Hunterdon Care Center LLC
1 Leisure Court, Flemington, NJ 08822 · For profit - Limited Liability company · 185 certified beds · (908) 788-9292 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — 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
- its independent health-inspection rating is low (2/5)
- about 27% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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 — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.7% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.4% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.7% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.1% | 2.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.1% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.0% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.2% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.9% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.8% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.4% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.9% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.47 | 1.11 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
63.2% 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 491 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 76.8% 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 216 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.2%CMS range 59.7–66.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.4%CMS range 10.2–15.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 76.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 77.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 74.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 4.4–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 185 beds and averages 167.0 residents a day — about 90% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.16 hrs/resident/day on weekends vs 3.43 on weekdays — 8% thinner on weekends. RN hours go from 0.59 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · J2025-08-14 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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: 2582599 Based on interview, review of the medical records, and review of other pertinent facility documents, it was determined that the facility failed to ensure a safe discharge for a resident (Resident #3) with severe cognitive impairment, who lived in the community alone, and was denied at home nursing care services upon discharge. This deficient practice was identified for 1 of 4 residents reviewed (Resident #3). Resident #3, who was had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating a severely impaired cognition with an admission diagnosis of cognitive impairment, was discharged from Medicare Part A services with a last date of coverage on [DATE]. Resident #3 lost an appeal and was discharged to the community on [DATE]. Resident #3 was assessed upon discharge to need at home nursing services, physical therapy (PT), and occupational therapy (OT). A review of a denial email from the home care nursing services (HCNS #1) [name redacted] indicated that since the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-14 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # 2582599Based on interview, review of the medical records, and review of other pertinent facility documents, it was determined that the facility failed to ensure a discharge summary was written at the time a resident (Resident #3) was discharged from the facility. This deficient practice was identified for 1 of 4 residents reviewed (Resident #3).The surveyor reviewed the closed medical record for Resident #3.According to the admission Record (AR) face sheet, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: mild cognitive impairment, enterocolitis due to clostridium difficile (C. diff; a bacteria infection that causes diarrhea and gastrointestinal cramping), hyperlipidemia (high cholesterol), essential hypertension (high blood pressure), unspecified protein-calorie malnutrition, and Parkinson's Disease without dyskinesia (movement disorder).According to the discharge Minimum Data Set (MDS), an assessment tool dated 7/25/25, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-19 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to implement the facility's abuse policy to ensure that reference checks were completed for 10 of 10 employee files reviewed. This deficient practice was evidenced by the following: On 3/18/25 at 9:30 AM, the surveyor reviewed 10 randomly selected employee files, which revealed the following: 1. Licensed Practical Nurse/Unit Manager (LPN/UM) #3, with a hire date of 1/22/24, did not have a previous employee reference on file. 2. Licensed Practical Nurse (LPN) #2, with a hire date of 11/25/24, did not have a previous employee reference on file. 3. Certified Nursing Assistant (CNA) #2, with a hire date of 1/25/25, did not have a previous employee reference on file. 4. Activity Aide (AA) #1, with a hire date of 1/22/25, did not have a previous employee reference on file. 5. LPN #3, with a hire date of 11/18/24, did not have a previous employee reference on file. 6. CNA #3, with a hire date of 4/24/23, did not have a previous employee reference on file. 7. CNA #4,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to honor a resident's choice to a.) get out of bed at the resident's preferred time and b.) attend preferred activities for 1 of 1 resident (Resident #79) reviewed for choices. This deficient practice was evidence by the following: On 3/13/25 at 9:43 AM, the surveyor