Hamilton Grove Healthcare And Rehabilitation, LLC
2300 Hamilton Ave, Hamilton, NJ 08619 · For profit - Limited Liability company · 218 certified beds · (609) 588-5800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $54,275 in federal fines (most recent 2024-10-28)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- about 37% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.5% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.3% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.7% | 0.8% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 7.0% | 12.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.3% | 2.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 4.4% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.0% | 18.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 96.2% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.9% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.1% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.6% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.8% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.2% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.61 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.44 | 1.11 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.2% 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 201 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 83.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 118 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 0.17 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.2%CMS range 50.5–63.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.5–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 83.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 77.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 84.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.8%CMS range 6.0–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.37 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 218 beds and averages 204.5 residents a day — about 94% occupied, or roughly 14 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 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.95 hrs/resident/day on weekends vs 3.41 on weekdays — 14% thinner on weekends. RN hours go from 0.37 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · J2024-10-28 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 Complaint NJ #:178839 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement an abuse policy that addressed sexual abuse to ensure a resident was protected from staff-to-resident sexual abuse. This deficient practice was identified for one (1) of one (1) residents (Resident #59) reviewed for abuse, and was evidenced by the following: On 10/22/24 at 1:00 PM, two surveyors interviewed the Director of Nursing (DON) who stated that a Certified Nursing Assistant (CNA#1) reported that on 10/15/24, the CNA#1 observed a Licensed Practical Nurse (LPN #1) standing over Resident #59 in a compromising position. A review of the investigation revealed the Social Worker (SW) interviewed Resident#59, who stated, I gave him oral sex. Resident #59 stated that the sexual contact occurred in [Resident #59's] room and that Resident #59 told LPN #1, I'm scared because there are people around, and [LPN #1] shut the door. The resident began…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide preventive care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries and ensure that air mattresses were accurately set according to the resident's weight.This deficient practice was identified for 4 of 4 residents (Residents #6, #7, #106, and #151) reviewed for risk of pressure ulcers and was evidenced by the following:1.On 3/6/26 at 10:50 AM, the surveyor observed Resident #6 in bed with the air mattress setting set to 330 pounds.On 3/10/26 at 11:48 AM, the surveyor observed Resident #6 in bed with the air mattress setting set to 180-230 pounds.A review of the admission Record (AR) (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; hemiplegia (the total or partial paralysis of one entire side of the body) and hemiparesis (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure residents were transported from one area of the unit to another in a dignified manner. This deficient practice was identified for 1 of 1 residents (Resident #45) reviewed for dignity and was evidenced by the following. On 3/10/26 at 11:45 AM, during the initial tour of the [NAME] unit, the surveyor observed the Certified Nursing Assistant (CNA) transport Resident #45 in a recliner chair facing backwards from the hallway near room [ROOM NUMBER] to the lounge area across from the nursing station. The surveyor reviewed the electronic medical record (EMR) for Resident #45. 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; bipolar disorder (a mental health condition that causes extreme mood swings), chronic pain syndrome (pain that lasts over 3 months), localized edema…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-16 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent 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
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow up on a physician's recommendation for a gradual dose reduction (GDR) of an antipsychotic medication for 1 of 5 residents (Resident #5) reviewed for unnecessary medications.This deficient practice was evidenced by the following:On 3/6/2026 at 11:32 AM, the surveyor observed Resident #5 sitting in a reclining area in the hallway near the nursing station. The resident had a splint on their left hand/wrist. The surveyor reviewed the electronic medical record (EMR) for Resident #5.