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Embassy Manor At Edison Nursing And Rehabilitation

10 Brunswick Avenue, Edison, NJ 08817 · For profit - Limited Liability company · 280 certified beds · (732) 985-1500 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0609, F0610) — most recent May 2025Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$102,840 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0609, F0610) — most recent May 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $102,840 in federal fines (most recent 2025-05-12)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1636 Stelton Rd · (732) 253-4069 · Call to confirm hours
Pharmacy
4 Brunswick Ave · (732) 777-1717 · Call to confirm hours
Grocery
1761 Lincoln Hwy · (732) 339-1530 · Call to confirm hours
Park
(732) 572-0535 · Typically dawn to dusk
Place of worship
6 Kilmer Rd · (732) 739-7443

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 3 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.

Overall rating2★
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 increased4.1%8.7%15.4%better
Long-stay residents who lose too much weight3.8%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms24.9%12.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.3%2.3%3.3%typical
Long-stay residents whose ability to walk worsened3.0%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.5%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine97.4%97.2%95.3%typical
Long-stay residents with pressure ulcers3.3%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control5.0%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.5%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine77.2%80.1%79.4%typical
Short-stay residents rehospitalized after admission21.0%24.9%22.6%typical
Short-stay residents with an outpatient ER visit5.8%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.782.071.67typical
Long-stay outpatient ER visits per 1,000 resident days0.821.111.80better

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

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

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

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

32.1% 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 103 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

32.1%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
53.9%U.S. median 56.6%
Met the expected recovery
0.19U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 53.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 65 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 0.19 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 14% 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 SNF32.1%CMS range 23.8–42.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 8.5–14.110.7%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 discharge53.9%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 discharge56.9%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 discharge50.8%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 identified98.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.4%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%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 hospitalization6.8%CMS range 3.9–10.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 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

0.67
RN hours/ resident / day
0.38
LPN hours/ resident / day
2.27
Aide hours/ resident / day
3.31
Total nurse hours/ resident / day
0.57
RN hoursweekends
39.8%
Total nursing turnover
35.5%
RN turnover

How full it usually is: this home is certified for 280 beds and averages 223.1 residents a day — about 80% occupied, or roughly 57 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 2.94 hrs/resident/day on weekends vs 3.46 on weekdays — 15% thinner on weekends. RN hours go from 0.71 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as 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

