Alliance Care Rehabilitation And Nursing Center
155 40th Street, Irvington, NJ 07111 · For profit - Partnership · 212 certified beds · (973) 371-7878 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (27) — 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 | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.0% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.6% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.2% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 91.2% | 12.1% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 2.3% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 9.5% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.2% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.2% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.6% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.1% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 86.8% | 80.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.1% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.5% | 8.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.15 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.94 | 1.11 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ 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.
50.1% 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 116 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.7% 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 92 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 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 50.1%CMS range 39.2–61.0 | 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 | 11.4%CMS range 7.8–15.5 | 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 | 58.7% | 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 | 45.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.4% | 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 | 96.0% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 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 | 6.4%CMS range 4.0–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.42 | 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 212 beds and averages 204.1 residents a day — about 96% occupied, or roughly 8 beds typically open. It runs essentially full — expect a waiting list. 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 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.91 hrs/resident/day on weekends vs 3.52 on weekdays — 18% thinner on weekends. RN hours go from 0.76 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2022-11-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure: a.) there was no delay in implementing recommendations made by the consulting wound care Nurse Practitioner (NP), b.) care planned interventions to promote wound healing were implemented for a resident who was identified at risk for developing a pressure ulcer (PU) and developed a Stage 2 sacral PU, and c.) a thorough assessment for (PU) risk factors was completed. This deficient practice was identified for 1 of 5 residents reviewed (Resident #49) for PU, who developed a new PU on 10/27/22, and was evidenced by the following: On 11/07/22 at 10:15 AM, the surveyor toured the 300's Unit of the facility and observed Resident #49 in bed with the head of the bed elevated, facing the door, the feet rested on the mattress, and the eyes were closed. When inquired about the resident's status, the Certified Nursing Assistant (CNA) observed in the room stated, All he/she does is sleep all day. On 11/07/22 at 11:30 AM,…
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 · D2026-06-30 · 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
Based on record review, interview, and policy review, the facility failed to ensure an allegation involving an injury of unknown origin was reported as required for one out of one sampled resident (Resident (R)12) reviewed for reporting requirements. Specifically, R12 was discovered on 06/14/26 with an unwitnessed head injury after being observed attempting to climb back into bed. The facility's failure to report an injury of unknown origin had the potential to delay regulatory review and intervention, which could allow abuse, neglect, mistreatment, or exploitation to go unidentified and unaddressed, placing residents at risk for further harm.Findings include: Review of R12's Face Sheet located in the Electronic Medical Record (EMR) under the Profile tab revealed an initial admission date of 09/22/25 and the most admission date of 04/21/26. With the following diagnoses: included traumatic subdural hemorrhage without loss of consciousness (subsequent encounter), Parkinson's disease, Type 2 diabetes mellitus, and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-17 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to provide three of three residents (Residents (R)77, R268 and R54) a Centers for Medicare and Medicaid Services (CMS) for Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) when they completed their Medicare A therapy services. This failure to provide the CMS for SNF ABN prevented the resident from knowing they had days remaining under Medicare A. Findings include: Review of the facility's policy titled Policy, Procedures and Information last reviewed 07/06/24, Policy: Medicare will only pay for services which are determined to be no