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; major depressive disorder, single episode, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities), Post-Traumatic Stress Disorder (PTSD) (a treatable mental health condition triggered by experiencing or witnessing terrifying,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-16 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete a criminal background check prior to the first day of work for 1 out of 96 employees (Employee #4). This deficient practice was identified for newly hired employee files reviewed since last survey from 10/28/24 and was evidenced as follows:During the facility survey dates of 3/10/26-3/16/26, the survey team reviewed the newly hired employee files since the last survey which revealed the following:For Employee #4, a Certified Nursing Assistant (CNA), with a date of hire (DOH) of 2/28/25 and first day of work as 2/28/25, there was no evidence of a background check prior to the start of employment.On 3/13/26 at 2:02 PM, the survey team presented this finding to the administration team including the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional Nurse Consultant, and the [NAME] President of Clinical Services. The LNHA could not provide any additional information…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-16 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to complete a discharge Minimum Data Set (MDS), an assessment tool, as required for 1 of 1 system selected residents with a MDS record over 114 days reviewed (Resident #208), and was evidenced by the following:On 3/11/26 at 11:16 AM, the surveyor reviewed the system selected MDS record over 114 days which revealed Resident #208 was overdue for a MDS assessment. A review of Resident #208's electronic medical record (eMR) revealed that the resident was discharged from the facility on 11/3/25. A review of the residents' MDS assessments revealed the last MDS completed was a quarterly assessment dated [DATE]. There was no assessment completed for the resident's discharge. On 3/11/26 at 1:00 PM, the surveyor interviewed the MDS Coordinator, who confirmed Resident #208 was discharged from the facility on 11/3/25, and there was no completed MDS assessment for the discharge. The MDS Coordinator further stated that a discharge MDS assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with an order for enteral tube feeding. This deficient practice was identified for 1 of 1 resident reviewed for tube feeding (Resident #1), and was evidenced by the following:On 3/6/26 at 11:26 AM, during the initial tour of the facility, the surveyor observed Resident #1 sleeping in their bed. The surveyor observed the enteral tube feeding running at 70 ml/hr (milliliters per hour). The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dysphagia (difficulty swallowing), gastrostomy (feeding tube inserted directly into the stomach through the abdominal wall to provide nutrition, fluids, and medications), and gastro-esophageal reflux disease without esophagitis (stomach acid flows back up into the esophagus and causes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-16 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure nursing staff appropriately follow a physician orders (PO) and acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes. The deficient practice was identified for 1 of 2 residents (Resident #142) reviewed for smoking. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/06/2026 at 11:32 AM, during the initial tour of the secured Klockner unit, the surveyor observed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that incontinence care was provided to a dependent resident in a timely manner. This deficient practice was identified for 1 of 10 residents (Resident #147) observed during incontinence care rounds and b.) provide a resident with nail care during activities of daily living (ADL) care. This deficient practice was identified for 1 of 7 residents reviewed for ADL care (Resident #195),This deficient practice was evidenced by the following:1. On 3/11/26 at 7:54 AM, during incontinence rounds with Registered Nurse/Unit Manager (RN/UM) #1, the surveyor observed Resident #147's incontinence brief completely saturated with urine, and yellow urine-like stains on multiple areas on the top sheet. At that time, the surveyor asked RN/UM #1, if she had any concern with the observation. She stated that it was a concern because the resident was soaking wet. RN/UM #1 stated that the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and review of facility documents, it was determined that the facility failed to ensure tracheostomy (a surgical opening directly into the trachea (windpipe) used to assist breathing) care was completed using sterile technique per facility policy and clinical guidelines. This deficient practice was identified for 1 of 4 residents (Resident #46) reviewed for respiratory care and was evidenced by the following:On 3/11/26 between 10:20 AM and 10:37 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform tracheostomy care for Resident #46. During that time, the LPN was first observed performing hand hygiene, then placing a nonsterile drape over a bedside table. She was then observed opening and placing a tracheostomy care kit on the drape. She then opened a packet of 4x4 sterile gauze and a disposable inner cannula and placed them onto the drape. The LPN then used two single use sterile saline containers and emptied their contents into the open packet of sterile gauze. The LPN then reached into the packet (with bare hands) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-16 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of Certified Nursing Assistants (CNAs) on an annual basis.This deficient practice was identified for five (5) of five (5) CNAs whose randomly selected employee files were reviewed and was evidenced by the following:On 3/11/26 at 9:34 AM, the surveyor requested the education and performance reviews for five (5) randomly selected CNAs.The surveyor reviewed the education provided by the facility for the five (5) CNAs. No performance evaluations were provided.On 3/11/26 at 11:10 AM, the performance evaluations were requested from the Licensed Nursing Home Administrator (LNHA) who could not provide them.On 3/13/26 at 12:00 PM, the performance evaluations were requested from the Human Resources Director (HRD) who could not provide them.03/13/2026 at 12:16 PM, the HRD stated to the survey team There are no performance evaluations for the last year for CNAs because they are unionized. There are also no facility policies for performance evaluations.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.
