Peace Care St Joseph's
537 Pavonia Avenue, Jersey City, NJ 07306 · Non profit - Corporation · 139 certified beds · (201) 653-8300 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $170,052 in federal fines (most recent 2024-02-20)
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 9.9% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.7% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.4% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.1% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.6% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.5% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.1% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.7% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.2% | 15.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.2% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.6% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.5% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.1% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.78 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.99 | 1.11 | 1.80 | worse |
‡ 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.
57.9% 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 287 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.3% 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 140 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 57.9%CMS range 51.1–63.6 | 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 | 11.1%CMS range 8.4–14.0 | 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 | 64.3% | 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 | 54.3% | 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 | 69.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 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 | 7.5%CMS range 4.6–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 139 beds and averages 124.7 residents a day — about 90% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.09 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above 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 4.20 on weekdays — 13% thinner on weekends. RN hours go from 1.14 to 0.96 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2023-08-22 · 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 Complaint # NJ00161813 Based on interview and record review it was determined that the facility failed to provide effective care and services to promote healing of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. Resident #105's right heel wound was left untreated for more than a month. During this period the wound's length doubled in size. The deficient practice was evidenced by the following: The surveyor reviewed Resident #105's closed hybrid medical record which revealed the following information. The admission Record indicated the resident was admitted to the facility from the hospital on [DATE]. The nurse documented in a 12/5/22 admission Summary Progress Note that the resident had a small skin opening on the coccyx and an Ace Wrap (an elastic bandage wrap) on the right lower extremity. The nurse documented in a 12/6/22 Nursing admission Screening/History report that the resident was admitted with a fibula and tibia fracture (not indicating whether left or right leg) and a Stage II…
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 before2026-04-15 · 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 record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner for 3 of 4 kitchenettes (2nd, 3rd, 4th), and b) maintain kitchen equipment in a clean, safe and sanitary manner 4 of 4 pantries (1st, 2nd, 3rd, 4th), on the nursing floors as evidenced by the following. On 4/09/26 at 11:50 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following on the nursing units:The kitchenette microwaves had multicolored food debris on the interior ceiling of the units for 3 of 4 units, (2nd, 3rd, and 4th). The FSD acknowledged and agreed that they were not cleaned according to facility policy. The pantry microwaves had multicolored food debris on the interior ceiling of the units and food particles on the rotating tray for 3 of 4 units (2nd, 3rd, and 4th). The FSD acknowledged and agreed that they were not cleaned according to facility policy. The refrigerators on 2 of 4unit pantries, (1st and 3rd,) were observed to have copious amounts of standing water on 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 · D2026-04-15 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint NJ# 2593527Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to include a resident in the planning of care by informing them of the risks and benefits of proposed care. This was observed in 1 of 2 residents (Resident #109), reviewed for use of anticoagulant medications.The deficient practice was evidenced by the following: On 4/9/26 at 11:11 AM, the surveyor interviewed Resident # 109 The surveyor asked the resident about his concerns with a discontinued medication in August of 2025. The resident answered My Eliquis was stopped at the end of May and The doctor never talked to me about it, there was no notice, no discussion, I found out when the cariologist caught it in July. The resident added The doctor never discussed it with my sister either. The cardiologist restarted it the day I saw him in July, and he figured out it was stopped. The resident acknowledged his sister was his durable power of attorney for health care. A review of Resident # 109's admission record indicates he was admitted to 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 · D2026-04-15 · 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 observation and interview it was determined the facility failed to maintain the residents' living