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Lincoln Park Care Center

499 Pine Brook Road, Lincoln Park, NJ 07035 · For profit - Corporation · 547 certified beds · (973) 696-3300 Medicare & Medicaid certified

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1 immediate-jeopardy citation$21,645 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $21,645 in federal fines (most recent 2026-03-24)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
174 Harvest Ln · (973) 696-0944 · Call to confirm hours
Pharmacy
166 Main St Ste 3 · (973) 305-8105 · Call to confirm hours
Grocery
191 Main St · (973) 633-7878 · Call to confirm hours
Park
34 Chapel Hill Rd · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 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 2 to 1 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.9%8.7%15.4%better
Long-stay residents who lose too much weight7.9%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.6%0.9%better
Long-stay residents with a urinary tract infection0.4%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms53.8%12.1%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.0%2.3%3.3%better
Long-stay residents whose ability to walk worsened1.9%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication41.5%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine99.0%97.2%95.3%typical
Long-stay residents with pressure ulcers4.5%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control2.0%15.6%21.2%better
Short-stay residents who newly got an antipsychotic medication1.8%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine84.3%80.1%79.4%typical
Short-stay residents rehospitalized after admission23.6%24.9%22.6%typical
Short-stay residents with an outpatient ER visit9.1%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.852.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.131.111.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

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.

69.7% 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 769 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

69.7%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
63.3%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 63.3% 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 401 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF69.7%CMS range 65.3–72.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 9.1–12.410.7%Oct 2022–Sep 2024no 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 discharge63.3%56.6%Oct 2024–Sep 2025CMS 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 discharge62.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge67.1%50.0%Oct 2024–Sep 2025CMS 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 identified99.4%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 5.1–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.311.02Oct 2022–Sep 2024CMS 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

0.41
RN hours/ resident / day
0.86
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.41
Total nurse hours/ resident / day
0.28
RN hoursweekends
43.6%
Total nursing turnover
34.5%
RN turnover

How full it usually is: this home is certified for 547 beds and averages 527.4 residents a day — about 96% occupied, or roughly 20 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.07 hrs/resident/day on weekends vs 3.55 on weekdays — 13% thinner on weekends. RN hours go from 0.47 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

12
deficiencies at the latest standard inspection (2025-12-15)
4
at the previous standard inspection (2024-08-26)

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.

