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Avalon Rehabilitation And Healthcare Center

1059 Edinburg Road, Hamilton, NJ 08690 · For profit - Limited Liability company · 180 certified beds · (609) 588-0091 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Jun 20241 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$83,672 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (37) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $83,672 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 (1/5)
  • its payroll-based staffing rating is low (2/5)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3525 Quakerbridge Rd · (609) 570-2071 · Call to confirm hours
Pharmacy
3500 Quakerbridge Rd · (800) 575-2667 · Call to confirm hours
Grocery
79 Cooney Ave · (609) 890-6219 · Call to confirm hours
Park
Unnamed Road · (609) 448-1947 · Typically dawn to dusk
Place of worship

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 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 increased3.6%8.7%15.4%better
Long-stay residents who lose too much weight9.6%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection1.2%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms9.5%12.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%2.3%3.3%better
Long-stay residents whose ability to walk worsened3.2%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.3%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine96.5%97.2%95.3%typical
Long-stay residents with pressure ulcers3.4%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control11.0%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.3%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine38.1%80.1%79.4%worse
Short-stay residents rehospitalized after admission28.5%24.9%22.6%worse
Short-stay residents with an outpatient ER visit8.3%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.452.071.67worse
Long-stay outpatient ER visits per 1,000 resident days0.941.111.80better

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.

48.7% 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 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.7%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
85.0%U.S. median 56.6%
Met the expected recovery
0.07U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 85.0% 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 100 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 0.07 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% 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 SNF48.7%CMS range 39.5–56.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 7.5–15.810.7%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 discharge85.0%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 discharge63.0%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 discharge75.0%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 discharge96.9%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 stay2.4%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 worsened4.3%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 4.6–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 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

0.43
RN hours/ resident / day
0.91
LPN hours/ resident / day
1.75
Aide hours/ resident / day
3.08
Total nurse hours/ resident / day
0.29
RN hoursweekends
31.6%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 155.8 residents a day — about 87% occupied, or roughly 24 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 3.08 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.88 hrs/resident/day on weekends vs 3.16 on weekdays — 9% thinner on weekends. RN hours go from 0.48 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2025-12-02)
11
at the previous standard inspection (2024-06-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

37 citations, most serious first. The 15 most serious are shown; the remaining 22 are one tap away and print in full.

  • Immediate jeopardy · J2024-06-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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, record review, and review of facility policy, the facility failed to ensure residents were free from abuse for one (1) of five (5) residents (Resident #13) reviewed for abuse. In addition, this failure has the potential to affect 143 other residents residing in the facility who were not protected from the alleged perpetrator. The facility's failure to ensure all residents were free from abuse, by not investigating an allegation of abuse reported by Resident #13 posed a likelihood of serious harm to Resident #13 and all residents. This resulted in an Immediate Jeopardy (IJ) situation. On 06/11/24 at 9:50 PM, the Administrator and Director of Nursing (DON) were notified that the failure to identify and protect one resident from alleged abuse which constituted an Immediate Jeopardy to the health and safety of all residents in the facility at F 600: Free from Abuse and Neglect. The Immediate Jeopardy began on 01/05/24, when Resident #13 reported that Certified Nursing Assistant (CNA #1) pushed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2024-06-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that two (2) of two (2) residents (Resident #13 and Resident #40) reviewed for accident hazards were given adequate supervision while transporting hot liquids. This failure caused Resident #13 to have a first degree burn on the pelvic area on 01/05/24 and a first degree burn to the abdomen with second degree burns on the left thigh and penis on 05/10/24. Both burns resulted from Resident #13 heating up coffee in the unit microwave which was located in the unlocked nutritional room on the unit. On 11/01/23, Resident #40 suffered a second degree burn to the right hip from self-transferring coffee from the dining room. On 06/10/24, a Past-Non-Compliance (PNC) Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were safe from accident hazards. The IJ was determined to exist on 05/10/24, when a second-degree burn occurred to Resident #13. The IJ was…

    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 · Past Non-Compliance
  • Actual harm · G2025-10-24 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a significant medication error did not occur by failing to administer 14 doses of a physician ordered antihypertensive (medicine used to control high blood pressure) medication to a resident who was subsequently transferred to the hospital for uncontrolled hypertension on 8/12/25 and was diagnosed with a Hypertensive Emergency. This deficient practice was identified for 1 of 2 residents reviewed for change in condition (Resident #3) and was evidenced by the following: On 10/24/25 at 10:00 AM, the surveyor reviewed the electronic medical record for Resident #3 which revealed the following: An Emergency Department hospital record with a Physician (MD) History and Physical dated 8/12/2025 at 21:09 (9:09 PM) revealed: Chief Complaint: Patient presents via emergency medical service from [facility name redacted] for uncontrolled HTN (hypertension), blood pressure at facility was 200 [mmHg] (millimeters of mercury)/96 (normal range 120/80), Patient unsure if…

