Shore Pointe Care Center
139 Grant Ave, Eatontown, NJ 07724 · For profit - Partnership · 178 certified beds · (732) 542-4700 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)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $135,795 in federal fines (most recent 2025-11-17)
- 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)
- about 20% of its spending goes to commonly-owned related companies
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 | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.0% | 4.6% | 5.4% | better |
| 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 | 0.8% | 0.8% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 10.7% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.0% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.0% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.8% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.1% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 66.7% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 19.1% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.3% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.50 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.24 | 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.
34.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.1% 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 38 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 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 34.9%CMS range 24.0–45.3 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 8.5–16.9 | 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 | 42.1% | 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 | 31.6% | 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 | 34.2% | 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.8% | 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 | 3.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 4.8–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 178 beds and averages 145.1 residents a day — about 82% occupied, or roughly 33 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 2.67 hrs/resident/day on weekends vs 3.29 on weekdays — 19% thinner on weekends. RN hours go from 0.81 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · J2025-11-17 · 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 observation, interviews, and a review of medical records and pertinent facility documents on 11/12/25, it was determined that the facility failed to provide adequate supervision to a severely cognitively impaired resident (Resident #2) with a known history of wandering behaviors, who eloped from the facility on 10/29/25. The deficient practice was identified for 1 of 5 residents reviewed for elopement (Resident #2). During the survey, a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 483.25 (d)(2) F 689, as the facility failed to provide adequate supervision to a severely cognitively impaired resident (Resident #2) with a known history of wandering behaviors who eloped from the facility on 10/29/2025. Registered Nurse (RN) #1 who was assigned to Resident #2 last observed the resident at approximately 4:45 p.m. on 10/29/2025. At approximately 5:05 p.m. Resident #2's assigned Certified Nurse Aide, (CNA) #1 went to the resident's room and observed the resident was not in there. CNA #1 then initiated a search for the resident in the dining room,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-01-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to prevent unintended insidious (gradual but with harmful effects) weight loss of 31.5 pounds (lbs.) in one year from 1/3/24 through 1/1/25, and significant weight losses to include a 14 lb./10.5% loss in 6 months from 4/2/24 through 9/2/24; a 15 lb./11.2% loss in 6 months from 5/5/24 through 10/1/24; a 6.5 lb./5.6% loss in 1 month from 11/1/24 through 12/3/24; and an additional 4 lb. loss from 12/3/24 through 1/1/25; which was also a 16.5 lb./13.4% loss in 6 months from 8/1/24 through 1/1/25. The facility failed to prevent and address these weight losses in a timely manner, which included the failure to a.) ascertain (to find out) food preferences, b.) implement fortified foods (foods that are nutrient dense in calories and protein), c.) provide culturally appropriate alternate meal options d.) implement and monitor weekly weights, and e.) consistently monitor intake and record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-09 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's Registered Dietitian (RD) reviewed and approved the menus (American and Korean) for nutritional adequacy and in accordance with nationally accredited standards, and b.) residents received care planned and physician ordered fortified foods for 3 of 3 residents (Resident's #41, 71 and 118) reviewed for food. The deficient practice was evidenced by the following: 1. On 1/2/25 at 9:46 AM, two surveyors toured the kitchen with the Food Service Director (FSD), the Regional RD and the Assistant Licensed Nursing Home Administrator (ALNHA). At that time, the FSD stated that the facility followed a three-week cycle menu (a menu prepared in advance which was repeated after three weeks). On 1/2/25 at 10:38 AM, the surveyor met with the facility Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Assistant DON (ADON). At that time, the LNHA…
