Accela Post Acute Care At Hamilton
3 Hamilton Health Place, Hamilton, NJ 08690 · For profit - Corporation · 55 certified beds · (609) 631-2555 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $11,175 in federal fines (most recent 2025-10-24)
- 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 (1/5)
- nursing-staff turnover (62%) runs well above the national median (45%)
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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 28.6% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 32.6% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.1% | 8.1% | 12.0% | better |
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.
64.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 395 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.4% 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 122 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 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | 64.2%CMS range 59.1–68.8 | 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 | 11.3%CMS range 8.9–13.7 | 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 | 66.4% | 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 | 65.6% | 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 | 61.5% | 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 | 95.7% | 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 | 1.4% | 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 | 9.0%CMS range 6.2–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 55 beds and averages 50.1 residents a day — about 91% occupied, or roughly 5 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 4.48 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 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 3.93 hrs/resident/day on weekends vs 4.70 on weekdays — 17% thinner on weekends. RN hours go from 0.71 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above 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.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2025-10-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, medical record review and review of pertinent facility documents on 10/20/2025 and 10/24/2025, it was determined that the facility failed to: a.) ensure that pressure ulcers were initially documented, assessed, and measured weekly as required by professional standards of practice; b.) implement and update care plans (CP) after a change in condition; c.) provide treatment and services to prevent two facility acquired pressure ulcers; one stage 3 and one stage 4.A review of Resident #3's Electronic Medical Record (EMR) revealed the resident arrived to the facility with no evidence of a pressure ulcer. Additional review of the EMR revealed a lack of adherence to physician orders, lack of monitoring, a failure to implement CP, and a lack of assessments resulting in Resident #3 developing a stage 3 and a stage 4 pressure ulcer within 9 days of admission.This deficient practice occurred for 1 of 3 residents reviewed for pressure ulcers (Resident #3). This deficient practice was evidenced by 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 · D2025-10-24 · tag F0727 — failed to provide required RN coverage — isolatedHave 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
Complaint #: 2638834Based on interview and review of facility documents on 10/20/25, it was determined that the facility failed to ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day for 2 of 14 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Reports completed by the facility for the weeks of 09/28/25 through 10/11/2025, revealed that the facility failed to provide RN coverage for all shifts on 09/28/25 and 10/06/2025.The surveyor reviewed the facility's policy titled Staffing updated October 2017 which indicated under Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment and under Policy Interpretation and Implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.NJAC 8:39-25.2(h)
- Potential for harm · Fcited before2025-02-14 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Repeat Deficiency Based on observations, interviews, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-14 · tag F0622 — patternNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 # NJ 183474 Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to document the circumstance for which randomly selected residents, from the facility provided discharge list from 9/1/24 to 2/14/25, were discharged to another long-term care (LTC) facility, for 7 of 7 residents (Resident #182, #183, #184, #185, #186, # 187, #188) reviewed.This deficient practice was evidenced by the following: 1.The surveyor reviewed the electronic medical record (EMR) for Resident #182. 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; Polyosteoarthritis, unspecified (a condition that involves break down of [NAME] in multiple joints leading to pain, stiffness, and reduced mobility). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 8/24/24, revealed the resident had a Brief Interview for Mental Status (BIMS) 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 · E2025-02-14 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ00183474 Refer to F 622 Based on interviews, record review and review of facility documentation, it was determined that the facility failed to provide written notification of the transfer to the Office of the Long-Term Care (LTC) Ombudsman (LTCO) for 7 of 7 residents (Resident #182, #183, #184, #185, #186, # 187, #188) reviewed for transfer to another LTC facility. This deficient practice was evidenced by the following: 1.The surveyor reviewed the electronic medical record (EMR) for Resident #182. 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; Polyosteoarthritis, unspecified (a condition that involves break down of [NAME] in multiple joints leading to pain, stiffness, and reduced mobility). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 8/24/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-14 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
REFER to F756 Based on observation, interviews and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times from December 2024 until surveyor inquiry February 2025. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-14 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
