Alaris Health At Kearny
206 Bergen Ave, Kearny, NJ 07032 · For profit - Limited Liability company · 120 certified beds · (201) 955-7067 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 3 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 | 11.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.8% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.0% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.9% | 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 | 1.5% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.7% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.5% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.2% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.9% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 31.6% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.6% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.56 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.34 | 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.
49.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.3% 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 27 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 56% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | 49.4%CMS range 38.2–63.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.7–14.1 | 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 | 59.3% | 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 | 48.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.3% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.0% | 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 | 8.3%CMS range 4.5–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 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 114.3 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.86 hrs/resident/day on weekends vs 3.27 on weekdays — 13% thinner on weekends. RN hours go from 0.69 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · F2026-02-11 · 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 documents, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation practices as well as store, and label in a manner intended to prevent the spread of food borne illness for 2 of 2 days of kitchen observation. This deficient practice was evidenced by the following: On 2/5/26 at 9:48 AM, the surveyor, in the presence of the Food Service Director (FSD), and the Regional Director, toured the 3rd Floor kitchen. The FSD stated the main kitchen was offsite and arrived as cooked at the facility. The FSD further stated that the facility utilized the steam table, temperatures were taken and then food was served to the residents. The FSD also stated that the facility had two satellite kitchens, one on each floor (3rd and 4th). On that same date and time, the surveyor observed the following during the kitchen tour:On 2/5/26 at 10:11 AM, on the 3rd floor satellite kitchen, the surveyor observed the stand-up freezer with open boxes of strawberry and chocolate ice cream 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 · D2026-02-11 · 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 review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for 1 of 17 newly hired licensed staff reviewed, Staff Member (SM) #35 evidenced by the following: On 2/5/26 at 9:56 AM, during entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the personnel files of the facility's 36 new hire employees since their last recertification survey. A review of the facility provided documents, 1 of 17 licensed staff personnel files included the following:SM #35, a Registered Nurse (RN), with a date of hire (doh) of 1/30/26, had a License Verification Report which was dated 2/1/26. There was no documented evidence that SM #35's license was verified prior to the doh. On 2/10/26 at 12:29 PM, the surveyor interviewed the Business Office Manager (BOM) who stated that she verified licenses on the website. The surveyor asked the BOM when the license verification was done. The BOM stated 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 · D2026-02-11 · tag F0628 — isolatedProvide 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
Based on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the Resident or Resident Representative with written notification of the facility's bed hold policy for 1 of 2 residents, (Residents #126), reviewed for hospitalizations.This deficient practice was evidenced by the following: The surveyor reviewed the medical records of Resident #126, and revealed the following: The admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; personal history of transient ischemic attack (TIA), cerebral infarction (a type of ischemic stroke where a blockage in a blood vessel disrupts blood flow, causing brain or retinal cell death (necrosis) due to lack of oxygen) without residual deficits, unspecified atrial fibrillation, traumatic subdural hemorrhage without loss of consciousness, and unspecified dementia. A review of the most recent Discharge Return Anticipated Minimum Data Set (MDS) revealed in…