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 · Fdisputed · IDR2025-01-09 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was dedicated solely to the infection prevention and control program (IPCP) from 8/9/24 and ongoing. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. An individual certified by the Certification Board of Infection Control and Epidemiology or meets the requirements under N.J.A.C. 8:39-20.2; or b. A Physician who has completed an infectious disease fellowship; or c. A healthcare professional licensed and in good…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 2 of 6 residents (Resident #90 and Resident #125) having lunch in the East Unit Sunshine Room in wheelchairs or recliners and 1 of 2 residents (Resident #124) utilizing overbed tables. This deficient practice was evidenced by the following: 1.On 1/02/25 at 11:10 AM, the surveyor observed Resident #90 out of bed, in a recliner in the Sunshine Room. A bead [NAME] activity center was noted on an overbed table in front of the resident. The resident was noted with closed eyes. No distress was noted. On 1/06/25 at 12:07 PM, the surveyor observed facility staff sitting next to Resident #90 in the Sunshine Room providing verbal cues/assisting as needed with lunch. The surveyor observed Resident #90's recliner with dried brown substances on sides of recliner. A review of the admission record reflected that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report and initiate an investigation for an injury of unknown origin in accordance with their abuse and neglect policy until surveyor inquiry. This deficient practice was identified for one (1) of one (1) resident reviewed for abuse (Resident #47), and was evidenced by the following: On 1/2/25 at 10:44 AM, the surveyor observed Resident #47 in bed. The resident had a line down the bridge of their nose with a reddish/brown colored marking and a dried scab. The surveyor attempted to interview the resident but the resident was not responding to the surveyor. On 1/3/25 at 9:00 AM, the Director of Nursing (DON) provided the surveyor with two investigations for Resident #47 from August 2024 and October 2024. The DON verified that there were two investigations in the past six (6) months and no other investigations. A review of the two investigations for Resident #47 revealed that there was no investigation regarding a marking on the resident's nose. 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.
- Potential for harm · Dcited before2025-01-09 · 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
REFER to F759 Based on observation, interview, and record review, it was determined that the facility failed to follow acceptable professional standards of clinical practice by borrowing a medication (Lidocaine 4% patch) from another resident's supply. The deficient practice was identified for one (1) of three (3) nurses observed during medication administration for one (1) of six (6) residents, (Resident #122). 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,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
REFER to F658 Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 1/3/25, the surveyor observed three (3) nurses administer medications to six (6) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.4%. The deficient practices were identified for one (1) of six (6) residents, (Resident #122), that were administered medications by one (1) of three (3) nurses that were observed. The deficient practices were evidenced by the following: On 1/3/25 at 8:59 AM, during the morning medication administration pass, the surveyor observed Registered Nurse (RN#1) at the door of Resident #122's room with the medication cart. RN#1 stated that she was about to administer the resident's eye drops and patches. RN#1 showed the surveyor the container of eye drops, and two (2) packages labeled Max Strength Aspercreme with 4% Lidocaine pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · 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 observations, interviews, and record review it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP)(designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 2 of 3 unsampled residents (Resident #99 and #Resident #106) reviewed for EBP on 2 of 2 units (North Unit and East Unit) and was evidenced by the following: 1. On 1/03/25 at 07:58 AM, during incontinence rounds with the Acting Unit Manager / Infection Preventionist (UM/IP) on the North Unit, the surveyor observed the UM/IP approach unsampled Resident #99 who was lying in bed. The UM/IP donned gloves, asked permission to check the resident's brief, the resident granted permission. The UM/IP pulled down Resident #99's pants, opened the brief, pulled down the front of the brief, and allowed the surveyor 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 · Ecited before2023-09-29 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ #165453; 159439; 156933; 164687 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a clean, comfortable, homelike environment for the residents. This deficient practice was identified on 3 of 3 nursing units, (the 100, 200, and 300 units) and was evidenced by the following: On 09/21/23 at 12:54 PM, in room [ROOM NUMBER], the surveyor observed that the window in the resident's room had a portable air conditioning unit which had a piece of cardboard surrounding the cylinder that was positioned outside of the window. The cardboard was observed to be bent, exposing outside air. On 09/22/23 at 8:50 AM, on the 300 unit, the surveyor was standing in Resident #104 and Resident #149's room and observed a