REFER to F698 Based on observation, interview and record review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from December 2024 until surveyor inquiry for one (1) of six (6) residents, (Resident #21), reviewed for medication management. The deficient practice was evidenced by the following: On 2/4/25 at 10:09 AM, the surveyor interviewed Resident #21, who stated that they had been here (in the facility) since late November but had gone to the hospital for a week in January and returned. The resident also stated that they (the nurses) frequently run out of their medications. The resident added specifically I don't get my Renvela (Sevelamer) (a medication used to lower the amount of phosphorous in the blood when receiving dialysis). The resident also stated that they went out of the facility for dialysis on Tuesdays, Thursdays and Saturdays at approximately 10 AM. The resident added they were waiting to be picked up this morning. On 2/5/25 at 8:32 AM, during the morning medication administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-14 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required for 3 of 5 randomly selected CNA (CNA # 3, #4, #5) files reviewed for in-service training. This deficient practice was evidenced by the following: On 2/07/25 at 9:17 AM, the surveyor reviewed in-service education hours for five randomly selected CNA files which were provided by the Director of Nursing (DON). The surveyor reviewed the following for the 2023 to 2024 calendar year, corresponding with the CNA hire dates: CNA #3 was hired on 4/1/22, CNA #4 was hired on 6/15/23, and CNA #5 was hired on 1/19/23. The facility could not provide evidence of in-service education training for the current 12-month period from hire date. On 2/07/25 at 2:01 PM, the Licensed Nursing Home Administrator (LNHA), in presence of survey team, stated that the facility cannot find the education for CNAs # 3,4 and 5. The LNHA stated the responsibility for ensuring the annual education on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-14 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure reference checks were completed for 6 of 10 newly hired employee files reviewed. This deficient practice was evidenced by the following: On 2/7/25, the surveyor reviewed Ten (10) randomly selected new employee files which revealed the following: 1. Licensed Practical Nurse (LPN)/Unit Manager with a Date of Hire (DOH) of 7/22/24, did not have a previous employee reference on file. 2. LPN #2 with a DOH of 7/22/24, did not have a previous employee reference check on file. 3. LPN/Nurse Supervisor with a DOH of 7/22/24, did not have a previous employee reference check on file. 4. Registered Nurse #1 with a DOH 7/30/24, did not have a previous employee reference check on file. 5. Physical Therapist with a DOH 6/19/24, did not have a previous employee reference check on file. 6. Dietary staff with a DOH of 11/1/24, did not have a previous employee reference check on file. On 2/7/25 at 11:04 AM, the surveyor interviewed the Human Resources/Staffing…
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 · D2025-02-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #NJ00176931 Based on interviews, record review and pertinent facility documents, it was determined that the facility failed to investigate an allegation of poor nursing care for 1of 4 residents (Resident #232) reviewed for abuse. This deficient practice was evidenced by the following: A review of the facility provided Reportable Event Record Report dated 319/2024, revealed the facility reported an event alleging that the resident had poor nursing care while at the facility to the New Jersey Department of Health (NJDOH). The surveyor reviewed the electronic medical record (EMR) for Resident #232. 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; Type 2 Diabetes Mellitus with Diabetic Chronic kidney disease (a condition in which the body has trouble controlling blood sugar that can affect the kidneys) and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder that can cause…
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 · D2025-02-14 · 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 observations, interviews, 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 morning medication administration observation on 2/5/25, the surveyor observed three (3) nurses administer medications to five (5) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. The deficient practice was identified for two (2) of five (5) residents, (Resident #21 and #82), that were administered medications by two (2) of three (3) nurses that were observed. The deficient practices were evidenced by the following: 1. On 2/5/25 at 8:36 AM, during the morning medication administration pass, the surveyor observed Licensed Practical Nurse (LPN#1) administering medications to Resident #21. The resident stated that they would like their pain medication and their cough medicine. On 2/5/25 at 8:37 AM, the surveyor observed LPN#1 preparing to administer the resident's pain medication and cough medication. LPN#1…
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 17 citations
- Potential for harm · Dcited before2025-02-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and facility policy review, the facility failed to prevent the potential for cross contamination by placing a resident with open wounds on Enhanced Barrier Precautions (EBP), meaning a gown and gloves be worn when performing high contact care, for one of two residents (Resident #7) with open wounds. The deficient practice was evidenced by the following: On 2/4/25 at 10:21 AM, the surveyor observed Resident #7 self-propelling their wheelchair in the hallway. The resident stated they can wheel the chair but can not stand. The surveyor observed a dressing on the right leg. The surveyor reviewed the electronic medical record (EMR) for Resident #7. A review of the Order Summary Report revealed a physician order (PO) dated 1/24/25 for Collagen-Antimicrobial External Sheet (Collagen-Antimicrobial) to the Right Lateral Ankle topically one time a day. There was also a PO dated 1/10/25 for Weekly Skin Checks every day shift every Friday. A review of the comprehensive admission Minimum Data Set (MDS), (an assessment tool) dated 1/10/25, revealed…
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 before2024-05-14 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complain #: NJ171631 Based on interview and record review on 05/13/2024 and 05/14/2024, it was determined that the facility failed to accurately encode a resident's wound in the Minimum Data Set (MDS) assessment for 1 of 5 residents (Resident #2) reviewed for MDS accuracy. This deficient practice was evidenced by the following: Reference: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023, under Section M: Skin Conditions .M0210 Unhealed Pressure Ulcers/Injuries .Coding Instructions Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days. Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers. Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed 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.
