Arnold Walter Nursing & Rehabilitation Center
622 S Laurel Avenue, Hazlet, NJ 07730 · For profit - Partnership · 202 certified beds · (732) 787-6300 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- 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
- a high number of inspection citations overall (26) — 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
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| 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 held steady at 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 | 11.5% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.6% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.2% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.1% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.2% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.2% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.5% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 5.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 12.5% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.2% | 12.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.6% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.9% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.4% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.17 | 2.07 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.32 | 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.
52.8% 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 291 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 69.8% 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 215 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 52.8%CMS range 46.9–59.0 | 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 | 9.9%CMS range 7.3–12.5 | 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 | 69.8% | 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 | 66.5% | 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 | 57.7% | 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 | 95.3% | 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 | 97.1% | 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 | 93.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.3% | 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 | 3.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.7%CMS range 7.2–13.1 | 7.1% | Oct 2023–Sep 2024 | worse than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.50 | 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 202 beds and averages 172.0 residents a day — about 85% occupied, or roughly 30 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 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 3.31 hrs/resident/day on weekends vs 3.25 on weekdays — about the same on weekends as weekdays. RN hours go from 0.44 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as 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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #s: NJ2676162, NJ2786980Based on observation and interview, it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 1 of 4 units, (D Wing) and was evidenced by the following: On 6/09/2026 at 10:19 AM, during initial tour of D wing, the surveyor observed dark brown areas on the floors throughout the hallways. On 6/10/2026 at 8:58 AM, the surveyor observed the D wing hallways to have multiple dark brown areas on the floors. On 6/11/2026 at 10:01 AM, the surveyor observed the D wing hallways with wet floor signs in front of the nurse's station. The floor around the wet floor sign was observed with multiple dark brown areas. On 6/11/2026 at 10:15 AM, the surveyor interviewed a porter who stated that the floors were mopped daily as were the hallways. He further indicated that he had worked the prior two days and that the hallways on D wing were mopped daily. He further explained that D wing needed to be stripped and waxed, that this stuff (indicating to the floor) wouldn't come up with…
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 · D2026-06-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00187199 (406115), 2676162Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to timely provide incontinence care to residents who required assistance with the activities of daily living (ADL). This deficient practice was identified for 2 of 9 residents (Resident #7 and 141) reviewed for Incontinence care.This deficient practice was evidenced as follows:This deficient practice was evidenced as follows:1.) On 6/12/26 at 9:13 AM, during incontinence rounds with the Licensed Practical Nurse Unit Manager (LPN UM), Resident #7 was agreeable to be checked, and it was noted that the resident's incontinence brief was saturated with urine, the draw sheet was soaked with urine, and the bed pad was soaked with urine. The LPN UM confirmed Resident #7's incontinence brief was saturated with urine through to the draw sheet, and bed pad. The LPN UM stated the process for a resident who was incontinent was the resident should be changed at…
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 before2026-06-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and pertinent facility documentation, it was determined that the facility failed to ensure a.) a medication (Lactulose solution) was properly labelled for one (1) of four (4) medication carts inspected and b.) an expired refrigerated medication (Omeprazole solution) was removed from active inventory for one (1) of two (2) medication refrigerators inspected. The deficient practices were evidenced by the following: 1. On 6/10/26 at 8:16 AM, during the medication administration observation, the Licensed Practical Nurse (LPN #1) was preparing medications for unsampled Resident #64. LPN #1 stated there was a physician's order for Lactulose solution (a medication used to relieve constipation) and removed the bottle from the medication cart. The surveyor with LPN #1 reviewed the bottle for a label. LPN #1 stated the label came off but she knew the bottle of Lactulose was for unsampled Resident #64 and showed the surveyor a corner of a label remaining that was unreadable. LPN #1 asked the surveyor if that was allowed. A review of the Order…
