM, LPN11 was asked what emergency equipment needed to be at the bedside of a resident that has a tracheostomy. LPN1 stated, suction machine, Yankauer suction and a tracheostomy care kit. I don't remember what else needs to be in there. LPN1 was asked if he/she went into the resident's room and the tracheostomy cannula was dislodged, what would he/she do. LPN1 stated, I cannot remember but if you could help me out, I could use it. LPN1 stated that she could not remember receiving any in-service training regarding emergency tracheostomy care at the facility.During an interview on 02/17/26 at 2:45 PM, LPN 2 was asked what emergency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-21 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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, record review, and policy review, the facility failed to ensure that one resident (Resident (R) 119) out of five residents did not receive an unnecessary medication during medication pass. Findings include: Review of R119's admission Record located in the Electronic Medical Record (EMR) under the tab Census revealed readmitted to the facility on [DATE] with a diagnosis of chronic pain syndrome. Observation during medication pass on 02/17/26 at 8:34PM, Registered Nurse (RN) 1 administered to R119 Ibuprofen 800 milligrams (mg) by mouth (PO) because R119 had complained of pain. During review of R119's Order Summary Report located in the EMR under the tab Orders dated 02/18/26 indicated no evidence of an order for Ibuprofen 800 mg being ordered as of 02/17/26. Review of R119's Blister Package dated 01/07/26 indicated, Ibuprofen 800 mg one tablet by mouth (PO) every six hours (Q6H) when needed (PRN) for moderate to severe pain for 14 days.Interview on 02/18/26 at 3:45 PM, RN1 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-21 · 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, record review, interviews, and facility policy review, the facility failed to ensure that one resident (Resident (R) 142) out of five residents observed during medication administration received medication in a manner to prevent possible cross contamination in a sample of 36 residents. Findings include: Observation during medication pass on 02/17/26 at 8:34 PM, Registered Nurse (RN) 2 placed all of R142's medications into the medication cup except one medication, gabapentin (medication to treat neuropathic pain) 300 milligram (mg). RN2 placed the gabapentin in another medication cup. RN2 picked up the gabapentin with her bare right hand, opened the gabapentin capsule and with her bare hands, poured the contents on top of the other medication. RN2 then administered R142 his/her medications. Review of admission Record, located in the Electronic Medical Record (EMR) under the Census tab was admitted to the facility with diagnoses of type2 diabetes mellitus, and contracture of muscle-right upper arm, and right thigh. Review of R142's Order Summary Report dated…
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 before2025-12-05 · 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 interview, and record review, and review of pertinent documentation it was determined that the facility failed to fully investigate and implement measures to address an allegation that a visitor provided illegal, unapproved substance to a resident with history of substance abuse; which the resident ingested and reported it to the facility. This deficient practice was identified for 1 of 4 resident reviewed (Resident #1). The evident is as followed: A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but not limited to; opioid dependence, anxiety disorder, muscle wasting and atrophy. A review of Resident #1's quarterly Minimum Data Set (MDS), an assessment tool dated 11/4/25, revealed that the resident had a Brief Interview Mental Status (BIMS) score of 15 out of 15, indicating that the resident's cognition was intact. A review of Resdient#1's Medication Administration Record (MAR), revealed a physician order initiated on 11/14/25 for Buprenorphine HCL naloxone HCL dihydrate give 1 film sublingually 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.