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 · D2026-02-11 · 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 and record review, it was determined that the facility failed to accurately complete a portion of the Minimum Data Set (MDS), an assessment tool that facilitate the plan of care, to accurately reflect the resident's status for 1 of 26 residents reviewed (Resident #2). The deficient practice was evidenced by the following:On 2/5/26 at 11:54 AM, Surveyor #1 (S #1) observed Resident #2 being wheeled into the resident's room coming from an activity. The resident stated that they were okay. On 2/9/26 at 12:25 PM, Surveyor #2 (S #2) was given the assignment sheet in which indicated Resident #2 was on the list as a feeder. On 2/9/26 at 12:36 PM, S #2 observed Resident #2 seating in the wheelchair with lunch tray untouched and uncovered. On 2/9/26 at 12:40 PM, S #2 notified the Registered Nurse/Unit Manger (RN/UM) the concern that no one fed the resident when the lunch was served and left uncovered at the bedside when the Certified Nursing Assistant (CNA) assignment showed that the resident was a feeder. The RN/UM stated that the resident was a set up and not a feeder. S…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a resident with severe cognitive impairment, who was at risk for elopement and had a known history of wandering was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building for 1 of 1 resident reviewed for elopement (Resident #44).This deficient practice was evidenced by the following: On 2/5/26 at 10:25 AM, the surveyor observed Resident #44 asleep in their bed. A review of Resident #44's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; delirium due to known physiological condition (an acute, fluctuating disturbance in attention, awareness, and cognition directly caused by an underlying medical condition, such as infection, metabolic imbalance, or organ failure), hypertension (high blood pressure), and bipolar disorder (a chronic mental health condition characterized by extreme…
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 · D2026-02-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and review of pertinent facility documents, the facility failed to ensure the indwelling urinary catheter drainage tubing was stored in a manner to prevent Urinary Tract Infection (UTI) for 1 of 1 resident reviewed for urinary catheter care or UTI (Resident #88).The deficient practice was evidenced by the following: On 2/5/26 at 10:46 AM, the surveyor observed Resident #88 seated in a wheelchair (w/c) in their room with a visitor seated in the room. There were no staff members in the room. The surveyor observed that there was a urinary catheter tubing and drainage bag that was hung on the side of the bed that was not connected to Resident #88. Further observation of the tubing that was leaning against part of the bed frame reflected that the end of the tubing was not capped. The urinary catheter drainage bag and tubing was not properly stored. Resident #88 stated that the staff changed the drainage bag to a leg bag but was not sure what they did. On 2/5/26 at 10:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN)…
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 before2026-02-11 · 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, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure that the comprehensive care plan and nursing documentation were updated to reflect a physician's order for oxygen therapy for 1 of 2 residents (Resident #9) and b.) ensure that a resident receiving oxygen therapy had their oxygen saturation monitored as a standard of practice for 1 of 2 residents (Resident #11) reviewed for respiratory care. This deficient practice was evidenced by the following: 1.On 2/10/26 at 10:55 AM, Surveyor #1 (S #1) observed Resident #9 was lying in bed with oxygen (O2) in place via nasal cannula (n/c) at 2 liters per minute (2LPM) delivered by concentrator. The O2 tubing and humidifier on the O2 concentrator were labeled. S #1 reviewed the medical records of Resident #9 and revealed: A review of the admission Record or face sheet (an admission summary) reflected that Resident #9 was admitted at the facility with diagnoses that included but were not limited to; pneumonia, dysphagia…
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 · D2026-02-11 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times to accommodate for dialysis scheduled times and documenting accurate medication administration times. This deficient practice was identified for 1 of 2 residents, (Resident #12), reviewed for dialysis services. The deficient practice was evidence 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…
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 · D2026-02-11 · 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, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents received feeding assistance in accordance with residents' plan of care. This deficient practice was identified for 2 of 4 residents (Resident#2 and Resident #8) observed during meal time, and was evidenced by the following:1.On 2/5/26 at 10:44 AM, Surveyor #1 (S #1) observed the Nursing Home Resident Care Staffing Report (NHRCSR) for 2/5/26, 7 AM-3 PM (7-3) shift with a census of 111, and the ratio of the Certified Nursing Aid (CNA) to Resident was 1:9.3, and was posted on the 3rd floor bulletin board. On 2/6/26 12:34 PM, S #1 reviewed the provided 2/6/26, 7-3 shift CNA Assignment sheet of 3rd floor nursing unit that was provided by the Work Clerk/Central Supply Staff (WC/CSS) and revealed the following: -Assignment #1, CNA #1 with 11 residents and included in the assignment three resident who needed assistance with feeding or eating. -Assignment #2, CNA #2 with 10 residents 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 · D2026-02-11 · 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 observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure proper documentation of 3 controlled dangerous substances (CDS) medications for 3 residents; 1 Unsampled Resident (Unsampled Resident #1), Resident #44, and Resident #89, by 1 of 3 nurses observed during the medication storage task. 