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 before2025-10-30 · 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 interviews, record review, and review of other pertinent facility documents, it was determined that the facility failed to: ensure a physician's order to administer medication was followed for one of two residents reviewed, Resident # 2. Resident #2 did not received their Liothyronine medication (medication used to treat hypothyroidism) insufficient thyroid hormone. The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse…
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 · F2025-01-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/16/25 at 9:23 AM, during the initial tour of the facility kitchen in the presence of the Food Service Director (FSD) and the Regional FSD (RFSD), the surveyor observed the following: The FSD performed hand hygiene at the hand washing station and was timed by the surveyor using a digital stopwatch to lather her hands with soap for 16 seconds prior to rinsing. The trash receptacle by the hand wash station was positioned under a stainless-steel shelf which had a tray of clean plastic cups stacked. When the FSD used the foot pedal to open the receptacle lid, it hit against the tray of clean cups. Paper towels at the hand washing station were not stored in the paper towel dispenser, they were stored on the stainless-steel shelf above the trash receptacle, with the first few paper towels of the stack appeared to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-24 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 2 of 4 nursing units (A Wing and D Wing) reviewed for environmental concerns, and was evidenced by the following: 1. On 1/16/24 at 9:24 AM, the surveyor observed the A-wing nursing unit and identified the following concerns: The Shower Room was a large room with two shower stalls, three windows, and three metal wall heaters. The left shower stall had copious amount of standing water with a white milky coloring that filled half of the shower floor. Two of the three metal wall heaters had a red/orange discoloration on the heaters and on the tile under the heaters. The three window units' coverings were made of a thin paper-like material that contained holes throughout which did allow for privacy making the shower room visible from the outside. Resident Room #A-30 had a damaged window screen that did not fit into the window frame. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when 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 observation, interview, and reviewed of pertinent facility documents, it was determined that the facility failed to a) label, date, and store respiratory equipment in a manner to prevent contamination for infection control; b) obtain a physician's order for the administration of oxygen; c.) document the assessment of vital signs as ordered for a nebulizer treatment; and d) perform tracheotomy care with aseptic (sterile) technique to prevent infection. This deficient practice was identified for 3 of 4 residents reviewed for respiratory care (Resident #71, #73, and #85) and 1 of 1 resident reviewed for tracheostomy care (Resident #115), and was evidenced by the following: 1. On 1/16/25 at 10:15 AM, during the initial tour of the facility, the surveyor observed Resident #85 sleeping in their bed. Resident #85 was receiving oxygen via nasal cannula (device that delivers additional oxygen through the nose) at 2 liters per minute (lpm). On 1/16/25 at 11:18 AM, the surveyor observed the nasal cannula tubing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-24 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) that a physician's ordered pain medication specified a pain level and b.) appropriate monitoring of pain with adequate assessment and re-assessment was consistently completed for a resident who exhibited pain. This deficient practice was identified for 1 of 1 resident reviewed for pain management (Resident #133), and was evidenced by the following: On 1/16/25 at 9:39 AM, the surveyor interviewed Resident #133 who was sitting at the side of the bed. The resident was cognitively intact and stated that they were admitted to the facility with a right below knee amputee (BKA). The surveyor observed that the resident had a dressing intact to the right stump area and that was wrapped in a bandage. The resident reported that they had frequent pain in the surgical area of the right stump. On 1/17/25 at 10:20 AM, the surveyor reviewed the medical record for Resident #133. A review of the Resident Face Sheet reflected the resident was admitted to the facility with the diagnoses which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-24 · 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
