Lakeland Nursing & Rehab
25 Fifth Avenue, Haskell, NJ 07420 · For profit - Partnership · 201 certified beds · (973) 839-6000 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- about 22% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 4 years ago — the star rating may not reflect current conditions
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 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 | 5.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.8% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 19.1% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 2.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.9% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.4% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.1% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.2% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.6% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.2% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.97 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.38 | 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.
52.3% 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 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.2% 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 55 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 52.3%CMS range 41.1–68.4 | 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 | 9.0%CMS range 6.1–12.8 | 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 | 78.2% | 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 | 69.1% | 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 | 60.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.9% | 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 | 9.6%CMS range 5.4–15.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.40 | 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 201 beds and averages 136.5 residents a day — about 68% occupied, or roughly 64 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 3.65 on weekdays — 13% thinner on weekends. RN hours go from 0.36 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 25% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
This trend is not current. The most recent of these two inspections was over 4 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2022-09-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 policy review, the facility failed to ensure resident's nutrition needs were met for one of nine residents (Resident (R)103) reviewed for nutrition. The facility failed to reconcile discrepancies between facility weights, reflecting stable weight, and hospital weights, reflecting significant weight loss. R103 was weighed during the survey and weighed 126 pounds; the most recent facility weight two weeks earlier was 170.6 pounds. Due in part to the failure to obtain accurate weights, review the hospitalization documentation in the resident's record, and physically/clinically assess the resident, R103's tube feeding regimen was not increased to address weight loss, severe protein malnutrition, and a worsening sacral pressure ulcer. Findings include: 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab, revealed R103 was admitted to the facility on [DATE] with diagnoses including sepsis, hypoglycemia (low 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 before2024-07-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
COMPLAINT #NJ162233 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for 1 of 1 resident reviewed, Resident #70. This deficient practice was evidenced by the following: On 7/22/24 at 11:02 AM, during initial tour, the surveyor observed Resident #70 resting in their bed with their eyes closed. The surveyor also observed the Registered Nurse (RN) in the room who stated that she assessed the resident's vital signs. On 7/22/24 at 11:32 AM, the surveyor reviewed the form that was provided by the facility titled, Reportable Event Record/Report for a Facility Reported Event (FRE) dated 3/9/23 which included the following: Today's date: 3/9/23 Date of Event: 3/7/23 Was This a Significant Event: Yes Was Significant Event Called in? Yes Date: 3/8/23 Time: 2:30 PM Type of Incident: Other, specify: Resident had a tuft fracture (a break at the tip of the fingers or toes) of the left thumb. The surveyor…
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 before2024-07-29 · 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 #NJ162233 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for 1 of 1 resident reviewed, Resident #70. This deficient practice was evidenced by the following: On 7/22/24 at 11:02 AM, during initial tour, the surveyor observed Resident #70 resting in their bed with their eyes closed. The surveyor also observed the Registered Nurse (RN) in the room who stated that she assessed the resident's vital signs. On 7/22/24 at 11:32 AM, the surveyor reviewed the form that was provided by the facility titled, Reportable Event Record/Report for a Facility Reported Event (FRE) dated 3/9/23 which included the following: Today's date: 3/9/23 Date of Event: 3/7/23 Was This a Significant Event: Yes Was Significant Event Called in? Yes Date: 3/8/23 Time: 2:30 PM Type of Incident: Other, specify: Resident had a tuft fracture (a break at the tip of the fingers or toes) of the left thumb. The surveyor…
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 before2023-09-19 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00165369 Based on interviews, and record review, as well as review of pertinent facility documents on 9/13/23, 9/14/23, and 9/19/23, it was determined that the facility failed to report an allegation of a resident-to-resident physical and verbal abuse to the New Jersey Department of Health (NJDOH) and to follow the facility policy Abuse Neglect Exploitation Mistreatment and missappropriatin of Property Prevention for 1 of 3 residents (Resident #7) reviewed for grievance. This deficient practice is evidenced by the following: According to the admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; Dementia, Post Traumatic Stress Disorder, and Obsessive Compulsive Disorder. A Minimum Data Set (MDS), an assessment tool, dated 9/7/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated his/her cognition was intact and the resident needed assistance with activities of daily living…