longer meet skilled nursing or rehab need. The facility's policy fails to direct staff to complete the Skilled Nursing Facility Advanced Beneficiary Notice Centers for Medicare and Medicaid (CMS) form 10055 for residents at the anticipated end of their Medicare covered stay. 1.Review of the electronic medical record (EMR), under the census tab, for R77 revealed an admission date of 07/08/24 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 · D2024-10-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review, interviews, and review of facility policy, the facility failed to prevent resident-to-resident abuse on 03/24/23 when Resident (R)54 pushed and hit R411 in the back. This deficiency has the potential to facilitate future resident-to-resident physical altercations resulting in serious injury or serious physical or psychosocial impairment. Findings include: 1. Review of the Census tab located in the electronic medical record (EMR) revealed R411 was admitted to the facility on [DATE]. Review of the Med Diag [Medical Diagnoses] tab located in the EMR revealed R411 had diagnoses including dementia, bipolar disorder, and dementia with agitation. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/13/23 and located in the EMR revealed R411 had a Brief Interview for Mental Status (BIMS) score of six out of 10 indicating severe cognitive impairment. R411 exhibited no behaviors as indicated in Section E. Review of the Care Plan (CP) located in the EMR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · 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 NJAC 8:39-9.4(f) Based on interview, record review, and facility policy review, the facility failed to thoroughly investigate resident-to-resident abuse incidents for three residents (Residents (R)54, R210, and R411) reviewed for abuse out of a sample size of 31. This failure has the potential for further resident-to-resident abuse occurring and not being investigated so interventions can be put in place. Refer to F600 Findings include: 1. Review of the Census tab located in the electronic medical record (EMR) revealed Resident (R)411 was admitted to the facility on [DATE]. Review of the Med Diag [Medical Diagnoses] tab located in the EMR revealed R411 had diagnoses including dementia, bipolar disorder, and dementia with agitation. Review of the Census tab located in the EMR revealed R54 was admitted to the facility on [DATE].Review of the Med Diag tab located in the EMR revealed R54 had diagnoses including end-stage renal disease, vascular dementia, and previous stroke. Review of a Reportable Event…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and facility policy review, the facility failed to ensure a resident was appropriately positioned with head elevated while receiving nutrition through a feeding tube for one of one resident (Resident (R) 91) reviewed for tube feeding out of a sample of 31 residents. The lack of head elevation could result in aspiration. Findings include: Review of the facility's policy titled, Tube Feeding Policy, last reviewed 05/10/24, revealed, All resident [sic] to remain in Semi-Fowler's position [head of the bed elevated between 30 degrees and 45 degrees] during the feeding and for one hour following the feeding to prevent aspiration. Review of R91's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/24 and located in the MDS tab of the electronic medical record (EMR), revealed the resident was unable to complete a Brief Interview for Mental Status (BIMS), and the staff assessment for cognition indicated severely impaired cognition. R91 had a gastrostomy tube and received over half of his nutrition through tube…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to have medications available to administer as ordered, document why the medications were not given, and maintain accessible records for a controlled medication for three of seven residents (Resident (R) 141, R261, and R366) reviewed for medication administration or pain. This had the potential to result in adverse health outcomes. Findings include: 1. Review of R366's admission Record under the electronic medical record (EMR) Profile tab revealed she was admitted to the facility on [DATE]. R366 had diagnoses which included failure to thrive. Review of R366's Order Summary Report, located in the Orders tab of the EMR revealed orders which included: -magnesium oxide 400mg 1 tablet twice daily as a supplement, ordered 10/08/24, and -dronabinol 2.5mg twice daily for appetite stimulant, ordered 10/08/24 Review of R366's Medication Administration Record (MAR), located in Orders tab of the EMR, revealed the dronabinol 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 · D2024-10-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent during observation of medication administration. The facility had three errors in twenty-five opportunities, which resulted in a 12 percent error rate. This affected one (Resident (R) 366) out of four residents observed. Medication errors have the potential to result in adverse health outcomes. Refer to F755. Findings include: Review of the facility untitled policy regarding medication administration, dated 06/22/24, revealed, Medications are to be administered within a two-hour time frame (i.e. one hour before or after the medication order time. The licensed