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Complete Care At Regent LLC

50 Polifly Road, Hackensack, NJ 07601 · For profit - Individual · 180 certified beds · (201) 646-1166 Medicare & Medicaid certified

Call the home — (201) 646-1166 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Feb 2025
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 17% 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.

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

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
30 S Newman St · (201) 488-1188 · Call to confirm hours
Pharmacy
101 Polifly Rd · (201) 525-1149 · Call to confirm hours
Grocery
201 Essex St · (551) 303-7243 · Call to confirm hours
Park
59 Polifly Rd · Typically dawn to dusk
Place of worship
29 Parkway

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.8%8.7%15.4%better
Long-stay residents who lose too much weight3.6%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.5%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms6.1%12.1%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.9%2.3%3.3%better
Long-stay residents whose ability to walk worsened7.9%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.3%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine97.2%97.2%95.3%typical
Long-stay residents with pressure ulcers4.6%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control29.0%15.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.4%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.1%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine70.2%80.1%79.4%worse
Short-stay residents rehospitalized after admission21.9%24.9%22.6%typical
Short-stay residents with an outpatient ER visit10.9%8.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.962.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.201.111.80better

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

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

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

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

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

50.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.7%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
46.9%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 46.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 96 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.7%CMS range 40.4–59.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 6.2–12.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge46.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge55.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.4–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.61
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.30
Total nurse hours/ resident / day
0.53
RN hoursweekends
34.8%
Total nursing turnover
26.9%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 163.8 residents a day — about 91% occupied, or roughly 16 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.03 hrs/resident/day on weekends vs 3.40 on weekdays — 11% thinner on weekends. RN hours go from 0.64 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below 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

17
deficiencies at the latest standard inspection (2025-02-03)
5
at the previous standard inspection (2023-10-02)

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.