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 well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Dcited before2026-02-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, 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 lack of indication, reason for use or benefit versus risk analysis for 1 of 5 (Resident #6) residents reviewed for unnecessary medications. The deficient practice was evidenced by the following: The surveyor reviewed the electronic medical record (EMR) for Resident #6 which revealed the following:A review of the admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but was not limited to type 2 diabetes (high blood sugar due to the body's inability to use insulin properly) and chronic obstructive pulmonary disease (COPD)(a common lung disease causing restricted airflow). The AR did not reflect a diagnosis of seizures or essential tremors. A review of Resident #7's quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate 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 · D2026-02-11 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure the menu (or diet slip) was followed and b.) ensure that residents received food and beverage in accordance with their preferences. This deficient practice was identified for 1 of 15 residents (Resident #92) observed in the dining room and 1 of 3 residents (Resident #3) observed in the 3rd floor unit during meals, and was evidenced by the following:1.On 2/6/26 11:40 AM, during lunch observation in the 4th floor dining room, the surveyor observed the Licensed Practical Nurse (LPN) was feeding Resident #92 and there was no 4 fluid ounces of whole milk served to the resident which was according to the dietary slip that was on top of the resident's table. On 2/6/26 at 12:00 PM, the surveyor asked the Infection Preventionist Nurse (IPN) who were at the dining area regarding the concern that Resident #92 did not receive their milk according to the diet slip, and the IPN did not respond. The LPN confirmed that the resident did not receive the milk. On 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 · D2026-02-11 · 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, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices for 4 of 7 residents, (Residents #39, #52, #70, and #104) during meal observation and b.) follow appropriate hand hygiene and use of personal protective equipment (PPE) for 1 of 4 nurses (1 Registered Nurse), observed during medication administration pass (med pass), 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 the 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…
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 · D2026-02-11 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) 1 of 2 tub (shower) rooms (3rd floor), b.) 2 of 5 residents' rooms privacy curtains (rooms [ROOM NUMBERS]), and c.)1 of 1 nourishment area observed during environmental tour.This deficient practice was evidenced by the following: 1.On 2/5/26 at 10:50 AM, the surveyor with the Registered Nurse/Unit Manager (RN/UM) toured the 3rd floor Tub Room, also known as the shower room of the residents in the unit as per the RN/UM. Both the surveyor and the RN/UM observed in the middle of the tub room the ceiling vent with accumulation of grayish substances which the RN/UM confirmed accumulation of dust, and the RN/UM stated that the Housekeeper would be notified to clean it. The 1st and 2nd shower cubicles with ceiling vents also observed with accumulation of dust which the RN/UM confirmed. The 3rd shower cubicle had no privacy curtain and with no posted…
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 · E2024-09-27 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, the facility failed to honor residents' choices to have their food warmed by staff members daily for 99 of 107 residents that received meals in the facility. This failure resulted in the residents' choices being denied. Findings include: During a group meeting of 19 alert and oriented residents on 09/26/24 at 2:01 PM, the residents stated they had concerns related to staff not being allowed to heat food up for them if they wanted something heated up after 7:00 PM. The residents stated that in the past, the nurse aides could take food to the breakroom and heat it up for the residents, but they could no longer do that. The residents stated they had been told it was facility policy that foods could not be heated up for them after 7:00 PM because dietary staff were no longer present at the facility. During an interview on 09/27/24 at 3:22 PM, Certified Nursing Aide (CNA) 4 confirmed she was not allowed to heat up food for residents and residents could not have their food warmed up after 7:00 PM daily. During an interview on 09/27/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure the call light was within reach for one of one resident (Resident (R) 69) out of a sample of 26 residents reviewed for accommodation of needs and preferences. This failure had the potential to cause R69 to have unmet care needs. Findings include: Review of R69's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R69 was admitted to the facility on [DATE] with diagnoses which included heart failure, osteoarthritis, age related osteoporosis without current pathological fracture, and history of falls. Review of R69's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/23/24, located under the RAI (Resident Assessment Instrument) tab, showed a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. R69 was assessed to have no upper or lower extremity impairment and required partial/moderate assistance to go…