environment in a safe and homelike manner for 1 of 25 residents (Resident #12) reviewed. The deficient practice was evidenced by the following:On 4/8/26 at 12:15 PM, the surveyor observed Resident # 12 in bed. The surveyor observed a bed controller with the cord attached to it, which was laying on the resident's bedside. The cord sheath attached to the bed controller was broken in several areas and the wires were exposed. The resident stated that the cord was like that for many months and the resident had told the facility about it a while ago but it was never fixed.At 12:41 PM, the surveyor asked the Licensed Practical nurse (LPN), who cared for Resident # 12, to come into the resident's room. The surveyor showed the LPN the broken cord sheath. The LPN stated that she did not notice that the cord sheath was broken and she had been in the resident's room around about 11:45 AM.At 12:49 PM, the surveyor interviewed the Director of Nursing (DON), who also stated that she did 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 · D2026-04-15 · 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
Complaint NJ-2803539 Based on observation, interview, and record review it was determined that the facility failed to ensure 1 of 2 residents (Resident #14) was free from neglect. The facility failed to provide personal care and assistance from the assigned Certified Nursing Assistant (CNA) for one 8-hour shift. The deficient practice is evidenced by the following.On 4/9/26 at 10:40 AM, the surveyor observed the resident awake in bed. The resident spoke to the surveyor in Arabic and did not understand the English language. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated a translator phone number is posted in the resident's room to communicate with the resident. He stated the resident's 2 daughters visit daily during the day shift.A review of the electronic medical record (EMR) revealed the following information.The 3/4/26 admission Minimum Data Set (MDS) assessment tool indicated that the resident had no cognitive deficits and exhibited no mood or behavioral concerns. The resident was noted to be independent eating meals after staff set-up 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 · D2026-04-15 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that the facility failed to ensure newly hired employees underwent criminal background checks before they began employment at the facility. The deficient practice was identified for 9 of 82 employee records reviewed (Employee #12, 13, 14, 17, 34, 38, 54, 55, 67). The deficient practice is evidenced by the following. On 4/13/26 and 4/14/26, the surveyor reviewed the Human Resources records including Criminal Background Investigations (CBI) for 82 employees who were hired since the previous Department of Health Recertification Inspection. The following concerns were revealed.Employee #12, a Certified Nursing Assistant (CNA), began employment on 10/20/25. The CBI was requested by the facility on 10/27/25.Employee #13, a nurse, began employment on 10/20/25. The CBI was requested on 2/10/26.Employee #14, a nurse, began employment on 12/15/25. The CBI was requested on 2/9/26.Employee #17, a nurse, began employment on 5/5/25. The CBI was requested on 10/3/25.Employee #34, a housekeeper, began employment on 6/2/25. The CBI was requested…
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 · D2026-04-15 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 (one) of 1 resident (Resident#104), system selected for resident assessment for MDS record over 120 days old. This deficient practice was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1) the Assessment Reference Date (ARD) of the Quarterly MDS (QMDS) was within 92 days after the ARD of the previous MDS, and 2) the completion date was no later than 14 days after the ARD. On 4/12/26 at 10:00 AM, the surveyor reviewed the electronic Medical Record (eMR) 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 · Dcited before2026-04-15 · 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 observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to a) provide pharmaceutical services in accordance with professional standards to ensure signing from the reconciliation form Controlled Drug Administration Record Tablet (CDART; declining inventory log) form after the dispensed and administered a controlled dangerous substance with high potential for drug diversion medication for 1 (one) of 1 resident (Resident #107) and b) follow physician orders for 1 of 1 resident (Resident #5) reviewed for medication storage and labeling. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding,…
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 · D2026-04-15 · tag F0836 — isolatedEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #2613352Based on interview, and review of facility documentation, it was determined that the facility failed to provide services in compliance with applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles for a resident who was denied admission to the facility to provide services. This deficient practice was identified for 1 of 3 residents' referrals reviewed, Resident #138.This deficient practice was evidenced by the following:Reference: According to the Centers for Disease Control (CDC) guidelines dated 4/24/24, the Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) for Candida Auris (C. Auris; a multidrug- resistant fungus that can cause severe infections in very sick, vulnerable patients) are similar to those used for other multidrug-resistant organisms (MDROs). In most instances, facilities equipped to care for patients with other MDROs can also care for patients with C. Auris. In nursing homes and skilled nursing facilities, healthcare providers should use either Contact…