    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
  • Actual harm · Gcited before2025-08-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents on 8/7/25, it was determined that the facility failed to follow a resident's care plan interventions to provide safe transfer of a resident utilizing a mechanical lift. Resident #2 was assessed by the facility to weight bear as tolerated and required the use of a mechanical lift for transfers. On 3/11/2025, Resident #2 requested staff transfer the resident from a chair to their bed. The resident became anxious and did not want to wait for the mechanical lift to be transferred. Resident #2 began to slide themself forward from the chair. Two staff members transferred the resident to bed without the use of the mechanical lift. After this transfer occurred, the resident began to complain of pain and a diagnosis of fracture of right distal tibia/fibula was made. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #2). The deficient practice was evidenced by the following:According to an admission Record, Resident #2 was admitted to the facility with diagnoses that included…

    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
  • Actual harm · Gcited before2025-03-11 · 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 NJ00181366, NJ00175401. Based on observation, record review of the medical records, and other pertinent facility documents on 3/11/25 and 3/12/25, it was determined that the facility failed to ensure that a resident received care in accordance with professional standards of practice, 1.) failing to follow Physician's order; 2.) failing to monitor a resident that required continuous oxygen; and 3.) failing to ensure that a resident's oxygen concentrator was on . This deficient practice was identified for 1 of 6 residents, (Resident #1), reviewed for oxygen usages and was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but not limited to: Acute and Chronic Respiratory Failure with Hypercapnia (the body can't adequately remove carbon dioxide, leading to a buildup in the blood), Pneumonia (lung infection) and Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause progressive airflow obstruction and breathing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-12-02 · 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 facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.On 11/20/25 at 9:15 AM, the surveyor in the presence of the Food Service Director (FSD#1) observed the following during the kitchen tour:1. In preparation area #1, the surveyor observed a can opener with a reddish caked-on debris on the handle and can opener blade. Also observed on the spice rack; 16-ounce (oz) garlic powder, 16oz taco seasoning, 16oz poultry seasoning, 16oz old bay seasoning, 16oz plastic bottle with a yellowish oil-like substance, and 26oz container of salt all opened and without a use by or discard labels. Under the preparation table the surveyor observed a 1-gallon container of distilled vinegar opened without a use by or discard label, per Dietary Aide #1 (DA#1) the can opner should be cleaned after each use and everything should be labeled with open/use by dates. 2. In the cooking area, the surveyor observed on the top of the standing dish warmer a dust-like…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-02 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to 756Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that a physician's order for an as needed (PRN) anti-anxiety medication was limited to 14 days for 1 of 6 residents (Resident #89) and b.) follow up on a physicians recommendation for a gradual dose reduction (GDR) of an antipsychotic medication for 1 of 6 residents (Resident #27) reviewed for unnecessary medications.This deficient practice was evidenced by the following:1. On 11/20/2025 at 11:45 AM, the surveyor observed Resident #89 sitting in front of the nurse's station. The surveyor reviewed the electronic medical record (EMR) for Resident #89.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; anxiety disorder, unspecified (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-02 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, interviews and review of pertinent facility documents, it was determined that the facility failed to ensure that blood and urine lab testing ordered by the physician was completed to monitor and potentially identify changes in a resident's health. This deficient practice was identified for one (1) of one (1) resident, Resident #4, reviewed for completion of ordered lab tests. The deficient practice was evidenced by the following: On 11/20/25 at 12:31 PM, during the initial tour, the surveyor observed Resident #4 lying in bed with their eyes closed and a sheet pulled up to their chest. The surveyor reviewed the electronic medical records (EMR) for Resident #4. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; muscle wasting and atrophy (the wasting or thinning of muscle mass), adult failure to thrive (a state of progressive decline), moderate protein-calorie malnutrition, and type 2 diabetes mellitus with unspecified complications. A review of the Quarterly…