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain a resident's dignity while providing feeding assistance. This deficient practice was identified for 1 of 29 residents observed for dignity (Resident #7), and was evidenced by the following: On 1/16/25 at 12:09 PM, during initial tour of the facility, the surveyor observed Resident #7 in bed in their room with a Certified Nurses Aid (CNA #3) providing feeding assistance to the resident. CNA #3 had the tray table with the lunch tray back and slightly to the side behind her while she stood over Resident #7 feeding them. CNA #1 was observed turning away from the resident to obtain a spoonful of food which was positioned away from the resident and she was not seated alongside the resident during this care. On 1/17/25 at 11:02 AM, the surveyor observed Resident #7 in their room, who informed the surveyor that the CNAs in the facility usually stood while assisting them with their meal. Resident #7 stated that one CNA sometimes sat on the side 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 · D2025-01-24 · 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 interview and review of pertinent facility documents, it was determined that the facility failed to a) revise an individual comprehensive care plan (ICCP) for a resident with floor mats and b) revise an ICCP for residents who received oxygen. This deficient practice was identified for 2 of 29 residents reviewed for care plans (Resident #71 and Resident #85), and was evidenced by the following: 1. On 1/16/25 at 10:15 AM, during the initial tour of the facility, the surveyor observed Resident #85 sleeping in their bed. Resident #85 was receiving oxygen via nasal cannula (device that gives additional oxygen through the nose) at 2 liters per minute (lpm). The surveyor observed floor mats folded up in the resident's room. On 1/17/25 at 11:12 AM, the surveyor observed Resident #85 lying in bed awake looking around the room. Resident #85 was receiving oxygen via nasal cannula at 2 lpm. The surveyor observed floor mats located on both sides of the resident's bed. The resident's bed was in a low position with…
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 16 citations
- Potential for harm · Dcited before2025-01-24 · 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 Based on observation, interview, and record review, it was determined that the facility failed to: a) properly secure medication being administered during medication pass and b) ensure that a resident received care and services for the provision of dressing changes to a peripherally inserted central catheter (PICC) site consistent with professional standards of practice. The deficient practice was identified for 2 of 29 residents reviewed for medication administration (Resident #77 and Resident #127) . Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a…
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 before2025-01-24 · 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, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the accountability of the narcotic shift count logs were completed and b.) accurately document the administration of controlled medications. This deficient practice was identified on 2 of 4 medication carts reviewed for medication storage, and was evidenced by the following: During medication storage review on 1/22/25 at 11:15 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the D Wing medication cart #2's November 2024, December 2024 and January 2025 Change of Shift Controlled Medication Accountability Record (a shift-to-shift controlled substance and narcotics (narc) count sheet signed by the outgoing and incoming nurses each shift) which revealed the following: The nurses' signatures were blank for the outgoing nurse for the following shifts: For the day shift (7:00 AM to 3:00 PM) on: 11/26/24, 12/30/24, 1/6/25, and 1/17/25. For the evening shift (3:00 PM to 11:00 PM) on: 11/3/24, 11/11/24, 11/14/24, 11/19/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a) properly label opened multidose medications and b) properly secure prefilled normal saline syringes. This deficient practice was identified in 2 of 4 medication carts reviewed for medication storage and labeling and 1 of 4 nursing units (D Wing) and was evidenced by the following: 1. On 1/22/25 at 11:15 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #1), observed the D Wing nursing unit's medication cart #2. The following was observed: Two (2) opened foil pouches of ipratropium bromide 0.5 milligram (mg)/albuterol sulfate 3 mg inhalation solution (medication used to treat symptoms of lung disease), which were not dated with an opened date. One (1) prescription artificial tears bottle (medication used to treat dry eyes), which was not dated with an opened date or labeled with the resident's identifying information on the medication bottle. One (1) prescription fluticasone propionate and salmeterol inhalation powder 113 microgram…
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 · D2025-01-24 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to ensure that food brought in to residents by family and visitors were stored and handled in a safe and sanitary condition. This deficient practice was identified for 1 of 2 facility freezers reviewed during kitchen tour, and was evidenced by the following: On 1/16/25 at 9:23 AM, during initial tour of the facility kitchen, the surveyor, in the presence of the Food Service Director (FSD) and the Regional FSD (RFSD), observed a one and a half (1.5) quart container of black raspberry ice cream which was approximately three quarters (3/4) empty dated opened 9/23/24, stored in the ice cream freezer. On 1/16/25 at 9:24 AM, the RFSD informed the surveyor that this was a specific resident's personal ice cream that was being stored by the facility. The container was not labeled with a resident's name, and the RFSD stated the resident was no longer at the facility and the ice cream should have been labeled with the resident's name. The surveyor reviewed the facility's Resident Food from 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 · E2023-12-14 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ166916 Based on interview, medical record review and other pertinent documentation, it was determined that the facility failed to a.) ensure skin conditions were addressed in accordance with professional standards by failing to obtain physician's orders and treatments for a surgical site dressing, leg wound, and skin tear; assess and document monitoring of a surgical site, leg wound and heel blister b.) ensure a care plan was in place which addressed actual