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 before2026-04-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control measures to prevent the potential spread of infection for failing to ensure a midline intravenous (IV) connector cap was properly secured for 1 of 1 residents (Resident # 12) with a midline IV.The deficient practice was evidenced by the following: On 4/8/26 at 12:15 PM, the surveyor observed Resident # 12, in bed, with a midline IV on the resident's left arm with a date of 4/6/26 on the dressing which covered the IV site. The surveyor observed that the midline IV line was clamped but the connector was uncapped. The resident stated that the nurses gave the resident medicine in the IV yesterday.A review of the resident medical records revealed the following:Resident # 12 was admitted with diagnoses which included, but were not limited to sepsis and cellulitis of right lower limb.The Quarterly Minimum Data Set (MDS) (an assessment tool), dated 2/3/26, revealed that Resident # 12 had a Brief Interview for Mental Status (BIMS) score of 15/15, that…
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 before2024-11-07 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) consistent maintenance of the system of record keeping of the Drug Enforcement Agency (DEA) order Form-222 (a federal narcotic requisition form), that enabled accurate reconciliation of controlled-dangerous substances (narcotic medications, that due to their high potential for abuse, are tracked with a degree of detail and attention) that was ordered and received, b) the development and implementation of policy and procedure for DEA order Form-222, c) removal and disposition of a discharged Resident's medication from the active inventory, and d.) properly label an opened blood glucose test strip. The deficient practice was identified for five (5) of 12 DEA Form-222s reviewed, one (1) of two (2) medication storage rooms, one (1) of three (3) medication carts inspected during the medication storage and labeling observation. The evidence was as follows:…
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 15 citations
- Potential for harm · Ecited before2024-11-07 · 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
REPEAT DEFICIENCY Based on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 4 of 4 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: On 10/31/24 at 10:00 AM, upon entrance conference, the surveyor requested to review the QA meeting sign in sheets for the last few quarters of QA meetings held. On 11/4/24 at 10:30AM, the surveyor received QA meeting sign in sheets dated, 10/17/24, 7/18/24, 4/18/24 and 1/18/24, which revealed that the Infection Preventionist (IP) was not in attendance for any of those scheduled meetings. At 10:35 AM, the surveyor interviewed the Administrator who stated that if the IP is in the building during the QA meeting, then, she will attend and could not explain why she was not in attendance for those 4 QA meetings. The surveyor reviewed the Infection Preventionist policy and procedure, dated 2/2024, which revealed that the facility's IP must have time necessary to participate in required…
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 before2024-11-07 · 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) maintain infection control standards and procedures during wound care treatments for 2 of 5 residents (Resident #181, #6) reviewed for care and services for pressure ulcers, b) provide a safe and sanitary environment to prevent the potential spread of infection and cross-contamination to both residents and staff by sharing personal care items between residents and a linen cart which contained linen for multipe residents was brought into a Resident room (room [ROOM NUMBER]) and then back out into the hallway, observed for 1 of 3 CNAs (CNA #1) on 1 of 4 nursing units, (4th-floor unit) and c) failed to practice acceptable hand hygiene as recommended by the CDC. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for 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 · E2024-11-07 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure pneumococcal vaccination was offered according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations for Residents #23, #36 and #83. This deficient practice was identified for three (3) of five (5) residents reviewed for immunization status. The deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 9/12/24, included the following. The CDC recommends a single dose of PCV21 (pneumococcal 21-valent conjugate vaccine; Capvaxive), PCV20 (pneumococcal 20-valent conjugate vaccine), or PCV15 (pneumococcal 15-valent conjugate vaccine) greater than or equal to 1 year after the last PPSV23 (pneumococcal 23-valent polysaccharide vaccine; Pneumovax23) dose. Reference [previous guidelines] A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Resident #22, #109, and #87) observed for incontinence care on 1 of 3 units, the 4th floor Unit. This deficient practice was evidenced by the following: a. On 11/4/24 at 11:55 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) on the 4th floor unit. CNA #1 stated that she had 8 residents on her assignment and was also helping another aide with some of their residents. On 11/4/24 at 12:00 PM, the surveyor and CNA #1 entered Resident #22's room and observed the resident in bed. CNA #1 stated that she had not provided care to Resident #22 yet as she was very busy all morning. The CNA exposed Resident #22's incontinence brief which was saturated with urine. At that time when CNA #1 exposed the incontinence brief another incontinence brief was observed…
