No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

CareOne at The Highlands

1350 Inman Avenue, Edison, NJ 08820 · For profit - Corporation · 122 certified beds · (908) 754-7100 Medicare & Medicaid certified

Call the home — (908) 754-7100 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent May 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 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 quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2301 Park Ave · (908) 941-9860 · Call to confirm hours
Pharmacy
2125 Park Ave · (908) 754-7607 · Call to confirm hours
Grocery
1083 Inman Avenue · (908) 769-6173 · Call to confirm hours
Park
4 Gentore Ct · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.4%8.7%15.4%typical
Long-stay residents who lose too much weight6.7%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder2.8%0.6%0.9%worse
Long-stay residents with a urinary tract infection2.5%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms28.0%12.1%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.0%2.3%3.3%better
Long-stay residents whose ability to walk worsened9.9%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.4%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine87.3%97.2%95.3%typical
Long-stay residents with pressure ulcers9.4%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control8.2%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.7%12.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.3%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine29.6%80.1%79.4%worse
Short-stay residents rehospitalized after admission24.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit2.1%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days0.992.071.67better
Long-stay outpatient ER visits per 1,000 resident days0.411.111.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

55.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 426 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.9%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
63.5%U.S. median 56.6%
Met the expected recovery
0.51U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 63.5% 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 96 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.9%CMS range 50.7–60.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.5–11.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge92.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization10.2%CMS range 7.8–13.07.1%Oct 2023–Sep 2024worse than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.75
RN hours/ resident / day
1.12
LPN hours/ resident / day
2.16
Aide hours/ resident / day
4.03
Total nurse hours/ resident / day
0.62
RN hoursweekends
23.7%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 122 beds and averages 97.6 residents a day — about 80% occupied, or roughly 24 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 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.67 hrs/resident/day on weekends vs 4.17 on weekdays — 12% thinner on weekends. RN hours go from 0.80 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 24% 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

7
deficiencies at the latest standard inspection (2025-05-28)
13
at the previous standard inspection (2024-01-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · D2025-10-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint Survey Complaint # NJ00187927F686 D Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 Residents (Resident #2) reviewed for care and services for pressure ulcers. 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…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    COMPLAINT #NJ00187927Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by ensuring two medications (Breo Ellipta Aerosol (a combination inhaler used to prevent and control symptoms of asthma) and Triamcinolone topical cream (a steroid cream)) were obtained in a timely manner and administered as per prescribed physician's orders for one (1) of four (4) residents sampled. 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…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-28 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines for 7 of 12 residents (Residents #5, #21, #26, #46, #51, #88 and #242), who were reviewed for MDS coding accuracy. This deficient practice was evidenced by the following: 1. On 5/21/25 at 12:30 PM, the surveyor observed Resident #5 sitting in the bed, awake and alert, able to answer the surveyor's inquiry. On 5/22/25 at 11:33 AM, the surveyor reviewed the electronic Health Record (eHR)/hybrid medical record (paper and electronic) of Resident #5, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #5 was admitted with diagnoses that included but were not limited to systemic lupus erythematosus, (an autoimmune disease that mistakenly attack its healthy cells and tissues) unspecified, schizophrenia (a condition…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-28 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving antipsychotic and opioid medications. This deficient practice was identified for 3 of 7 residents (Resident #5, 26, and #51) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 5/21/25 at 12:30 PM, the surveyor observed Resident #5 sitting in the bed, awake and alert, able to answer the surveyor's inquiry. Resident #5 stated that they are not informed about the medication they are receiving. On 5/22/25 at 11:33 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #5, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #5 was admitted with diagnoses that included but were not limited to systemic lupus erythematosus, (an autoimmune disease…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #NJ00174157 Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) promptly for 1 of 2 residents (Resident #143) reviewed for investigations and was evidenced by the following: A review of Resident #143's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnose that included but were not limited to dysphagia (difficulty swallowing), atherosclerotic heart disease(a buildup of plaque in or on the artery walls) and pain in the left knee. A review of Resident 143's admission Minimum Data Set (MDS), an assessment tool dated 5/9/24, reflected that the resident had a brief interview for mental status score of 10 out of 15 which indicated the resident had moderate cognitive impairment. Further review revealed the resident had lower extremity impairment to one side. A review of a nursing progress note dated 5/18/24 at 8:18 AM revealed that the resident had an x-ray at the facility of the left…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-28 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    On 5/22/25 at 12:35 PM, the surveyor observed Resident #16 in bed, with both eyes closed with a urinary drainage bag in a privacy bag hanging on the bed frame. The surveyor reviewed Resident #16's electronic medical records. A review of the admission Record, an admission summary revealed the resident had diagnoses which included but were not limited to hypertension (high blood pressure), benign prostatic hyperplasia (enlarged prostate) and retention of urine (difficulty urinating). A review of the physician order summary (POS) dated active orders included an order dated 5/1/25 for urinary catheter care every shift. Further review revealed an order dated 5/1/25 for urinary catheter size 16F Coude balloon size 10 ml, change prn for obstruction as needed change catheter if obstructed. A review of the resident's current care plans revealed that the was no comprehensive care plan developed regarding the resident's order for the urinary catheter. On 5/23/25 at 9:28 AM, the surveyor interviewed the Director of Nursing (DON) , who stated that the unit managers and herself develop and update…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed a.) to follow a Physician's Order (PO) and b.) create a PO for an Oxygen (O2) dependent resident in accordance with professional standards of practice for 2 of 2 residents, (Resident #26 and # 82), reviewed for respiratory care. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to document the physician's order as prescribed accurately. This deficient practice was identified for 1 (one) of 7 residents (Resident #46) reviewed for unnecessary medications. 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 practice of nursing as 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-28 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to follow appropriate infection control procedures during medication administration. This deficient practice was identified for 1 of 3 nurses observed during the medication administration observation. On [DATE] at 8:47 AM, the surveyor during medication pass observation of the registered nurse (RN), made the following observations: The RN prepared the oral medication for Resident #44, set them aside and began to prepared 3 Lidocaine external patches 4% patches (to relieve pain), artificial tears solution 1.4% eye dropsused to relieve dry eyes) , and Lovenox injection solution prefilled syringe 40 mg/0.4 ml (used to prevent blood clots). The RN brought them to the bed side, after administering the oral medication the RN donned a pair of gloves and instilled one drop to each to eye, then without changing gloves or performing hand hygiene applied the Lidoderm patches one patch 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-16 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop 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