ABCDEFGHIJKL

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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · J2026-03-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of medical records, and review of other pertinent facility documents on 3/19/2026 and 3/24/2026, it was determined that the facility failed to maintain a safe environment to ensure adequate supervision to prevent the elopement of a resident (Resident #2). Resident #2, who was noted to exhibit in the presence of staff exit seeking behavior, was transferred to a secure unit on 03/04/2026. Resident #2 also had a Wander Guard in place since admission to the facility since 2024. This device would initiate an alarm and alert staff in the event of an attempt to leave the secured unit. This deficient practice was identified for 1 of 3 (Resident #2) reviewed for elopement. During the survey a finding that constituted an Immediate Jeopardy (IJ) was identified under CFR 483.12(a) (1) for F689. The facility failed to maintain a safe environment on a secured unit with adequate supervision to prevent an elopement of Resident #2 who was a known elopement risk. On 03/08/2026, between 9:00 PM-10:00…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-15 · tag F0805 — failed to prepare food in a form residents can eat — widespread
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 facility documentation, it was determined that the facility failed to prepare resident meals in the proper consistency for 3 of 6 residents (Resident #53, #224, and #326) reviewed on a modified diet during dining observation.This deficient practice was evidenced by the following: 1. On 12/8/25 at 12:17 PM, the surveyor observed Resident #53 in the 2nd floor dining room. Certified Nursing Assistant (CNA#1) provided Resident #53 with their lunch tray. The surveyor observed the resident received whole French fries. Surveyor interviewed CNA#1, who stated Resident #53's diet is chopped consistency. CNA#1 cut Resident #53's French fries to the chopped consistency prior to eating.On 12/8/25 at 12:19 PM, the surveyor reviewed Resident #53's electronic medical record (E-mar). A review of the resident's Face sheet (FS) (an admission summary) revealed Resident #53 was admitted to the facility with diagnoses that included: dementia (loss of cognitive functioning thinking,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-15 · tag F0806 — failed to honor food preferences — widespread
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 5 of 5 residents (Resident #53, #134, #224, #326 and #501) reviewed for dietary preferences during meal observations.This deficient practice was evidenced as follows:1. On 12/8/25 at 12:17 PM, the surveyor was observing the lunch meal on the second-floor dining room. The surveyor observed Resident #53's tray, per the tray ticket, Resident #53 was supposed to receive an egg salad sandwich, 1/2 cup fortified mashed potatoes and 4 ounces (oz) sherbet, all three items were missing from the resident's tray. On 12/8/25 at 12:19 PM, the surveyor reviewed Resident #53's electronic medical record (E-mar). A review of the resident's Face sheet (FS) (an admission summary) revealed Resident #53 was admitted to the facility with diagnoses that included: dementia (loss of cognitive functioning…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.On 12/04/25 at 9:24 AM, the surveyor in the presence of the Food Service Director observed the following during the kitchen tour:1. In preparation area #1, the surveyor observed dietary aide (DA#1) and the Chef both wearing hooped earrings. DA#1 stated hooped earrings are ok as long as they do not hang down to your shoulders.2. In the walk-in freezer, the surveyor observed multiple items stored higher than 18 inches from the ceiling and a full tray of meatloaf labeled with a use by date of 12/2/25. Per the FSD the meatloaf was mislabeled and the 12/2/25 date was when the item was placed into the freezer and was not the use by date but would dispose of the meatloaf due to the mislabeling. 3. In the walk-in refrigerators, the surveyor observed two containers of egg salad and tuna salad with use by labels dated for 12/3/25. Per the FSD those items should have been disposed of yesterday.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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-15 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and review of facility policies, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris.This deficient practice was observed and evidenced by the following:On 12/4/25 at 9:24 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and garbage area and found the following: There was garbage debris that included carboard, food wrappers, food containers, cups, gloves, paper products, plastic bottles, medication cups, and around the dumpster and surrounding areas. The FSD stated the maintenance department should have cleaned the area.On 12/4/25 at 1:24 PM, the FSD provided the surveyor with a facility policy titled, Refuse Receptacle/Dumpster Use with a revised date of December 2008. The policy interpretation and implementation revealed, 4. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.On 12/10/2025 at 1:50 PM, the surveyor met…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-15 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably 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 observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 8 of the 35 residents (Resident #3, 6, 9, 13, 135, 209, 365, and #481) reviewed for reasonable accommodations of needs/preference.The deficient practices were evidenced by the following: 1. On 12/8/25 at 7:30 AM, the surveyor observed Resident #135 in bed. The surveyor observed that the call bell was wrapped around the light, on the wall above the bed, which was not within the resident's reach. A review of Resident #135's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; dementia and schizophrenia (a brain disorder that disrupts how a person thinks, behaves, and feels, leading to a distorted perception of reality). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 9/17/25, reflected that the resident had a brief interview…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-15 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide a homelike environment for residents on 4 of 13 units and was evidenced by the following.On 12/10/25 at 9:10 AM, the surveyor knocked on the door of room W218 and asked Resident #11 if he could inspect their bathroom. The surveyor entered the bathroom in W218 and observed approximately a 7-foot white trim molding, one urinal, and one bucket inside the bathtub. The bathtub which contained staining in the front near the faucet. On 12/10/25 at 11:30 AM, the surveyor showed the picture of the bathroom to the Licensed Nursing Home Administrator who stated that those items should not be inside the bathtub and that he was going to the room and have the items removed. The surveyor toured Unit 3 [NAME] on 12/04/2025 at 11:30 AM. On 12/4/25 at 11:30 AM, the surveyor observed in room [ROOM NUMBER] that the bathroom floor, toilet seat, and toilet bowl were heavily soiled with a yellow substance. On 12/4/25 at 11:33 AM,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-15 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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 (a).to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 2 of 34 residents (Resident#7 and Resident #11) observed during the medication review and 1of 6 residents (Resident #584) observed during medication administration and b) accurate reconciliation and administration of narcotic medication with potential for drug diversion.Repeat deficiency The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-15 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 a communication device for Resident #468 identified with a language barrier. This deficient practice was identified for one (1) of six (6) residents (Resident #468) observed during the medication administration and was evidenced by the following: Reference: According to the manufacturer's specifications for Breo Ellipta (fluticasone furoate and vilanterol trifenatate powder) section 2.3 Administration Information: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis (fungal infection in the mouth, and the throat). On 12/9/25 at 8:30 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #468 that included, Breo Ellipta 100-25 milligram (mg), give 1 puff by mouth, one time a day for Chronic Obstructive Pulmonary Disease (COPD; a progressive lung condition that blocks airflow, making breathing difficult). The physician order for Breo was started on 4/16/25.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #2561471 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 5 residents (Resident #302, #320, and # 275) observed for incontinence care on 1 of 2 units (3rd-floor North Nursing Unit).This deficient practice was evidenced by the following:On 12/8/25 at 7:30 AM, the surveyor completed an incontinence tour on the 3rd floor Nursing Unit and observed the following: 1.On 12/8/25 at 8:06 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA) observed Resident #302 in bed. The CNA exposed Resident #302's incontinence brief, and the surveyor observed that it was saturated with urine. The CNA confirmed that the brief was saturated with urine. A review of Resident #302's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to, Alzheimer's Disease…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-15 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Repeat Deficiency Based on observation, interview, record review, and review of facility policies it was determined that the facility failed to clarify the medication route for a resident from the Consultant Pharmacist (CP) monthly medication review for 1 of 6 Residents, (Resident #425).The deficient practice was evidenced by the following:On 12/4/25 at 11:19 AM, the surveyor observed Resident #425 in their bed with their eyes closed. The surveyor observed an enteral feeding machine (delivers liquid nutrition through a flexible tube directly into the stomach or small intestine) and enteral feeding (TF) products at bedside.On 12/4/25 at 11:45 AM, the surveyor reviewed Resident #425's electronic medical record (e-MAR) which revealed the following: A review of Resident #425's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but not limited to; dysphagia (difficulty swallowing), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and unspecified…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2025-12-15 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 12/9/25, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. The deficient practice was identified for two (2) of six (6) residents, (Resident #318 and #399), that were administered medications by two (2) of six (6) nurses that were observed.The deficient practices were evidenced by the following:1). On 12/09/25 at 8:40 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) entered the room of Resident #399. The surveyor observed RN#1 informing Resident #318 that she would be administering the resident's medications. The surveyor observed the resident who was sitting on their bed.On 12/09/25 at 8:42AM, the surveyor observed RN#1 preparing to…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 4 of 13 medication carts and 2 of 4 medication room refrigerators inspected.This deficient practice was evidenced by the following: a). On 12/11/25 at 10:15 AM, the surveyor inspected the 2nd floor east wing high-side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened multi-dose vial of Fluphenazine Decanoate 25 mg/ml (anti-psychotic) that had an opened date of 10/31/25 and was expired. At that time, the surveyor interviewed LPN#1 who acknowledge that the Fluphenazine Decanoate multi-dose vial once opened had a 28-day expiration date and that it was expired and should have been removed from active medication. b). On 12/11/25 at 10:25 AM, the surveyor inspected the 3rd floor east wing high-side medication cart in the presence of LPN#2. The surveyor observed an opened and undated Humalog insulin pen. At that time, the surveyor interviewed LPN#2 who acknowledge that the Humalog insulin…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and other facility documentation, it was determined that the facility failed to follow infection control procedures on 3 of 3 nursing units. This deficient practice was identified with 5 of 13 staff members not wearing required personal protective equipment (PPE).On 12/4/25 at 10:50 AM, the surveyor conducted the initial tour of the JDT building. Per the Unit Manager (UM), the JDT building was having a Covid outbreak and surgical masks must be worn in common area such as the hallways, nursing station and non-Covid positive rooms. Currently Residents #1 and 2 were Covid positive. On 12/4/25 at 10:51 AM, the surveyor observed a laundry employee on the first floor unit without a surgical mask. The surveyor interviewed with housekeeper, who revealed they were unaware a surgical mask was required to be worn in the JDT building.On 12/4/25 at 10:55 AM, the surveyor observed the Licensed Nursing Home Administrator (LNHA) and Information Technology (IT) employee enter the first floor unit without wearing a surgical masks. Both the LNHA 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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, interviews, and review of pertinent facility documents, it was determined the facility failed to a.) follow appropriate infection control practices and perform appropriate hand hygiene as indicated during meal service observation in 2 of 12 units (first floor JDT and 2 East) for 2 of 4 staff observed during meal service and, b.) follow appropriate infection control practices and perform hand hygiene as indicated for 1 of 1 Resident (Resident #139) observed during tracheostomy care. This deficient practice was evidenced by the following: A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-26 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure an antipsychotic medication was administered in accordance with professional standards of clinical practice to Resident #112 who had episodes of auditory hallucinations. This deficient practice was observed for one (1) of four (4) nurses who administered to one (1) of six (6) residents during the medication administration observation 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 or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-26 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to consistently provide pharmaceutical services in accordance with professional standards to ensure a.) a refrigerator that contained prescription medications was lockable, b.) disposition (destruction) and reconciliation of controlled dangerous substance (narcotic; medications, that due to their high potential for abuse, are tracked with detail) was removed from active inventory when Unsampled Resident # 399 was discharged from the facility, c.) against borrowing medications from other residents to administer to a newly admitted resident (Unsampled Resident #1073), d.) a discontinued medication for Unsampled Resident #359 was removed from active inventory, and e.) a biological supply that required dating was dated. These deficient practices were identified for one (1) of five (5) medication storage rooms and three (3) of 13 medication carts inspected during the medication storage observation. a.) On 8/20/23 at 10:31…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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 Resident #114 was offered pneumococcal vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. This deficient practice was identified for one (1) 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 2/13/23, included the following. The CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown . A review of the facility's policy for Pneumococcal Vaccine dated/reviewed 9/10/23, included the following: Policy Statement: All residents…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-09 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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 2. On 7/18/22 at 2:07 PM, the surveyor interviewed Resident #484. Resident #484 was seated in a wheelchair in their room. Resident #484 was pleasant and eager to speak with the surveyor. Review of Resident #484's Face Sheet (an admission summary) reflected that Resident #484 was admitted to the facility with diagnoses that included but were not limited to essential (primary) hypertension, Schizophrenia, and acquired absence of left leg below knee. The Quarterly MDS dated [DATE], revealed a BIMS score of 10 out of 15 which indicated that the resident's cognition was moderately impaired. Review of the resident's May, June, and July 2022 MAR revealed a physician's order dated 6/21/18 for Amlodipine 5 mg daily for hypertension (hold for blood pressure (BP) less than 120). The documentation from the May 2022 MAR indicated that on five days of the month Amlodipine 5 mg was administered when the BP was less than 120. The May 2022 MAR documented nurses signatures as administered on 5/3/22 BP 112, 5/16/22 BP 114, 5/22/22…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-09 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide 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