observed Resident #79 lying in bed. The resident stated he/she preferred to be out of bed by 9:30 AM every morning. The resident further stated that there was a Coffee Social activity scheduled for 10:30 AM in the dining room that they wanted to attend. When asked about the resident's usual get up time, the resident stated that staff normally get them up around 11:00 AM which meant they missed their preferred activities. At 10:30 AM, the surveyor observed the Coffee Social activity in the dining room and Resident #79 was not present. On 3/17/25 at 10:31 AM, the surveyor observed Resident #79 lying in bed. The resident stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 #00172794 Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to submit the facility investigation to the New Jersey Department of Health (NJDOH) within five (5) days, specifically when a resident sustained a fracture of unknown origin for 1 of 2 residents (Resident #53) reviewed for abuse. This deficient practice was evidenced by the following: A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: dementia, history of traumatic fracture, and polyarthritis (a condition characterized by inflammation and pain in multiple joints). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 2/17/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. A review of the individual comprehensive care plan (ICCP) included a focus area, initiated on 11/10/17, that the resident had a cognitive loss with confusion, disorientation, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #NJ00172794 Based on interviews, record review, and review of facility documents, it was determined that the facility failed to conduct a thorough investigation for a resident who sustained a significant injury of unknown origin. This deficient practice was identified for 1 of 2 residents (Resident #53) reviewed for abuse, and was evidenced by the following: On 3/17/25 at 10:30 AM, the surveyor reviewed Resident #53's electronic medical record (EMR). A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: dementia, history of traumatic fracture, and polyarthritis (a condition characterized by inflammation and pain in multiple joints). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 2/17/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. A review of the individual comprehensive care plan (ICCP) included a focus area, initiated on 11/10/17, that the resident had a cognitive loss 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.
- Potential for harm · Dcited before2025-03-19 · tag F0641 — isolatedEnsure 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 1 of 34 residents (Resident #121) reviewed for MDS coding accuracy. This deficient practice was evidenced by the following: On 3/17/25 at 9:15 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #121. A review of the admission Record, an admission summary, revealed that Resident #121 had diagnoses that included, but were not limited to, heart failure, depression, and anxiety disorder. A review of the comprehensive MDS assessment, with an Assessment Reference Date (ARD) of 12/18/24, revealed under section K (Swallowing/Nutritional Status) that the resident was coded for a significant weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The resident weight was documented as 128 pounds (lbs.). A review of the resident's documented weights revealed the following: 6/6/24: 133.2 lbs.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 interviews and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of the receipt of a controlled substance for three (3) of six (6) Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on two (2) Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for one (1) of five (5) residents reviewed for unnecessary medications. (Resident #74). The deficient practice was evidenced by the following: The surveyor reviewed Resident #74's electronic medical record (EMR) which revealed the following. A review of the admission Record (AR, an admission summary), reflected that the resident was admitted to the facility with diagnoses which included, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods) and diastolic congestive heart failure, (a condition that occurs when the heart muscle can't pump blood efficiently). A review of most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/22/25, reflected that the resident had a Brief Interview for Mental Status (BIMS), score of 2 out of 15, which indicated the resident was severely cognitively impaired. A review of Section H…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control and sanitary practices for storing medical devices and equipment while not in use. This deficient practice was identified in one (1) of three (3) observations during the Medication Pass observation (med-pass). This deficient practice was evidenced by the following: On 3/17/25 at 9:00 AM, the surveyor observed medication being administered to Resident #91. The surveyor then observed an oxygen mask, tubing and a nebulizer machine (a device used administer liquid medications by inhalation) on the floor at the foot of the bed of Resident #9, the roommate of Resident #91. The mask, tubing and machine were not observed to be in a bag or other container. The surveyor completed the med-pass observation and contacted the Licensed Practical Nurse/Unit Manager (LPN/UM#3) for that unit. The surveyor showed LPN/UM#3 the nebulizer, mask and tubing located on the floor and asked if that was the way the equipment should be stored when 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.