    Complaint: NJ00180728 Based on interviews, medical record reviews, and review of pertinent facility documents on 05/14/2025 and 05/16/2025, it was determined that the facility failed to follow their, Accidents and Incidents - Investigating and Reporting policy, and conduct a thorough investigation after a resident was found on the floor after a fire alarm for 1 of 3 residents (Resident #6) reviewed for accidents and incidents. This deficient practice was evidenced by the following: Review of the admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to unspecified atrial flutter (rapid pumping in the heart's upper chambers resulting in palpitations, shortness of breath, and fatigue); anemia (unspecified); Type 2 diabetes mellitus without complications; muscle weakness (generalized); difficulty walking, not elsewhere classified; and cognitive communication deficit. Review of the Minimum Data Set (MDS), an assessment tool, dated 11/08/2024, revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) score…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-05-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 Complaint: NJ00180728 Based on interviews, record review, and review of pertinent facility documents on 05/14/2025 and 05/16/2025 it was determined that the facility failed to follow the facility policy Weight Assessment and Intervention and follow physician orders (POs) for weekly weights. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for nutrition. The deficient practice was evidenced by the following: The admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to anemia (unspecified); Type 2 diabetes mellitus without complications; unspecified severe protein-calorie malnutrition; muscle weakness (generalized); dysphagia, oral phase; and cognitive communication deficit. Review of Resident #6's Minimum Data Set (MDS), an assessment tool, dated 11/08/2024, was conducted. The MDS revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint # NJ 00174172 Based on interview, medical records (MR) review, and review of pertinent facility documents on 8/8/24 and 8/12/24, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) and follow their facility policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating for 2 of 5 sampled residents (Resident #2 and Resident #4) reviewed for investigation and reporting. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to unspecified Dementia, Difficulty in Walking, and Muscle Weakness. The Minimum Data Set (MDS), an assessment tool dated 12/5/2023, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 0/15 which indicated the resident's cognition was severely impaired. Review of the Care Plan (CP), initiated on 12/13/2023 and revised on 4/2/2024, indicated that Resident #2 had cognitive loss related to Dementia. The CP…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C# NJ00174172 Based on interviews, and record review, as well as review of pertinent facility documents on 8/8/2024 and 8/12/2024, it was determined that the facility failed to ensure that the residents' care plan (CP) was revised for 2 of 5 (Resident #2 and Resident #4) reviewed for CP revision. This deficiency is evidenced by the following: 1. According to the admission RECORD (AR), Resident #2 was admitted with diagnoses that included but were not limited to: Dementia, Muscle Weakness, Cognitive Communication Deficit, and Difficulty in Walking. The Minimum Date Set (MDS), an assessment tool dated 3/10/2024, indicated that the Resident had a Brief Interview for Mental Status (BIMS) of 0/15 which indicated the Resident's cognition was severely impaired and needed help during Activities of Daily Living (ADL). The CP initiated on 12/05/2023 and revised on 04/02/2024 indicated that Resident #2 had actual skin breakdown, on 1/14/24 at about 1:00 p.m. the Resident sustained skin tear to back of her/his right arm, on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to maintain dignity during mealtime for a resident who needed assistance with eating. This deficient practice was observed for 2 of 26 residents observed, Resident #27 and Resident #72 and was evidenced by the following: 1. On 1/4/24 at 12:09 PM, the surveyor observed the Certified Nurse's Aide (CNA) on the [NAME] Unit, standing and holding a supplement in her right hand while Resident #27 was drinking the supplement via a straw. The surveyor also observed the CNA observing and holding her personal cellphone in her left hand while assisting the resident during feeding. The surveyor interviewed the CNA on 1/4/23 at 12:14 PM, who stated that she normally stands while feeding the resident because she was also assisting another resident (Resident #27's roommate) at the same time in the same room. A review of the admission Record for Resident #27 reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Fracture part of right clavicle;…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 the confidentiality of the resident information on the Electronic Health Records system. This deficient practice was observed during unit observation and was evidenced by the following: On 1/8/24 at 1:11 PM, the surveyor observed a paper documenting written information placed on top of the medication cart showing resident's