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 · D2024-09-27 · 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 record review and staff interviews, the facility failed to develop a comprehensive care plan directing measurable goals and interventions related to the use of an anticoagulant for one of five resident (Resident (R) 105) reviewed for unnecessary medications out of a total sample of 26. This failure placed the resident at risk for unmet care needs and the inability to monitor for signs and symptoms of abnormal bleeding. Findings include: Review of R105's Comprehensive Care Plan, located in the electronic medical record (EMR) under the Care Plan tab, revealed R105 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation. Review of R105's Medication Administration Record (MAR), dated 09/2024 and located under the Orders tab of the EMR, revealed R105 received apixaban, (an anticoagulant used in the treatment of atrial fibrillation) five milligrams (mg) twice daily. Review of R105's Comprehensive Care Plan, did not show a focus, measurable goals, or interventions for the use 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 · D2024-09-27 · 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, and record review, the facility failed to provide assistance with showering for one of three residents (Resident (R) 14) reviewed for activities of daily living (ADLs) out of a total sample of 26. This failure increased the potential for R14 to have unmet hygiene needs. Findings include: Review of the facility's policy titled, Shower Sheets, approved 02/14/24, revealed, To ensure accurate documentation of resident showers. This policy applies to all nursing staff providing shower assistance with showers. After assisting with or observing a resident's shower, staff will complete the Shower Sheet for that day. The following information must be included: Date of the shower . Observations of the resident's skin condition . Residents will be offered showers on their assigned days. If a resident requests a shower on a non-shower day, it will be accommodated. If a resident refuses a shower, this must be noted on the Shower Sheet . Review of the facility's policy titled, ADL [activities…
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 · D2024-09-27 · 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 interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 51) reviewed for dialysis out of a total sample of 26 was offered a snack and/or fluids on dialysis days when away from the facility during mealtimes and failed to accurately document the resident's nutritional intake. This had the potential to cause hypoglycemic incidents and provided inaccurate data for the resident's nutritional assessments. Findings include: Review of the facility's policy titled, Dialysis, dated 05/11/10, revealed, . The nurse admitting the resident will verify the center/clinic, the schedule and transportation arrangement made for the resident. If no transportation arrangement has been made, the nurse will then call and make the transportation arrangement from the resident. The dietary department will be notified of the resident's admission. Type of diet ordered and provided resident with a brown bag (snack) if applicable, on days of dialysis schedule, if Dialysis…
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 before2024-09-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure staff followed physician ordered parameters for blood pressure (BP) medications for one of five residents (Resident (R) 105) reviewed for unnecessary medications. R105 received antihypertensive medications when the systolic blood pressure (SBP) was below the parameters set by the attending physician. This had the potential to cause hypotensive episodes for the resident. Findings include: Review of R105's Comprehensive Care Plan, located under the Care Plan tab of the electronic medical record (EMR), revealed R105 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure). Review of R105's Medication Administration Record (MAR), located under the Orders tab of the EMR and dated 09/18/24, revealed R105 was to receive Entresto Oral Tablet (a cardiac medication used to treat hypertension), 24-26 milligrams (mg) and metoprolol tartrate (a cardiac medication used to treat hypertension)…