- Potential for harm · Fcited before2024-10-18 · tag F0550 — failed to protect resident dignity and rights — widespreadHonor 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, interviews, and review of facility policy, it was determined that the facility failed to ensure residents were treated with dignity and respect by failing to remove the weekly menus posted from resident's rooms who had a physician's order (PO) for NPO (nothing per orem (mouth)). This deficient practice was identified for 3 of 3 residents (Resident #40, #88, and #141) reviewed that had a PO for NPO. The deficient practice was evidenced by the following: 1. On 10/10/24 at 10:13 AM, the surveyor observed Resident #141 seated on a Geri-chair (geri-chair is a large, padded chair that is designed to help seniors with limited mobility) in their room awake with their ongoing tube feeding (TF) (a way of providing nutrition directly into the gastrointestinal tract through an enteral access device (feeding tube) that is placed with its tip in the stomach or small intestine) machine. The surveyor further observed the facility's weekly menu posted on the wall next to Resident #141's bed. A review of Resident #141 medical records revealed that the resident was admitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-18 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and review of facility records, it was determined that the facility failed to consistently serve the residents a nourishing snack when there were more than 15 hours between dinner and breakfast mealtimes. This deficient practice was identified for 4 of 5 residents (Residents #29, #61, #132, and #144) who attended during the resident council meeting and was evidenced by the following: On 10/11/24 at 10:00 AM, the surveyor conducted a group meeting with 5 alert and oriented residents selected by the facility to attend the group meeting. Four of the five residents stated they did not receive bedtime snacks. On 10/10/24 at 11:19 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the kitchen provided the five units in different floors with bedtime snacks. She could not provide an information if there was an accountability system the nursing staff used to document and ensure the residents were served their bedtime snacks. The FSD stated they do not keep a snack log to document and cannot provide accountability for the snacks that 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.
- Potential for harm · F2024-10-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, it was determined that the facility failed to maintain appropriate kitchen sanitation practices and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: During the initial tour of the kitchen, the surveyor, together with the facility's Dietary Manager (DM) on 10/9/2024 at 10:15 AM, the surveyor observed the following: Upon entering the room where the dish machine was located, the surveyor observed 2 dietary staff inside cleaning the dishes that were used during breakfast. The surveyor asked the DM to turn on the dishwasher machine. When the DM turned on the dishwasher, the surveyor observed a significant amount of water splashing towards the drying rack where there were trays placed. The DM stated to the surveyor to step back because the dishwasher had water splash. The DM stated that the rack that was placed next to the dishwasher was a drying rack used to dry the meal trays. The surveyor observed the drying rack that was placed right next to the dishwasher…
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 20 citations
- Potential for harm · Dcited before2024-10-18 · 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 policy review it was determined the facility failed to document PO (by mouth) intake of a resident who is NPO (nothing by mouth). This deficient practice was observed for 1 of 9 residents reviewed for Nutrition, Resident #40, and was evidenced by the following: On 10/10/24 at 10:50 AM, the surveyor observed Resident #40 with eyes closed in bed and their ongoing Tube Feeding (TF) (a way of providing nutrition directly into the gastrointestinal tract through an enteral access device that is placed with its tip in the stomach or small intestine) machine. A review of Resident #40's medical record revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), and Muscle Weakness. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate management of care, dated 7/2/24, revealed the resident's Brief Interview of Mental Status score could not be obtained…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of other documentation, it was determined that the facility failed to: a.) consistently follow a physician's order (PO) for the application of a hand splint to the left arm, b.) consistently document accountability for the placement of heel booties, and c.) follow the residents individualized comprehensive care plan (ICCP). The deficient practice was identified for 3 of 3 residents (Resident #51, #45 and #96) reviewed for positioning and mobility. This deficient practice was evidenced by the following: 1. On 10/9/24 at 11:05 AM, the surveyor observed Resident #51 in bed. There were two heel boots on the bedside table. On 10/10/24 at 12:30 PM, the surveyor observed Resident #51 in bed. There were two heel boots on the bedside table. The surveyor reviewed Resident #51 electronic Medical Record (eMR). A review of the residents admission Record (AR) (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 nutritional evaluation for a resident on a 3-day calorie count were addressed in a timely fashion. This deficient practice was identified for 1 of 8 residents reviewed for Nutrition (Resident #20), and was evidenced by the following: On 10/10/24 at 10:07 AM, the surveyor observed Resident #20 awake in their room. During the surveyor's interview, Resident #20 stated, the food was horrible and were lacking flavor. The resident further added they have not seen the Registered Dietitian (RD) to address these concerns and believed they may have lost weight. A review of Resident #20 Face Sheet (an admission record) revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), and Gastritis. A review of the most recent Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 8/6/24…
