Health Center At Galloway, The
66 West Jimmie Leeds Road, Galloway Township, NJ 08205 · For profit - Limited Liability company · 120 certified beds · (609) 748-9100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $76,958 in federal fines (most recent 2023-11-02)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- about 24% 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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.9% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.4% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.4% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.4% | 2.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 14.7% | 8.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 26.3% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.6% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.4% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.4% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 60.8% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 31.8% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.1% | 8.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 3.10 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.03 | 1.11 | 1.80 | worse |
‡ 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.
66.0% 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 247 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 135 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 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 66.0%CMS range 58.9–70.5 | 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 | 10.6%CMS range 8.0–14.3 | 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 | 61.5% | 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 | 63.0% | 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 | 50.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 4.8–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.20 | 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 120 beds and averages 101.4 residents a day — about 84% occupied, or roughly 19 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 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.65 on weekdays — 10% thinner on weekends. RN hours go from 0.52 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Kcited before2023-11-02 · tag F0658 — failed to meet professional standards of care — patternEnsure 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, interviews, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to A.) administer physician prescribed insulin to diabetic residents as ordered for 8 of 24 residents (Residents #22, #24, #33, #73, #74, #81, #260, and #261) residing on 2 of 2 floors and B.) failed to follow a physician order for weekly weights on 1 of 3 residents reviewed for nutrition, (Resident # 35). Failure to administer the prescribed insulin and/or blood sugars (BS) put diabetic residents at risk for hyperglycemic reactions (high blood sugar that affects people with diabetes. Skipping doses or not taking enough insulin to lower blood sugar can lead to hyperglycemia, hospitalization, and possible death). This deficient practice resulted in an Immediate Jeopardy (IJ) situation which was identified on 10/30/2023, when the facility staff failed to administer physician prescribed insulin. The facility Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified of the IJ on 10/30/2023 at 2:04 PM. A removal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-19 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
NJ#2643473Based on observation, interview, and record review, it was determined that the facility failed to a.) Re-implement a comprehensive care plan (CCP) for a resident (Resident #72) who had a previously identified history of inappropriate sexual behaviors b.) implement a CCP for a resident (Resident #11) who was on psychotropic medications with behaviors, c.) develop a person-centered care plan for a resident who changed the setting on the oxygen concentrator (Resident #129) d.) develop a person-centered care plan for 1 of 5 residents (Resident #130) reviewed for unnecessary medications who was prescribed an anticoagulant (a medication used to prevent blood clots). This deficient practice occurred for 4 of 29 residents surveyed (Resident #11, #72, #129, and #130) and was evidenced by the following: 1. On 2/12/2026 at approximately 10:00 AM, the surveyor attempted to conduct an interview with Resident #72 during the initial tour of the facility. It was determined from interview with staff and review of the electronic medical record that Resident #72 no longer was a resident 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.
- Potential for harm · E2026-02-19 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint# NJ2699824 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, by failing to ensure that critical laboratory results obtained on 12/15/25 were immediately conveyed to the physician, which resulted in a three (3) day delay in notification on 12/18/25 and immediate transfer to the hospital for evaluation and treatment. This deficient practice was identified for 1 of 1 resident (Resident #123), reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-19 · tag F0880 — failed to prevent and control infections — patternProvide 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 facility documentation, it was determined that the facility failed to a.) prevent the potential for cross contamination by not initiating and implementing Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for a resident with a wound in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. b.) follow appropriate infection control practices in a manner to prevent the potential spread of infection and/or cross-contamination during the provision of a wound care treatment and c.) transport linen in a manner that prevents the spread of infection for 1 (one) of 1 resident (Resident #11) reviewed for pressure ulcers d.) maintain the feeding tube pump pole, overbed table, and wall in a sanitary manner, for 1 of 2 residents (Resident #2) reviewed for tube feeding e.) implement Enhanced Barrier Precautions (EBP) in accordance with the facility policy, physician orders, 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 · D2026-02-19 · 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