nurse Immediately notifies nursing supervisor if medication is unavailable for administration and notifies Physician/NP [nurse practitioner] of the same. Contacts pharmacy to obtain medication. The licensed nurse Assures the 5 rights: Compares the medication name, strength, route and dosage schedule 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 · Dcited before2024-10-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and policy review, the facility failed to utilize the proper personal protective equipment (PPE) for enhanced barrier precautions (EBP) and failed to perform proper hand hygiene for one of five residents (Resident (R) 91) reviewed for EBP out of a sample of 31 residents. This created a potential for the transmission of infection to staff and other residents. Findings include: Review of the facility's Enhanced Barrier Precautions policy, dated 04/01/24, revealed it stated: Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . The use of gown and gloves for high-contact resident care activities is indicated, . for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The following situations would warrant Enhanced Barrier Precautions: (EBP) . Wounds and/or indwelling…
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 before2023-08-04 · 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
Based on record review, observation, and interviews, the facility failed to maintain a safe clean homelike environment for residents. This involved three resident rooms affecting four (Resident (R) 25, R26, R27, and R19) of 27 sampled residents who currently reside in the facility. Findings include: Review of R25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/23 located in the MDS tab of the electronic medical record (EMR) revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Observation on 08/03/23 at 8:50 AM, 1:45 PM and on 08/04/23 at 10:50 AM the floor in R25's room had dirt built up along the walls. A fan was observed in the room with the cover off exposing the blades. On 08/03/23 at 8:50 AM and 1:45 PM the fan was running with the blades exposed and not protected. During each of the observations there was a brown spot on the wall next to the outlet located next to the hand sink in the room. R25 stated she had been in the facility for three weeks and the floor and the spot 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 · F2022-11-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, it was determined that the facility failed to maintain the kitchen, and pantry areas, in a clean and sanitary manner to limit the spread of infection and potential food borne illness by failing to ensure: a.) the environment and kitchen equipment was maintained in a manner to limit the potential for microbial growth, b.) the dish machine was operated within appropriate temperature specifications per the policy, c.) the chlorine test strips were used per manufacturer's directions, and d.) resident food stored in unit refrigerators was labeled and dated. The deficient practice occurred was observed in the main kitchen, and in the second, third and fourth floor resident pantry, and was evidenced by the following: Reference: U.S. Food & Drug Administration, 2017 Food Code, 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49…
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 · F2022-11-23 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures for management of on-going outbreak of Candida Auris (C. Auris, an emerging fungus that presents a serious global health threat) which dated back to October 2020 on the Ventilator Unit. This deficient practice was identified by the following. Reference F880, F882 On 11/07/22 at 10:53 AM, during entrance conference, the facility Licensed Nursing Home Administrator (LNHA) informed the survey team that the facility was currently in an outbreak of C. Auris. The survey team was informed that there were currently nine cases in the facility and the residents resided on the first floor ventilator unit. The LNHA stated the facility Infection Preventionist, communicated with the Department of Health and there was a line listing for the C. Auris cases. On 11/09/22 at 11:16 AM, during an interview with the survey team, the facility regional Registered Nurse (RRN) stated that the facility…
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 · Fcited before2022-11-23 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor B 4. On 11/10/22 at 11:39 AM, the surveyor observed a staff member (who was later identified as a Licensed Practical Nurse Apprentice (LPNA)) wearing an N95 mask, glasses (not protective goggles or face shield) and gloves, deliver a lunch tray to Resident #92. She placed the lunch tray on the bed side table and moved the table over to the side of the resident's bed. The LPNA removed her gloves and exited the room. She then used hand sanitizer donned a gown and gloves and went back into room and assisted the resident with his/her meal. The surveyor observed signage on the outside of the resident's room: a STOP, Must See Nurse sign, a Droplet Precautions Everyone Must: .Make sure their eyes, nose and mouth are fully covered before room entry sign, and a Contact Precautions Everyone Must: .Put on gown before room entry. Discard gown before room exit sign. There was a stocked PPE bin located outside of the room which contained hand sanitizer, gloves, gowns, and masks. 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 · F2022-11-23 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #NJ00158982 Based on facility staff interviews and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control and was qualified by certification and experience for 1 of 1 staff member reviewed in accordance with Center for Medicare and Medicaid Services (CMS) and New Jersey State guidelines. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. An individual certified by the Certification Board of Infection…