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · F2025-02-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: 1. On 1/27/25 at 9:16 AM, the surveyor, in the presence of the Food Service Director (FSD) observed the following during the initial kitchen tour: On a shelf in a refrigerator, there was an opened pack of shredded mozzarella cheese. The pack had an open date of 1/17/25 and a use by date of 1/24/25. The FSD stated that the pack of cheese should not be there and took it out to be discarded. The FSD further explained the item was good for seven days after opening and that all dietary staff were responsible for ensuring expired food items were removed. 2. On 1/28/25 at 10:19 AM, the surveyor, in the presence of the FSD conducted a follow up tour in the kitchen. The surveyor observed Dietary Staff (DS) #1 with their hair sticking out of their hairnet on the sides behind their ears. DS #1 was serving fruits in individual cups for…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-03 · tag F0919 — failed to provide a working call system — widespread
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview on 1/27/2025 in the presence of the Director of Maintenance (DM), it was determined that the facility failed to ensure that the devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation at 1:28 PM, revealed that the call bell system did not give audible or visual notification of the activation of the call bell system at the nurse's station when it was test for room [ROOM NUMBER]. Upon further investigation by the DM, it was discovered that the call bell annunciator at the nurse's station was not plugged in. In an interview at the time, the DM confirmed that the call bell annunciator panel was unplugged, and confirmed that with the annunciator panel unplugged, any activation of the call bell system from any room on floor 4 would not be heard or seen at the nurse's station. The DM plugged the call bell annunciator back in and informed the nursing…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-03 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 3 of 3 units, (2nd, 3rd, and 4th units) and 2 of 2 residents' rooms. This deficient practice was evidenced by the following: 1. On 1/27/25 at 1:58 PM, during the initial tour of the 4th floor nursing unit, the surveyor observed a gray, dust or dirt-like substance adhering to the air circulation vent covers on the 4th floor unit in the hallways and above the nursing station. The surveyor observed four vent covers in the 4th floor hallways and one vent cover above the nursing station. On 1/28/25 at 9:30 AM, the surveyor observed the vent covers on the 2nd and 3rd floors. The surveyor observed that the vent covers on the 2nd and 3rd floors also had a gray, dust or dirt-like substance accumulated on them. The surveyor asked the Director of Nursing (DON) who was responsible for the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-03 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for 5 of 8 newly hired licensed staff reviewed, Staff Member (SM) #1, #4, #5, #6, and #7 evidenced by the following: On 1/28/25 at 11:12 AM, the surveyor reviewed ten randomly selected newly hired employee files. The review for license verification for eight of the new licensed employees revealed the following: 1. A review of Staff Member #1 (SM#1), a Certified Nursing Assistant (CNA #1), hired on 5/30/24, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. There was no documented evidence that SM#1's license was verified prior to the date of hire (doh). 2. A review of Staff Member #4 (SM#4), a CNA,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-03 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the residents or resident representative written notification of the facility's bed hold policy for 4 of 5 residents, (Residents #12, #84, #94, and #97), reviewed for hospitalizations. This deficient practice is evidenced by the following: 1. On 1/27/25 at 10:59 AM, Surveyor #1 (S#1) observed Resident #12, seated on the side of the bed and informed the surveyor that they were a short-term resident and had been in and out of the facility for more than three times hospitalizations due to a heart condition. The surveyor reviewed the medical records of Resident #12, and revealed the following: The admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cardiac arrhythmia (irregular heartbeat) unspecified, unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), essential hypertension (elevated blood…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents receiving oxygen according to the standard of clinical practice and the facility's policy and procedure. This deficient practice was identified for 3 of 3 residents, Residents #23, #88, and #142, reviewed for respiratory care, 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,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-03 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure that the resident's call light was readily accessible within reach. The deficient practice was identified for 1 of 1 resident, Resident #309, reviewed for accommodation of needs. This deficient practice was evidenced by the following: On 1/27/25 at 10:27 AM, the surveyor observed the resident resting in bed, alert, soft spoken, and verbally responsive. The surveyor observed the resident's call light was tied to the left siderail, dangling down towards the floor and not clipped onto the bed within the resident's reach. The surveyor asked Resident #309 about call bell use, and the resident replied that sometimes they could not reach the call bell and stated, like now I don't know where my call bell is. At that same time, the surveyor notified the resident where their call bell was and asked if they could reach it. Resident #309 replied No .I can't even see where it is. The surveyor asked Resident #309 what would happen in those instances where they could not find their call bell…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-03 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    REPEAT DEFICIENCY Based on 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 3 of 34 residents, (Residents #23, #308, and #309), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:59 AM, the surveyor observed Resident #23 lying on the bed with BIPAP (Bilevel positive airway pressure, is a machine that helps resident breathe and a form of noninvasive ventilation) and nebulizer machine on top of the nightstand table. On 1/28/25 at 11:16 AM, the surveyor observed the resident lying on the bed, and informed the surveyor that they use the oxygen (O2) as PRN (as needed) and the BIPAP at night. The surveyor reviewed the medical records of Resident #23, and revealed: The admission Record (AR, an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to sleep apnea (a potentially serious…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, review of medical records and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical and psychosocial needs. This deficient practice was identified for 2 of 34 residents (Residents #8 and #146) reviewed for a care plan. This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:58 AM, the surveyor observed Resident #8 lying on the bed with eyes closed with the call bell within reach. On 1/28/25 at 11:14 AM, the surveyor observed the resident lying in bed asleep. On 1/29/25 at 10:39 AM, the surveyor observed the Activities Aide Recreation (AAR) with a cart in the hallway near the resident's room. The surveyor interviewed the AAR, who informed the surveyor that she knew Resident #8 and the resident's preferences. She further stated that the resident preferred to sleep late at night and wake up late in the morning. She acknowledged that preference of the resident should be in the care plan (CP) in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-03 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to adhere to professional standards of clinical practice by failing to a.) ensure the practitioner aware of the situations where other practitioner had potentially misdiagnosed the resident for 1 of 5 residents, Resident #12, reviewed for unnecessary medications (meds) and b.) administer a medication (med) in accordance with the manufacturer's specifications for 1 of 6 residents, Resident #129, reviewed during the med pass observation. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2025-02-03 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to carry out activities per resident's care plan for 1 of 1 resident, Resident #8, reviewed for activities. This deficient practice was evidenced by the following: On 1/27/25 at 10:58 AM, the surveyor observed Resident #8 lying on the bed with eyes closed with the call bell within reach. The surveyor reviewed the medical records of Resident #8, and revealed: A review of the Resident's admission Record (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; essential hypertension (occurs when a resident has abnormally high blood pressure that was not the result of a medical condition), unspecified mood (affective) disorder, and depression unspecified. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with assessment reference date (ARD) 10/31/24, Section C Cognitive Skills with a brief interview for mental status (BIMS) score of 13 out of 15, which…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, by failing to; a.) follow the physician's order (PO) for laboratory and daily weight, b.) ensure congestive heart failure assessment was accurately done according to the PO, and c.) follow through the recommendations of the cardiologist. This deficient practice was identified for 1 of 32 residents, Resident #12, 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 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 medical regimes as prescribed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-03 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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, and record review, it was determined that the facility failed to clarify physician's orders to ensure appropriate care and services for a resident receiving enteral feedings. This deficient practice was identified for 2 of 3 residents (Residents #7 and #94), reviewed for enteral (tube) feeding. This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:19 AM, the surveyor observed Resident #7 lying in their bed with the head of bed elevated and the resident's representative (RR) was visiting at the bedside. The resident was alert and verbally responsive to simple questions. Resident #7 had tube feeding supplies at the bedside. The RR stated that the resident receiving enteral feedings and was also on a diet to receive PO (by mouth) foods. The RR stated that the intake via enteral feeding had decreases as the resident's PO intake increased. The RR had no concerns with the resident's enteral feeding care or nutrition. On 1/28/25 at 12:24 PM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #7. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-03 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint NJ #176546 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey and b.) answer call bells and provide incontinence care in a timely manner. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. 1. On 1/27/25 at 9:30 AM, the surveyor interviewed the second floor Unit Manager (UM) regarding…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-03 · tag F0728 — failed to protect against nurse-aide misconduct — isolated
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    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 # 168864 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure and have documented evidence a.) that Temporary Nurse Aides (TNAs) were enrolled in school prior to 5/11/23 and completed their Certified Nurse Aide (CNA) certification by 9/11/23 as mandated by Centers for Medicare and Medicaid Services (CMS) and New Jersey Department of Health (NJDOH) in order to continue to work after 5/11/23; b.) of verification that the non-certified NAs were currently enrolled and actively taking classes in a New Jersey state-approved Certified Nursing Aide (CNA) Training Program and validate completion of Module 1 in their CNA Training Program prior to allocating an independent resident assignment, 2 of 2 non-certified NAs that were previously working as TNAs; and c.) there was a delineated policy and/or program in place for the hiring, staffing, and assignments of non-certified NAs. This deficient practice was evidenced by the following: Reference: CMS…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-03 · tag F0732 — isolated
    Post nurse staffing information every day.
    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 post the accurate Nursing Home Resident Care Staffing Report daily for 2 of 5 days in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: 1. On 1/27/25 at 8:52 AM, the survey team entered the facility and met with the Receptionist and the Director of Nursing (DON). The surveyor was unable to see the posted Nursing Home Resident Care Staffing Report (NHRCSR) not until the surveyor had to go inside the Receptionist's area where the NHRCSR was covered by a vase of flowers, which was not easily visible to residents, staff, and visitors. The posted NHRCSR was dated 1/24/25 Day Shift, 7:00 AM-3:00 PM, census of 161 that included 17 CNAs (Certified Nursing Aides) with staff to resident ratio of 1 CNA:9.5 Residents. At that same time, the surveyor asked the DON why the posted sign was dated 1/24/25 and not the date for today, and the Receptionist stated that…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-03 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 2 of the 34 residents reviewed, (Residents #12 and #23). This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:59 AM, the surveyor observed Resident # 12 seated on the side of the bed and informed the surveyor that they were a short-term resident and had been in and out of the facility more than three times hospitalizations due to a heart condition. The surveyor reviewed the medical records of Resident #12, and revealed the following: The admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; major depressive disorder (recurrent and mild), cardiac arrhythmia (irregular heartbeat) unspecified, unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), essential hypertension (elevated blood pressure),…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00167634 Based on interview, review of resident medical records, and review of other pertinent facility documentation on 10/04/23, it was determined that the facility failed to: a.) follow a physician's order (PO) to remove a midline catheter (an 8-12 centimeter catheter inserted in the upper arm used to administer medications into the bloodstream) prior to discharging the resident and b.) coordinate discharge planning for Resident #1, 1 of 4 residents reviewed for discharges. The deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #1: 1. According to the admission Record, Resident #1 was admitted to the facility on [DATE] with medical diagnoses which included but were not limited to: local infection of the skin and subcutaneous (under the skin) tissue, pressure ulcer (injury that forms as a result of prolonged pressure on the skin) of left heel, Stage 2 (wound extends into the bottom layer of the skin), and end stage renal disease.