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 before2023-09-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00165369 Based on interviews and review of medical records (MRs) and other facility documentation on 9/13/23, 9/14/23, and 9/19/23, it was determined that facility failed to thoroughly investigate an alleged staff-to-resident verbal abuse allegation and to follow facility policy titled Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention for 1 of 3 residents (Resident #2). This deficient practice is evidenced by the following: A review of the statement written by the Certified Nursing Assistant (CNA #1) to the Facility's Regional Human Resources (RHR) via email, dated 9/11/23 at 12:51 a.m., revealed that CNA #1 heard and seen [CNA #2] abuse, scream, and disrespect patients and their Families on XX unit. The statement further revealed that CNA #1 reported the aforementioned incident to the Licensed Practical Nurse (LPN #1). According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C #: NJ00160399 and NJ00167145 Based on interviews, medical record review, and review of other pertinent facility documents on 9/13/23, 9/14/23, and 9/19/23, 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 the facility protocol for 3 of 4 residents (Resident #2, Resident #3, and Resident #4) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility admission Record (AR), Resident #2 was admitted on [DATE], with diagnosis that included but were not limited to: Hemiplegia and Hemiparesis, and Alzheimer's Disease. The Minimum Data Set (MDS), an assessment tool, dated 9/7/23, 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 (ADLs). Review of Resident #2's DSR (ADL Record)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-09-01 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff and resident interviews, the facility failed to develop a comprehensive plan of care directing measurable goals and interventions for five residents in a total sample of 25 (Resident (R) 3, R32, R43, R101, and R103). The facility failed to develop a care plan for pain for R3, resident choices for R101, side rails for R32, behaviors for R43, and nutrition for R103. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses that included dementia, stroke, and heart failure. Review of the current Order Summary located in the Orders tab of the EMR revealed R3 was prescribed Tramadol [a pain medication] 50 mg [milligram] every six hours for moderate-severe pain on 07/26/22. Review of the quarterly Minimum Data Set (MDS) assessment with an 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 · D2022-09-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, interviews, and review of facility policy, the facility failed to ensure one of one resident's (Resident (R) 101) right to make choices about his life that were important to him, were encouraged. Specifically, the facility failed to ensure R101 could go out for walks into the community, interact with members of the community, and encouraged to promote the self determination of needs for resident. The facility also failed to ensure R101 was being included and updated in any discussions about his choice to go for walks in the community. By not promoting resident choices this resident was left feeling as though his needs were not being met to address his right to go into the community for walks. Findings include: 1. During observation and interview on 08/28/22 at 11:22 AM, R101 was observed walking independently from his room to look out a window on the first floor. R101 was well groomed, wearing shorts, t-shirt, and tennis shoes. During interview R101 stated, I want to go walking. I love going outside and getting fresh air. I used to go outside…
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 · D2022-09-01 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 advance directives and Practitioner Orders for Life-Sustaining Treatment (POLST) information was completed and obtained for three of 25 sampled residents (Resident (R) 68, R62, and R105). The failure created the potential for residents to not have their wishes known should they suffer a health emergency. Findings include: 1. Review of R78's Census tab of R78's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Review of R78's diagnoses, located under the Diagnosis tab of her EMR, revealed diagnoses which included chronic atrial fibrillation and atherosclerotic heart disease. Review of R78's Physician's Orders, located in R78's EMR under the Orders tab, revealed the resident had a code status of ''DNR'' (do not resuscitate) resuscitation status. Review of R78's Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/11/22 revealed the facility assessed R78 to have a Brief…
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 before2022-09-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and review of the facility policies, the facility failed to report to administration when one of two residents (Resident (R) 68) in a total sample of 25 experienced a resident-to-resident altercation. This failure placed the residents at risk for further altercations and a diminished quality of life. Findings included: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R68 was admitted to the facility on [DATE] with diagnoses that included fragile X chromosome abnormality (an inherited condition characterized by an X chromosome abnormality which tends to have limited intellectual disabilities.) Review of the 05/13/20 Behavior Care Plan located in the Care Plan tab of the EMR revealed, .Behaviors: laughing/talking to self loudly, yelling out, vocal outbursts, kicking/hitting staff, scratching self, wandering into others' rooms and touching others belongings, looking for snacks, attempting to use bathroom…
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 · D2022-09-01 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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, the facility failed to identify the need for a new Preadmission Screening and Resident Review (PASARR-a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness) when a resident had a new diagnosis of mental illness for one of three residents (Resident (R) 17) reviewed for PASARR. This failure placed R17 at risk for not receiving necessary services for her mental health. Findings included: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R17 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of the 06/18/18 Level I PASARR located in the Miscellaneous tab of the EMR revealed, R17 had a diagnosis of major depressive disorder and did not require a Level II evaluation (an evaluation to identify specialized services required by the resident for conditions identified in a Level I). 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.