Based on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman's Office of a resident transfer to an acute care hospital in a timely manner.This deficient practice was identified for 1 of 2 residents (Resident #123) reviewed for hospitalization and was evidenced by the following: On 2/17/26 at 10:20 AM, the surveyor reviewed the closed medical record of Resident #123.A review of the admission Record, an admission summary, revealed the resident was admitted to the facility with diagnoses which included but were not limited to: acute respiratory failure, chronic obstructive pulmonary disease (COPD) (a condition which makes it difficult to breathe), heart failure, unspecified, and Type 2 (two) diabetes mellitus (a condition in which the body does not produce enough insulin or use it effectively).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/18/25, included the resident had 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 · D2026-02-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) properly store a bi-level positive airway pressure (BiPAP), machine [helps breathing by delivering air through a face mask), in a bag when not in use, b.) ensure that oxygen was being administered as per physician's orders, and c.) ensure that oxygen was humidified in accordance with professional standards of practice. This deficient practice was identified for 2 of 2 residents (Resident #116 and Resident # 129) reviewed for respiratory care and was evidenced by the following:1.On 2/12/26 at 10:58 AM, the surveyor observed Resident #129 sitting upright in bed. Resident #129 had a nasal cannula (clear plastic tubing used to deliver supplemental oxygen to a patient through the nostrils) that delivered humidified oxygen via an oxygen concentrator set at eight (8) liters. The humidification bottle connected to the oxygen concentrator contained a small amount of liquid. On 2/13/26 at 8:46 AM, the surveyor reviewed Resident #129's electronic medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility failed to ensure physician supervision and oversite of medical care for 1 of 2 residents (Resident #11) reviewed for pressure ulcer management and was evidenced by the following:The surveyor reviewed Resident #11's Electronic Medical Records (EMRs) which revealed the following information:A review of the admission Record, an admission summary, indicated that Resident #11 was admitted to the facility with diagnoses that included but were not limited to dementia: (a loss of mental functioning that affects thinking, memory, mood, and behavior) and diabetes mellitus (a condition in which the body is unable to properly regulate blood sugar due to problems with insulin production or use).A review of the admission Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 12/14/2025, indicated that the resident scored 3 (three) out of 5 (five) on the Basic Interview for Mental Status (BIMS), which indicated that the resident had severe cognitive impairment. Further review of the MDS also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 medical records and other facility documentation, it was determined that the facility failed to a.) develop an individualized Comprehensive Care Plan (ICCP) with specific interventions to address dementia care, and b.) follow the facility policy for dementia care. This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for dementia care and was evidenced by the following: A review of the admission Record (admission summary) indicated that Resident #11 was admitted to the facility with diagnoses that included but were not limited to dementia and diabetes mellitus.A review of the comprehensive Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 12/14/2025, indicated that the resident scored 3 (three) out of 15 (fifteen) on the Basic Interview for Mental Status (BIMS) assessment which indicated that the resident had severe cognitive impairment. The MDS also indicated that Resident #11 did not exhibit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · 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 facility documentation, it was determined that the facility failed to ensure that the pharmacy consultant conducted a monthly review of each resident's medication regimen b.) to clarify a physician's order, c.) address a pharmacy consultant recommendation for one (1) of five (5) residents reviewed for unnecessary medications (Resident #113). This deficient practice was evidenced by the following:On 2/12/26 at 11:20 AM, the surveyor observed Resident #113 lying in bed.On 2/13/26 at 1:40 PM, the surveyor reviewed the electronic medical record for Resident #113.A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: type 2 diabetes mellitus (a chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond to insulin properly) and rheumatoid arthritis (a chronic autoimmune disorder where the immune system attacks joint linings (synovium), causing painful, stiff, and swollen joints,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 3 nurses administer medications for 3 residents with 26 opportunities for error. There were 2 errors resulting in an error rate of 7.6% as evidenced by the following: During the medication pass observation on 2/13/2026 from 8:27 AM until 8:35 