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 · D2024-09-27 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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, and facility policy review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for one of 26residents (Resident (R) 63) whose beds were observed for bed rail safety out of a total sample of 26. The facility failed to ensure R63's bed rails were identified and repaired timely when broken, which had the potential to cause injury to the resident. Findings include: Review of the facility's policy titled, Side Rail Policy, last reviewed 07/23/24, revealed, The purpose of these guidelines is to ensure the safe use of side rails . Side rails may be appropriate when used to assist with mobility and transfer and to maintain safety related to the resident's medical condition . When side rail usage is appropriate, the facility maintenance department will ensure that side rails are secure and in proper working order. Review of R63's Face Sheet, located under 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 before2022-10-18 · 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 facility documentation, it was determined that the facility failed to maintain resident call bells accessible and within reach of all residents. This deficient practice occurred for 1 of 20 residents reviewed (Resident #64). This deficient practice was evidenced by the following: 1. On 10/5/22 at 11:04 AM, two surveyors observed Resident #64 in bed. Resident #64 was disoriented and confused when interviewed. The surveyors observed that the resident did not have a call bell (a bell used to call for staff assistance) within their reach. The surveyor observed that there was a plug in the wall attached to the facility's call bell system but that no wire or button was attached to the plug. The surveyor did not observe another button or bell that the resident could use to call for staff assistance. On 10/6/22 at 11:19 AM, the surveyor observed Resident #64 in bed. The surveyor observed that the resident did not have a call bell within their reach. The surveyor observed that there was a plug in the wall attached to the facility's call bell…
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 · D2022-10-18 · 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 interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 1 of 3 residents reviewed for resident assessment, Resident #1. This deficient practice was evidenced by the following: On 10/14/22 at 10:10 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System for Medicad/Medicare. The facility must complete and electronically transmit the MDS up to 14 days of the resident assessment completion. Resident #1 was triggered under the survey facility task as MDS record over 120 days old. The surveyor reviewed the MDS 3.0 assessments, including all the completed MDS's for Resident #1 which revealed that the resident had a quarterly MDS with an Assessment Reference Date of 7/29/22 and was due to be transmitted no later…
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 · D2022-10-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to appropriately remove, clarify, accurately administer, and document resident's physician ordered medications. This deficient practice was identified for 4 of 23 residents reviewed (Resident #22, #23, #24, #54, #73, #80, #93 and #57) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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…
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 before2022-10-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to obtain a physician's order for the administration of oxygen. This deficient practice was observed for 1 of 3 residents (Resident #62) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/5/2022 at 11:20 AM, the surveyor observed Resident #62 in bed. The resident received Oxygen (O2) at four liters per minute by way of a nasal cannula attached to an oxygen concentrator (a free-standing device used to deliver oxygen). The surveyor reviewed the hybrid medical record. The admission Record indicated that the resident had medical diagnoses that included but were not limited to Unspecified Sequelae of Cerebral Infarction (stroke), COVID-19, virus not identified, Other Seizures, and Heart Failure. The 8/26/2022 Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care indicated no evidence of oxygen use and no evidence of shortness of breath. The Brief Interview for Mental Status (BIMS) score was 9 out of 15, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-18 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to immediately notify the hospice agency about a significant change in a resident's condition and a resident's death. This deficient practice was identified for 1 of 3 residents, Resident #83, reviewed for hospice/end-of-life care. The deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #83. The reviewed admission Record indicated that the resident had medical diagnoses that included but were not limited to Sepsis, Pressure Ulcer of Sacral Region, Aphasia (loss of ability to understand or express speech), Cerebral Infarction (stroke), Acute Kidney Failure, and Altered Mental Status. Review of the [DATE] significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed that Resident #83 had a Brief Interview for Mental Status score of 99, which indicated that the resident was unable to complete the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ALARIS HEALTH — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 7 homes this chain runs (chain average 3.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WEST HUDSON SUB ACUTE CARE CENTER LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2010 |
| EISENREICH, AVERY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2010 |
| SCHENKER, MIRIAM | Individual | W-2 MANAGING EMPLOYEE | — | since 03/05/2014 |
| STERN, SAMUEL | Individual | CORPORATE OFFICER | — | since 12/09/2010 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 90% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 315192. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, 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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