Peace Care St Ann's
198 Old Bergen Road, Jersey City, NJ 07305 · Non profit - Corporation · 120 certified beds · (201) 433-0950 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection 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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — 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 fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.3% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.7% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.3% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 6.9% | 12.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.3% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.3% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.7% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.6% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.4% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 13.8% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.3% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.2% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.8% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.0% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.37 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.21 | 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.
57.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 297 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 31.3% 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 166 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 47% 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 | 57.0%CMS range 51.5–61.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.2%CMS range 10.6–16.4 | 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 | 31.3% | 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 | 25.3% | 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 | 54.2% | 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 | 71.7% | 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 | 98.1% | 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 | 99.3% | 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 | 0.4% | 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 | 8.7%CMS range 6.0–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 120 beds and averages 112.0 residents a day — about 93% occupied, or roughly 8 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 3.66 hrs/resident/day on weekends vs 4.01 on weekdays — 9% thinner on weekends. RN hours go from 1.09 to 0.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · F2026-03-09 · 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 the 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 the management of staffing contingency plans in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 107 residents who currently live in the facility.This deficient practice was evidenced by the following:During the entrance conference on 3/3/26 at 10:08 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the Facility Assessment (FA). The LNHA stated that the facility's census (the number of residents currently under the care of a specific facility) was 107.A review of the facility's Facility Assessment with resident population profile dates from 8/11/24 to 8/10/25, did not include information about the facility's contingency plan for staffing and grid to follow for staffing.A review of the Nurse Staffing Report (NSR) for the week from 8/31/25 to 9/13/25, 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 · E2026-03-09 · 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, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 2 of 3 units (2nd and 3rd floors), 2 of 3 Residents rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), and common areas (3rd floor family room, 2nd and 3rd floors dining rooms, 2nd and 3rd floors Bather, 2nd and 3rd floors hallways, and 2nd floor soiled utility room) and was evidenced by the following:The deficient practice was evidenced by the following: 1.On 3/3/26 at 10:18 AM, Surveyor #1 (S#1) observed the 3rd floor Certified Nursing Assistant (CNA) charting area on the low side, the desk with peeling wood on the lower drawer. S #1 interviewed the Licensed Practical Nurse (LPN) who confirmed that the wood was peeling and that residents will use the phone on the desk to make phone calls. The LPN stated that she did not know how long the drawers have been like that and work orders were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-09 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of pertinent facility documents, it was determined that the facility failed to verify the credentials and substantiated findings for staff in the Criminal Background Screening Report and reference checks prior to date of hire in accordance with the facility's abuse policy and procedure for the screening of newly hired employees. This deficient practice was identified for 9 of 79 newly hired employees (Staff #24, #33, #42, #43, #56, #64, #69, #71, and #78) as evidenced by the following: 1.On 3/5/26 at 1:20 PM, Surveyor #1 (S #1) reviewed total of 30 new employee files and revealed: A review of Staff #24's file, a Recreation Aide, with a date of hire (DOH) of 7/9/25, revealed a criminal background screening report (CBSR) dated 7/22/25. The CBSR was completed after Staff #24's DOH. A review of Staff #33's file, a Certified Nursing Aide, with a DOH (rehired) of 12/29/25, revealed a CBSR dated 3/9/26. The CBSR was completed after Staff #33's DOH. A review of Staff #42's file, a Certified Nursing Aide, with a DOH of 11/17/25, revealed a CBSR dated 3/9/26. 