Show the remaining 12 citations
- Potential for harm · D2022-09-01 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
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, the facility failed to notify the state mental health authority after a significant change in condition for one (Resident (R) 68) of three sample residents who were reviewed for Preadmission Screening and Resident Review (PASARR- a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness). This has the potential for failure for the facility to identify the resident's needs and provided services appropriate for the residents mental health. Finding included: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R68 was admitted to the facility on [DATE] with a diagnosis of fragile X chromosome abnormality (an inherited condition characterized by an X chromosome abnormality which tends to have limited intellectual disabilities.) Review of the 05/05/20 Level I PASARR located in the Miscellaneous tab of the EMR revealed, R68 was marked positive for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-01 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
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 that the resident and/or the resident's responsible party (RP) for two of two residents (Residents (R) 61 and R103) reviewed for baseline care plans, had baseline care plans developed and implemented to address the resident's immediate needs within 48 hours of admission to the facility. The facility failed to ensure the residents and/or representatives were in attendance of a baseline care plan and provided with a written summary of the baseline care plan that included, at a minimum, the initial goals of the resident; medications, nursing, and dietary instructions; and services and treatments to be administered by the facility and personnel. Findings include: Review of the facility's 02/02/22 policy titled, Baseline Care Plan, indicated, Intent: Every resident will have an Interdisciplinary Care Plan, with the Baseline Care Plan completed within 48 hours of admission. The care plan will identify priority…
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 · D2022-09-01 · 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 observation, interview, and record review, the facility failed to ensure the care plan was updated for one of 29 residents (Resident (R) 96) reviewed. The failure to keep a care plan current could affect the appropriateness of care provided to any of the 127 current residents receiving care in the facility. Findings include: 1. Observation of R96 on 08/29/22 at 12:45 PM showed a tube feeding running at 65 milliliters per hour that was dated as hung on 08/29/22 at 11:00 PM. Review of R96's admission Record printed from the electronic medical record (EMR) Profile tab showed an admission date of 10/14/20, and a readmission date of 08/09/22, with medical diagnoses that included pneumonia, hypertension, dysphagia, moderate protein calorie malnutrition, dementia with behavioral disturbance, major depressive disorder, generalized anxiety disorder, and gastrostomy. Review of R96's Progress Notes, from the EMR Prog Notes tab showed: 8/26/2022 12:09 [12:09 PM] General Nurses Note Note Text: .Resident is presently…
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 · D2022-09-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and policy review, the facility failed to ensure one of seven residents (Resident (R) 66) reviewed for falls received appropriate care and services following an unwitnessed fall in which she sustained a bruise below her eye. Neurological (neuro) checks were not completed to rule out a head injury after the fall. Findings include: 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R66 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, history of cerebral infarction (stroke), osteoarthritis, type two diabetes mellitus, and abnormalities of gait and mobility. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/13/22 in the EMR under the MDS tab revealed R66 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 10 (score of 8 - 12 indicates moderate cognitive impairment) out of 15. R66…
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 · D2022-09-01 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents (Resident (R) 31 and R103) reviewed for pneumonia vaccinations and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R31 the opportunity to be vaccinated with Pneumococcal polysaccharide vaccine (PPSV23) and if this vaccination was not available to offer one dose of Prevnar 20 (PCV20). The facility failed to offer R103 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) in accordance with nationally recognized standards. Findings include: 1. Review of R31's admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R31 was admitted to the facility on [DATE] and was older than [AGE] years of age at the time of admission. Review of the Immunizations…
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 · E2019-03-13 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice continued over a two month period of time for 3 of 31 residents (Resident #8, #88, #117) reviewed and was evidenced by the following: 1. On 03/07/19 at 10:20 AM, the surveyor observed Resident #8 laying in bed eating breakfast. The surveyor reviewed Resident #8's medical record. According to the Admitting Face Sheet, Resident #8 was admitted to the facility on [DATE] with diagnoses that included Emphysema, Hypertension and Paraplegia. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 03/03/19, the facility assessed Resident #8 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The surveyor reviewed the January 2019 and February 2019 Physician's Order Form (POF) that revealed Resident #8's physician had not…
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 · E2019-03-13 · tag F0712 — patternEnsure 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 observation, interview and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every 60 days. This deficient practice continued over several months for 4 of 31 residents (Resident #8, #88, #89, #117) reviewed and was evidenced by the following: 1. On 03/07/19 at 10:20 AM, the surveyor observed Resident #8 laying in bed eating breakfast. The surveyor reviewed Resident #8's medical records. According to the Admitting Face Sheet, Resident #8 was admitted to the facility on [DATE] with diagnoses that included Emphysema, Hypertension and Paraplegia. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 03/03/19, the facility assessed Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The surveyor reviewed Physician Progress Note that revealed Resident #8's physician had not performed 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 · D2019-03-13 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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