skin impairment c.) complete an incident report for a skin tear and d.) ensure timely physician notification and timely transfer of a resident to the hospital. This deficient practice was identified for 1 of 28 residents (Resident #287) reviewed for quality of care and was evidenced by the following: 1. According to the Resident Face Sheet, Resident #287 was admitted to the facility with diagnoses which included but were not limited to; postprocedural hematoma (collection of blood under the skin) of skin and subcutaneous tissue following other procedure, and lymphedema (swelling). According to 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 · Dcited before2023-12-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #NJ 161020 Based on interviews, record review, and review of pertinent documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 5 residents reviewed for investigations and was evidenced by the following: On 12/4/23 at 12:30 PM, the surveyor interviewed Resident #93, who stated that while at the facility, they had broken their arm. The resident further said a resident had pushed them at the nurse's station and caused the broken arm. A review of Resident #93 Face Sheet (an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included hypertension, open-angle glaucoma, and left eye cataract. A review of Resident #93's Annual Minimum Data Set (MDS), an assessment tool, dated 9/8/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. A review of a nursing progress note dated 12/5/22 at 12:24 AM, revealed at 5:00 PM on 12/4/22, the Registered Nurse Night-Shift Supervisor (RNS#2) was summoned…
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 before2023-12-14 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 27 residents reviewed (Resident #116 and #97). This deficient practice was evidenced by the following: 1. On 11/30/2023 at 9:40 AM, the surveyor observed Resident #116 in bed eating lunch. The surveyor reviewed the medical record for Resident #116. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included chronic congestive heart failure and essential hypertension. A review of Resident #116's August 2023 Nursing Progress Notes included an entry dated 8/14/2023 at 12:37 PM, which indicated the resident was admitted to the facility for longterm care and was receiving Hospice services. A further review of the resident's medical record revealed hospital records dated 8/11/23 at 4:31 PM, which indicated the hospital…
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 before2023-12-14 · 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 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to a) properly transcribe a physician's order for 2 of 27 residents reviewed for medications (Resident #59 and #388); b) failed to follow physician's order to obtain blood sugar and administer insulin for 1 of 27 residents reviewed for medications (Resident #388). These deficient practices were evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act…
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 before2023-12-14 · 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
Complaint # NJ166083 Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a dispensed and administered controlled substance medication was accurately accounted for 1 of 1 residents reviewed, Resident #187. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 12/13/23 at 11:54 AM, the surveyor reviewed the closed medical record for Resident #187. A review of the admission 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 · D2023-12-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review and review of other facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #116), and was evidenced by the following: On 11/29/2023 at 1:02 PM, the surveyor observed Resident #97 sitting on the bed eating lunch. The surveyor observed the resident wearing oxygen. The surveyor reviewed the medical record for Resident #97. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Chronic Obstructive Pulmonary Disease with (acute) exacerbation. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 9/29/23, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which demonstrated an intact cognition. On 12/12/2023 at 12:56 PM, the surveyor reviewed the facility's Medication Regime Review (MRR) for 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 · D2023-12-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other documentation, it was determined that the facility failed to maintain infection control standards and procedures when performing a wound care treatment for 1 of 1 residents (Resident #4) performed by 1 of 1 nurses observed providing a wound care treatment. This deficient practice was evidenced by the following: On 11/29/23 at 11:41 am, the surveyor observed Resident #4 sitting in bed eating lunch. A review of the Resident Face Sheet, Resident #4 was admitted to the facility in 9/2021 with diagnoses that included cerebral infarction (damage to the brain due to loss of oxygen), hemiplegia (one-sided paralysis of the body) and stage 4 pressure ulcer to the sacrum. A review of Resident #4's Annual Minimum Data Set (MDS), an assessment tool dated 8/16/23, revealed that the resident's Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicated that the resident had severe cognitive impairment. Further review revealed the resident required extensive to total dependency for activities of daily living (ADL) 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 · D2023-12-14 · 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 #NJ 161020 Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) for 1 of 5 residents reviewed for investigations and was evidence by the following: On 12/4/23 at 12:30 PM, the surveyor interviewed Resident #93, who stated that while at the facility, they had broken their arm. The resident further said a resident had pushed them at the nurse's station and caused the broken arm. A review of Resident #93's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension, open-angle glaucoma, and left eye cataract. A review of Resident #93's Annual Minimum Data Set (MDS), an assessment tool, dated 9/8/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. A review of a nursing progress note dated 12/5/22 at 12:24 AM, revealed at 5:00 PM, on 12/4/22, the Registered…