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 · E2026-03-09 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint NJ#2616278Based on interviews, record review, and review of facility provided documents, it was determined that the facility failed to provide information to the resident or the Resident Representative (RR) that explains the Bed Hold and Reserve Bed Payment policy. This deficient practice was identified for 3 of 3 residents, (Resident #11, #129, and #132), reviewed for discharge process.The deficient practice was evidenced by the following: 1. A review of closed medical records revealed that Resident #132 had an acute transfer on September 2025 due to diagnoses of hypernatremia (high sodium concentration in the blood) and sepsis (serious condition in which the body responds to an infection). On 3/4/26 at 1:49 PM, Surveyor #1 (S#1) reviewed Resident #132's medical records (MR) which revealed an admission Record (AR; an admission summary) diagnoses that included but not limited to, cerebral infarction (stroke), Parkinson's disease (neurodegenerative disorder) with dyskinesia (movement disorder) without mention of fluctuations, unspecified dementia, unspecified severity,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ #2616278Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents received care consistently with professional standards of practice, by failing to; a.) monitor, evaluate, report and document changes in the skin condition as soon as identified b.) develop a relevant care plan that includes measurable goals for management of pressure ulcer/pressure injuries (PU/PIs) with appropriate interventions c.) use clean technique for PU/PI dressing protocols, and d.) utilize a formal method of evaluating PU/PIs in accordance to facility's policies. This deficient practice was identified for 4 of 5 residents (Resident #17, #118, #131, #132) reviewed. 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-09 · 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, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that residents that received oxygen (O2), and nebulizer treatments received the necessary respiratory care and services, according to the standard of clinical practice, specifically that respiratory equipment were stored in accordance with infection control measures and develop an individualized care plan for 4 of 4 residents reviewed for respiratory care (Resident #5, #76, #119 and #130). 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 3 of 22 residents (Residents #1, #10, and #96) call bells were within reach and able to use to accommodate residents' needs.This deficient practice was evidenced by the following:On 3/3/26 at 10:09 AM, during an initial tour of the facility, the surveyor observed Resident #10, seated in a chair, with the call bell device wrapped around a siderail, and hung down past the bed between the bed and the wall. On that same day at 10:31 AM, the surveyor observed Resident #96, in bed with a breakfast tray. The surveyor observed the call bell device hung off the bed near the floor. The surveyor asked the resident how they call for help if they need it, and the resident stated that they use the button, and someone comes. While the surveyor was in the resident's room, a Certified Nurse Aide (CNA) from an outside provider and assigned to Resident #96 entered the room and greeted the resident. The CNA took the call bell and placed it on the resident's bed where it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for 2 of 25 residents, (Residents #1 and #130), reviewed for Minimum Data Set (MDS).This deficient practice was evidenced by the following:According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2025 showed:An SCSA must be completed within 14 days of determining a significant change from baseline.The resident's condition is not expected to return to baseline within two weeks.Comparison with the most recent comprehensive and quarterly assessments is crucial.Criteria for SCSA include two areas of decline or improvement, or IDT (Interdisciplinary team) recommendation.Documentation of criteria met is essential in the resident's medical record.Required for various scenarios like hospice enrollment, a consistent pattern of changes,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, it was determined that the facility failed to transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 2 of 25 residents, (Residents #1 and #131), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2025, revealed:The Entry tracking record, the transmission date no later than entry date + 14 calendar days.The Discharge Return Not Anticipated (DRNA), the transmission date no later than the MDS completion date + 14 calendar days.1. The Surveyor reviewed the medical records of the following residents and their MDS and revealed:A review of Resident #1's Entry MDS with an assessment reference date (ARD) of 12/26/25, was completed on 1/2/26, and transmitted on 1/10/26. The transmission date was two days late.A review of Resident #131's DRNA MDS with an ARD of 1/5/26,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 5 of 25 residents, (Residents #1, #4, #119, #131, and #133), reviewed for MDS accuracy.This deficient practice was evidenced by the following: 1.On 3/6/26 at 8:04 AM, Surveyor #1 (S #1) reviewed the medical records of Resident #1 and revealed: A review of the admission Record (AR; an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; type 2 diabetes mellitus without complications, other seizures, dementia in other diseases classified elsewhere, unspecified severity, and difficulty in walking, not elsewhere classified. A review of the Misc (miscellaneous) tab in electronic medical records revealed a Visit Report dated 10/15/25, a wound visit notes that the sacrum wound measurement was 2 x 3.5 x 0.2 cm (centimeter) and was a stage 3 (not healed). A review of the Misc tab…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Dcited before2026-03-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure expired resident-use supplies were removed from medication (med) storage areas and med storage areas were maintained in accordance with professional standards of nursing practice. This deficient practice was identified in 2 of 2 med rooms reviewed for med storage and label review.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 or 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · 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, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure residents who received enteral feeding received care in accordance to standard of practice by failing to, a.) properly label enteral feeding equipment and b.) total volume was documented and order was clarified. This deficient practice was identified for 2 of 3 residents (Residents #5 and #11) reviewed for enteral feeding.