    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 before2025-12-02 · tag F0712 — pattern
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 # NJ2666691 Based on observations, interviews, record review, and pertinent facility documents it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission and b.) were seen by the attending physician or Nurse Practitioner (NP) every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 4 of 4 residents (Resident #2, #6, #10, and #125) reviewed for physician visits.This deficient practice was evidenced by the following:1.On 11/20/25 at 10:57 AM, the surveyor observed Resident #10 sitting in their chair with their eyes closed. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #10.A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but not limited to: Type 2 Diabetes Mellitus (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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-02 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to F 605Based on observations, interviews, review of the medical record, and review of other facility documentation, it was determined that the facility failed to respond to the monthly Consultant Pharmacist (CP) recommendations. This deficient practice was identified for 2 of 6 residents reviewed for unnecessary medications (Resident #89 and #27).The deficient practice was evidenced by the following: 1. On 11/20/2025 at 11:45 AM, the surveyor observed Resident #89 sitting in front of the nurse's station. The surveyor reviewed the electronic medical record (EMR) for Resident #89.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; anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and Alzheimer's Disease, unspecified (a brain disorder that slowly destroys memory and thinking skills). A review of the Minimum…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to follow fall prevention interventions as written on the resident's plan of care. This deficient practice was identified for 1 of 4 residents (Resident #120) reviewed for accidents. This deficient practice was evidenced by the following: On 11/20/2025 at11:50 AM, the surveyor observed Resident #120 in bed. There was a fall mat on the floor to the right side of the bed. The surveyor reviewed the electronic medical record (EMR) for Resident #120.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; unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions) and Type 2 Diabetes Mellitus with Diabetic Chronic kidney disease (a condition in which the body has…

    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 · D2025-12-02 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint # NJ 2601539 Based on observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication, nourishment supplementation and monitoring administration times 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 and was not administered on nine (9) dialysis days from an admission in August 2025 until discharged in September 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…

    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 · D2025-12-02 · 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 documents, it was determined that the facility failed to have a process in place to post the daily per shift nurse staffing report. This deficient practice was identified on 11/24/2025. This deficient practice was evidenced by the following: On 11/24/2025 at 8:30 AM, the surveyor observed nurse staffing posted at the front receptionist desk for Friday 11/21/25, day shift. On 11/25/2025 at 9:50 AM, the surveyor interviewed the Staffing/Human Resource (SHR) staff member, who stated she posted the staffing at the desk for day and evening shifts and the night supervisor posted the night shifts. The surveyor asked who posted the staffing on the weekend, the SHR stated I do when I come in on Monday. She added the weekend supervisors do not have access to the reports so she did it on Monday, so it was the real count. On 11/25/2025 at 10:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated the nurse staffing was posted at the receptionist desk every day, every shift. She stated 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-02 · 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

    Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) insulin pen devices were dated when opened and had expiration dating on the label in two (2) of four (4) medication carts inspected, b.) a medication for inhalation (Budesonide) was labeled when opened and had expiration dating in one (1) of four (4) medication carts inspected, and c.) an insulin pen device was labeled appropriately with a resident's name (Resident #178) in one (1) of four (4) medication carts inspected. The deficient practices were evidenced by the following: On 11/25/25 at 10:32 AM, the surveyor, in the presence of another surveyor, inspected the 200 Hall medication cart in the presence of the Registered Nurse (RN #1). The surveyor observed an insulin pen device for Lispro (a fast-acting insulin) labelled for Resident #179 that had no date when the insulin pen device was removed from the refrigerator. RN #1 stated she was on that cart for the day and had not administered the resident any insulin. RN #1 acknowledged there should be a date when opened and 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-29 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint: NJ176793 Based on interviews, medical record review, and review of pertinent facility documentation on 5/27/25 and 5/29/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit with in the initial 30 day time period. The facility also failed to follow its policy titled, Physician Visits. This deficient practice was identified for 1 of 9 residents (Resident #2). This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) on 5/27/25 and 5/29/25 was as follows: According to Resident #2's admission Record (AR), the resident was admitted to the facility in October 23, 2023, with diagnoses that included but were not limited to: Schizophrenia, Asthma, and Diabetes. According to the Minimum Data Set (MDS), an assessment tool dated 05/02/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of Residents #2's Progress Notes (PNs) from…

    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
Show the remaining 22 citations
  • Potential for harm · D2025-05-29 · 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