- Potential for harm · D2025-03-19 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews on 3/13/2025 and 3/14/2025, in the presence of the Director of Maintenance (DOM), it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning. This deficient practice had the potential to affect 6 of 170 residents and was evidenced by the following: An observation on 3/13/2025 at 12:22 PM, revealed that the call bell for resident room C-113 did not give audible notification of activation at the nurse's station when tested by the DOM. An observation at 12:25 PM, revealed that the call bell for resident room C-117 did not give audible notification of activation at the nurse's station when tested by the DOM. An observation at 12:30 PM, revealed that the call bell for resident room C-119 did not give audible notification of activation at the nurse's station when tested by the DOM. At the time, the surveyor interviewed the DOM who confirmed the observation and stated that the call bell system was recently upgraded and the section of the building that we were testing was part…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Fcited before2023-02-16 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene procedures were followed to potentially prevent the development and transmission of communicable diseases for four of four dining observations involving residents (Resident (R) 18, R137, R99, and R107) on the locked dementia unit. This had the potential to affect all 31 residents who reside on the locked dementia care unit. Findings include: 1. During a continuous dining observation on 02/13/23 at 11:40 AM through 11:51 AM, the following was observed: Dayroom Hostess (DH) was observed seated with R18 and R137, feeding both residents at this time. DH was noted to touch the hand and shoulder of R137 prompting him to eat and putting R137's fork in his hand, while simultaneously feeding R18. When R137 would not follow DH's prompts to eat, DH would begin to feed R137, while feeding and wiping the mouth of R18. This process went back and forth throughout the duration of the observation. DH did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-02-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 observations, interview, record review, and policy review, the facility failed to ensure that the unit nourishment rooms refrigerators and ice machines were maintained to prevent potential foodborne illness. The facility identified a census of 163 residents at the time of the survey. Findings include: On 02/14/23 at 2:15 PM an observation of the nourishment room refrigerator on Birch unit was done with the unit clerk. She stated that they keep milk and different types of juices for the residents. A reading of the thermometer found in the refrigerator door read 50 degrees Fahrenheit (F). She stated that if there's a problem with the refrigerator, she contacts maintenance. A tour of the facility nourishments rooms was conducted on 02/15/23 at 12:08 PM through 12:46 PM with the Food Service Director (FSD). The following concerns were noted: On 02/15/23 at 12:08 PM in the nourishment room on the Spruce unit the FSD confirmed that there was no thermometer in the refrigerator. The FSD took the temperature of a four-ounce orange juice which measured 42 degrees Fahrenheit (F) and a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-16 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to honor a resident's choice of a shower over bed baths for one resident (Residents (R) 67) of one resident reviewed for choices out of a total sample of 32 residents. Findings include: Review of R67's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed he was admitted [DATE] with diagnoses that included Congestive Heart Failure (CHF), hemiplegia (paralysis on one side) and hemiparesis (weakness on one side) following cerebral infarction (stroke), morbid obesity, and Diabetes Mellitus (DM). Review of R67's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/22, located in the EMR under the MDS tab, revealed a Brief Interview for Metal Status (BIMS) score of 15 out of 15 which indicated R67 was cognitively intact. Continued review of the MDS revealed it was very important for R67 to be able to choose between a tub bath,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's hospice designation for one (Resident (R) 20) of one resident sampled for hospice out of a total sample of 32 residents. This failure could result in the residents' needs, strengths, and areas of decline not being addressed. Findings include: Review of R20's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R20's admission Assessment Form, dated 12/09/22, located in the resident's EMR under the Misc [Miscellaneous] tab revealed R20 was admitted to the facility on hospice. Review of R20's admission Minimum Data Set (MDS), located in the resident's EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/15/22, revealed the MDS did not accurately reflect R20's hospice designation. During an interview on 02/16/23 at 9:08 AM the MDS Coordinator stated,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure one of two residents (Residents (R) 76) reviewed out of a total sample of 32 had completed a Pre-admission Screening and Resident Review (PASARR) upon receipt of a new mental health diagnoses. This failure placed resident at risk for unmet care needs and for not