Show the remaining 17 citations
- Potential for harm · D2026-03-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure medications were administered to a resident according to standards of practice. This deficient practice was identified for 1 of 36 (Resident #9) residents reviewed and was evidenced by the following:On 3/6/26 at 1:30 PM, the surveyor observed Resident #9 lying in their bed, awake, eating their lunch which was on their overbed table. The surveyor observed a medication cup with two (2) unidentified medication tablets in it, on the overbed table. At that time, the surveyor requested the Licensed Practical Nurse/Unit Manager (LPN/UM) come to the room. The LPN/UM acknowledged that in the medication cup there were two tablets: one pink and one white. At this time, the resident stated that they thought they took all their medications. The LPN/UM stated that the nurse should stay with the resident when administering their medications to ensure that they took all of them. She further stated that the nurses should never leave medications at the resident's bedside.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-16 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a medication error rate below 5%. This deficient practice was identified for 2 of 5 residents (Resident #2 and #197) on 2 of 4 units. The surveyor observed 2 nurses administered 28 doses of medication and there were 2 errors resulting in a medication error rate of 7.14%. The deficient practice was evidenced by the following: 1.On 3/11/26 at 8:55 AM, during the morning medication administration pass, the surveyor observed the Licensed Practical Nurse (LPN #1) on the Klockner Unit, preparing the medications (meds) for Resident #2 using the electronic Medication Administration Record (eMAR) while pulling the medications. The surveyor observed an order for one tab of sennosides-docusate sodium 8.6 -50 mg for constipation. At that time, LPN #1 pulled Geri-Kot (Senokot) 8.6 mg one tab and stated, this is the only one we have at the facility and then administered the medication to Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Complaint #: 2788031Based on interviews, record reviews, and review of other pertinent documentation, it was determined that the facility failed to ensure that a cognitively impaired resident received nectar thick liquids (slightly thicker consistency than water, coats a spoon) as ordered and failed to develop interventions to ensure that the resident did not receive liquids that were inconsistent with their ordered diet. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for diet accuracy and was evidenced by the following:Resident #2 was no longer in the facility; a closed record review was conducted. A review of the admission Record (AR) for Resident #2, revealed that the resident was admitted with diagnoses including but not limited to: metabolic encephalopathy (brain dysfunction caused by non-traumatic issues like organ failure (liver, kidney), chemical imbalances, or toxins); need for assistance with personal care; dysphagia (difficulty swallowing), oral phase; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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, facility document review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 2) sampled for medication errors, was free from significant medication errors of 11 sample residents. Specifically, R2 was administered another resident's medications. This continued practice fails to protect residents from receiving the wrong medications that could result in significant harm.Findings include:Review of the facility's policy titled, Medication Administration, dated 09/25, revealed It is the policy of the facility to administer medications according to accepted standards of practice.Medication and treatment errors and/or undesirable effects are to be immediately reported to the attending physician, and the resident will be monitored. A medication/treatment error report will be turned in to the nursing office as part of the quality assurance program.Prepare all meds for the resident as ordered for the time it is due. Take meds to the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-28 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ 178839 Refer to F 600 Based on interviews and review of the medical record and other facility documentation, it was determined that the facility staff failed to report an allegation of sexual abuse by a staff member to a resident to the New Jersey Department of Health (NJDOH) as required. This deficient practice was identified for 1 of 1 resident (Resident #59) and was evidenced by the following: On 10/22/24, the surveyor reviewed Resident #59's medical record which included a quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/24, which indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition and diagnoses which included but were not limited to diabetes (high blood sugar), respiratory disease, anxiety disorder, and depression. On 10/22/24, a review of an investigation provided by the facility revealed that on 10/15/24, a staff member observed the resident in a compromising position with another staff member (Licensed Practical Nurse (LPN) #1). A review of the investigation revealed the Social Worker (SW)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide services in a manner consistent with standards of practice to maintain a urinary catheter from 8/28/24 until surveyor inquiry. The deficient practice was identified for one (1) of three (3) residents, (Resident #55), reviewed for urinary catheter care. The deficient practice was evidenced by the following: On 10/22/24 at 10:42 AM, the surveyor observed Resident #55 in a wheelchair in their room. The resident stated that they had just returned from physical therapy and was exhausted. The surveyor had not observed a urinary catheter drainage bag (a device inserted to collect urine from the bladder into a drainage bag). On 10/22/24 at 10:49 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that she was familiar with Resident #55 and had the resident on her assignment. CNA #1 added that the resident had a urinary drainage bag when they were in bed and when the resident was