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 beforedisputed · IDR2021-08-19 · 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
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to investigate the root cause of a facility-acquired pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #6). The evidence was as follows: During the initial tour of the facility on 8/12/21 at 11:38 AM, the Unit Manager (UM) informed the surveyor that Resident #6 had a facility-acquired pressure ulcer to the left heel that was unstageable (full thickness tissue loss in which wound depth is not visible due to coverage of dead tissue and cannot be determined). The surveyor reviewed the medical records for Resident #6. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted with diagnoses which included end stage renal disease, heart failure, diabetes, edema (swelling), and weakness. A review of a comprehensive significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/10/21 reflected that the resident had a brief interview for mental…
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 beforedisputed · IDR2021-08-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment tool for assessing pressure ulcer risk, behaviors of wandering, and a dental assessment. This deficient practice was identified for 2 of 22 residents reviewed for MDS accuracy (Resident #6 and #53). The evidence was as follows: 1. During the initial tour of the facility on 8/12/21 at 11:38 AM, the Unit Manager (UM) informed the surveyor that Resident #6 had a facility-acquired pressure ulcer to the left heel that was unstageable (full thickness tissue loss in which wound depth is not visible due to coverage of dead tissue and cannot be determined). The surveyor reviewed the medical records for Resident #6. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted with diagnoses which included end stage renal disease, heart failure, diabetes, edema (swelling), and weakness. A review of the Pressure Ulcer Injury Risk…
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 beforedisputed · IDR2021-08-19 · 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 follow acceptable professional standards of clinical practice by not accurately following a Physician's Order (PO) for the administration of one dose of insulin. The deficient practice was identified for 1 of 22 residents reviewed for professional standards of practice (Resident #81), and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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 8/13/21 at 10:58 AM, the surveyor observed Resident #81 in a common room participating in an exercise program being televised. 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 · Ddisputed · IDR2021-08-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to ensure: a.) the appropriate storage of a urinary leg bag to prevent catheter-associated urinary tract infections in accordance with nationally accepted guidelines for infection prevention and control, b.) a care plan for the use of a urinary leg bag, and c.) the policy addressed storage of urinary leg bags to prevent urinary tract infection. This deficient practice was identified for 1 of 2 residents reviewed with an indwelling urinary catheter (Resident #74). The evidence was as follows: On 8/17/21 at 9:25 AM, the surveyor observed Resident #74 in bed, awake and watching TV. The surveyor observed an indwelling urinary catheter bag secured to the bed frame in a dignity bag. The urine in the tubing was pale yellow with a small amount of sediment in it. The resident agreed to be interviewed at that time. The resident stated that he/she has had several urinary tract infections and that he/she had them even prior to admission to the facility due to multiple co-morbidities. He/She stated…
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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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 EXCELSIOR CARE GROUP — 33 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 | 3 of 5 | 2.5 | +0.5 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.2 | +0.8 vs chain |
The other 32 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| GITBERK LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2026 |
| JBL 120 LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2026 |
| JM AND MAZEL LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2026 |
| BERKOWITZ, SAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2026 |
| SPRINGBERG, SUSAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2026 |
| ZUPNICK, JOEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2026 |
| EXCELSIOR CARE GROUP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/21/2019 |
| MAHADEO, SARAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/19/2024 |
| RIBIAT, YITZCHOK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/12/2024 |
| STEINBERG, MOSHE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/12/2019 |
| STERN, SAMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2021 |
| TASHAROFI, KAMRAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2025 |
CMS files one row per role, so the 25 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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 315119. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-24, 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.