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 · D2024-11-07 · 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, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 1 resident, (Resident #6). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 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…
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 · D2024-11-07 · tag F0725 — failed to have enough nursing staff — isolatedProvide 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, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide (CNA) to every eight residents for the day shift; (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members…
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 before2024-09-20 · 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 interviews, record review, and review of pertinent facility documentations, it was determined that the facility failed to ensure medication orders for a newly admitted resident from the hospital were completely and accurately relayed to the Attending Physician (AP). On the day Resident #1 was admitted to the facility, there were six discontinued medications not clarified with the AP for continuance. This deficient practice was observed in one of three newly admitted residents (Resident #1) reviewed for admission orders as evidenced by the following: According to Resident #1's admission Record (AR), the Resident Information revealed that Resident #1 had diagnoses of which included but not limited to Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis without Necrosis or Infection. According to the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities and helps the facility identify…
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 · D2024-09-20 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and review of pertinent facility documentations, it was determined that the facility failed to keep an accurate and complete list of Resident #1 discharged medical records from the hospital which entailed important medication discharge instructions for reference upon admission of the Resident to the facility. This deficient practice was evidenced in one out of three residents (Resident #1) reviewed for admission orders as follows: According to Resident #1's admission Record (AR), the Resident Information revealed that Resident #1 had diagnoses of which included but not limited to Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis without Necrosis or Infection. According to the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities and helps the facility identify residents' health problems, dated 06/07/2024, showed that Resident #1 Brief Interview for Mental Status (BIMS) Summary Score is 15 which indicated Resident's cognition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-22 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to a.) assess for complications upon their return from the renal dialysis center for 2 of 2 residents (Resident #61, and #49) and b.) consistently monitor fluid restriction instructions in accordance with the physician's order for 1 of 2 resident (Resident #49) reviewed for dialysis care. The deficient practice was evidenced by the following: 1. The surveyor observed Resident #61 awake in bed on 8/14/23 at 11:41 AM. At that time, the unit Licensed Practical Nurse (LPN #1) stated the resident went to the renal dialysis (RD) clinic on Tuesdays, Thursdays, and Saturdays. The LPN stated an assessment of vital signs and the RD access site prior to leaving for the RD clinic and upon return from the RD clinic were documented in electronic nurse progress notes. A review of the hybrid medical record revealed the following information: The 6/15/23 Quarterly Minimum Data Assessment (MDS) tool indicated the resident had end stage renal disease and was dependent on renal dialysis (Section I). 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 before2023-08-22 · 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 assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 2 of 2 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: On 8/09/23 at 10:25 AM , the surveyor requested to review the QA meeting sign in sheets for the last 2 quarters dated April 26, 2023 and January 25, 2023 upon entrance. On 8/10/23 at 10:00 AM, the Administrator asked the surveyor for more time to locate the QA meeting sign in sheets. On 8/14/23 at 9:40 AM, the Administrator stated that he needed more time to find the QA meeting sign in sheets, as the person who was responsible for holding those documents is away on vacation and unable to be reached. He stated that he will look one more time in that person's office to locate the sign in sheets. On 8/15/23 at 9:24 AM, the Administrator stated that he cannot locate the QA meeting sign in sheets and that there were QA meetings held in January 2023 and April 2023. The Administrator stated that he does…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-22 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 5 of 24 residents reviewed (Residents #34, 49, 52, 48, and #84). The deficient practice was evidenced by the following: 1. On 08/10/23 at 10:10 AM, the surveyor observed Resident #34, eyes closed, sitting in the wheelchair in front of the nurses' station, talking to the other residents. The surveyor reviewed the medical records of Resident #34, which revealed the following: The Significant MDS (SMDS), dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating that the resident's cognition is severely impaired. The SMDS Section J Fall History on Admission/Entry/Reentry was coded 0 (zero) or No, which did not reflect the resident's fall incident on 7/02/23. The Care Plan initiated on 7/02/23 reflected, Focus: Is at risk