small black bug flying around the room. A Certified Nursing Assistant (CNA) was also in the room at the time of the surveyor's observation. The surveyor asked the CNA if she saw the bug and the CNA did not respond to 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 · E2023-09-29 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ#: 159439; 165453 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain an effective pest control program. This deficient practice was identified on 2 of 3 nursing units, (the 200 and the 300 unit), for 4 of 29 residents, (Resident #17, #64, #104 and #149), reviewed for concerns related to pests, and by 5 out of 6 alert and oriented residents during the Resident Council meeting. This deficient practice was evidenced by the following: On 09/21/23, the surveyor toured the 200 unit and observed dead insects on the floors in rooms [ROOM NUMBERS]. At 11:16 AM, on the 200 unit, the surveyor observed a fly on Resident #17's forehead. At that time, the resident stated that the facility had, quite a few flies. Resident #64, the roommate, told the surveyor that the facility supposedly fumigated a couple of days ago. The surveyor asked if the residents had seen bugs in their rooms since. Both residents told the surveyor that they…
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 · D2023-09-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and review of medical record it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for a resident's personal preference to wear a specific urinary collection device (leg bag) during the day while the resident was out of bed. This deficient practice was identified for 1 of 29 residents reviewed, (Resident #25) and was evidenced by the following: On 09/21/23 at 11:19 AM, during tour the surveyor observed the resident sitting up in his/her wheelchair in their room. The resident was interviewed at this time and stated that he/she had an indwelling urinary catheter. The resident stated that he/she wore a leg bag (urine collection storage bag) during the day and a urinary drainage storage bag at night that hung on the resident's bedframe. According to the admission Record, Resident #25 was admitted to the facility with the diagnoses which included but was not limited to: heart failure, history of urinary tract infections (UTI), benign prostatic hyperplasia (enlarged prostate), and obstructive…
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 14 citations
- Potential for harm · Dcited before2023-09-29 · 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, review of the medical record, and review of other facility documentation, it was determined that the facility failed to complete an incident report, after a resident sustained an injury in the facility. This deficient practice was identified for 1 of 3 residents reviewed for skin issues (Resident #28), and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is…
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 · D2023-09-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint NJ: 165453, 163618 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to provide dependent residents with routine and appropriate incontinence care, specifically by applying double briefs. This deficient practice was identified for 1 of 6 residents observed for incontinence care, (Resident #71) and was evidenced by the following: On 09/27/2023 at 8:47 AM, the surveyor performed a care tour of the 200 unit with the Licensed Practical Nurse/Unit Manager (LPN/UM). At 08:55 AM, Resident # 71 gave permission to the surveyor and the LPN/UM to observe his/her adult brief. The surveyor observed that Resident #71 had two green colored briefs on. The briefs were dry. At that time the LPN/UM confirmed that Resident #71 had two briefs on and said, I am sorry. On 09/27/2023 at 9:01 AM, the surveyor interviewed the assigned Certified Nursing Assistant (CNA) who confirmed she was assigned to Resident #71. When asked when the last time incontinence care was provided for Resident #71 the CNA…
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 before2023-09-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint#: NJ157073 Based on interview, review of clinical records, and other pertinent facility documentation it was determined that the facility failed to provide timely treatment and care for a resident. This deficient practice was identified for 1 for 32 residents, (Resident #252) reviewed for quality of care and was evidenced by the following: According to the admission Record (AR), Resident #252 was admitted to the facility with the diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing) and benign prostatic hyperplasia (BPH - an enlarged prostate). The admission Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care dated 07/01/2022, indicated that the resident was cognitively intact and required extensive assistance of two staff members for activities of daily living. The surveyor was unable to interview Resident #252. The resident was discharged from the facility on 07/28/22, with a Deep Vein Thrombosis (DVT -…