    Complaint: NJ176793 Based on interviews, record review, and review of other pertinent facility documentation on 05/29/2025, it was determined that the facility staff failed to a.) consistently document the care provided in the Documentation Survey Report v2 (DSR) b.) follow the facility's policy titled, Point of Care (POC) Documentation. for a resident (Resident #2). This deficient practice was identified for 1 of 9 residents (Resident #2) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to Resident #2's admission Record (AR), the resident was admitted to the facility with diagnoses that included but were not limited to: Schizophrenia, Asthma, and Diabetes. According to the Minimum Data Set (MDS), an assessment tool dated 05/02/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of the facility's DSR commonly called the POC, for August and September 2024, revealed no documentation indicating that…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-11 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C#: NJ 00181366, NJ00175401 Based on interviews, record review, and review of other pertinent facility documents on 03/11/2025, 03/12/2025, it was determined that the facility failed to address a family concern of resident #4 with bathing and changing of clothes. This deficient practice was identified for 1 of 6 residents, Resident #4, and was evidenced by the following: According to the admission Record (AR), Resident #4 was admitted on [DATE] with diagnoses that included but were not limited to Psychoactive Substance Dependence with Psychoactive Substance-Induce Mood Disorder, (depressive, anxiety, psychotic, or manic symptoms that occur as a physiological consequence of the use of substances of abuse or medications), Muscle Wasting and Atrophy (is a loss of muscle and strength). According to the Minimum Data Set (MDS), an assessment tool, dated 12/16/2024, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 1/15, which indicated that the resident's cognition was severely impaired. The MDS also…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ00181366, NJ00175401. Based on observation, record review of the medical records, and other pertinent facility documents on 3/11/25 and 3/12/25, it was determined that the facility failed to update and revised a resident's Comprehensive Care Plan for 1 of 6 residents (Resident #1), reviewed for oxygen. The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered. According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but not limited to: Acute and Chronic Respiratory Failure with Hypercapnia (the body can't adequately remove carbon dioxide, leading to a buildup in the blood), Pneumonia (lung infection) and Chronic Obstructive Pulmonary Disease The Minimum Data Set (MDS), an assessment on, 01/04/2024 re-admitted to facility on 2/05/2024 and was discharged . Resident #1 returned to the facility on 2/16/2024 and was discharged on 2/26/2024. The MDS dated [DATE], indicated that Resident #1 had a 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-11 · 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

    NJ00181366, NJ00175401. Based on observation, interview, and record review it was determined that the facility failed to administer the correct oxygen dose as order according to the Physician's order for 1( Resident#2) of 6 resident reviewed for respiratory care and services. The deficient practice was evidenced by the following information: On 3/11/2025 at 10:10 a.m.,the Surveyor and Unit Manager (UM) entered Resident #2 room and observed resident in bed with nasal cannula out of both nostrils and concentrator towards the wall in resident room. According to the gauge on the concentrator (indicate how much oxygen was being delivered to the resident). The Surveyor observed the gauge at 3 liters of oxygen per minute. The Surveyor interviewed UM at this time, she confirmed the oxygen rate was set at 3 liter per minute. The UM left the room to check physician order, return with a new nasal cannula and placed it in resident's nostril's and connect it to the concentrator and confirmed Resident #2 physician ordered stated Oxygen at 2 Liter/Minute via Nasal Cannula every shift . The UM…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-13 · tag F0761 — failed to label and store drugs safely — pattern
    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 facility policy review, the facility failed to ensure one of seven medication carts was secured and failed to remove expired supplements and blood equipment from one of two medication storage rooms. This failure has the potential to expose residents to hazards of unsecure medications and expired equipment. Findings include: 1. One of three medication carts located at the nurses' station between 800 hall and 700 hall was observed to be unlocked on 06/12/24 at 11:33 AM. Two staff members were in the office at the nurse station with their backs to the window and the unlocked medication was not in their line of sight. Registered Nurse (RN) 4 was engaged in conversation with another staff member. During this time, several staff members passed by the unlocked cart. One Certified Nursing Assistant (CNA) went to the cart for a straw and left. Two unidentified residents were observed walking by the cart. At 11:59 AM, RN4 returned to the unlocked cart. During an interview on 06/12/24…

    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 · D2024-06-13 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to accurately complete Medicare Part A form Centers for Medicaid and Medicare Services (CMS)-10123 Notice of Medicare Non-Coverage (NOMNC) for one of three residents (Resident (R) 6) and accurately complete CMS Skilled Facility Nursing Advanced Beneficiary (SNFABN) CMS-10055 form for two of three residents (R6 and R79) reviewed for beneficiary notices of 29 sample residents. The forms were used to notify Medicare Part A beneficiaries when their skilled therapy or skilled nursing services were ending. Findings include: 1. Review of the admission Record located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE]. Review of the NOMNC provided by the facility and issued to R6 with a last covered day of 03/08/24, revealed it did not contain the TTY (teletypewriter phone number) a service for the hard of hearing or deaf to assist them in filing an appeal. The form was also missing…