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-02 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to accurately complete and/or timely transmit the Minimum Data Set (MDS) for 5 of 46 residents reviewed, Residents #13, #37, #51, #131, #113. The deficient practice was evidenced by the following: On 9/26/23 at 12:30 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. The following residents were identified as not to having their MDS transmitted timely: 1. Resident #13 was observed to have a Discharge Return Not Anticipated MDS with Assessment Reference Date (ARD) of 4/28/23 and was due to be transmitted no later than 5/26/23. The MDS was not transmitted until 9/21/23. Further review of Resident #13's MDS assessments revealed that the resident had an Entry MDS (E/MDS) with ARD 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-02 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 7 of 29 residents, Resident #3, #135, #8, #15, #126, #204, and #98 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 9/20/2023 at 11:30 AM, the surveyor observed Resident #3 in their room watching television. The surveyor also observed that the resident was only able to communicate in Russian. The surveyor reviewed Resident #3's electronic medical record (EMR). Review of Resident #3's Face Sheet (FS) (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility on [DATE] with diagnosis that included but were not limited to adjustment disorder with mixed Anxiety and Depressed Mood, Anemia, Essential (primary) Hypertension and Obesity. Review of the A section 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-02 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, medical records, and facility policies, it was determined that the facility failed to follow acceptable standards of clinical practice with regards to 1. label and date an Enteral feeding bottle and water flush bag. This deficient practice was observed for Resident #135, 1 of 3 facility residents reviewed for Tube Feeding and 2. accurately following a physician's order (PO) for parameters. This deficient practice was observed for Resident #135, 1 of 5 residents reviewed for following a PO for parameter accuracy. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 observation, interview, and record review, it was determined that the facility failed to accurately assess and implement interventions for the care and management of a resident with a contracture (a permanent shortening of muscle, tendon, or scar tissue, leading to deformity and rigidity of joints) and limited range of motion (ROM) for 1 of 1 resident, Resident #48, reviewed for rehab and restorative services. This deficient practice was evidenced by the following: On 9/21/23 at 11:13 AM, the surveyor observed Resident #48 lying in bed, alert and conversant. The resident's left hand was observed with a contracture. The resident's fingers were flexed towards the palm of the hand. Resident #48 informed the surveyor that they spend most of the time in bed and required staff assistance with getting out of bed to the wheelchair. The resident explained that they were not receiving any rehabilitation therapy and were not sure what the future plans for their care was. The surveyor reviewed the electronic health…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to secure stored controlled medications, as well as ensure that expired, and discontinued medications were removed from the medication cart in a timely manner. This deficient practice was identified in 3 of 3 facility units inspected. The deficient practice was evidenced by the following: 1. On 9/20/23 at 12:15 PM, the surveyor inspecting the 2nd floor refrigerator. The Narcotic Plastic Lock Box located in the 2nd floor refrigerator was secured to the shelf via a metal chain link and keyed lock. The metal link chain was loosely attached, which allowed the surveyor to insert her hand into the box and remove the control substances (medications that are rated by their abuse risk and placed in Schedules by the Federal Drug Enforcement Administration) stored inside of the box. The controlled substances found in the box were Lorazepam (anxiolytic, sedative) 2mg/milliliters (ml) 30 ml bottle, #20 gel tabs delivered 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and review of facility documentation, it was determined that the facility failed to follow a Physician's Order (PO) for the use of Oxygen (O2). This deficient practice was identified for one (1) of two (2) residents reviewed, (Resident #67) for respiratory care and was evidenced by the following: On 6/06/22 at 11:16 AM, the surveyor observed Resident #67 in their room watching the news on his/her iPad. The resident was observed wearing O2 at four and a half (4.5) Liters Per Minute (LPM) via nasal cannula. The surveyor asked the resident how much O2 he/she needed to use to help him/her not feel short of breath and the resident stated, whatever they put it on. On 6/08/22 at 11:20 AM, the surveyor observed the resident in his/her room conversing with his/her roommate and another resident. The resident was not observed wearing O2 at the time of the surveyor's observation. On 6/09/22 at 10:37 AM, the surveyor observed the resident seated in his/her room seated on a wheelchair not wearing the O2 via nasal cannula. The resident stated that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-14 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 6/6/22 and 6/7/22, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 33 opportunities, and four (4) errors were observed which calculated to a medication administration error rate of 12.12 %. This deficient practice was identified for two (2) of four (4) residents, (Residents #47 and #57), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced as follows: 1. On 6/7/22 at 8:30 AM, the surveyor observed a Certified Nursing Assistant (CNA) carrying food trays to a food cart. The CNA stated that he was returning the empty breakfast trays to the food cart and that Breakfast was pretty much over. On 6/7/22 at 8:32 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she was preparing to administer medications and that the residents were done…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to COMPLETE CARE — 85 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.1-1.1 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 4 of 52.3+1.7 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 84 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Complete Care At Chestnut Hill LLCPassaic, NJ 1 of 5Complete Care At HagerstownHagerstown, MD 1 of 5Complete Care At Harston Hall LLCFlourtown, PA 1 of 5Complete Care At Kimberly Hall NorthWindsor, CT 1 of 5Complete Care At Laplata LLCLaplata, MD 1 of 5Complete Care At Milford Manor LLCWest Milford, NJ 1 of 5Complete Care At Wayne Hills Rehab & Resp CenterWayne, NJ 1 of 5Complete Care at Care AgeBrookfield, WI 1 of 5Complete Care at KensingtonWaukesha, WI 1 of 5Complete Care at Maple Grove LLCMadison, WI 1 of 5Complete Care at Margate ParkChicago, IL 1 of 5Complete Care at the BoulevardChicago, IL 2 of 5Complete Care At Brakeley ParkPhillipsburg, NJ 2 of 5Complete Care At Fox HillVernon, CT 2 of 5Complete Care At Harborage LLCNorth Bergen, NJ 2 of 5Complete Care At Harrington CourtColchester, CT 2 of 5Complete Care At HyattsvilleHyattsville, MD 2 of 5Complete Care At Inglemoor, LLCEnglewood, NJ 2 of 5Complete Care At Monmouth, LLCLong Branch, NJ 2 of 5Complete Care At Ocean Grove LLCOcean Grove, NJ 2 of 5Complete Care At Prospect Heights LLCHackensack, NJ 2 of 5Complete Care at Christian Home LLCWaupun, WI 2 of 5Complete Care at Grande PrairiePleasant Prairie, WI 2 of 5Complete Care at Heritage LLCDundalk, MD 2 of 5Complete Care at Linwood, LLCLinwood, NJ 2 of 5Complete Care at Nazareth LLCStoughton, WI 2 of 5Complete Care at Voorhees, LLCVoorhees, NJ 2 of 5Complete Care at Wall LLCWall, NJ 3 of 5Complete Care At Fair Lawn EdgePaterson, NJ 3 of 5Complete Care At Holiday CityToms River, NJ 3 of 5Complete Care At Lehigh LLCMacungie, PA 3 of 5Complete Care At Oak Ridge LLCCharleston, WV 3 of 5Complete Care At Orange ParkEast Orange, NJ 3 of 5Complete Care At Phillipsburg, LLCPhillipsburg, NJ 3 of 5Complete Care At Severna Park LLCSeverna Park, MD 3 of 5Complete Care At Shrewsbury LLCShrewsbury, NJ 3 of 5Complete Care At Silver Lake LLCDover, DE 3 of 5Complete Care At SpringbrookSilver Spring, MD 3 of 5Complete Care at Brick LLCBrick, NJ 3 of 5Complete Care at Corsica Hills LLCCentreville, MD