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 · D2023-09-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ#: 164539; 165453 Based on observation, interview, record review, and review of facility documents it was determined that the facility failed to: a.) accurately document body check assessments, b.) obtain physician orders based on the recommendations of the wound care consultant in a timely manner, and c.) ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 2 of 4 residents (Resident #49 and #255) reviewed for pressure ulcers and was evidenced by the following: 1.) The surveyor reviewed Resident #255's closed Electronic Medical Record (EMR). According to the admission Record, Resident #255 had diagnoses which included, but were not limited to: multiple sclerosis (MS), pressure ulcer of sacral region stage 4, difficulty in walking, vascular dementia with behavioral disturbance, and muscle weakness. Review of the significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-29 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility failed to maintain ongoing complete communication notes between the facility and the dialysis center. This deficient practice was identified for 1 of 1 resident reviewed for dialysis, (Resident #110) and was evidenced by the following: On 09/26/23 at 09:45 AM, on the North wing 300 unit, Resident #110 was observed seated in a chair in the main dining room. The resident stated that before he/she went to dialysis (a treatment to remove waste and extra fluids from your blood when the kidneys are not able to) that the nurse checked his/her vital signs and that he/she would take the dialysis binder with them. The resident denied the nurse ever checked the fistula (a surgically created connection between a vein and artery for direct access to the bloodstream for dialysis) in their arm or listened to it with a stethoscope. On 09/26/23 at 12:26 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that Resident #110 went to dialysis every Tuesday, Thursday, and Saturday and that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-05-26 · 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 review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 5/3/2022 from 9:38 to 10:24 AM, the surveyor, accompanied by the Dietary Aide (DA) observed the following in the kitchen: 1. In the dish room on a top shelf of the drying rack, a stack of 5 bowls and an additional solo bowl used to serve resident meals were not in the inverted position or covered. The food contact surfaces were exposed to contamination. The DA stated, We have bins that we store them in covered. They should be covered. On a middle shelf of the same drying rack a cleaned and sanitized pot used to cook resident meals was stored uncovered and not in the inverted position with the food contact surface exposed. The DA agreed the pot should be in the inverted position. On a separate drying rack adjacent to the above referenced rack (2) stacks of resident meal tray's used to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-26 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the resident's call bell was in reach and able to be used. The deficient practice was observed on the North Unit, for 3 out of 3 residents (Residents #444, #55, #83) reviewed for the Environmental Task . The deficient practice was evidenced by the following: On 5/3/22 at 10:08 AM during the initial tour, the surveyor observed Resident #444 in bed. At that time, the surveyor observed the call bell on the floor out of reach from the resident. On 5/9/22 at 9:27 AM, the surveyor observed Resident #55 in bed. At that time, the surveyor observed the call bell between the bed frame and mattress, out of reach from the resident. On 5/9/22 at 9:26 AM, the surveyor observed Resident #83 in bed. At that time, the surveyor observed the call bell attached to the privacy curtain, out of reach from the resident. During an interview with the surveyor, Resident #83 stated, I can't reach it from there. On 5/10/22 at 8:51 AM, the surveyor observed Resident #83 in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to provide privacy for a resident during hygienic care by not using the privacy curtain, exposing the resident. The deficient practice was identified for 1 out of 2 residents reviewed for Dignity, (Resident #55). This deficient practice was evidenced by the following: On 5/10/22 at 9:43 AM, in the hallway of the North Unit, the surveyor observed Resident #55 in bed laying on his/her left side. Resident #55's buttocks were exposed and visible from the hallway. At that time, Certified Nursing Assistant (CNA) #2 saw the surveyor in the hallway and pulled the privacy curtain around Resident #55's bed. During an interview with the surveyor on the same date at 9:56 AM, CNA #2 said the resident's door was open and it should have been closed during care. During an interview with the surveyor on 5/16/22 at 11:10 AM, the Director of Nursing said her expectation of privacy for the residents during care was that the privacy curtains are pulled at all times. She further stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the general public. This deficient practice was evidenced by the following: On 5/12/2022 at 11:00 AM, the surveyor conducted a group meeting with five alert and oriented residents (#106, # 34, #98, # 76, and #118 in attendance.) Five of the five residents stated that they were not aware of the location of the State Survey results and that facility staff has never spoken to them about the results. On 05/12/22 at 12:41 PM, the surveyor observed a green folder containing the survey results in a common hallway in a plastic holder attached to the wall approximately 5 feet of off the floor. The surveyor observed there was no signage to direct resident's, families, and the general public to the location of the survey results. On 05/12/22 at 12:54 PM the surveyor observed Resident # 34 in his/her wheelchair access the survey results. Resident #34 stated he/she can reach the results but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 3 units, (North Wing and [NAME] Wing) and was evidenced by the following: On the [NAME] Wing the surveyor #1 observed the following: 1. On 5/10/22 at 11:45 AM, an orange-colored stain on the floor next to the treatment cart. 2. On 5/10/22 at 11:46 AM there were black colored and red colored stains on the floor by the back wall next to the entrance of the nurse's station. 