- Potential for harm · Dcited before2024-05-14 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ 171631 Based on interview, medical record review, and review of other pertinent facility documentation on 5/13/2024 and 5/14/2024, it was determined that the facility failed to develop a Baseline Care Plan (BCP) for a newly admitted resident with a Sacral wound. This deficient practice was identified for Resident #2, 1 of 5 residents reviewed for BCP. This deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the admission Record, Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to End Stage Renal Disease (gradual loss of kidney function), Major Depressive Disorder, Difficulty in Walking and Anemia (deficiency of red blood cells in the blood). Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/07/2023 indicated that Resident #2 had a BIMS (brief interview for mental status) score of 13 indicating the resident was cognitively intact. Review of Resident #2's admission Evaluation Assessment…
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 · D2024-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 #: NJ171631 Based on interview, observation, record review, and facility policy reviewed on 5/13/2024 and 5/14/2024, it was determined that the facility failed to provide 1 of 5 residents (Resident #2) reviewed for Activities of Daily Living (ADLs) with showers twice a week as scheduled. The Certified Nursing Aide (CNA) also failed to follow their job description. This deficient practice was identified for Resident #2, and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the admission Record, Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to End Stage Renal Disease (gradual loss of kidney function), Major Depressive Disorder, Difficulty in Walking and Anemia (deficiency of red blood cells in the blood). Review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/07/2023 indicated that Resident #2 had a BIMS (brief interview for mental status)…
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 · D2023-10-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaints: NJ 157428, NJ 160764, NJ 161041, NJ 162453, NJ 167007 Based on observations, interviews, and record review, the facility failed to respond in a timely manner to the resident's requests for assistance for one Resident (R)27 of 27 sample residents. Findings include: Review of R27's admission Record located in the resident's electronic medical records (EMR) section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, urinary tract infection, adjustment disorder, and dysphagia. Review of R27's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/23 revealed the resident Brief Interview for Mental Status Score (BIMS) of 11 out 15 points indicating that she had moderately impaired cognition. The resident was dependent on staff for activities of daily living and toileting. The resident was occasionally incontinent of urine and frequently incontinent bowel. During an interview on 10/16/23 at 11:30 AM R26…
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 · D2023-10-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 #: NJ 151270, NJ 162453 Based on interview, record review and review of facility policy, the facility failed to notify the responsible party/family of one Resident (R)5 of 27 sample residents regarding R5's return to the facility with the x-ray and treatment results after the resident's emergency room visit. Findings include: Review of R5's admission Record located in the resident's electronic medical records (EMR) revealed the resident was admitted to the facility 10/27/21 with diagnoses that included diabetes mellitus type II, malignancy of the prostate, dysphagia, hemiplegia, and fall history. The resident was discharged home on [DATE]. Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/21 located in the resident's EMR section titled MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15 indicating the resident had severely impaired cognition status; the resident was dependent on staff for all activities of daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 166867 Based on interview, record review, and policy review, the facility failed to ensure the resident assessment accurately reflected the resident's skin conditions for one (Resident (R) 9) of 27 sampled residents. This failure could result in the residents' individual needs not being addressed. Findings include: Review of R9's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R9's admission Assessment Form, dated 08/10/23 and located in the resident's EMR under the Assessments tab, revealed R9 was admitted to the facility with intact skin. Review of R9's admission Minimum Data Set (MDS), located in the resident's EMR under the MDS tab and with an Assessment Reference Date (ARD) of 08/12/23, indicated R9 was not at risk for pressure ulcers and did not have any unhealed pressure ulcers. Review of R9's modified admission MDS, located in the resident's EMR under the MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-20 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ 167007 Based on interviews, record review, and review of facility policy, the facility failed to provide a baseline care plan within 48 hours of admission for three residents (Resident (R) 3, R26 and R27) reviewed for base line care plans out of 30 sampled residents. Findings include: 1. Review of R3's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/31/23 and located in the electronic medical record (EMR) section titled MDS, documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident's cognition was intact. It was documented that the resident required limited assistance with one-person physical assistance with all activities of daily living (ADLs), had incontinence of bladder and bowel, had an unsteady balance and gait but was able to stabilize with assistance. It was also documented that the resident required the use of a wheelchair for mobility. Review of R3's Care Plans, located in the resident's EMR section titled Care Plans, failed to reveal a baseline care plan for R3.