photos, resident's names, resident's room numbers, vital signs including blood pressure, heart rate, blood glucose level, and temperature associated with each resident. Further observation revealed other documented notes about the residents next to their names. The surveyor observed two family members passed by the medication cart where the paper was placed having documented information available for viewing by anyone passing by. On 1/8/24 at 1:20 PM, the surveyor observed the Registered Nurse (RN) walking towards the medication cart. The RN stated to the surveyor that she was assigned to the medication cart. The RN further stated that the piece of paper 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) - Discharge Assessment in accordance with federal guidelines. This deficient practice was identified for 1 of 26 residents reviewed for resident assessment, Resident #84. This deficient practice was evidenced by: On 1/9/24 at 11:22 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. After transition of the MDS, a quality measure will be transmitted to enable a facility to monitor the residents decline or progress. On 1/9/24 at 11:30 AM, the surveyor reviewed Resident #84's electronic medical record Review of the record revealed that the resident was discharged to the community on 11/22/23. The surveyor reviewed the resident's MDS 3.0…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 26 residents, Resident #105 and Resident #47, reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 1/11/24 at 2:18 PM, the surveyor reviewed the closed hybrid (paper and electronic) medical records for Resident #105. A review of the admission Record (a summary of important information about the resident) documented Resident #105 with diagnoses that included but were not limited to Chronic Kidney Disease, Hematuria, Anemia, and Muscle Weakness. A review of a discharge MDS for the resident, dated 11/4/23, under section A documented it was a Discharge assessment-return not anticipated .Planned discharge . to a Short-Term General Hospital. A review of the Patient Discharge Summary/Instructions form dated 11/3/23 documented that Resident #105 was discharged home. On 1/11/24 at 10:51 AM, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #NJ00154940 Complaint #NJ 00153394 Based on observation, interview, and record review it was determined that the facility failed to accurately document and clarify the administration of medication for 3 of 36 residents, Resident #39, #43 and #21. 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 practice of nursing as a licensed practical nurse is defined as…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent medical records, it was determined that the facility failed to follow physician orders related to the use of continuous oxygen (O2) for 1 of 1 resident, Resident #15, reviewed for O2 therapy. This deficient practice was evidenced by the following: On 1/4/24 at 11:00 AM, the surveyor observed Resident #15 seated in a wheelchair in their room. Resident #15 was receiving O2 delivered through a nasal cannula (NC) (plastic prongs attached to a tube, inserted into the nostrils that oxygen flows through) utilizing a concentrator (an oxygen delivery system) at 4 Liters per minute (LPM). The surveyor reviewed the resident's paper and electronic medical chart. A review of the admission Record (a summary of important information about the resident) documented the resident's diagnoses included but were not limited to Heart Failure, Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Chronic Systolic Heart Failure (CHF). A review of a comprehensive Minimum Data Set (an assessment tool to facilitate care) dated 10/23/23,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders (PO) to ensure that the residents' current medical regimen was current and accurate. This deficient practice was observed for 4 of 46 residents reviewed, Resident #76, Resident #51, Resident #47, and Resident #27 and was evidenced by the following: 1. On 1/4/24 at 11:27 AM, the surveyor observed Resident #76 in bed alert and responsive. The surveyor reviewed the admission Record (one page summary of important information about a resident) (AR) for Resident #76. The resident was admitted to the facility with diagnoses that included but was not limited to End Stage Renal Disease; Major Depressive Disorder; Cognitive Communication Deficit and Muscle Weakness. A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, dated 11/21/23, reflected that Resident #76 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 1 of 26, Resident #76, reviewed for physician visits and was evidenced by the following: 1. On 1/4/24 at 11:27 AM, the surveyor observed Resident #76 in bed. When interviewed, Resident #76 was noted alert and responsive. The surveyor reviewed the admission Record (one page summary of important information about a resident) for Resident #76. The resident was admitted to the facility with diagnoses that included but were not limited to End Stage Renal Disease; Major Depressive Disorder; Cognitive Communication Deficit and Muscle Weakness. A review of the Quarterly Minimum Data Set , an assessment tool used to facilitate the management of care, dated 11/21/23, reflected that Resident #76 had a Brief Interview for Mental Status score of 12 out of 15, indicating moderately impaired cognition. A review of…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired and discontinued medications were removed from active inventory after it had expired and/or had been discontinued by the physician in accordance with professional standards of clinical practice. This deficient practice was identified for 2 of 2 units inspected involving Resident #6, #28, #36, #49, #66, #90, #260, #263, #265, #266, #268, #269 and #270, This deficient practice was evidence by the following: 1. On 1/4/2024 at 11:47 AM, the surveyor inspected the [NAME] Unit Nursing Station. Inspection of the [NAME] Unit Nursing Station resulted in the absence of an Emergency Kit (designed to help nursing facilities provide medication to their residents during emergency situations). The [NAME] Unit Registered Nurse and Licensed Practical Nurse (LPN1) on the unit could not locate or explain why there was no required Emergency Kit on the unit when interviewed. 2. On 1/4/2024 at 11:55 AM, the surveyor inspected the medication cart 3 (MC3) on the East Unit. The surveyor…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to clarify medication dosage for a newly admitted resident to the facility during the initial medication review for 1 of 1 Residents, Resident #21. The deficient practice was evidenced by the following: On 1/4/24 at 11:16 AM, the surveyor interviewed Resident # 21 in the resident's room. The resident stated they had anxiety which they took the medication sertraline (Zoloft) and they had been receiving the incorrect dose. Resident #21 explained that prior to admission to the facility they were receiving 75 milligrams (mg) of sertraline and since admission to the facility had been receiving 50mg daily. The resident stated they noticed this about a week ago. Resident #21 reported to a staff member and had not heard anything since that time. The surveyor reviewed Resident #21's paper and electronic medical records which revealed the following: A review of the resident's admission Record (an admission summary) documented that the resident was admitted to the facility with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/04/24 09:17 AM, the surveyor in the presence of the Culinary Director (CD), observed the following during the kitchen tour: 1. On a storage shelf below Chef Preparation Table #3, the surveyor observed an opened one (1) gallon bottle of molasses with a label that read, use by 12/10/23. 2. In the food preparation area, the surveyor observed dietary aide (DA) #1 with hair not fully restrained under their hairnet and DA #2 wore large, hooped earrings. The CD stated, all dietary staff need to have their hair fully restrained under the hairnets and large hooped earrings were not allowed to be worn in the kitchen. The CD stated the bottle of molasses should have been discarded on 12/10/23. On 1/10/24 at 10:30 AM, the CD provided the surveyor facility policies titled, Food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    Based on observation, interview, and record review, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 1 of 22 residents reviewed (Resident #42). This deficient practice was evidenced by the following: On 1/5/24 at 11:02 AM, the surveyor observed Resident #42 in their room sitting in a reclining chair, watching television. The resident was awake, alert, and verbally responsive to simple questions. On 1/11/24 at 12:20 PM, the surveyor reviewed the hybrid (paper and electronic) medical records of Resident #42. According to the admission Record (an admission summary), Resident #42 had diagnoses that included but were not limited to: Epilepsy, Type 2 Diabetes Mellitus, muscle weakness, dysphagia, and Chronic Obstructive Pulmonary Disease. A Quarterly Minimum Data Set (QMDS) assessment, a tool used to facilitate management of care, dated 12/18/23, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #42 scored 00 out of 15, which…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, it was determined that the facility failed to maintain proper infection control practices which was identified during dining observation and was evidenced by the following: On 1/9/24 at 12:28 PM, the surveyor observed a Certified Nursing Assistant (CNA) in the [NAME] Wing dining room and was holding a clear plastic bag. In addition the surveyor observed the CNA walking towards a resident who was eating their lunch. The CNA was observed touching the resident's meal tray and the resident's utensils while holding the clear bag. The surveyor interviewed the CNA who stated that the clear bag contained a dirty bib (food protector) for one of the residents who was also in the dining room. The CNA then placed the clear plastic bag on top of the bedside table in the hallway, sanitized her hands using an alcohol-based hand rub gel, took the soiled plastic bag and went to the dirty utility room to discard the bag. On 1/9/24 at 1:48 PM, the Administrator, and the Clinical Lead RN were made aware of the surveyor's observation. They both agreed that the CNA failed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0836 — isolated
    Ensure 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