AM, the surveyor observed the following: At 8:27 AM, the surveyor observed Licensed Practical Nurse #8 (LPN #8) prepare five medications for Resident #100 including Coreg tablet 25 mg (milligram) (carvedilol); give one tablet by mouth two times a day for HTN (hypertension) take with food, and Metformin HCL tablet 1000 mg; give one tablet by mouth two times a day for DM (diabetes mellitus) with a pharmacy cautionary label indicating to take this medication with food. At the time of the medication administration, the facility breakfast trays had not been delivered, and LPN #8 had not provided, offered, or instructed the resident to take the medication with food. At that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 secure a treatment cart during a wound treatment observation that was conducted on 2/17/2026. This deficient practice occurred with 1 of 1 nurse observed for the provision of a wound treatment and was evidenced by the following:On 2/17/2026 at 10:20 AM, the surveyor conducted a wound treatment observation on the third floor nursing unit with the Licensed Practical Nurse (LPN #1). LPN#1 was observed gathering treatment supplies from the treatment cart. LPN #1 then proceeded to put the treatment supplies on top of the treatment cart. She then entered a resident's room, and left the treatment cart with the treatment supplies on top of the cart unlocked, unattended and out of her line of sight. LPN#1 returned to the cart to obtain additional supplies, then re-entered the resident's room, again leaving the cart unlocked, unsecured, and unattended.The treatment supplies left on top of the treatment cart consisted of one bottle of normal saline solution (NSS), one…
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 15 citations
- Potential for harm · D2026-02-19 · tag F0809 — failed to serve meals on a reasonable schedule — isolatedEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to offer snacks to residents between meals and at bedtime. This deficient practice was identified for 2 of 4 residents (Resident #80, Resident #83,) who attended a resident's group meeting and for an additional two residents interviewed for the provision of snacks, (Resident #5, Resident #130).This deficient practice was identified on 2 of 2 nursing units (Second and Third Floor) and was evidenced by the following:On 2/13/2026 at 10:31 AM, the surveyor conducted a meeting with four alert and oriented residents. When asked about bedtime snacks, two residents stated that snacks were not passed out at night. Resident #83 stated that they did not receive snacks and worried about their blood sugars as a diabetic. Resident #83 further stated that they had spoken to the Dining Director (DD) previously about it and they had agreed to look into it.On 2/17/2026 at 11:47 AM, the surveyor observed Resident #5 seated in a wheelchair in their room eating lunch. When the surveyor asked if they received a snack at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-25 · 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 interview, review of medical records and other pertinent facility documents on 9/26/25, it was determined that the facility failed to maintain an accurately documented and complete an investigation in accordance with acceptable standards and practice. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed and was evidenced by the following: The surveyor reviewed a Facility Reported Event (FRE) that was submitted to the New Jersey Department of Health (NJDOH) on 9/16/25. The FRE was submitted by the Licensed Nursing Home Administrator (LNHA) and revealed that Resident #3 alleged that, someone raped me. The resident then went on to describe the person as, a short black male wearing tan, that was standing outside of the window. The FRE also included that the allegation was not substantiated as the resident's visitor's log was reviewed and a review of the staff schedule was conducted, and both did not reveal anyone that matched the description. Additionally, Resident #3's room was located on the second floor and the window did not allow for a body to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint 2579597Based on interviews, medical record review, and other pertinent facility documentation on 08/07/25, it was determined that the facility failed to obtain a physician's order (POs) for the resident's (Resident #7) oxygen in accordance to professional standards of practice. This deficient practice was identified for 1 of 14 residents and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11.…
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 before2025-08-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # 360598Based on observations, interviews, and record reviews on [DATE], it was determined that the facility failed to ensure infection control guidelines were followed for a resident who had a sick cat visiting the facility to prevent infection. This deficient practice was identified for 1 of 14 residents reviewed for infection control (Resident #6). This deficient practice was evidence by the following:A review of the Electronic Medical Record (EMR) was as follows:According to the admission Record (AR) face sheet, Resident #6 was admitted to the facility with diagnoses which included but were not limited to Spondylosis (degenerative changes in the spine), expressive language disorder, dysphagia (difficulty swallowing), sepsis, and muscle weakness.A review of the Minimum Data Set (MDS), an assessment tool, dated [DATE], Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact.A review of Resident #6's Order Summary Report (OSR), 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 · Fcited before2024-09-13 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 6 days of 10 weeks reviewed. This deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 11/05/2023, 12/31/2023 thru 01/06/2024 revealed the facility had no RN coverage for 8 consecutive hours for all shifts on 11/05/2023, 11/08/2023, 11/11/2023, 12/31/2023, 01/01/2024, and 01/06/2024. On 09/12/2024 at 03:15 PM, the surveyors conducted an interview with the facility Director of Nursing (DON) and the surveyor said she reviewed the facility staffing sheets which indicated that the facility had days without a Registered Nurse (RN) for at least 8 consecutive hours. When asked should there be an RN on duty for at least 8 consecutive hours daily the DON replied, Yes, we should have 8 hours minimum for RN on duty per day. A review of the facility provided policy titled Staffing, revised October 2017, revealed 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 · F2024-09-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 09/09/2024 from 7:39 to 8:23 AM, the surveyors, accompanied by the cook and the Food Service Director (FSD), observed the following in the kitchen: 1. Prior to entering the walk-in refrigerator and freezer the surveyors reviewed the temperature logs. Review of the September 2024 Refrigerator Temperature log revealed that no AM or PM temperatures were recorded on 9/7, 9/8, and 9/9/2024. On interview the FSD stated that the aide was responsible for recording the refrigeration temperatures and that the aide had not worked on those days. 2. On a lower shelf in the walk-in freezer, a sheet pan contained frozen hamburger patties. The hamburger patties were covered with plastic wrap. There were no dates labeled on the pan or plastic wrap. 3. On 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 · Ecited before2024-09-13 · tag F0658 — failed to meet professional standards of care — patternEnsure 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
C/O #NJ 174603 Based on observation, interview, review of the Electronic Medical Record (EMR) it was determined that the facility nursing staff failed to document in the progress notes (PN) unusual incidents, specifically regarding a.) a fracture found on x-ray, b.) staff to resident abuse allegation and c.) a resident-to-resident altercation. This deficient practice was identified for 4 of 26 sampled residents (Resident #13, Resident #5, Resident #48 and Resident #257) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, 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 prescribed by a licensed or otherwise legally authorized physician or dentist. Reference:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined that the facility failed to maintain resident dignity when staff were observed standing while feeding residents their meals on 1 of 2 Nursing units, 2nd floor, for 1 of 1 resident reviewed for dignity (Residents #20). This deficient practice was evidenced by the following: On 09/10/2024 at 12:13 PM, the surveyor observed a facility staff on the 2nd floor dining room at the lunch meal assisting Resident #20 to eat. The staff was standing next to the table to assist the Resident #20 to eat from a standing position. Resident #20 was seated in a wheelchair at a table in the center of the dining room facing the television. The staff did not attempt to get a chair while assisting Resident #20 to eat. The staff continued to feed Resident #20 from the standing position throughout the meal. On interview, the staff who identified herself as a Licensed Practical Nurse (LPN #1). The surveyor asked LPN #1 what the facility procedure is when assisting residents at meal time. LPN #1 stated to the surveyor, Should I be seated? According to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-13 · 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
Based on observation, interview review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to report an injury of unknown origin, specifically a fracture of the right distal femur, as well as an allegation of staff to resident abuse to the New Jersey Department of Health (NJDOH) in a timely manner for 2 of 26 sampled residents, (Resident #13 and Resident #257). This deficient practice was evidenced by the following: 1. During the initial tour of the unit, Resident #13 told Surveyor #1 that he/she had pain due to a fracture of the hip. Resident #13 denied having fallen and said he/she will be following up with the orthopedic physician on Thursday. A review of the EMR was conducted on 09/09/2024 at 01:05 PM and included the following: According to the admission Record Resident #13 was admitted to the facility with diagnoses including but not limited to: HIV (Human immunodeficiency virus) chronic pain syndrome and disorder of bone density and structure (osteoporosis). A review of a the most recent comprehensive…
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 before2024-09-13 · 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 documents, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's medical and nursing needs specifically by failing to implement a care plan for an antibiotic that was infused through a Peripherally Inserted Central Catheter (PICC) used to deliver the antibiotic, and 2.) a resident diagnosed with PTSD (Post Traumatic Stress Disorder) on admission. The deficient practice was identified for 2 of 26 sampled residents, (Resident #86 and Resident #99). The deficient practice was evidenced by the following: 1.) On 09/09/2024 at 08:28 AM, during the initial tour, Resident #86 was identified by the nurse preparing an Intravenous Antibiotic (IV Antibiotic), as being ordered an IV antibiotic for an infection. A review of Resident #86's admission Record revealed that he/she had a diagnosis that included but not limited to: Cutaneous Abscess of Buttock, and Local Infection 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.