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ 155628, NJ 158542, NJ167007, NJ 166867 Based on record review, interviews, and facility policy review, the facility failed to ensure wound care treatment was documented as provided according to physician orders for one Resident (R)3 out of 27 sample residents. Findings include: Review of R3 admission Record located in the resident's electronic medical record (EMR) section titled Profile revealed the resident was admitted to the facility 08/25/23 with diagnoses that included malignant neoplasm of the prostate, osteosarcoma status post resection and total humerus resection. Review R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/31/23 located in the EMR section titled MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating the resident's cognition was intact. The resident required limited assistance with one-person physical assistance for all activities of daily living. The resident had incontinence of bladder and bowel. The resident was at risk of skin breakdown. The resident had an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-20 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure 12 hours of required in-service training was provided for one (Certified Nurse Aide (CNA) 4) of five CNAs whose training records were reviewed. Findings include: On 10/19/23 at 11:00 AM, the Assistant Administrator was asked to provide the employee records for five CNAs employed at the facility. Review of the employee records revealed no documentation CNA4 had received 12 hours of in-service education in the past year. On 10/20/23 at 10:30 AM, the Assistant Administrator confirmed CNA4 did not receive the required in-service education. NJAC 8:39-43.17 (b)
- Potential for harm · D2023-10-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 161041 Based on observation and interview, the facility failed to secure resident medications in one of four medication carts and one of one treatment cart to prevent an unauthorized person from accessing the residents' medications. Findings include: 1. Observation of a medication cart in the hallway near resident room [ROOM NUMBER] on 10/17/23 at 8:51 AM with the Assistant Administrator revealed Licensed Practical Nurse (LPN) 10 was in room [ROOM NUMBER] and the medication cart was unlocked. The medication cart was not in the visual path of any staff member, and residents were noted in the hallway. Interview with the Assistant Administrator during the observation confirmed an unauthorized person could access the residents' medications on the cart without staff knowledge. Interview with LPN10 on 10/17/23 at 8:53 AM confirmed the medication cart was not secured and an unauthorized person could have accessed the mediations. 2. Observation on 10/18/23 at 4:35 PM revealed the Director of Nursing (DON)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-20 · 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 #: NJ 167007 Based on observation, interview, and record review, the facility failed disinfect glucometers after use for one (Resident (R) 21) of one resident observed receiving a fingerstick blood sugar check and failed to perform pressure ulcer dressing changes in a manner to prevent cross-contamination for one (R26) of one sampled resident observed during dressing changes. Finding included: 1. Review of R21's electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses that included diabetes. Observation of Licensed Practical Nurse (LPN) 9 on [DATE] at 11:50 AM revealed LPN9 obtained a plastic basket which contained the blood sugar monitor and supplies from the medication cart and carried the basket into R21's room. LPN9 placed the basket on R21's bed. LPN9 removed the blood sugar meter from the basket and placed it on R21's over bed table, next to the resident's personal items without cleaning the table surface. LPN9 obtained R21's blood sugar, disposed 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 · Ecited before2023-01-12 · 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 and review of pertinent facility documents it was determined that the facility failed to a.) ensure the soiled and clean laundry areas were maintained and operated in a sanitary manner to prevent infection control breaches and b.) maintain mop bucket systems in a sanitary manner. This deficient practice was evidenced by the following: On 1/11/23 at 12:10 PM, the surveyor observed the hallway leading to the laundry area as well as both the soiled and clean laundry rooms in the presence of a second surveyor which revealed the following: 1. In the hallway just prior to entering the soiled laundry room, there was a yellow mop bucket that had a shallow amount of dark colored soiled standing water and a soiled mop head. 2. In that same area, there was a black oval mop bucket on a yellow housekeeping cart with a shallow amount of dark colored soiled standing water and a soiled mop head which sat directly in the soiled water. 3. In the soiled laundry room, there were two yellow mop buckets both of which had a shallow amount of dark colored soiled standing…