    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 · D2024-06-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and policy review, the facility failed to ensure an incident of alleged physical abuse by one of five residents (Resident (R) 13) reviewed for abuse out of 29 sampled residents was reported to the state agency (SA) within two hours of knowledge of the alleged physical abuse. This failure placed R13 at risk for serious injury, serious harm, serious impairment, and/or death. Findings include: Review of R13's undated ''admission Record'' provided by the facility, indicated R13 was re-admitted to the facility on [DATE] with diagnoses of diabetes mellitus, chronic pain syndrome, and personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of R13's quarterly Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 12/04/23, revealed a ''Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. He was able to make himself understood and understand others. Review of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and facility policy review, the facility failed to ensure an incident of alleged physical abuse was thoroughly investigated for one of five residents (Resident (R) 13) reviewed for abuse of 29 sampled residents This failure placed R13 at risk for serious injury, serious harm, serious impairment, and/or death. Findings include: Review of R13's undated ''admission Record'' and provided by the facility, indicated R13 was re-admitted to the facility on [DATE] with diagnoses of diabetes mellitus, chronic pain syndrome, and personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of R13's quarterly Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 12/04/23, revealed a ''Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. He was able to make himself understood and understood others. Review of the '' Full Quality Assurance (QA) Report'' and provided by…

    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 · D2024-06-13 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 record review, interview, and policy review, the facility failed to ensure the Pre-admission Screen and Resident Review (PASARR) level one screen was completed correctly prior to admission for one of one resident (Resident (R) 112) reviewed for PASARR of 29 sampled residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission. Findings include: Review of R112's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder. Review of R112's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/05/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. R112 was admitted from the hospital. Review of the Orders tab of R112's EMR revealed the following…

    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 before2024-06-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure that an activity care plan was developed for one of 29 sampled residents (Resident (R) 49) that included the preference for one-to-one activities. This failure had the potential to cause the resident to experience increased depression. Findings include: Review of R49's admission Record located in the resident's electronic medical records (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included aftercare for hip replacement surgery; hemiplegia, hemiparesis affecting left side; major depressive disorder, seizures, and cerebral infarct. Review of R49's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/13/24 located in the resident's EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The resident was dependent on staff…