Showing 40 of 84; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
PC HMH OPCO HOLDNGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/16/2023
PC HMH HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 03/16/2023
SMS 2021 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 03/16/2023
STEIN, SHALOMIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNFsince 03/16/2023
ELSEBAI, KARINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/16/2023
GOTTESMAN, MOSHEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2023
KARIM, KARIMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2023
ZACKAI, RAANANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
EEF CAPITAL LLCOrganizationADP OF THE SNFsince 03/16/2023
PC HMH PROPCO INTERMEDIATE 9 LLCOrganizationADP OF THE SNFsince 03/16/2023
PC HMH TOPCO PROPCO HOLDINGS LLCOrganizationADP OF THE SNFsince 03/16/2023
PEACE CAPITAL HOLDINGS LLCOrganizationADP OF THE SNFsince 03/16/2023
REGENT PROPCO HOLDCO LLCOrganizationADP OF THE SNFsince 03/16/2023
REGENT PROPCO LLCOrganizationADP OF THE SNFsince 03/16/2023
SCHLAFF, BENNYIndividualADP OF THE SNFsince 03/16/2023
SCHLAFF, NACHUMIndividualADP OF THE SNFsince 03/16/2023
SIRINGAN, NILOIndividualADP OF THE SNFsince 11/13/2023

CMS files one row per role, so the 26 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$12.7M
Net patient revenuemost recent cost report
-38.4%
Operating marginrevenue minus expenses
$3.0M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 7%Other / private 25%

This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$416per resident / day
operating cost
$12,635per month
≈ monthly operating cost
$300per day
avg. revenue, all payers

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

What families pay in NJ

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315295. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-03, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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