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 · F2020-10-20 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview on 10/16/2020, in the presence of the facility Maintenance Director and laundry staff member, it was determined that the facility failed to maintain 2 of 2 commercial clothes dryer drums in a safe and effective operating condition. This deficient practice was evidenced by the following: On 10/16/2020 at 11:52 AM, the surveyor observed 2 of 2 commercial clothes dryer drums in the facility laundry room. Both dryer drums contained a heavy coating of an unknown brown plastic-like substance embedded into the rear vents on the interior of the stainless steel rotating drums. The substance covering the vent holes could produce a delay in the heating process and cause an unsafe and ineffective operating condition. At that time, the surveyor interviewed the facility Maintenance Director and laundry staff worker. They both stated that the facility utilized water soluble bags for the laundry and that the water soluble bags may not fully dissolve in water. They further stated that when the clothes were placed into the clothes dryers, the remnants of the bags…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-10-20 · 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 Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that Medical Transport Staff (MTS) implemented the appropriate infection control precautions for donning and doffing Personal Protective Equipment (PPE) prior to entering and upon exiting a resident's room. The resident was on droplet transmission-based precautions for the observation of signs and symptoms of COVID-19. This deficient practice was identified for 2 of 2 MTS observed during the transport of 1 of 1 resident (Resident #6) and was evidenced by the following: On 10/19/20 at 10:19 AM, the surveyor observed a sign posted outside of Resident #6's door that indicated, STOP. Further instructions on the sign indicated that if a person was to enter the resident's room, an isolation gown, eye protection, and a surgical mask over a KN95 mask must be worn. The surveyor observed a plastic bin outside of the resident's room, which was stocked with surgical masks, KN95 masks,…
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.
- No harm found · C2023-01-12 · tag F0732 — widespreadPost 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 documents, it was determined that the facility failed to routinely post the Nursing Home Resident Care Staff Report (NHRCSR) since 12/23/22 (13 days) in a place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 1/5/23 at 9:45 AM, the surveyor observed the NHRCSR dated 12/23/22 for the day, evening, and night shift. Each shift indicated a census of 39. The NHRCSR was observed posted behind the mounted glass wall display case to the left of the receptionist desk in the front lobby. On 1/5/23 at 1:05 PM, the surveyor interviewed the Director of Nursing who stated that a staff person from Medical Records was responsible for posting the daily nursing staffing ratio but that staff member has been out of work for two weeks and the Human Resource/Staffing Coordinator was responsible for posting the daily nursing staffing ratio. On 1/5/23 at 1:30 PM, the surveyor interviewed the Human Resource Coordinator who confirmed she was responsible 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.
- No harm found · Ccited before2023-01-12 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review of pertinent facility documents, it was determined that the facility failed to notify the Centers for Medicare & Medicaid Services (CMS) and apply for a change in ownership and facility name change upon 30 days of their sale in July 2021 in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required,…
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
$11,175 in federal fines across 1 penalty.
- $11,175 — penalty dated 2025-10-24
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SPRING HILLS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2021 |
| OAK SPRING HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| OAK SPRING HOLDINGS NJ INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| MARKOWITS, ALEXANDER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| CZIMENT, RAFAEL | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 07/01/2021 |
| HOOK, GREGORY | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 07/01/2021 |
CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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 $190K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 315519. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-14, 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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