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 · D2024-10-18 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management 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 ensure a resident's routine pain level assessment was being completed and documented according to the facility's policy and standard of practice. This deficient practice was identified for 1 of 2 residents (Resident #16) reviewed for pain management. This deficient practice was evidenced by the following: On 10/9/24 at 9:45 AM, the surveyor observed Resident #16 awake in bed. The resident reported they had pain to their wound on the back. The resident further stated that they request to take pain medication frequently. On 10/9/24 at 12:17 PM, the surveyor reviewed Resident #16's electronic medical record and revealed the following information: A review of the admission Record (an admission summary) reflected that Resident #16 was admitted to the facility with diagnoses that included but were not limited to Chronic Osteomyelitis (inflammation of the bone), Open Wound Left Lower Leg, Pressure ulcer of sacral region unstageable, Pressure ulcer of left heel stage 3, and Paraplegia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · 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 observation, interview, record review, it was determined that the facility failed to monitor and document any potential side effects (SE) for a resident who was psychotropic medication as per Physician's Order (PO). This deficient practice was identified for 1 of 5 residents (Resident #94) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 10/9/24 at 11:28 AM, the surveyor observed Resident #94 in bed with eyes closed. On 10/10/24 at 11:38 AM, the surveyor reviewed the electronic medical record of Resident #94, which revealed the following: A review of Resident #94's admission Record (an admission summary) reflected that Resident #94 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory), unspecified Severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety (feeling of uneasiness). A review of the most recent Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 9/26/24,…
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 · Fcited before2023-06-08 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring a.) that the Infection Preventionist Nurse (IPN) was aware and involved in the facility's surveillance and monitoring of facility's water management according to standards of clinical practice, facility policy, and IPN's job description to prevent Legionella and other opportunistic waterborne pathogens to grow and spread, this deficient practice has a potential to affect the 172 residents in the facility and b.) that the linens were handled in accordance to standards in order to maintain hygienically clean laundry and prevent the spread of infection for one (1) of five (5) units, (4th-floor unit). This deficient practice was evidenced by the following: 1. On 5/22/23 at 9:53 AM, during an Entrance Conference, the Licensed Nursing Home Administrator (LNHA) in the presence of the Assistant Administrator (AA), and the Director…
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 · E2023-06-08 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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
Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure certified nurse aide (CNA) credentials were verified upon hire. This deficient practice was identified for 4 (four) of 5 (five) newly hired staff reviewed, (CNA #1, CNA #2, CNA #3 and CNA #4) and was evidenced by the following: On 6/07/23 at 01:48 PM, the surveyor reviewed the facility provided employee files of five randomly selected newly hired employees. The review included the following: CNA #1 with a date of hire (doh) of 3/21/23 had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. CNA #2 with a doh of 3/27/23 had a NJDOH online Public Registry license verification printout which was dated 4/21/23 which was after the doh. CNA #3 with a doh of 5/15/23 had a NJDOH online Public Registry license verification printout…
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 · E2023-06-08 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ#00163298 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate, a.) timely report, (Resident#372 and #117) and b.) a hematoma of unknown origin on 4/07/23 of Resident#95. This deficient practice was identified for three (3) of seven (7) residents reviewed for abuse and was evidenced by the following: 1. A review of the reportable event record/report (FRE; Facility Reported Event) was called in on 4/10/23 at 9:00 PM, with an event date of 4/07/23 at 11:56 PM. The incident was reported as an allegation of resident-to-resident abuse. The event was described as follows: While Resident #372 was transferring from bed to wheelchair, Resident #117 allegedly pulled Resident #372's wheelchair from underneath him/her. This resulted in Resident #372's fall with no injury. The FRE showed there was no plan of care or planned interventions prior to the event. Further review of the event reflected that Resident #117 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 · Ecited before2023-06-08 · tag F0641 — patternEnsure 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, 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 three (3) of 34 residents, (Resident #40, #103, and #162) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified 12/01/21, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to a.) implement interventions, clarify a physician's order to consistently monitor behaviors and document an incident in the medical record to prevent resident to resident altercations for one (1) of seven (7) residents reviewed for abuse (Resident #24); b.) ensure a resident with severe cognitive impairment, who was at risk for elopement and had a known history of wandering was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building for one (1) of one (1) resident reviewed for elopement (Resident #162); and c.) conduct an investigation and determine causal factors of a fall incident that resulted in a hematoma for one (1) of nine (9) residents, (Resident #95) reviewed for incident and accident. This deficient practice was evidenced by the following: 1. On 5/26/23 at 10:00 AM, the surveyor reviewed the facility provided Reportable…