for falls r/t Gait/balance problems/Vision problems (legally blind) actual fall 7/2/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-22 · 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 a comprehensive, person-centered care plan addressing a resident's continence (Resident #48) and addressing a resident's hospice care (Resident #52). The deficient practice was observed for 2 of 23 residents reviewed for comprehensive care plans and is evidenced by the following: 1. The surveyor observed Resident #48 awake in bed on 8/9/23 at 12:03 PM. The surveyor interviewed the unit Licensed Practical Nurse (LPN #1) on 8/18/23 at 11:32 AM. She stated the resident was admitted with an external urinary catheter and had begun to use a urinal. Additionally, the Certified Nursing Assistant (CNA #1) stated the resident had bowel movements in the adult incontinence brief and called staff to be cleaned. A review of the hybrid medical record revealed the following information: The 5/11/23 Skilled Charting tool, documented by nursing, indicated the resident was incontinent of urine and used an external urinary…
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 before2023-08-22 · 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 to a.) accurately document the administration of medications in the electronic administration record and electronic treatment administration record, and b.) clarify duplicate physician's orders for an over-the-counter pain patch (Lidocaine) and document the removal of the Lidocaine patch. The deficient practice occurred for 5 of 9 residents, (Resident #34, #48, #49, #52 and #67) reviewed for medication management. 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…
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 before2023-08-22 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, record review and policy review, it was determined that the facility failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 8/9/23 at 11:48 AM, in the presence of the Food Service Director (FSD) and the Administrator, the surveyor observed the following: On a shelf near the wall of the kitchen, the surveyor observed eight quarter sized deep-set steam table pans stacked with water between them, 15 eighth sized steam table pans stacked with water between them, and 12 small square steam table pans stacked with water between them. The FSD stated that these should be air dried before stacking. The surveyor reviewed the ware washing policy and procedure dated 10/1/22, which revealed that once equipment or utensils onto a clean surface to air dry and once equipment and utensil are completely air dried, they can be returned to storage. NJAC 8:39-17.2(g)
- Potential for harm · Dcited before2023-08-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to a.) adhere to accepted standards of infection control practices for the proper disposable of gloves, b.) implement hand hygiene between glove changes during care, and c.) perform proper hand washing to prevent the spread of infection during care and preparation of food. This deficient practice was evidenced by the following: On 8/10/23 at 12:15 PM, the surveyor observed meal service in the 3rd-floor dining room. The dietary aide (DA) doffs gloves and places them on the cart used for food preparation in front of her. The DA continued to prepare the food after removing the gloves and did not perform hand hygiene. The surveyor got the DA's attention, then went to the sink and washed her hands. The surveyor observed the DA performing hand washing. The aide washed her hands for 18 seconds and did not completely wipe off her hands with the paper towel, and the water dripped onto both hands. The dietary aide was asked how long they should be handwashing; she responded 20 seconds and did 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.
“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
$170,052 in federal fines across 21 penalties. 1 Medicare payment denial on record.
- $4,938 — penalty dated 2024-02-20
- $4,893 — penalty dated 2024-02-12
- $14,814 — penalty dated 2024-01-22
- $4,938 — penalty dated 2024-01-08
- $4,587 — penalty dated 2024-01-02
- $13,762 — penalty dated 2023-12-11
- $4,587 — penalty dated 2023-11-20
- $4,587 — penalty dated 2023-11-13
- $4,587 — penalty dated 2023-11-06
- $4,587 — penalty dated 2023-10-30
- $4,587 — penalty dated 2023-10-23
- $4,587 — penalty dated 2023-10-17
- $4,587 — penalty dated 2023-10-10
- $4,587 — penalty dated 2023-10-02
- $4,587 — penalty dated 2023-09-25
- $4,587 — penalty dated 2023-09-18
- $4,587 — penalty dated 2023-09-11
- $4,545 — penalty dated 2023-09-05
- $4,587 — penalty dated 2023-08-28
- $57,944 — penalty dated 2023-08-22
- $4,587 — penalty dated 2023-08-21
- Medicare payment denial — starting 2025-02-07 for 6 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PEACE CARE INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2016 |
| PEACE MINISTRIES INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 06/01/2016 |
| BUCCIANTI, SILVANA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 07/01/2018 |
| DONOHUE, TERESA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 03/28/2016 |
| DOREN, ELIZABETH | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 07/01/2018 |
| HREBEN, KYLE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2022 |
| LYNCH, DONALD | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2022 |
CMS files one row per role, so the 17 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $452K 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 315452. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, 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 →
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