    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: 1. maintain ongoing complete communication notes between the facility and the dialysis center and 2. maintain an assessment of a resident's condition and monitoring for complications upon return from dialysis. This deficient practice was identified for 3 of 4 residents reviewed for dialysis, Residents #138, #108 and #135). The deficient practice was evidenced by the following: 1. On 7/18/22 at 11:46 AM, the surveyor observed Resident #138 was not in their room. The unit's Assistant Director of Nursing (ADON) informed the surveyor that the resident was at hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) and had dialysis sessions every Monday, Wednesday, and Friday. The surveyor reviewed Resident #138's hybrid medical records (paper and electronic medical record) that revealed the following: According to the admission Record, Resident #138 was admitted with diagnoses…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 record review it was determined that the facility failed to provide access to a call bell for a 3-week period for 1 of 35 residents (Resident #320) reviewed. The evidence for the deficient practice is as follows: On 7/18/22 at 11:57 AM, the surveyor knocked on the door to room two South-206 window. Resident #320, in the window bed of the three bedded room, called out loudly come in. During the interview between the surveyor and the resident, Resident #320 stated they had no call bell access since moving to the room. The resident stated that they call out when needing assistance from staff. The resident stated staff routinely responded to their verbal calls for assistance. The surveyor was unable to locate a call bell in the vicinity of the resident's bed. On 7/19/22 at 1:30 PM, the surveyor again visited the resident in their room. The resident stated they needed assistance the prior evening and had called out for assistance and staff had responded. The surveyor again observed no call bell present in the area surrounding the resident's window…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-09 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 full visual privacy when providing personal care for, 1 of 35 residents, Resident #247. The deficient practice was evidenced by the following: On 7/19/22 at 10:51 AM, the surveyor observed from hallway, standing outside the resident's room door, a Certified Nursing Assistant (CNA) providing hygiene care to Resident #247. The door to the room was open and the privacy curtain between Resident #247's bed and the room door was partially pulled back. Resident #247 could be seen lying in the bed from the hallway exposed from abdomen to feet. The resident was not covered with a blanket and their gown was pulled up to their abdomen. The surveyor observed the CNA providing hygiene care and changing the resident's incontinent brief. On 7/19/22 at 10:57 AM, the surveyor observed the door and privacy curtain remained open as the CNA continued to provide hygiene care to the resident. The surveyor called the Assistant Director of Nursing (ADON) to the outside of the door of the resident's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-09 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 2 residents reviewed for hospice care, Resident #85 as evidenced by the following: According to the Resident Assessment Instrument (RAI) Manual Version 3.0 of CMS guidelines, updated October 2019 under Chapter 2 page 23, included that, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provide) or changes hospice providers and remains a resident at the nursing home. The Assessment reference date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later that the date of the hospice election statement, but not earlier than) This is to ensure a coordinated plan of care between the hospice and nursing home is in place. On 7/20/22 at 10:32 AM, the surveyor observed Resident #85 in bed with eyes closed and in the presence of the Behavioral Assistant by 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 wound care in a manner that would decrease the possibility of the wound deteriorating. This was found with 1 of 4 residents reviewed for wound care, Resident # 9. The deficient practice was evidenced by the following: On 7/19/22 at 1:24 PM, the surveyor observed the resident in bed awake, the resident asked for food after trying for a few minutes to formulate the question. The resident was on a pressure relieving mattress. The resident was under a sheet and their legs appeared contracted. The resident was clean. The surveyor was able to visualize booties on the residents feet under the sheet. The resident was laying on their back. On 7/21/22 at 10:56 AM, the surveyor observed the resident in bed with eyes closed. The resident was clean and appeared comfortable. The resident was covered with a sheet. The surveyor was able to visualize booties on both feet. On 7/21/22 at 11:00 AM, the surveyor reviewed the resident's medical record which revealed the following: A physician's order…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined that the facility failed to provide indwelling catheter care in a manner to reduce the spread of infection. The deficient practice was identified for 1 of 4 residents (Resident #120) reviewed for urinary catheters and evidenced by the following: On 07/18/22 at 12:07 PM, the surveyor observed Resident #120 awake in bed. The resident's indwelling urinary drainage collection bag was hanging from the bed frame. On 07/19/22 at 10:44 AM, the surveyor observed the resident seated at the bedside in a wheelchair. The surveyor inspected the resident's bathroom. A blue privacy bag was hung from the hand-rail next to the toilet. A used large urinary drainage collection bag was stored in the privacy bag. The tubing of bag was uncapped and open to air. On 07/20/22 at 11:57 AM, the surveyor observed in the resident's bathroom a blue privacy bag hung on the hand-rail next to the toilet. A used large urinary drainage collection bag was stored in the privacy bag. The uncapped end of the tubing rested on the floor adjacent 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 review of facility records, it was determined that the facility failed to ensure that a resident's low oxygen saturation (the amount of oxygen circulating in the blood) was responded to appropriately for 1 of 2 residents (Resident #159) reviewed for respiratory care. This deficient practice was evidenced by the following: On 7/19/22 at 1:20 PM, the surveyor observed Resident #159 awake in bed and observed that the resident was wearing a nasal cannula (a device to provide supplemental oxygen therapy) attached to an oxygen concentrator. The surveyor observed that the flow rate