8
deficiencies at the latest standard inspection (2025-05-12)
9
at the previous standard inspection (2023-03-10)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2025-05-12 · 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 #NJ182121Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident physical abuse for a cognitively intact resident (Resident #381) who reported being roughly handled by a Certified Nursing Assistant (CNA #1). This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381).A review of the Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381, a cognitively intact resident, reported to the Registered Nurse (RN #1) that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a Certified Nursing Assistant (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising (age undetermined) around the area and that she administered the prescribed 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2025-05-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #NJ182121Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy by thoroughly investigating an allegation of staff-to-resident physical abuse to a cognitively intact resident (Resident #381) who reported the allegation to the Registered Nurse (RN #1) on 12/28/24. This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381).A review of the Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381, a cognitively intact resident, reported to the Registered Nurse (RN #1) that they were fearful of staff at the facility due to an incident that had occurred two days prior (12/26/24). The resident reported that a Certified Nursing Assistant (CNA #1) roughly repositioned the resident causing the resident's already fractured leg to have intense pain. RN #1 documented that Resident #381 had a discoloration with purple bruising (age undetermined) around the area and that she administered the prescribed pain medication. RN #1 made 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-05-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to a.) maintain kitchen equipment in a clean and sanitary manner and b,) maintain 2 of 6 nourishment room refrigerators in a sanitary manner. The evidence was as follows: On 4/29/25 at 10:20 AM, in the presence of the Food Service Director (FSD) and the Regional FSD, the surveyor observed the following during kitchen tour: 1. The steamer unit floor drain was filled with debris and sediment. The FSD acknowledge it was not properly cleaned according to facility policy. 2. Two convection ovens were soiled with baked on brown coloring on the glass doors and interior of the unit. The FSD acknowledged and stated, it was not cleaned according to facility policy. 3. Two steamer units were drained into a floor trap and the trap screen had debris covering it. The FSD acknowledged and stated, it was not cleaned according to facility policy. 4. The six-burner stove top and oven were covered with cooked on grease and sediment crusted around the burners. The oven had food sediment and debris on 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-12 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to administer ten doses of an anti-convalescent medication (clonazepam) prescribed for seizures according to physician's orders. This deficient practice was identified for 1 of 35 residents reviewed for quality of care (Resident #47), and was evidenced by the following: On 4/29/25 at 11:324 AM, during initial tour of the facility, the surveyor observed Resident #47 lying in their bed with the bed positioned low with a fall mat located at the side. On 4/30/25 at 10:49 AM, the surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; hypertension (high blood pressure), seizures (abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior), and mood disorder (mental health condition that primarily affects your emotional state). 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-12 · 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 a.) to treat each resident with respect and dignity and b.) care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life recognizing each resident's individuality. This deficient practice was identified for 1 of 35 residents reviewed for dignity (Resident #206), and was evidenced by the following: On 4/29/25 at 11:09 AM, during initial tour of the facility, the surveyor observed a Certified Nurse Aide (CNA #1) walking alongside Resident #206 in the hallway towards the shower room. CNA #1 and Resident #206 entered the shower room, and the door closed. The surveyor then heard Resident #206 begin to yell inside the shower room. At that time, CNA #1 opened the door and asked for the facility's translator to assist with translating the resident's needs. The Translator entered the shower room, and the surveyor observed the resident, who was still fully dressed, speaking with the Translator who then informed CNA #1 that the resident did not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order to carry out a resident's wishes for code status. This deficient practice was identified for 2 of 38 residents reviewed for code status and advanced directives (Residents #167 and #230), and was evidenced by the following: 1. On 4/29/25 at 12:34 PM, the surveyor reviewed Resident #167's electronic medical record (EMR). A review of the admission Record face sheet (an admission summary) indicated that the resident was re-admitted to the facility with diagnosis which included but were not limited to; malignant neoplasm of colon (malignant colon cancer), malignant neoplasm of the liver (liver cancer), and malignant neoplasm of the lung (lung cancer). A review of the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) indicated the resident's wishes were to be a Do Not attempt resuscitation (DNR) and allow natural death and Do not intubate (DNI) in the event the resident had no pulse and/or was not breathing (code…

    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 before2025-05-12 · 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

    Complaint #NJ183871, NJ183873 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan for a.) a resident who was receiving dialysis (a medical procedure that acts as an artificial kidney filtering waste and excess fluid from the blood) treatments and b.) a resident with a surgical wound. This deficient practice was identified for 2 of 35 residents reviewed for care plans (Resident #73 and Resident #531), and was evidenced by the following: 1. On 4/29/25 at 12:13 PM, the Resident #73 was observed in bed with a blanket pulled over their head. The resident did not want to be interviewed. The surveyor reviewed the medical record for Resident #73. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; end stage kidney disease, heart failure, difficulty in walking, and diabetes (high blood sugar). A review of the comprehensive Minimum Data Set (MDS), an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure recommendations by the wound care consultant were implemented to prevent worsening of a pressure ulcer. This deficient practice was identified in 1 of 4 residents reviewed for pressure ulcers (Resident #333), and was evidenced by the following: The surveyor reviewed the medical record for Resident #333. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; kidney failure, hypertension (high blood pressure), and pneumonia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 4/26/25, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. A review of Section M, Skin Conditions, reflected that the resident had a pressure ulcer upon admission to the facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) store all drugs and biologicals in locked compartments and b.) properly store medications and maintain clean and sanitary medication storage areas. This deficient practice was identified in 1 of 1 observed treatment cart and 2 of 6 observed medication carts, and was evidenced by the following: 1. On 4/30/25 at 12:12 PM, the surveyor observed a wound treatment cart on the Second-floor nursing unit by the nurse's station in front of the elevators which was unattended and left unlocked. The surveyor remained near the treatment cart and observed two nursing staff members walk past the treatment cart and did not acknowledge or identify that the treatment cart was unsecured. On 4/30/25 at 12:29 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that treatment carts contained medications and should be treated as medication carts and should always be locked when unattended by the nurse. At that time, the surveyor asked…