- Potential for harm · D2024-09-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to follow up on a psychiatry recommendation to discontinue an antipsychotic medication, failed to monitor residents' behavior for the use of the antipsychotic, and failed to develop a care plan for the use of an antipsychotic. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications, (Resident #74) and was evidenced by the following: On 9/10/2024 at 08:58 AM, the resident was observed lying in bed with his/her eyes closed. On 9/10/2024 at 12:30 PM, the resident was observed in his/her room with a therapist eating lunch. There were no behaviors exhibited. On 9/11/2024 at 08:39 AM, the resident was observed lying in bed with his/her eyes closed. On 9/12/2024 at 12:00 PM, the resident was observed ambulating with therapy. Resident was smiling, replied fine when asked how he/she was today. No behaviors were exhibited. On 9/09/2024 at 12:19 PM, a review of the Electronic Medical Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-22 · 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
COMPLAINT #: NJ00171580, NJ00171582 Based on interviews, medical record review, and review of other pertinent facility documents on 02/22/24, it was determined that the facility failed to develop a comprehensive person-centered care plan (CP) for a resident involved in two incidents of inappropriate sexual behavior. The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for CP and was evidenced by the following: According to the Face Sheet, Resident #1 was admitted to the facility with diagnoses that included but were not limited to: Type 2 Diabetes, heart disease, and Schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly). Review of Resident #1's 12/17/23 Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Reviewed of Resident #1's incident reports (IR), provided by the facility revealed the following: -An IR, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-02 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 4 of 10 weekends reviewed. This deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 08/13/2023, 08/20/2023, 10/08/2023, and 10/15/2023 revealed the facility had no RN coverage for all shifts on 08/19/2023, 08/20/2023, 10/08/2023, and 10/21/2023. During an interview with the surveyor on 10/30/2023 at 12:51 PM, the Licensed Nursing Home Administrator (LNHA) confirmed yes, are we missing Registered Nurse's for 24 hours on the staffing sheets. It is all weekends. The Director of Nursing said Correct either it was a call out or RN not scheduled and couldn't find coverage when asked if there were shifts on the staffing sheets that showed no RN's worked. NJAC 8:39-25.2(h)
- Potential for harm · Ecited before2023-11-02 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to store respiratory equipment in a manner to prevent the spread of infection for 3 of 3 resident's reviewed for respiratory care, (Resident # 2, Resident #41, and Resident #53). This deficient practice was evidenced by the following: 1. During the initial tour of the 2nd floor on 10/24/2023 at 10:26 AM, Resident #2's oxygen tubing was observed to be wrapped around the side rail uncovered. The nebulizer mask was resting on top of the nebulizer machine on the bedside table, exposed and uncovered. On 10/25/2023 at 8:48 AM, the surveyor observed Resident #2's nebulizer mask on the bed side table on top of the machine, uncovered and exposed. The oxygen tubing was wrapped around the side rail, uncovered and exposed. According to the admission Record, Resident #2 was admitted to facility with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD)…
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 · D2023-11-02 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to utilize facility protocols regarding feeding tube nutrition and care specifically by not labeling the nutritional formula being used on a resident. The deficient practice was identified for 1 of 1 resident (resident #54) investigated for Tube Feeding. On 10/24/2023 at 10:27 AM during the initial tour, the surveyor observed Resident #54 in bed. At that time, the surveyor observed a nutritional formula bottle hung from a pole adjacent to the resident's bed. At that time, the surveyor observed that the nutritional formula bottle did not have the resident's name, room number, date, start time, and rate of milliliters per hour as indicated by the manufacturer label. On 10/27/2023 at 10:31 AM, the surveyor observed Resident #54 in bed. At that time the surveyor observed a nutritional formula bottle hung from a pole that was connected to a pump. The pump was on at that time. The surveyor observed that the nutritional formula bottle did not have 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.
“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
$76,958 in federal fines across 1 penalty.
- $76,958 — penalty dated 2023-11-02
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CONTINUUM HEALTHCARE — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 2 of 5 | 2.8 | -0.8 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 12 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|
| BRUCKSTEIN, DANIEL | Individual | DIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 10/03/2019 |
| BRUCKSTEIN, ROBERT | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 10/03/2019 |
| GALLOWAY REAL PROPERTY LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE HOLDINGS LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 10/03/2019 |
| LITMAN, WARREN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2024 |
| CONTINUUM HEALTHCARE I INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/06/2025 |
| EXECUCARE ASSOCIATES | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/15/2025 |
| LESHKOWITZ & COMPANY LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/06/2025 |
| TWOMAGNETS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/06/2025 |
| DASONDI, VIVEKKUMAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/03/2019 |
| DORN, CHERYL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 10/03/2019 |
| MANDELBAUM, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 10/03/2019 |
| SHAFFER, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/03/2024 |
| STONEBRIDGE HEALTHCARE MEMBER I LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE MEMBER II LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
| STONEBRIDGE HEALTHCARE MEMBER III LLC | Organization | ADP OF THE SNF | since 10/03/2019 |
CMS files one row per role, so the 28 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.
9 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 $3.7M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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 315210. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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 →
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