on the oxygen concentrator was set to two liters per minute (LPM). At the same time the surveyor interviewed Resident #159. Resident #159 stated that they always wear the oxygen and that ordinarily the flow rate is set to 2 LPM. On 7/19/22 at 2:27 PM, the surveyor interviewed the Licensed Practical Nurse #1 (LPN #1) about Resident #159's use of oxygen therapy. LPN #1 stated that Resident #159 was previously sent to the hospital because their oxygen saturation, dropped really…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-09 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that 1.) the Consultant Pharmacist failed to identify the need for routine pain management medication review for 1 of 38 residents reviewed, Resident #108, and 2.) the facility failed to respond to the Consultant Pharmacist recommendations for 2 of 38 residents reviewed, Resident #211 and Resident #484. The deficient practice was evidenced by the following: 1. On [DATE] at 10:30 AM, the surveyor interviewed Resident #108 in the resident's room. The resident informed the surveyor that they attend dialysis on Tuesday, Thursday, and Saturday each week. Resident #108 informed the surveyor that due to a previous fall prior to their facility admission and arthritis, they suffer from regular knee pain. Review of Resident #108's Face Sheet (an admission summary) reflected that Resident #108 was admitted to the facility with diagnoses that included but were not limited to Essential (primary) Hypertension, Anemia in Chronic Kidney Disease and End Stage…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to properly store medications meant to be refrigerated in 2 of 13 medication carts inspected. The deficient practice is evidenced by the following: 1. On 7/26/22 at 9:41 AM, the surveyor inspected the 3rd floor JDT high side medication cart in the presence of Licensed Practical Nurse (LPN) #1. The surveyor observed a bag labeled Refrigerate. Inside the bag, the surveyor observed a Frivanq (an antibiotic used to treat infections) Solution 50 milligrams/ milliliter bottle labeled, Must Be Refrigerated. The surveyor observed that the Firvanq bottle felt room temperature. At that time, the surveyor interviewed LPN #1 who stated that her shift started at 7 AM and that she did not take the Firvanq out of the refrigerator. LPN #1 stated that the nurse who worked the previous shift told her that he could not find the Firvanq in the refrigerator and that he gave a dose from the backup stock of medications because he did not know that the medication was in the cart. LPN #1 stated that the Firvanq…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-09 · tag F0849 — isolated
    Arrange 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 consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs. The deficient practice was identified for 1 of 2 residents (Resident # 9) reviewed for hospice/end of life care. The deficient practice was evidenced by the following: On 7/19/22 at 1:24 PM, the surveyor observed Resident # 9 in bed and awake. The resident asked for food after trying for a few minutes to formulate the question. The resident was on a pressure relieving mattress. The resident was under a sheet. The resident was clean. On 7/20/22 at 9:15 AM, the surveyor spoke with the Licensed Practical Nurse (LPN) who was assigned to the resident. The LPN said the Hospice Nurse went to the facility very often, 2 times per week, and the hospice aide went to the facility every morning. The LPN stated when I come in at 7 AM she is already there. The surveyor asked the LPN where the hospice care plan was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-08-09 · tag F0625 — widespread
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of the medical record, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy upon transfer to the hospital for 4 of 4 residents (Resident #50, # 135, #467, # 479) reviewed for hospitalizations. The deficient practice was evidenced by the following: 1. On 7/25/22 at 1:32 PM, the surveyor reviewed the medical record of Resident # 50 which revealed the following: A New Jersey Universal Transfer Form (NJUTF) indicated the resident was sent to the hospital on 5/12/22 at 8:55 AM due to a change in speech and an asymmetrical smile. A Nurses Note dated 5/14/22 indicated the resident was re-admitted to the facility on that day. 2. On 7/25/22 at 10:00 AM, the surveyor reviewed the medical record of Resident # 135 which revealed the following: A Physician/APN (Advanced Practice Nurse) note dated 4/27/22 read, Readmitting [AGE] year-old from [redacted] hospital. [The resident] was sent out from 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$21,645 in federal fines across 1 penalty.

  • $21,645 — penalty dated 2026-03-24

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.

Part of a chain

This home belongs to CENTER MANAGEMENT GROUP — 16 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 →

RatingThis homeChain avg
Overall 1 of 53.2-2.2 vs chain
Health inspection 1 of 52.9-1.9 vs chain
Staffing 3 of 51.8+1.2 vs chain
Quality measures 1 of 54.3-3.3 vs chain
The other 15 homes this chain runs (chain average 3.2★, 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 / managerTypeRoleSince
GROS, CHARLES-EDOUARDIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/30/2013
KLEIN, MIRIAMIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/30/2023
NEWPORT REAL ESTATE CAPITAL LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 12/31/2012
LEVI, SHLOMOIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2019
MORALES, DEBORAHIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2013
WOLF, HOWARDIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/09/2014
KLEIN, BARUCHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
LUHANA, MANISHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015
VINITSKY, AVROHOMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2013

CMS files one row per role, so the 20 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$57.4M
Net patient revenuemost recent cost report
+0.1%
Operating marginrevenue minus expenses
$7.7M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 82%Medicare 14%Other / private 4%

About 82% 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 $7.7M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$335per resident / day
operating cost
$10,176per month
≈ monthly operating cost
$335per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

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 315249. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-15, 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 →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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