    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 before2024-06-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure that the care plan was revised to reflect a sustained coffee burn for one of two residents (Resident (R) 40) reviewed for accident hazards of 29 sample residents. This failure had the potential to affect resident safety resulting in potential reoccurrence of coffee burns. Findings include: Review of R40's admission Record located in the resident electronic medical records (EMR) under the Profile tab, revealed the resident was initially admitted on [DATE] with diagnoses that included diabetes mellitus type II, depression, acute kidney failure, transient ischemic attacks, and cerebral infarct. Review of the facility's accident/incident log for 2023-2024 and provided by the facility, revealed R40 sustained coffee burns while attempting to transport coffee from dining room to his room sustained second degree burn to the right thigh/hip areas. Review of the facility's investigation, dated 11/01/23 and provided 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · 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 Based on record review, interview, and facility policy review, the facility failed to provide quality care in accordance with physician orders for one of one resident (Resident (R) 78) of 29 sample residents. Specifically, the facility failed to weigh R78 as ordered. This placed R78 at risk for an unmonitored weight loss. Findings include: Review of the undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated R78 was admitted to the facility on [DATE] with diagnoses which included anoxic brain injury, muscle wasting, type II diabetes mellitus, dysphasia, and altered mental state. Review of R78's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/07/24 and located in the MDS tab of the EMR, revealed R78 had a feeding tube (TF) which provided 51% or more of daily total calories. R78's weight was documented as 190 pounds (lbs.) upon admission. Review of the care plan located in the EMR under the Care Plan tab, revealed a focus area, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) while providing care for one of five residents (Resident (R) 49) reviewed on Enhanced Barrier Precautions of 29 sample residents. This failure could promote the spread of multi drug resistant organisms throughout the facility. Findings include: Review of R49's admission Record located in the resident's electronic medical records (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnosis that included aftercare for hip replacement surgery, hemiplegia, hemiparesis affecting the left side, diabetes, mellitus, major depressive disorder, seizures, and cerebral infarct. Review of R49's Weekly Wound Progress Notes, dated 06/06/24 and located in the resident's EMR under the Evaluation tab, documented the resident had an open area on the right buttocks. During an observation on 06/13/24 at 10:45 AM, a sign…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to consistently document urinary catheter care according to the physician's orders. This was identified for 1 of 2 residents (Resident #8) reviewed for urinary catheters. This deficient practice was evidenced by the following: The surveyor observed Resident #8 sitting up in bed with a urinary catheter bag and tubing at the side of the bed on the following dates and times: 04/01/22 at 11:53 AM, 04/05/22 at 9:39 AM, 04/06/22 at 9:50 AM, 04/08/22 at 9:45 AM, 04/11/22 at 10:12 AM, and 04/12/22 at 9:35 AM. According to the admission Record, Resident #8 had diagnoses that included, but were not limited to, Chronic Kidney Disease, unspecified (kidney failure). A review of the Physician's Order Sheet for March and April 2022 revealed an order for urinary catheter care: Foley catheter care - Maintain Foley to straight drainage at all times. Observe and record Foley output every shift, dated 03/16/22. A review of the Treatment Administration Record 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-04-13 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to act on or respond to comments made by the Consultant Pharmacist (CP) in a timely manner during the Medication Regimen Review (MRR). This deficient practice was identified for 1 of 6 residents (Resident #42) reviewed for MRR and was evidenced by the following: According to the Resident Profile, Resident #42 had diagnoses that included, but were not limited to, Dementia, Anxiety, and Depressive Disorder. Review of the February 2022 CP report, dated 02/02/22, revealed that the CP reviewed Resident #42's medication management and recommended to Make PRN Ativan order for 14 days & then evaluate continued need. The CP report had a handwritten notation of Hospice med [medication]. Will discuss with hospice nurse. Review of Resident #42's April 2022 Physician Order Sheet revealed a physician order (order) dated 01/27/22 for Ativan (an antianxiety medication) 0.5 milligrams (mg) every four hours as needed (prn) for anxiety. The surveyor observed the order did not contain a duration. Review of the February…

    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 · Ecited before2022-04-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of other facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 04/01/22 at 10:40 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. A food service worker (FSW) was observed prepping food. The FSW had a beard and was not wearing a beard guard. 2. The surveyor requested to be directed to the designated handwashing sink. The surveyor observed there was no plastic bag lining the trash can. When interviewed, the FSD stated there was usually a bag inside of the trash can. 3. In the cook's walk-in refrigerator, an opened and undated 32-ounce carton of liquid whole egg was stored on a multitiered shelf. When interviewed, the FSD stated that the carton should have been labeled when opened and that it should not have been stored in the cook's walk-in refrigerator. 4. In the cook's…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-13 · 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 interview, record review, and review of other facility documents, it was determined that facility staff failed to complete neurological checks for a resident who sustained a fall with head injuries. This deficient practice was identified for 1 of 3 residents (Resident #83) reviewed for incidents and accidents and was evidenced by the following: During the initial tour of the 800 Unit on 04/01/22 at 11:47 AM, the surveyor observed Resident #83 sitting in a wheelchair visiting with a family member. The surveyor observed that Resident #83 had a wound and bruising to his/her forehead. The resident was pleasantly confused and was unable to provide any additional information about his/her injuries. According to the Resident Profile, Resident #83 had diagnoses that included, but were not limited to, Anemia, history of falling and muscle wasting (wasting of muscle tissue). Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/19/22, revealed the resident had a Brief Interview for Mental Status of 05, which indicated…

    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 · D2022-04-13 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer medication in accordance with a physician's order. This deficient practice was identified for 1 of 1 nurse, on 1 of 5 units (300 Unit) observed during the medication pass and was evidenced by the following: 1. The surveyor observed the Licensed Practical Nurse #2 (LPN) administer medication to Resident #66 on 04/04/22 at 8:44 AM. The resident's medications included Naproxen 375 milligrams (mg), a medication used to treat pain. During the medication pass, LPN #2 stated that the Naproxen was not available in the medication supply, and she would need to obtain it from the automated pharmacy dispensing machine, where back-up supplies of medication are stored. LPN #2 administered all other medication to Resident #66 as ordered but did not follow-up to obtain the missing Naproxen medication. During an interview with surveyor, at the conclusion of the medication pass observation, at approximately 9:25 AM, LPN #2 did not address the missing…