receiving appropriate mental health support/services needed. Findings include: Review of R76's admission Record from the electronic medical record (EMR) Profile tab showed an original admission date of 02/27/20; readmission dates of 03/02/21 and 06/14/21; with medical diagnoses that included gastroesophageal reflux disease (GERD), hypertension, anxiety disorder, edema, poly-osteoarthritis, and major depressive disorder. The 06/14/21 readmission added the diagnoses of unspecified psychosis (loss of touch with reality) not due to a substance or known physiological condition, insomnia, and delusional disorder (firmly held beliefs not based in reality). Review of R76's EMR Misc [Miscellaneous] tab showed a Level I PASARR dated 06/08/21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure that a resident received consistent range of motion exercises for one (Residents (R) 125) of one resident reviewed for range of motion out of a total sample of 32 residents. Findings include: Review of R125's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed she was admitted [DATE] with diagnoses that included hemiplegia (paralysis on one side) and hemiparesis (weakness on one side) following cerebral infarction (stroke), pain, and polyneuropathy (numbness and tingling). Review of R125's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/22, located in the EMR under the MDS tab, revealed a Brief Interview for Metal Status (BIMS) score of 15 out of 15 which indicated R125 was cognitively intact. The MDS also revealed R125 required extensive assistance of one person with bed mobility. Review of R125's Care Plan, last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and policy review, the facility failed to ensure two of five residents (Resident (R) 119 and R152) who received psychoactive medications, and reviewed for unnecessary medications, had monitoring for efficacy for the target symptoms (reasons for use) for the medication. This failure had the potential to keep residents from receiving the lowest possible effective psychoactive medication dose. Findings include: 1. Review of R119's admission Record, from the electronic medical record (EMR) Profile tab, showed an admission date of 01/18/23 with medical diagnoses that included major depressive disorder and insomnia. Review of R119's EMR Orders tab showed prescriptions for Cymbalta (generic name duloxetine, an antidepressant medication) 60 milligrams (MG) daily for major depressive disorder and to monitor for drowsiness or dizziness. Review of R119's EMR Care Plan tab showed a focus of: [R119's name] has episodes of anxiety, crying/yelling out, dx [diagnosis] depression with a goal of [R119's name] will demonstrate decreased episodes of anxiety. [R119's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-16 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 record review, interview, and facility policy review, the facility failed to ensure that one of one resident (Resident (R) 84) record reviewed for wound documentation out of a total sample of 32 residents reflected the visualized facial wounds. This failure had the potential to create incorrect assessments, care planning, or worsening of the wounds due to the lack of monitoring. Findings include: While completing interviews and observations on 02/13/23 at 2:15 PM, R84 self-propelled her wheelchair out of her room and was noted to have facial sores. Observation on 02/14/23 at 10:23 AM showed the facial sores from forehead to the left side of the chin area remained. R84 did not wish to be interviewed. Review of R84's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 05/02/17 with medical diagnoses that included schizophrenia, type 2 diabetes, bipolar disorder, hypertension, major depressive disorder, chronic obstructive pulmonary disease (COPD), edema, and unspecified sleep disorder. Further review of R84's EMR Progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-16 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure the appropriate coordination of hospice care by specifically failing to maintain hospice orders, care plan, and a hospice election form for one (Resident (R) 20) of one resident sampled for hospice out of a total sample of 32 residents. This failure had the potential result in the interruption of the resident's coordination of care. Findings include: Review of R20's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R20's admission Assessment Form, dated 12/09/22, located in the resident's EMR under the Misc [Miscellaneous] tab revealed the resident was admitted to the facility on hospice. Review of R20's complete medical record, including paper chart and EMR, revealed the absence of hospice orders, hospice election form, and hospice care plan. During an interview on 02/15/23 at 9:59 AM, Unit Manager (UM)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2020-10-09 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 record review, it was determined that the facility failed to ensure that an expired glucose medication (Glutose 15 gel) was removed from the active inventory stored in the medication cart from April 2020 to October 2020. This deficient practice was identified for 1 of 4 medication carts (Spruce Unit) that were inspected and was evidenced by the following: On 10/7/20 at 10:54 AM, the surveyor inspected the Spruce Unit medication cart with the Registered