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 · E2023-06-08 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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, record review, and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) dispensed and administered controlled substance (narcotic) medication were accurately accounted for (Unsampled Resident #170, #122, and #19), b.) discontinued medication was removed from active inventory (Resident #80), which were identified separately in 2 (two) of 3 (three) medication carts, and c.) failed to maintain a system of record keeping that ensured an accurate inventory and reconciliation of controlled dangerous substance (narcotics medications), with high potential for abuse and are tracked with detail observed during medication storage inspection. The deficient practice was evidenced by the following: 21 CFR 1305.16(b) Whenever any used or unused DEA Forms 222 are stolen or lost (other than in the course of transmission) by any purchaser or supplier, the purchaser or supplier must immediately upon discovery of the theft or loss, report 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 · E2023-06-08 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
2. On 5/26/23 at 7:35 AM, the surveyor asked the RDCC about Resident# 137's incident/accident reports, and the RDCC stated that she will get back to the surveyor. The surveyor reviewed Resident #137's medical record. Resident #137's AR reflected that the resident was admitted to the facility had diagnoses which included but were not limited to malignant neoplasm of kidney (also called kidney cancer or renal cell adenocarcinoma), schizophrenia (a serious mental disorder in which people interpret reality abnormally), alcohol abuse, and cocaine abuse. The resident's most recent qMDS with an ARD 4/25/2023 reflected that the resident had a BIMS score of 15 out of 15 which indicated the resident's cognition was intact. The PN dated 5/15/23 at 6:57 AM by LPN#2 revealed that on 5/14/2023 at 09:40 PM, the resident had a witnessed verbal altercation with Resident #64 and was struck in the head with a cane by resident #64. Resident #137 was noted to have swelling in the left eye and redness. LPN#2 obtained vital signs and initiated Neurologic checks on resident #137. The PN dated 5/14/23 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.
- Potential for harm · Dcited before2023-06-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to act upon rehab referral of nursing in accordance with standards of clinical practice for one (1) of two (2) residents, (Resident#103) reviewed for a limited range of motion (ROM). 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 Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: 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 · D2023-06-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a) follow the Nurse Practitioner's (NP's) order for a stat (an abbreviation of statim means immediately) order of xray and b) notify the physician or nurse practitioner of the results that fall outside the clinical reference ranges (abnormal results) in accordance with standards of clinical practice to ensure the facility identify and provide needed care and services in accordance to resident's goals for care of one (1) of 34 residents reviewed, (Resident #95). 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…
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 · D2023-06-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and review of pertinent facility documents, the facility failed to a) ensure the indwelling urinary catheter (tube that is inserted for continuous drainage of the bladder) drainage tubing was stored in a manner to prevent Urinary Tract Infection (UTI) and b) develop and implement a care plan (CP) that included interventions that addressed catheter care based on current professional standards of practice to prevent UTI for 1 (one) of 2 (two) residents reviewed for urinary catheter care or UTI (Resident #164). The deficient practice was evidenced by the following: Reference: The Healthcare Infection Control Practices Advisory Committee guidance titled GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 with an updated date of June 6, 2019, includes the following: III. Proper Techniques for Urinary Catheter Maintenance A. Following aseptic insertion of the urinary catheter, maintain a closed drainage system . 1. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting…
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 before2023-06-08 · 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 provided documents, it was determined that the facility failed to: a.) ensure physician orders for oxygen were implemented, and b.) maintain sustainability by following their plan of correction from the last recertification survey for the same deficient practice, and c.) perform appropriate hand hygiene during tracheostomy (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe) care observation consistent with professional standard of practice and Centers for Disease Control & Prevention (CDC) guidelines. This deficient practice was identified for 1 (one) of 2 (two) residents reviewed for respiratory care (Resident #111). The evidence was as follows: According to the last recertification survey date of 02/18/22, the facility failed to follow a physician's order for oxygen (O2). The facility submitted a plan of correction with a completion date of 3/11/22, which included that the Director of Nursing (DON) immediately in-serviced all nurses on O2 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.