    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 · D2022-04-13 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure that resident dietary preferences were accurately identified and implemented for 1 of 5 residents (Resident #84) reviewed for dining. This deficient practice was evidenced by the following: On 04/01/22 at 12:22 PM, during the initial tour of the facility, the surveyor observed Resident #84 seated in a wheelchair at the bedside. The surveyor noted that the resident's meal tray was on an overbed table outside of the room in the hallway and appeared to have been untouched. When interviewed, the resident stated that the chicken was inedible because it was too hard. The resident's Certified Nursing Assistant #1 (CNA) observed that the resident had not eaten and offered an alternative meal selection, but the resident refused. The resident stated the kitchen staff could not cook and indicated that he/she intended to eat egg salad that was stored in the resident's personal refrigerator instead. The resident further stated that he/she was always served…

    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 · D2022-04-13 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and review of other facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to cover the opening of 2 of 3 outside garbage dumpsters. This deficient practice was evidenced by the following: On 04/01/22 at 10:40 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and requested to see the outside garbage receptacle area. The surveyor observed three garbage containers (GC) on a cement slab. The surveyor observed that one of the three GC was uncovered and exposed to the elements. The GC had a closed lid on the right-side, but the left-side lid was open exposing multiple trash bags inside. When interviewed at that time, the FSD stated the GC lids should be closed when not in use. A review of the facility's Dispose of Garbage and Refuse policy, dated 08/2017, indicated all garbage and refuse would be collected and disposed of in a safe and efficient manner. NJAC 8:39-19.7

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to a.) ensure that staff wore the appropriate Personal Protective Equipment (PPE) and performed proper hand hygiene for a resident on Transmission Based Precautions (TBP) and b.) follow appropriate infection control procedures related to hand hygiene during the medication pass. This deficient practice was identified for 1 of 1 residents (Resident # 420) reviewed for TBP and 1 of 1 nurse, on 1 of 5 units (300 Unit) observed during the medication pass and was evidenced by the following: 1. During entrance conference with the Team Coordinator (TC) on 04/01/22 at 9:15 AM, the Director of Nursing (DON) stated that the facility had one new admission on the 700 Unit who was unvaccinated for COVID-19 and was on TBP (isolation). The DON further stated that the PPE required for the resident on TBP was a gown, gloves, N-95 mask, and goggles or a face shield. During the initial tour of the 700 Unit on 04/01/22 at 11:14 AM, the surveyor observed Resident #420 lying…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-04-13 · 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 interview and record review, it was determined that the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 2 residents (Resident #32) reviewed for accidents. This deficient practice was evidenced by the following: According to the admission Record, Resident #32 was admitted with diagnoses that included, but were not limited to, Alzheimer's disease, Dementia, muscle wasting and atrophy, and difficulty in walking. Review of the resident's Quarterly MDS, an assessment tool used to facilitate the management of care, dated 01/28/22, revealed in Section J, Health Conditions, that the resident had no falls since admission/entry or reentry or the prior assessment, whichever was more recent. Review of the resident's MDS list included that the last MDS assessment prior to the 01/28/22 Quarterly MDS was dated 10/31/21. Review of the resident's Care Plan (CP), revised 12/28/21, included that the resident was a risk for falls related to decreased mobility, incontinence, Dementia, and…

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

    Resident Assessment and Care Planning 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

$83,672 in federal fines across 5 penalties.

  • $7,590 — penalty dated 2025-10-24
  • $13,983 — penalty dated 2025-08-07
  • $31,096 — penalty dated 2025-03-11
  • $13,885 — penalty dated 2024-06-13
  • $17,118 — penalty dated 2024-06-13