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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and review of other facility documentation, it was determined that the facility failed to ensure that the physicians must review the residents' total program of care including medications and treatments and write and sign history and physical and other succeeding visit notes. This deficient practice was identified for 1 of 25 residents, (Resident #131), reviewed for physician services.This deficient practice was evidenced by the following:On 3/5/26 at 10:23 AM, the surveyor reviewed the medical records of Resident #131 and revealed:A review of the hospital discharge medication (med) list revealed that Resident #131 to Continue taking this med and follow the directions you see here for med furosemide 40 mg (milligram) tablet (tab), take 0.5 tab (20 mg total) by mouth one time each day.A review of January 2026 Orders, electronic Medication Administration Record (eMAR) did not reflect an order for furosemide 40 mg tab.Further review of the medical records revealed there was no documentation as to why the furosemide was not ordered. There was no documented evidence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by documenting an incorrect indication or diagnosis (Resident #4) and failure to monitor requested laboratory results (Resident #7) for 2 of 5 residents reviewed for unnecessary medications.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 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.1. The surveyor reviewed Resident #4's hybrid medical record (paper and electronic) and revealed the following.A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · 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 documents, it was determined that the facility failed to properly store and secure medications per standards of practice. This deficient practice was identified in 1 of 6 medication carts (med cart) observed during the medication pass (med pass) observation and 1 of 6 med carts observed while touring the facility.This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 3/5/26 at 1:54 PM, the surveyor, toured the 1st floor, observed a med cart, later identified as District 1 med cart, that was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene for 1 of 2 soiled utility rooms (room [ROOM NUMBER]) and b.) ensure that the eyewash stations were maintained clean and scheduled flushing was followed for 2 of 2 eyewash stations (rooms [ROOM NUMBERS]) and follow appropriate infection control practices, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy.This deficient practice was evidenced by the following:According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient .Before moving from work on a soiled body site to a clean body site on the same…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-09 · tag F0944 — isolatedConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 2 of 5 Certified Nursing Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following:On 3/4/26 at 12:06 PM, the surveyor requested from the License Nursing Home Administrator (LNHA) five randomly selected CNA files. On 3/5/26 at 1:55 PM, the surveyor reviewed the mandatory annual education hours for five randomly selected CNA files, which were provided by the facility. The Staff In-service Logs revealed the following: CNA #1, date of hire (DOH) of 8/1/22, Transcript Hours did not include QAPI training. CNA #2, DOH of 10/3/2018, Transcript Hours did not include QAPI training.On 3/6/26 at 9:35 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the Director of Staff Educator was responsible for CNA education. On 3/6/26 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 before2025-08-21 · 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
Complaint #: 413630Based on interviews, medical record review, and review of other pertinent facility documentation on 8/21/2025, it was determined that the facility nursing staff failed to consistently document on the Medication Administration Record (MAR) according to the acceptable standards of nursing practice for 2 of 5 residents (Resident #3 and Resident #4) reviewed for medication administration documentation.This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing…
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 F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure dignity was provided to one (Resident (R)165) out of one resident regarding grooming, in that nursing staff failed to remove excessive facial hair on a female resident's chin. This deficient practice could compromise the resident's dignity and comfort. Findings include: Review of the facility's undated policy titled, Activities of Daily Living (ADLs)revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate .care and services will be provided for the following activities of daily living: 1.grooming . Review of R165's Face Sheet located in the Electronic Medical Records (EMR) under the Profile tab revealed R165 was admitted to the facility on [DATE]. Review of R165's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/04/24, located in the EMR under the MDS tab…
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 F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to accurately code the Minimum Data Set (MDS) for one (Residents (R) R62) of two residents reviewed for anticoagulant medications. Inaccuracy of the MDS could lead to problems in the care area not being addressed appropriately in the care plan. Findings include: Review of the RAI manual, dated 10/24 located at https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf revealed N0415: High-Risk Drug Classes: Use and Indication, Coding Instructions .Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period (or since admission/entry or reentry if less than 7 days). Column 2: If Column 1 is checked, check if there is an indication noted for all medications in the drug class .Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to maintain acceptable nutritional parameters by not monitoring weights for accuracy, assessing weight changes, implementing interventions, monitoring meal intake, and/or providing meal assistance for two (Residents (R)49 and R52) of three residents reviewed for nutrition in the sample of 42 residents. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place. Findings include: Review of the facility's policy titled Clinical Nutrition Services, dated 10/24, provided by the facility revealed, The dietitian/qualified nutrition professional identifies residents who are at risk and/or potential risk for nutrition-related problems. The dietitian/qualified nutrition professional recommends interventions to maintain the resident's nutrition status, based on resident preference and tolerance .For residents at nutritional risk: Determine appropriate interventions based…