out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-28 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of facility documentation, it was determined that the facility failed to ensure that a.) all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training as required for 5 of 5 CNAs and b.) abuse prevention training was completed for 2 of the 5 CNA files reviewed for in-service training. This deficient practice was evidenced by the following: On 10/24/24, the surveyor reviewed in-service education hours for five randomly selected CNA files which were provided by the Director of Nursing (DON). The surveyor reviewed the following for the 2023 to 2024 calendar year, corresponding with the CNA hire dates: CNA #1 was hired on 8/17/18, with a total of 6 hours (hrs.) of in-service training for the current 12-month period. CNA #2 was hired on 8/25/15, with a total of 5.5 hrs. of in-service training for the current 12-month period. CNA #3 was hired on 8/10/23, with a total of 6 hrs. of in-service training for the current 12-month period, which did not include abuse prevention training. CNA #4 was hired on 9/27/18, with a total of 6.5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-28 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ 178839 Refer to F 600 Based on interviews, review of the medical record and other facility documentation, it was determined that the facility failed to thoroughly investigate an alleged incident of sexual abuse between a staff member and a resident. This deficient practice was identified for 1 of 1 resident (Resident #59) reviewed for abuse and was evidenced by the following: On 10/22/23, the surveyor reviewed Resident #59's medical record which included a quarterly Minimum Data Set (MDS), an assessment tool dated 08/21/24, which indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition and diagnoses which included but were not limited to diabetes (high blood sugar), respiratory disease, anxiety disorder, and depression. On 10/22/24, a review of an investigation provided by the facility revealed that on 10/15/24, a staff member observed the resident in a compromising position with another staff member (Licensed Practical Nurse (LPN) #1). A review of the investigation revealed the Social Worker (SW) interviewed Resident #59…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to ensure heel booties were consistently applied to prevent skin breakdown. This deficient practice was identified for Resident #72, 1 of 2 residents reviewed for position and mobility. This deficient practice was evidenced by the following: On 10/18/24 at12:18 PM, during initial tour, the surveyor observed Resident #72 sitting in a reclining chair in the main activity area. The resident was wearing white socks with their heels resting on the footrest. A review of the electronic medical record (EMR) for Resident #72 revealed the following: A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities) and Alzheimer's Disease, unspecified a brain disorder that slowly destroys memory and thinking skills.) A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, interview, and review of pertinent documents it was determined that the facility failed to ensure that the resident's care plan and smoking evaluation were followed to ensure the resident's ability to safely smoke cigarettes in accordance with their facility policy. The deficient practice occurred for 1 of 2 residents reviewed for smoking (Resident #74) and was evidenced by the following: On 10/18/24 at 12:45 PM, the surveyor observed Resident #74 in a wheelchair in the dining room waiting on lunch. On 10/23/24 at 1:34 PM, the surveyor observed Resident #74 outside smoking with supervision provided by the Director of Activity (DOA). The surveyor observed that the DOA lit the resident's cigarette. The surveyor did not observe a smoking apron in use for Resident # 74. Two other residents had smoking aprons applied before their cigarettes were lit. The DOA stated that Resident #74 does not use a smoking apron, he/she does pretty well. She further stated that the activity department supervised the smoking in the facility. On 10/23/24, the surveyor reviewed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-28 · tag F0712 — isolatedEnsure 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 Based on observations, interviews, and record review, 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 physician or nurse practitioner every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 2 of 9 residents (Resident #28 and #167) reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 10/18/24 at 12:10 PM, during the initial tour, the surveyor observed Resident #28 wearing a gray sweatshirt. The resident was walking around the unit. The surveyor reviewed the electronic medical record (EMR) for Resident # 28. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; metabolic encephalopathy (a chemical imbalance in the blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 interviews, medical records (MR) review, and review of pertinent facility documentation's, it was determined that the facility failed to update and revise a resident care plan (CP), add interventions as deemed necessary, for 1 of 3 (Resident #3) residents reviewed for CP revision. The deficient practice was evidenced by the following: A review of Resident #3's admission Record (AR) indicated the Resident was admitted with the following diagnoses which included but not limited to: Acute Embolism and Thrombosis, Atherosclerotic Heart Disease, Hypertension, Metabolic Encephalopathy, Dementia, Anxiety Disorder, Osteoarthritis, Mood Disorder, and Depression. A review of Resident #3's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities, in its quarterly assessment dated [DATE], revealed that Resident #3's Brief Interview for Mental Status (BIMS) score is 00 indicating that Resident's Cognitive Skills was severely impaired. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY COMPLAINT #: NJ00173980 Based on observation, interview, review of medical records and other pertinent facility documentation on 10/08/24 and 10/09/24 it was determined that the facility failed to follow acceptable standards of nursing practice by not documenting a registered nurse's (RN) assessment of a reported injury of unknown origin. This deficient practice was identified for 1 of 10 residents reviewed (Resident #10) and was evidenced by the following: On 10/09/24, at 10:12 A.M., the surveyor observed the resident lying in bed asleep. On 10/9/24, at 10:26 A.M., the surveyor interviewed the resident's assigned RN #1 for the day, who stated that the resident was receiving hospice services. She further stated that the resident was declining and although the resident would occasionally call out a family member's name, the resident was no longer verbal. According to the facility admission Record, Resident #10 was admitted with diagnoses that included, but were not limited to dementia, Parkinson's Disease (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