Nurse (RN) in the presence of another surveyor. The top drawer contained four (4) tubes of Glutose 15 gel (an oral glucose gel medication used to raise the blood glucose level when it becomes dangerously low). The surveyor observed that 3 of 4 available glucose gel tubes in the medication cart had an expiration date of 4/2020. At that time, the surveyor interviewed the RN in the presence of another surveyor. The RN stated that that the Glutose 15 gel tubes were over-the-counter (OTC) stock medication stored in the medication cart available for use when needed. The RN added that the nurses were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-10-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to develop a comprehensive care plan for a resident with dementia and on psychotropic medications. This deficient practice was identified for 1 of 30 residents (Resident #135) reviewed for comprehensive care plans. On 10/1/2020 at 11:12 AM, the surveyor observed Resident #135 reclined in a gerichair in the hallway near the nursing station. The resident was wearing a surgical mask. The surveyor observed the resident repeatedly stating, cover me even after a staff member covered the resident with blankets. The surveyor reviewed the medical record for Resident #135. A review of the admission Record face sheet (an admission summary) reflected that the resident had been admitted to the facility with diagnoses which included but were not limited to; unspecified dementia with behavioral disturbance and anxiety disorder. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/27/2020…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-10-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to communicate and document the physician's response to Wound Consultant recommendations in accordance with professional standards of nursing practice. This deficient practice was identified for 1 of 3 residents reviewed with pressure ulcers (Resident #146). The evidence was as follows: Reference: New Jersey Statues, Annotated Title 45, Chapter. 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 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 well being, and executing a 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-10-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility failed to ensure: a.) a pressure ulcer was cleansed upon direct contact with linens and b.) hand hygiene was performed between glove changes during the wound treatment observation. This deficient practice was identified for 1 of 3 residents reviewed for pressure ulcers (Resident #146). The evidence was as followed: On 9/30/2020 at 11:15 AM, the surveyor observed Resident #146 lying in bed on an air mattress. The resident had a pillow positioned under his/her right side. The surveyor attempted to interview the resident at that time, but the resident was unsure if he/she had any wounds. On 10/5/2020 at 10:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #146 had a pressure ulcer to the sacrum with slough (yellowing dead tissue). At that time, the LPN stated to two surveyors that she was going to perform Resident #146's sacral wound treatment with the assistance of a Certified Nursing Aide (CNA). The two surveyors observed the LPN prepare for the wound…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to OCEAN HEALTHCARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 3 of 5 | 2.9 | +0.1 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 10 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ROSENBERG HCC HOLDINGS LP | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/01/2013 |
| DREW, ZALMAN | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2009 |
| FEIGENBAUM, AVRAHAM | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2009 |
| FEIGENBAUM, DEBORAH | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2009 |
| FRIEDMAN, AARON | Individual | DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2009 |
| MAIEROVITS, AVROHOM | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2009 |
| MARFIELD INVESTMENTS INC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/01/2013 |
| R & F HEALTHCARE HOLDINGS, INC. | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/01/2013 |
| ROSDEV HOTEL MANAGEMENT SERVICES INC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/01/2013 |
| TR HUNTERDON HOLDINGS, LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/01/2013 |
| ROSENBERG, MARTIN | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/01/2013 |
| ROSENBERG, MICHAEL | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/01/2013 |
| ROSENBERG, THOMAS | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 11/01/2013 |
| NEWPOINT REAL ESTATE CAPITAL LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | since 05/01/2012 |
| DYNAMIC HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2009 |
| GASTFREUND, YOSEF | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/03/2022 |
CMS files one row per role, so the 36 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
7 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.
This home reported $5.5M paid to related parties — landlords or management companies under common ownership — equal to about 27% 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315226. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-19, 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.