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, interviews, record review, review of facility policies, and Centers for Disease Control (CDC) and Prevention guidance, the facility failed to clean and disinfect patient equipment after use for two of five residents (Resident (R) 16 and 54) reviewed for infection control and failed to follow hand hygiene practices during medication pass for one of five residents (R7) reviewed for medication administration. These failures could promote the spread of multi drug resistant organisms (MDROs) throughout the facility. Findings include: 1. Review of R16's undated admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 06/20/15. The admission Record revealed diagnoses of atrial fibrillation and hypertension. Review of R16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/05/24, located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R16 was cognitively intact. During an observation in R16's room on 10/16/24 at 8:20 AM, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-11-22 · 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: a.) the facility failed to store and serve potentially hazardous foods in a manner to prevent food borne illness in 3 of 3 Bistros, and b.) failed to maintain refrigerator temperatures and store food at the correct temperature for 1 of 3 Bistro refrigerators. This deficient practice was evidenced by the following: On 10/31/2022 at 10:46 AM, in the presence of the first floor Registered Nurse/Unit Manger (RN/UM) the surveyor observed the following: The surveyor observed on the first floor Bistro: 1.) The refrigerator had a clear, small bin that housed pre-sliced bologna deli meat wrapped in clear plastic wrap. The pre-sliced bologna was labeled and dated with an expiration date of 10/27/22. 2.) The refrigerator thermometer read 50 degrees Fahrenheit (F). The surveyor observed on the second floor Bistro: 3.) The refrigerator had a clear, small bin that housed pre-sliced ham and bologna deli meat wrapped in clear plastic wrap. The ham was labeled and dated with an expiration date 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 · D2022-11-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person centered care plan for an unstageable wound. This deficient practice was identified for 1 of 6 residents, (Resident # 9) reviewed for pressure ulcer injury. This deficient practice was evidenced by the following: On 11/2/22 at 11:51 AM, the surveyor observed Resident #9 out of bed seated in a wheelchair in the dayroom. The resident greeted the surveyor with a smile but was unable to answer any questions. The foot rest on the resident's wheelchair had a blue padded foot rest attached to the bottom of the wheelchair. On 11/16/22 at 10:00 AM, the surveyor in the presence of the Registered Nurse Unit Manager (RN/UM) and a Licensed Practical Nurse (LPN) observed the wound on the residents left foot. The LPN described the wound as a dry hard scab. The LPN further stated that she applied skin prep and left the wound open to air as ordered. The LPN and RN/UM further described the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-22 · 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 identified that the facility failed to appropriately transcribe a Physician's Order (PO) for the recommendation of a skin care treatment. This deficient practice was identified for 1 of 1 resident reviewed, (Resident #52) for general skin conditions. 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 casefinding, 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 10/31/22 at 10:43 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding residents on the unit that had skin impairments. The RN/UM stated that Resident #52 had a rash that was a fungal…
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 · D2022-11-22 · 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 record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice to accurately administer a medication, Potassium Chloride Extended Release to 1 of 7 residents, (Resident #47) by 1 of 3 nurses observed during the medication administration observation. 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 Practice Act for the State of New Jersey states: The practice…
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 · D2022-11-22 · tag F0851 — isolatedElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of two PBJ Report submissions reviewed, (Fiscal Year Quarter 3 2022, April 1 - June 30) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the third fiscal year quarter to the CMS. The dates of the third quarter included April 1, 2022, through June 30, 2022. On 11/01/22 at 10:17 AM, the facility's Administrator stated that the PBJ Report for the third quarter was not submitted on time and rejected by CMS because it was late. At that time, the facility's Administrator provided the survey team with documentation in electronic mail (e-mail) from CMS. A review of the e-mail dated, August 19, 2022 and timed at 7:14 AM from CMS indicated that the third quarter PBJ Report was not accepted because the facility did not submit the report in 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.
“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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PEACE CARE INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 06/01/2016 |
| PEACE MINISTRIES INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 06/01/2016 |
| BACKIEL, CHRISTINE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 06/30/2024 |
| BUCCIANTI, SILVANA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 06/30/2022 |
| DOREN, ELIZABETH | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 06/30/2022 |
| REYES, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| FRIENDS SERVICES FOR THE AGING | Organization | ADP OF THE SNF | — | since 05/01/2018 |
| NATIONAL LUTHERAN INC. | Organization | ADP OF THE SNF | — | since 01/01/2023 |
| PHARMACCURATE, LLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| STEVER ADVISORS, LLC | Organization | ADP OF THE SNF | — | since 05/12/2023 |
| UNIDINE CORPORTATION | Organization | ADP OF THE SNF | — | since 11/05/2013 |
| MOUSSA, GHIAS | Individual | ADP OF THE SNF | — | since 04/15/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
7 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 $681K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 315413. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-09, 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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