    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 · D2025-05-12 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents. This deficient practice was identified for 4 of 5 observed resident pantry rooms as evidence by the following: On 5/6/25 at 1:00 PM, the surveyor toured the 1st floor Subacute unit pantry room in the presence of the Food Service Director (FSD). The surveyor observed the following: the counter around the sink and backsplash had black discoloration. The caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet. On 5/6/25 at 1:11 PM, the surveyor toured the 2nd floor, 2A, and Chinese unit pantry room, in the presence of the FSD. The surveyor observed the following: the counter around the sink and backsplash had black discoloration and caulking was peeling and blackened along the edge of the sink, behind the sink, and around the faucet, and worn-down laminate countertops exposing the wood type surface under the laminate. On 5/6/25 at 1:23 PM, 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-12 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ182121, NJ183873 Based on interview, record review, and other pertinent facility documents, it was determined that facility to failed to ensure residents received the appropriate pain management by a.) administering pain medications according to the physician's ordered pain level parameters and b.) obtaining and administering pain medications as ordered by the physician. This deficient practice was identified for 2 of 2 residents reviewed for pain management (Residents #381 and Resident #531), and was evidenced by the following: 1. The surveyor reviewed the closed medical record for Resident #381. A review of the admission Record face sheet (admission summary) reflected that Resident #381 was admitted to the facility with the diagnoses that included but were not limited to; unspecified fracture of the left femur (thigh bone) and age-related osteoporosis (bone disease that occurs when the body loses too much bone, makes too little bone, or both). A review of the comprehensive Minimum Data Set (MDS),…

    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 before2024-07-25 · 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 # NJ160740, NJ166295, NJ167271, NJ169912 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/24/2024, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 3 residents (Resident #3) . The facility also failed to follow its policy titled Administering Medications. This deficient practice was evidenced by the following: 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 defined as diagnosing and treating human responses to actual or 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 prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Ecited before2023-03-10 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 a.) provide privacy and promote dignity during podiatry care for 3 of 3 residents observed (Residents #180, #205 and #264) and b.) provide care and services in a dignified and respectful manner during dining in 1 of 4 dining rooms observed. This deficient practice was evidenced by the following: 1. During the initial tour of the 2A unit on 2/21/23 at 11:13 AM, the surveyor observed the facility's podiatrist and his assistant enter Resident #205's room. Resident #205 was awake and seated in their wheelchair. The podiatrist sat on the floor in front of the resident, put on gloves and removed the resident's socks exposing the resident's toe nails. The Podiatrist opened a blue pad, chux (a disposable under pad) and placed it on the floor underneath the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-10 · tag F0658 — failed to meet professional standards of care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to: a.) accurately transcribe a physician's order for enteral flushes for 1 of 2 residents reviewed for tube feeding (Resident #23), b.) accurately transcribe a physician's order for contractures for 1 of 3 residents reviewed for range of motion (Resident #77), c.) follow a physician's order for weekly weights for 1 of 5 residents reviewed for weights (Resident #183), d.) ensure urinary output was accurately documented in the medical record for 1 of 3 residents reviewed for foley catheters (Resident #199), and e.) ensure neurological assessments neuro checks were completed for 2 of 4 residents reviewed for accidents (Residents #130 and #264). 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…

    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 · E2023-03-10 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis schedule for 1 of 2 residents (Resident #71) reviewed for dialysis. This deficient practice was evidenced by the following: During the initial tour of the facility on 02/21/23 at 11:22 AM, the Licensed Practical Nurse (LPN) #3 informed the surveyor that Resident #71 had begun dialysis (the process of removal of excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) approximately one month ago and was presently out of the facility for dialysis treatment. According to the admission Record (an admission summary), Resident #71 was admitted to the facility in January of 2023 with diagnoses which included but were not limited to: End stage renal (kidney) disease, dependence on renal dialysis, anemia (a deficiency of red blood cells or of hemoglobin in the blood that results in pallor (pale appearance) and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 policy review 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 2/21/23 at 9:43 AM, the surveyor, in the presence of the Dietary Director (DD), observed the following during the kitchen tour: 1. In the food preparation area, Dietary Aide #1 and Dietary Aide #2 were observed wearing baseball caps with their hair at the back of the head exposed and were not wearing hairnets. The DD acknowledged the dietary aides should have been wearing hairnets. 2. In the food preparation area, Dietary Aide #2 was observed wearing a surgical mask above his chin area and his facial hair was exposed. The DD stated Dietary Aide #2 should have facial hair covered and provided a facial hair restraint to the dietary aide. 3. On a shelf in the walk-in refrigerator, the surveyor observed an 8-lb container of macaroni salad, which had a manufacturer's label that had a best used by date of 01/03/23.…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to a.) perform hand hygiene before and after podiatry care for 3 of 3 residents (Residents #180, #205 and #264). This deficient practice was evidenced by the following: 1.During the initial tour of the 2A unit on 2/21/23 at 11:13 AM, the surveyor observed the facility's podiatrist and his assistant enter Resident #205's room. Resident #205 was awake and seated in their wheelchair. The podiatrist sat on the floor in front of the resident, put on gloves and removed the resident's socks exposing the resident's toe nails. The Podiatrist opened a blue pad, chux (a disposable under pad) and placed it on the floor underneath the resident's feet. The door to the resident's room remained opened as the podiatrist performed toenail care to the resident which was visible to the surveyor in the hallway. After the podiatrist completed the resident's toenail care, the podiatrist folded the blue pad, stood up off the floor, removed…