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: a.) perform an assessment of a resident's condition, b.) maintain documentation of monitoring for complications related to hemodialysis and c.) communicate with the hemodialysis center. This deficient practice was identified for 1 of 4 residents (Resident #69) reviewed for dialysis. The deficient practice was evidenced by the following: On 03/08/19 at 9:21 AM, the surveyor observed Resident #69 in the doorway of the room seated in the wheelchair. The surveyor reviewed Resident #69's medical records. A review of the Admitting Face Sheet, revealed that Resident #69 was admitted to the facility on [DATE] and with diagnoses that included End Stage Renal Disease (ESRD). The surveyor reviewed Resident #69's March 2018 Physician's Orders Form. The resident had orders dated 09/01/18 for the following: Hemodialysis (a therapy that filters waste and removes extra fluid from the body) three times weekly on Monday, Wednesday,…
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 · D2019-03-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
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 implement a gradual dose reduction (GDR) of an anti-psychotic medication for 1 of 4 residents (Resident #35) reviewed. The deficient practice was evidenced by the following: On 03/07/19 at 10:50 AM, the surveyor observed Resident #35 during a morning activity in the day room. The resident was seated in a recliner chair with eyes closed. The surveyor reviewed Resident #35's medical record. The resident was admitted to the facility on [DATE] and according to the March 2019 Physician's Order Form (POF) Resident #35 had diagnoses that included Dementia with Behavioral Disturbances, Psychosis, Anxiety and Alcohol Abuse. A review of Resident #35's March 2019 POF indicated that Resident #35 had a physician's order (PO) dated 01/15/18 for Seroquel 100 mg at bedtime, Seroquel 50 mg at bedtime and Seroquel 50 mg at 4:00 PM for Psychosis (Seroquel is an antipsychotic medication). The resident also had a PO dated 03/17/15 for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-03-13 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 promptly notify the physician of abnormal laboratory results that fall outside of the normal clinical reference range. This deficient practice was identified for 3 of 31 residents reviewed (Resident #52, #117, #128) and was evidenced by the following: 1. The surveyor reviewed Resident #52's medical records. According to the Admitting Face Sheet, Resident #52 was admitted to the facility on [DATE], with diagnoses that included Emphysema, Enlarged Prostate and Cerebral Vascular Accident. A review of the laboratory results dated [DATE], showed documentation that the result was faxed to the facility on [DATE], there was no documentation that the physician was notified of the results: high 140 Glucose level, high 107 Chloride level, low 19 CO2 (Carbon Dioxide) level and high 17 AGAP (Anion Gap) level. The surveyor reviewed the resident's Nurse's Notes (NN) from 02/04/19 to 03/04/19, which did not show any documentation that 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 · D2019-03-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, it was determined that the facility failed to follow proper infection control procedures and perform proper hand hygiene during 1 of 2 wound treatment observations. This deficient practice was observed for Resident #117 and was evidenced by the following: 1. On 3/12/19 at 09:13 AM, the surveyor observed the Licensed Practical Nurse Unit Manager (LPN UM) provide wound care to a pressure ulcer on Resident #117's left ischium. The LPN UM was observed to wash her hands eight times during the above procedures and was observed to be inconsistent with her technique. Twice the surveyor observed the LPN UM apply liquid hand soap and immediately lathered and rubbed her hands together under the running water for a total of five seconds. On four occasions the surveyor observed the UM lather and rub her hands together for 11 seconds or less. On 03/12/19 at 9:30 AM, the surveyor interviewed the LPN UM who stated that the proper procedure for hand washing included lathering and scrubbing her hands together for at least 30 seconds before rinsing…
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 · D2019-03-13 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to provide adequate maintenance to ensure that all the kitchen equipment was in safe operating condition. This deficient practice was evidenced by the following: On 03/07/19 at 10:08 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. A large amount of water was at the threshold of the kitchen that spread over the threshold and into the hallway and back across the floor into the main area of the kitchen. The water trail was traced back and originated from a leak on top of the dish machine where the temperature gauges were located. No wet floor sign was present. 2. The hood lights were off during food preparation and when turned on two of five lights were not working. The cook stated we usually leave the lights off. 3. The air/grease vent and backsplash on the back top of the six burner stove was visibly soiled with a build-up of splattered, dried and caked on food debris. 4. The hot box located to the left 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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to BEST CARE SERVICES — 10 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 | 4 of 5 | 2.3 | +1.7 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 5 of 5 | 2.4 | +2.6 vs chain |
The other 9 homes this chain runs (chain average 2.3★, 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 | Share | Since |
|---|---|---|---|---|
| LAKELAND OPERATOR HOLDCO, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/29/2022 |
| GREEN, DOV | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 09/29/2022 |
| MIARA, ABRAHAM | Individual | W-2 MANAGING EMPLOYEE | — | since 09/29/2022 |
| STERN, SAMUEL | Individual | CORPORATE OFFICER | — | since 09/29/2022 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 74% 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 $4.1M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 315261. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-09-01, 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.