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to MARQUIS HEALTH SERVICES — 87 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 1 of 53.0-2.0 vs chain
Health inspection 1 of 52.6-1.6 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 86 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Bay Harbor Post Acute Healthcare CenterSalisbury, MD 1 of 5Blueberry Hill Rehabilitation And Healthcare CtrBeverly, MA 1 of 5Canterbury Rehabilitation And Healthcare CenterRichmond, VA 1 of 5Cape Cod Post Acute CareBrewster, MA 1 of 5Crest Pointe Rehabilitation And Healthcare CenterPt Pleasant, NJ 1 of 5Highland Park Rehabilitation And Healthcare CenterChelsea, MA 1 of 5Mount Holly Rehabilitation & Healthcare CenterLumberton, NJ 1 of 5Nashua Post Acute CareNashua, NH 2 of 5Arbor Ridge Rehabilitation And Healthcare CenterWayne, NJ 2 of 5Atlantic View Post AcuteNewport News, VA 2 of 5Bayview Rehabilitation and Healthcare CenterNorth Kingstown, RI 2 of 5Collingswood Rehabilitation And Healthcare CenterRockville, MD 2 of 5Elmhurst Rehabilitation and Healthcare CenterProvidence, RI 2 of 5Graduate Post AcutePhiladelphia, PA 2 of 5Heritage Hills Nursing & Rehabilitation CenterSmithfield, RI 2 of 5Laurel Brook Rehabilitation And Healthcare CenterMount Laurel, NJ 2 of 5Lawrence Rehab & Hcc/The Meadows At LawrenceLawrenceville, NJ 2 of 5Lawrence Rehabilitation HospitalLawrenceville, NJ 2 of 5Lighthouse Rehabilitation And Healthcare CenterRevere, MA 2 of 5Lincolnwood Rehabilitation and Healthcare CenterNorth Providence, RI 2 of 5North End Rehabilitation And Healthcare CenterBoston, MA 2 of 5Orchard Hill Rehabilitation And Healthcare CenterTowson, MD 2 of 5Palm Springs Post AcuteChelmsford, MA 2 of 5Riverview Healthcare CommunityCoventry, RI 2 of 5Roosevelt Rehabilitation And Healthcare CenterPhiladelphia, PA 2 of 5Southampton Rehabilitation And Healthcare CenterRichmond, VA 2 of 5Springfield Rehabilitation And Healthcare CenterSpringfield, PA 2 of 5West Chester Rehabilitation And Healthcare CenterWest Chester, PA 2 of 5Westgate Hills Rehab & Healthcare CtrBaltimore, MD 2 of 5Willow Brook Rehabilitation And Healthcare CenterWilmington, MA 2 of 5YORK Post AcuteYorktown, VA 3 of 5Alexandria Rehabilitation And Healthcare CenterAlexandria, VA 3 of 5Aspen Hill Rehabiliation & Healthcare CenterHaverhill, MA 3 of 5Belmont Bay Rehabilitation And Healthcare CenterWoodbridge, VA 3 of 5Brighton Post Acute CareBrighton, MA 3 of 5Cambridge Rehabilitation And Healthcare CenterMoorestown, NJ 3 of 5Capitol Rehabilitation And Healthcare CenterHarrisburg, PA 3 of 5Chelsea Rehabilitation And Healthcare CenterGoochland, VA 3 of 5Exton Post AcuteExton, PA 3 of 5Hampden Post AcuteWilbraham, MA

Showing 40 of 86; 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
SK NEXGEN TROrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF14%since 08/01/2023
POPULAR BANKOrganization5% OR GREATER SECURITY INTERESTsince 08/01/2023
BOGDAN, JOSEFIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2023
HARMAN, DINAIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 08/01/2023
ROSENBLUM, ELIYAHUIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 08/01/2023
VIROJA, YOGESHIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 08/01/2023
POSEN, MINDEEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 08/01/2023
MARQUIS LIMITED LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/17/2025
RELIANT PRO REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/17/2025
LAURENTE, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2023
FLAGLER, OSHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/19/2025
KAHANOW, AVIVAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/17/2025
LEVOVITZ, TZVIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/17/2025
ROKEACH, FRAIDEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/17/2025
ROKOWSKY, YITZCHOKIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/19/2025
AVALON REAL PROPERTY LLCOrganizationADP OF THE SNFsince 08/01/2023
NFR 2020 IRRV TROrganizationADP OF THE SNFsince 08/01/2023
QUINTO NEXGEN LLCOrganizationADP OF THE SNFsince 08/01/2023
RSBRMK HOLDINGS LLCOrganizationADP OF THE SNFsince 08/01/2023
TRYKO NEXGEN HOLDINGS LLCOrganizationADP OF THE SNFsince 08/01/2023
UAK 2020 IRRV TROrganizationADP OF THE SNFsince 08/01/2023
UKR NEXGEN LLCOrganizationADP OF THE SNFsince 08/01/2023
YK NEXGEN TROrganizationADP OF THE SNFsince 08/01/2023
YR NEXGEN TROrganizationADP OF THE SNFsince 08/01/2023

CMS files one row per role, so the 35 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

13 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.

$8.1M
Net patient revenuemost recent cost report
-26.2%
Operating marginrevenue minus expenses
$868K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 5%Other / private 26%

This home reported $868K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$387per resident / day
operating cost
$11,772per month
≈ monthly operating cost
$307per 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 315223. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-02, 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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