    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 · D2023-03-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that a resident's mattress was maintained in a clean, sanitary, and homelike manner on 1 of 8 nursing units (Memory Care Unit). This deficient practice was evidenced by: During the initial tour of the facility on 02/21/21 at 11:08 AM, the surveyor observed Resident #108 seated in a wheelchair at the bedside beside his/her bed which was stripped. The mattress was heavily stained and soiled, with deep creases noted to the upper portion of the mattress. There was a strong smell of urine in the resident's room. The resident appeared well groomed and dressed and was not able to be interviewed due to his/her cognitive status. The surveyor inspected the bathroom and trash cans in the room which did not contain any waste products that would have contributed to the odor in the room. During an interview with the surveyor on 03/01/23 at 11:39 AM, Certified Nursing Assistant (CNA) #2 stated that Resident #108 sometimes did not make it 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan to address a resident's contracture for 1 of 3 Residents (Resident #77) reviewed for range of motion. This deficient practice was evidenced by the following: On 2/21/23 at 11:52 AM, Resident #77 was observed in wheelchair with their right hand contracted and bent at wrist with downward flexion. The resident was unable to follow commands. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 1/22/23, identified the resident as severely impaired and with impairments on both sides of the upper and lower extremities. A review of the medical record indicated that Resident #77 was admitted to the facility with diagnoses which included, but not limited to: Hemiplegia (severe or complete loss of strength) and Hemiparesis (mild loss of strength) following nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain) affecting the right…

    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 · D2023-03-10 · 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 Based on observation, interviews, and record review, it was determined that the facility failed to revise and update the care plan (CP) in a timely manner for residents who had falls. This deficient practice was identified for 2 of 35 residents reviewed for comprehensive care plans, (Residents #130 and #264) and was evidenced by the following: 1. On 2/21/23 at 11:22 AM, Resident #130 was observed sleeping in bed. According to the admission Record, Resident #130 was admitted to the facility in July 2022 with diagnoses which included but were not limited to; unspecified dementia. Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated, 2/13/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 5 out of 15 which indicated that the resident had severely impaired cognition. Additional review revealed that the resident had a diagnosis of dementia, required extensive assist of one staff with transfers, and had two falls since the prior assessment. Review of an incident report…