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 before2022-11-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of pertinent documentation, it was determined that the facility failed to provide a clean, and comfortable homelike environment to residents who resided at the facility. The lack of oversight to ensure equipment, and the environment was clean created a potential environmental hazard to the residents who resided at the facility. The deficient practice was observed in 10 rooms on 1 of 4 Resident units, and was evidenced by the following: On 11/07/22 from 10:10 AM to 11:47 AM, the surveyor conducted a tour of the 300's Unit low side and observed the following: The heating/cooling units in Rooms #303, #306, #310, #340, #344 revealed that all the heating and cooling units were covered with various bed linen, and the metal bases were covered with a rust like substance. The unit covers were missing in some of the rooms exposing copious amounts of embedded dirt, and dusty filters and debris stacked inside the heating and cooling units. Observations of Rooms # 304, #…
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 · E2022-11-23 · tag F0658 — failed to meet professional standards of care — patternEnsure 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, record review, and review of pertinent documents, it was determined that the facility failed to a.) apply physician ordered interventions that the staff signed as administered for Resident #105, 1 of 4 residents reviewed for wound treatments, and b.) administer medication with food as prescribed by the physician and improperly dispose of non-administered medication, for Resident #105 and an unsampled resident during medication administration observation. The evidence was as follows. a.) On 11/15/22 at 9:04 AM, Surveyor #2 observed Resident #105 lying in bed on his/her left side with both feet in direct contact with the bed. Surveyor #2 observed there were no heel protectors on the resident and no offloading of the resident's heels. A review of Resident #105's medical records revealed the following: An admission Record revealed he/she was admitted with diagnoses which included but were not limited to peripheral vascular disease (PVD - disease affecting the blood vessels), cellulitis (bacterial skin infection causing swelling and pain), unspecified…
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 · E2022-11-23 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to provide appropriate care for resident's who were dependent on staff to provide Activity of Daily Living (ADL) care. This deficient practice occurred for 4 of 4 dependent residents (Resident #49, #34 and #101 and #114) and on two of four resident care units (3rd and 4th floor) reviewed for ADL care and was evidenced by the following: 1. On 11/07/22 at 10:15 AM, the surveyor toured the 300's Unit of the facility and observed Resident #49 in bed with the head of the bed elevated, and was facing the door, and both feet rested directly on the mattress, and eyes were closed. The fingernails were observed as long and jagged, and contained a black coated substance underneath all of the fingernails. The upper lip and chin were covered with facial hair. When inquired about the resident's status to the Certified Nursing Assistant (CNA) observed in the resident's room at the time, the CNA 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.
- Potential for harm · E2022-11-23 · 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
Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to: a.) ensure that medications were administered in accordance with the physician order for 6 residents reviewed (Resident #3, #14, #24, #42, #92, #102) for two days (11/15/22 and 11/16/22), and b.) implement physician ordered interventions for 1 of 1 resident (Resident #105) reviewed for skin concerns. This deficient practice was evidenced by the following: a.) Surveyor #1 conducted a medication Pass Observation on 11/16/22 on the 300's Unit of the facility and observed that some of the medications were not available for administration. Resident #3 had diagnoses of essential hypertension and edema. Resident #3 had an order for Lasix (a loop diuretic) to be administered daily for edema. The documentation found on the Medication Administration Record (MAR) reflected that Resident #3 did not receive the Lasix on 11/15/22 and 11/16/22. Resident #14 had diagnoses of unspecified atrial fibrillation, hyperlipidemia, and cerebrovascular accident. 