C #: NJ00167104 Based on interviews, medical record review, and review of other pertinent facility documents on 12/21/23, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policy and protocol for 1 of 3 residents (Resident #3) reviewed for documentation. This deficient practice was evidenced by the following: According to the facility admission Record (AR), Resident #3 was admitted with diagnoses that included but were not limited to: Dementia, End Stage Renal Disease, Dependence on Renal Dialysis. The Minimum Data Set (MDS), an assessment tool, dated 8/10/23, revealed a Brief Interview of Mental Status (BIMS) of 3 which indicated the resident's cognition was severely impaired and the resident needed assistance with Activities of Daily Living (ADL) including toileting. Review of Resident #3's DSR (ADL Record) and the progress notes (PN) for the month of 8/2023 and 9/2023, lack any documentation to indicate that the care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to provide a physically impaired resident clear access to the handrails equipped in the hallways. This deficient practice was identified for Resident #27, 1 of 35 residents reviewed and was evidenced by the following: During an interview with Resident #27 on 07/06/2023 at 11:29 AM, the resident stated the handrails were blocked daily with carts and he/she did not have clear access to use the handrails along the hallways. The surveyor observed in the hallway directly outside Resident #27's room, there were three carts along both sides of the hallway. A linen cart, a medical cart, and a cart used by the CNAs. At the time of observation, none of the three carts were in use, the linen cart was on the left side against the handrails and the other two carts were placed against the handrails on the right side. The surveyor interviewed Certified Nurse Aide (CNA) who observed the three carts on both sides of the hallway. The CNA added their cart was being used but confirmed the other two carts were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility failed to reweigh a Resident with a significant weight gain in one week. This deficient practice was identified in Resident #86, 1 of 1 resident reviewed for tube feeding and was evidenced by the following: On 06/27/23 at 09:35 AM, the surveyor observed the resident in the bed awake. The resident was a tube feeding resident and the surveyor observed a syringe/container in a closed plastic container with a date of 06/27/23. The resident could not be interviewed due to cognitive status. Review of Resident #86 admission record revealed the resident was admitted to the facility in 2019. Medical diagnoses included, but not limited to diabetes (high blood sugar), dysphagia (inability to swallow), heart disease, and hypertension (high blood pressure). The surveyor reviewed the most recent quarterly Minimum Data Set (MDS) an assessment tool dated 5/8/23. Under section K, titled swallowing, and nutritional status, feeding tube was coded as one, meaning the resident had a feeding tube. Resident #86 had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 06/26/2023 at 9:58 AM, the surveyor accompanied by the Food service Director (FSD) observed the following in the kitchen: The surveyor observed a number of unlabeled and undated items located throughout the kitchen in the refrigerators and freezers which included seven bags of shredded cheese, two roasts, one crate of milk, two bags of frozen French fries, two bags of frozen tater tots, and one bag of frozen broccoli. There were also two metal containers over the shelf located in the food prep area with unlabeled and undated items which included six baggies filled with potato chips, 10 packs of crackers, and one bagel. The surveyor observed four personal disposable cups of beverages located in the food prep areas. The first item observed was an uncovered cup of ice water which was left next to 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$54,275 in federal fines across 1 penalty.
- $54,275 — penalty dated 2024-10-28
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 OCEAN HEALTHCARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 2 of 5 | 2.9 | -0.9 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 10 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DREW, ZALMAN | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 12/10/2010 |
| FEIGENBAUM, AVRAHAM | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/10/2010 |
| FEIGENBAUM, DEBORAH | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 12/10/2010 |
| MAIEROVITS, AVROHOM | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/10/2010 |
| M&T BANK | Organization | 5% OR GREATER MORTGAGE INTEREST | since 02/01/2016 |
| DYNAMIC HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/10/2025 |
| GOLDBERG, YEHUDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2025 |
| FEIGENBAUM, MELVIN | Individual | ADP OF THE SNF | since 12/10/2010 |
CMS files one row per role, so the 16 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 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.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $8.6M paid to related parties — landlords or management companies under common ownership — equal to about 37% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315423. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-16, 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.