    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 · D2023-03-10 · 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 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure a resident who was dependent on supplemental oxygen via a tracheostomy tube (a surgically created hole (stoma) in the windpipe (trachea)) received supplemental oxygen in accordance with physician orders for 1 of 2 residents reviewed for tracheostomy care (Resident #66). This deficient practice was evidenced by: During the initial tour of the building on 02/21/23 at 12:36 PM, the surveyor observed a stop sign posted outside of Resident #66's room which cautioned that an N 95 mask (filters 95% of particles) was required to enter the resident's room. From the doorway, the surveyor observed Resident #66 lying in bed asleep with the head of bed elevated. The resident had a tracheostomy tube and was noted to have a positive cough. According to the admission Record (an admission summary) Resident #66 was readmitted to the facility in August of 2022 with diagnoses 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-02-26 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to don appropriate Personal Protective Equipment (PPE) while in the rooms of residents placed on transmission-based contact and droplet precautions residing on the units designated for Persons Under Investigation (PUI) and on the COVID-19 positive unit. This deficient practice was identified for 6 of 6 staff members observed on 2 of 2 PUI units and for 2 of 2 staff members a COVID-19 positive unit in the facility. The deficient practice was evidenced as follows: 1. On 02/19/21 at 12:48 PM, the surveyor observed lunch meal service on the second floor unit, A/C- wing which had been designated as a PUI area for new and readmissions. The surveyor observed a PUI room with signs on the door which indicated to stop. There was another sign on the door that indicated to follow Contact and Droplet precautions and to wear gown, gloves, masks, and eye protection before entering the room. The surveyor observed a metal bin hanging on the resident's door 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-02-26 · tag F0604 — failed to not use physical restraints improperly — pattern
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) identify the use of bilateral hand mittens as a physical restraint, b.) assess and implement the least restrictive measures prior to the use of a physical restraint, and c.) obtain a consent with disclosure of risk versus benefits for the use of a physical restraint. This deficient practice was identified for 2 of 2 residents (Residents #131 and #330) who were reviewed for the use of physical restraints and was evidenced by the following: 1. On 02/19/21 at 12:21 PM, the surveyor observed Resident #330 in his/her bed, wearing white hand mittens on both the right and left hands. The hand mitts were tied at the wrist to hold them in place on the resident's hands but were not tied to the side rails or any other surface. The resident was able to move both arms freely. The surveyor attempted to interview the resident, but the resident did not verbally respond but mumbled 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-02-26 · 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 facility failed to address in a timely manner the recommendations made by the Consultant Pharmacist (CP) during the Monthly Medication Review. This deficient practice was identified for 1 of 6 residents reviewed for unnecessary medications (Residents #73) and was evidenced by the following: The surveyor reviewed Resident #73's 08/2020 Physician Order Sheet (POS) which revealed a physician Order (PO) dated 07/03/20 for Voltaren 1% gel (topical gel medication used to treat pain) to be applied twice daily to the left shoulder. The surveyor noted that there was no dosage amount documented for the Voltaren gel. The surveyor noted that both the 09/2020 and 10/2020 POS had the same order for Voltaren 1% Gel and no dosage amount. Review of Resident #73's 08/2020, 07/03/20,09/2020 and 10/2020 Medication Administration Record (MAR) had the same order as written on the POS and without dosage amount. Further review of Resident #73's POS revealed a handwritten readmission PO dated 10/11/20 for Voltaren 1% gel to be…

    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 · D2021-02-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, and review of other facility documents, it was determined that the facility failed to ensure that residents were free from unnecessary psychoactive medications. This deficient practice was identified for Resident #17, 1 of 2 resident reviewed for psychoactive medications and was evidenced by the following: Review of Resident #17's clinical record revealed that the resident was admitted to the facility with diagnoses which included: Coronary Artery Disease (Heart disease), Hypertension, aphasia (difficulty speaking) and cerebro-cascular accident (CVA- stroke). The resident's Quarterly Minimum Data Set (MDS) an assessment tool dated 02/02/2021, reflected that the resident was severely cognitively impaired. The surveyor observed the resident in bed with eyes closed during the initial unit tour on 02/19/2021 at 11:30 AM. On 02/23/21 at 11:39 AM, the surveyor observed Resident #17 in bed with eyes closed. At this time the resident was receiving nutrition through a gastrointestinal tube feeding which was infusing at the time of the…

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

    Pharmacy Service 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

$102,840 in federal fines across 1 penalty.

  • $102,840 — penalty dated 2025-05-12

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.

Who owns this facility

Owner / managerTypeRoleShareSince
ANTALA, RAKESHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST20%since 02/01/2021
DASONDI, NILESHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST21%since 02/01/2021
JOSHI, DARSHNAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST11%since 02/01/2021
PANDYA, YASHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST38%since 02/01/2021
PATEL, VISHALIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 02/01/2021
WEISSMAN, MOSHEIndividualW-2 MANAGING EMPLOYEEsince 02/01/2021

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.

$25.5M
Net patient revenuemost recent cost report
-13.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 76%Medicare 9%Other / private 16%

About 76% 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. 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

$359per resident / day
operating cost
$10,913per month
≈ monthly operating cost
$317per 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 315279. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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