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 · E2022-11-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to: a.) ensure interventions to prevent falls were in place per a resident care plan, b.) complete a fall risk assessment post fall per facility policy, and c.) determine the causal factor after each resident fall and implement appropriate interventions to prevent recurrence. This deficient practice was identified for 1 of 1 resident (Resident #119) reviewed for falls, had experienced four falls, and was evidenced by the following: On 11/07/22 at 11:35 AM, the surveyor observed Resident #119 in the room, sitting in a wheelchair. The resident was alert, and unable to communicate with the surveyor due to a language barrier. A nurse informed the surveyor that there were staff that were able to communicate in Resident #119's native language. On 11/14/22 at 11:45 AM, the surveyor interviewed Resident #119's Certified Nurse Aide (CNA #1), who stated she was able to communicate with the resident in his/her native language. The surveyor asked CNA #1 if 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 · E2022-11-23 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure a.) resident with a gradual weight loss, who was at risk for pressure ulcers with an actual stage 2 pressure ulcer, was identified and interventions put in place to prevent worsening (Resident #49), b.) complete fall risk assessment was done post fall to identify causal factors and put interventions in place (Resident #119), c.) appropriate activities of daily living (ADL) care was provided (Resident #49, #34, #101, #114) and d.) a resident's known behaviors were documented and addressed (Resident #19). This deficient practice was evidenced by the following: Refer to: F 686, F 689, F 677, and F 742 a.) Resident #49 was observed on 11/07/22 in bed on his/her back. The surveyor observed that the lunch cart arrived at 11:50 AM. The surveyor returned to Resident's #49's room at 12:05 PM to find the resident still sleeping. At 12:15 PM, the resident's lunch tray was observed on the bedside table untouched and out…
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 · E2022-11-23 · tag F0742 — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 medical record review, it was determined that the facility failed to: a.) document target behaviors for residents who are receiving psychotropic medications, b.) implement nonpharmacological interventions, and c.) develop care plan interventions to manage the behaviors of residents who displayed combative and wandering behavior and exhibited difficult to redirect behavior that was unpredictable. This deficient practice was identified for Resident #19, one of 2 residents reviewed for behavior, and was evidenced by the following: During the initial tour on 11/07/22 at 10:37 AM, the surveyor observed a resident entering and exiting other residents' rooms. The resident was identified as Resident #19. On 11/07/22 at 10:40 AM, the surveyor asked the Unit Manager about challenging residents on the unit, she stated there were none. On 11/07/22 at 11:15 AM, the surveyor observed Resident #19 wandering in other resident's room. Resident #19 was talking out loud while ambulating in 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 · E2022-11-23 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to provide documentation that the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly. This deficient practice was identified for 2 of 4 meetings for the year 2022, and was evidenced by the following: On 11/07/22 at 10:47 AM during the entrance conference meeting, the Licensed Nursing Home Administrator (LNHA) stated the facility held quarterly QAPI meetings. On 11/14/22 at 10:45 AM, Surveyor #2 interviewed the Infectious Disease Doctor (IDD) via speaker phone (with permission) in the presence of the survey team. The IDD stated that his role has been mainly for education and antibiotic stewardship. The IDD stated that he was not aware that the facility had consistent cases of Candida Auris. The IDD stated, That is a new one. He further stated, I did not realize there was an outbreak of Candida Auris at the facility, and if I knew I would have helped them to address it. The IDD stated that he was unaware that here had been cases of Candida Auris at the facility since 2020.…
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 · D2022-11-23 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation it was determined that the facility failed to have call bell system in place for two resident (Resident #114 and #119) and on 1 of 4 Resident units. The deficient practice was evidenced by the following: On 11/07/22 at 11:45 AM, the surveyor interviewed Resident #114 while the resident was in a wheelchair in the room. The surveyor did not observe a call bell located near the resident and the inquired to the resident about the call bell. Resident #114 stated I don't even know if it works, and when they come, they come, and I cannot say on time. On 11/16/22 at 7:59 AM, the surveyor observed Resident #114 awake in bed, and there was no call bell attached to the wall, or by the resident. The Certified Nurse Aide (CNA) assigned to Resident #114 was in the room and the surveyor asked about the call bell for Resident #114, and he stated, it is not there. At that time, the surveyor observed the roommate, Resident #119 sleeping in bed and there was no call bell attached to the wall and accessible to the resident. The surveyor