    Complaint #NJ00154940 Complaint #NJ00150195 Complaint #NJ00151010 Refer to deficiencies F658, F755 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: Nurse Staffing Reports were completed by the facility for 4 distinct periods of time equaling 8 weeks in total. The weeks of 09/12/2021 ending 09/25/2021; 12/19/2021 and ending 01/01/2022 and 5/14/23 ending 5/27/23 were reviewed due to complaints filed for low staffing during…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CAREONE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.4+0.6 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 36 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Care One At MillburyMillbury, MA 1 of 5Care One At RandolphRandolph, MA 1 of 5Careone At OradellOradell, NJ 2 of 5Care One At BrooklineBrookline, MA 2 of 5Care One At NewtonNewton, MA 2 of 5Care One At RedstoneEast Longmeadow, MA 2 of 5Care One At WeymouthWeymouth, MA 2 of 5CareOne At Hanover TownshipWhippany, NJ 2 of 5Careone At MiddletownAtlantic Highlands, NJ 2 of 5Rehab & Nursing Ctr Greater PittsburghGreensburg, PA 3 of 5Care One At LexingtonLexington, MA 3 of 5Care One At LowellLowell, MA 3 of 5Care One At New BedfordNew Bedford, MA 3 of 5CareOne At Madison AvenueMorristown, NJ 3 of 5CareOne At MoorestownMoorestown, NJ 3 of 5CareOne at New MilfordNew Milford, NJ 3 of 5Careone At East BrunswickEast Brunswick, NJ 3 of 5Careone At Ridgewood AvenueParamus, NJ 3 of 5Careone At WellingtonHackensack, NJ 4 of 5Care One At ConcordW Concord, MA 4 of 5Care One At Essex ParkBeverly, MA 4 of 5Care One At NorthamptonNorthampton, MA 4 of 5CareOne At TeaneckTeaneck, NJ 4 of 5Careone At CresskillCresskill, NJ 4 of 5Careone At EveshamMarlton, NJ 4 of 5Careone At LivingstonLivingston, NJ 4 of 5Careone At ParsippanyParsippany Troy Hill, NJ 4 of 5Careone At Somerset ValleyBound Brook, NJ 5 of 5Care One At HolyokeHolyoke, MA 5 of 5Care One At PeabodyPeabody, MA 5 of 5Care One At WilmingtonWilmington, MA 5 of 5CareOne At WallWall, NJ 5 of 5Careone At HolmdelHolmdel, NJ 5 of 5Careone At ValleyWestwood, NJ 5 of 5Careone At WayneWayne, NJ 5 of 5River Glen Health Care CenterSouthbury, CT

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

Who owns this facility

Owner / managerTypeRoleShareSince
CARE ONE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/01/2004
DES 2009 GST TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2021
DES HOLDING CO., INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST24%since 12/16/2007
DES-C 2009 GRATOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST21%since 10/26/2009
STRAUS, DANIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST38%since 04/21/2007
BARUCH, DAVIDIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/01/2021
CARE ONE MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2007
HEALTHBRIDGE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/25/2008

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$16.6M
Net patient revenuemost recent cost report
-15.0%
Operating marginrevenue minus expenses
$1.9M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 41%Medicare 24%Other / private 35%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 10% 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

$508per resident / day
operating cost
$15,438per month
≈ monthly operating cost
$442per day
avg. revenue, all payers

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

What families pay in NJ

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315132. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-28, 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.

What to do next