3. On 5/10/22 at 11:46 AM, a Geri chair in the hallway had white colored stains on the front portion of the footrest. 4. On 5/10/22 at 11:47 AM, next to the cabinet on which the fax machine was sitting, there were rust colored stains on the floor. 5. On 5/13/22 at 10:50 AM, the entrance floor into the main dining room had a large ring of brown and dark colored debris on the floor. 6. On 5/13/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to review and revise a care plan to reflect changes to a resident's activities of daily living (ADL's) status for 1 of 36 sampled residents, (Resident #35). This deficient practice was evidenced by the following: On 5/5/2022 at 11:26 AM, the surveyor completed a record review for Resident #35 as follows; According to Resident #35's most recent admission face sheet, Resident #35 had diagnosis including Alzheimer's disease, dementia, osteoarthritis, muscle weakness, history of falls, and difficulty walking. According to section C of the significant change Resident Assessment Instrument/Minimum Data Set (RAI/MDS) (an assessment tool), dated 2/9/2022, Resident #35 had a Brief Interview for Mental Status score of 5/15, which indicated severe cognitive impairment. In addition, section G revealed that Resident #35 required extensive assistance of one-person physical assist for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to A.) implement a resident-directed care consistent with the resident's care plan by not providing bilateral heel boots when in bed and B.) to transfer a resident consistent with the resident's care plan by not using a Hoyer lift (mobility tool used to help lift people out of bed or the bath) to transfer a resident from the bed into a wheelchair. This deficient practice was observed for 2 out of 4 residents (Resident #83 and Resident #55) reviewed for Position and Mobility. The deficient practice was evidenced by the following: A.) On 5/10/22 at 9:12 AM, the surveyor observed Resident #83 in bed. The resident was not wearing heel boots while in bed. Resident #83's heels were in contact with mattress. At that time, Resident #83 told the surveyor that he/she never has them on. He/She revealed that they would wear them if the heel boots were prescribed. Resident # 83 explained…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · 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 observations, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to apply a splint as ordered by a physician to prevent/reduce a contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that cause the joints to shorten and become stiff). This deficient practice was identified for 1 of 4 residents reviewed for position/mobility, (Resident #14), and was evidenced by the following: During the initial tour of the [NAME] Unit on 05/03/22 at 09:54 AM, the surveyor observed Resident #14 in bed with his/her eyes closed. The resident's hands were resting on top of the blanket. At that time, the surveyor observed that the resident's right hand was contracted. There was no splint or hand roll in place at that time. On 05/04/22 at 9:56 AM, the surveyor observed a Certified Nursing Assistant (CNA) bring Resident #14 in a recliner chair into the Main Dining Room (MDR) for activities. There was no splint on the resident'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.
- No harm found · C2025-01-09 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing…
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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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
$135,795 in federal fines across 2 penalties.
- $108,154 — penalty dated 2025-11-17
- $27,641 — penalty dated 2025-01-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to THE ROSENBERG FAMILY — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.7 | -1.7 vs chain |
| Health inspection | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 3.9 | +0.1 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 15 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GATEWAY CARE CENTER, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 03/27/2025 |
| ROSENBERG, JONATHAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2016 |
| GATEWAY EATONTOWN ASSOCIATES LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 10/01/2002 |
| STERN, SAMUEL | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2017 |
| ABBOUD, WALID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| CAPUANO, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/07/2022 |
CMS files one row per role, so the 13 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 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 $3.5M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 315177. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-09, 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 →
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