inquired to the CNA if he could show the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-09-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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.) use the appropriate personal protective equipment (PPE) for 1 of 2 staff, b.) disinfect the table prior to setting up equipment for tracheostomy (An opening created at the front of the neck so a tube can be inserted into the windpipe to allow direct access to the breathing tube) care, c.) properly dispose the inner cannula of the tracheostomy and used equipment. This was identified for 1 of 1 resident (Resident #92) reviewed for tracheostomy care, and e.) perform appropriate hand hygiene in 1 of 3 nurses observed during medication pass. This deficient practice was evidenced by the following: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines Summary for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during Shortages dated 4/9/21 indicated that Personal Protective Equipment: Respiratory Protection .Use surgical N95 respirators only for HCP [health…
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 · D2021-09-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services for a resident who was receiving a continuous oxygen treatment according to standards of practice. This deficient practice was identified for 1 of 2 residents (Resident #45) reviewed. This deficient practice was evidenced by the following: On 9/9/21 at 11:01 AM, the surveyor observed Resident #45 laying on a geri chair inside their room with oxygen via nasal cannula in use. On 9/13/21 at 12:00 PM, the surveyor observed a Certified Nursing Aide (CNA) feeding the resident in their room. The resident had oxygen via nasal cannula attached to the oxygen concentrator at 2 L/M (2 liters/minute). On 9/14/21 at 9:40 AM, the CNA informed the surveyor that Resident #45 was cognitively impaired, required total assistance with activities of daily living (adls) and a feeder. The CNA further stated that it was the nurse's responsibility to take care of the oxygen. The surveyor reviewed the medical record for Resident # 45. A review of 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 · D2021-09-23 · 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 record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 6 medication carts inspected. This deficient practice was evidenced by the following: On 9/15/21 at 10:15 AM, the surveyor inspected the 3rd floor high side medication cart in the presence of a Licensed Practical Nurse (LPN). The surveyor observed two opened Novolog Insulin vials that were inside a bag that contained a different resident's name than were on the insulin vial. At that time, the surveyor interviewed LPN who stated that the Novolog insulin vials should have been placed in the bag with the corresponding names. She stated that she should have double checked to make sure she was placing the vial into the right bag. On 9/15/21 at 1:15 PM, the surveyor met with the Licensed Nursing Home Administrator and the Director of Nursing (DON), and no further information was provided by the facility. A review of the facility's policy for Medication Storage dated 4/14 that was provided by the DON indicated the following: E).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2022-11-23 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, it was determined that the facility failed to ensure that the 24-hour staffing information was posted and displayed in a place that was readily accessible to residents, family members, and the public. This deficient practice was evidenced by the following: The surveyor did not observe the 24-hour staffing information posted in a prominent area that was readily accessible to the public, residents or visitors on 11/9/22, 11/10/22, 11/14/22, 11/15/22, 11/16/22, and 11/18/22. This deficient practice was evidenced by the following: On 11/9/22 at 8:40 AM, 11/10/22 at 8:42 AM, 11/14/22 at 8:45 AM, 11/15/22 at 8:30 AM, and 11/18/22 at 8:33 AM, the surveyor observed the facility's Alliance Staffing Sheet in a clear plastic sleeve at the receptionist desk. The staffing sheet listed the date, name of the facility, day shift, evening shift, and night shift. It did not include the total number and the actual hours worked by the licensed and/or unlicensed personnel. On 11/16/22 at 10:23 AM, the surveyor interviewed the Staffing Coordinator…
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 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 | 2 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 | 4 of 5 | 4.2 | -0.2 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 |
|---|---|---|---|---|
| LEIFER, JOEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/20/2021 |
| ZUPNICK, JOEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/20/2021 |
| WOODARD, KEVIN | Individual | W-2 MANAGING EMPLOYEE | — | since 12/20/2021 |
| STERN, SAMUEL | Individual | CORPORATE OFFICER | — | since 12/20/2021 |
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 75% 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 $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 315359. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-17, 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 →
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