- Potential for harm · D2023-06-08 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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 a resident's preference for nectar thickened water was honored (Resident #157). This deficient practice was identified for 1 (one) of 1 (one) resident reviewed for choices and was evidenced by the following: On 5/23/23 at 12:52 PM, the surveyor interviewed Resident #157. The resident stated that he/she asked and did not receive a nectar thickened water, I have requested multiple times and they keep giving me nectar thickened milk and nectar thickened apple juice. I have requested from the [Certified Nursing Assistant] CNA. I called my CNA, and she told me they don't have nectar thickened water in the building. The surveyor reviewed the medical record for Resident #157. The admission Record (an admission summary) reflected that the resident had been admitted with diagnoses which included dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), type 2 diabetes without complications, cerebral infarction due to unspecified occlusion (decreased…
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 · D2023-06-08 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer a resident the pneumonia vaccination. This deficient practice was identified for 2 (two) of 5 (five) residents, (Resident #95 and #143), reviewed for vaccination status and was evidenced by the following: Centers for Disease Control & Prevention (CDC) recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: (last reviewed 02/13/23). 1. On 5/22/2023 at 11:00 AM, the surveyor observed Resident #95 walking around the third floor hallway. The surveyor reviewed Resident #95's medical record. The resident's admission Record (AR; or face sheet; admission summary) reflected that the resident was admitted to the facility had diagnoses which included but were not limited to muscle weakness, essential…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2024-10-18 · tag F0641 — patternEnsure 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 complete the resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 1 of 33 residents (Resident #45) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 10/9/24 at 10:05 AM, the surveyor observed Resident #45 seated in their wheelchair in the dining room. The resident was unable to respond to the surveyor's questions. On 10/16/24 at 9:45 AM, the surveyor reviewed the electronic Medical Record of Resident #45, which revealed the following: A review of the admission Record (AR) (an admission summary) reflected that Resident #45 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory), unspecified severity with agitation. A review of the most recent Quarterly Minimum Data Set (Q/MDS), dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-06-08 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, it was determined that the facility failed to provide Saturday mail delivery services to residents. This deficient practice was identified for 5 (five) of 5 (five) residents interviewed during the resident council group meeting (Residents #9, #60, #61, #73 and #83) and was evidenced by the following: On 5/26/23 at 10:21 AM, during a resident council group meeting with Residents #9, #60, #61, #73 and #83, the surveyor asked the residents if they received mail on Saturdays. Resident #61 stated that they do not receive mail on Saturdays and that they have to wait until Monday to receive the mail from the Social Services Director (SSD). The other four residents were in agreement that mail was not delivered to them on Saturdays. A review of each of the residents most current Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that each of the resident's had an intact cognition. On 5/26/23 at 10:41 AM, the surveyor interviewed the SSD regarding…
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
$50,642 in federal fines across 1 penalty.
- $50,642 — penalty dated 2026-02-21
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ALLAIRE HEALTH SERVICES — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 3.1 | +0.9 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 19 homes this chain runs (chain average 2.6★, 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 | Since |
|---|---|---|---|
| ROSENBERG, JOSEPH | Individual | W-2 MANAGING EMPLOYEE | since 01/01/2021 |
| KURLAND, BENJAMIN | Individual | CORPORATE OFFICER | since 01/01/2021 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 87% 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 $299K 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 315147. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-21, 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.