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Lincoln Park Renaissance

521 Pine Brook Road, Lincoln Park, NJ 07035 · For profit - Limited Liability company · 189 certified beds · (973) 696-3300 Medicare & Medicaid certified

Call the home — (973) 696-3300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jul 2023
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (30) — 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)
  • about 17% of its spending goes to commonly-owned related companies

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.

4/5
CMS overall
4 of 5
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

Hospital
Urgent care / clinic
29 Station Rd · (973) 628-8442 · 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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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 rating4★
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 increased4.5%8.7%15.4%better
Long-stay residents who lose too much weight8.4%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms55.6%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 injury2.9%2.3%3.3%better
Long-stay residents whose ability to walk worsened2.1%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication30.7%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine97.1%97.2%95.3%typical
Long-stay residents with pressure ulcers2.4%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control25.6%15.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table3.3%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine58.6%80.1%79.4%worse
Short-stay residents rehospitalized after admission23.0%24.9%22.6%typical
Short-stay residents with an outpatient ER visit8.3%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.792.071.67typical
Long-stay outpatient ER visits per 1,000 resident days1.231.111.80better

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.

§ 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.

65.6% 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 842 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.6%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
59.1%U.S. median 56.6%
Met the expected recovery
0.58U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 59.1% 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 350 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 SNF65.6%CMS range 61.3–68.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 8.6–12.310.7%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 discharge59.1%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 discharge48.3%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 discharge60.6%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 identified99.8%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 setting99.2%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 discharge99.7%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 stay0.4%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 worsened2.7%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 hospitalization6.6%CMS range 5.2–8.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.281.02Oct 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

0.44
RN hours/ resident / day
1.00
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.56
Total nurse hours/ resident / day
0.28
RN hoursweekends
49.1%
Total nursing turnover
23.8%
RN turnover

How full it usually is: this home is certified for 189 beds and averages 178.5 residents a day — about 94% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.23 hrs/resident/day on weekends vs 3.69 on weekdays — 13% thinner on weekends. RN hours go from 0.51 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 49% is about the same as the national median of 45%.

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

Inspection trend

10
deficiencies at the latest standard inspection (2026-02-09)
9
at the previous standard inspection (2024-10-10)

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 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · Ecited before2026-02-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide ordered respiratory care consistent with professional standards of practice. This deficient practice was identified for 3 of 4 residents (Residents #13, #102, and #103) reviewed for respiratory care, and was evidenced by the following: 1.On 1/28/26 at 10:20 AM, the surveyor interviewed Resident #102. The resident was lying in bed and the surveyor observed a nasal canula connected to a wall oxygen outlet, which was was in use. The surveyor examined the wall oxygen meter and observed it was set at 0.5 liters/minute of flow. The humidification bottle attached to the wall meter had no date indicating start of use. The resident stated he was not short of breath and demonstrated no signs or symptoms of distress or difficulty breathing. A review of the resident's admission record reflected he was admitted to the facility on [DATE] with diagnoses including but not limited:…

    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 · E2026-02-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate administration of a medication (med) for 4 of 36 (Res. #14, #173, 205, 166 and 4) residents reviewed for medication regimen. 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 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 45, Chapter 11. Nursing Board. The Nurse…

    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 before2026-02-09 · 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 ensure the resident's call device was readily accessible. The deficient practice was identified for 1 (one) of the 32 residents (Resident #3) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: The surveyor observed Resident #3 on 1/28/26 at 10:02 AM in bed with eyes closed. The resident's call device was clipped to the sheet behind the head of the bed. The device cord hung down behind the bed out of the reach of the resident. The surveyor observed the resident on 2/4/26 at 9 AM in bed with eyes closed. The call device was in the same position as the previous observation, hanging down behind the head of the bed. The surveyor observed the wound treatment nurse perform a treatment to Resident #3 on 2/4/26 beginning at 11:38 AM. The call device was observed on the floor under the resident's bed throughout the 40 minute treatment observation. At the conclusion of the treatment, the nurse picked up the call device 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
  • Potential for harm · D2026-02-09 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 comprehensive Minimum Data Set (MDS) assessments within the appropriate timeframe and in accordance with federal guidelines for 2 of 35 residents (Residents #19, and #103), reviewed for resident assessments. This deficient practice was evidenced by the following:Reference: Centers For Medicare and Medicaid Services (CMS), RAI manual, Version 3.0, last revised in October 2025 indicated in Chapter 2, pages 2-8: .admission refers to the date a person enters the facility and is admitted as a resident.this date is considered the 1st day of admission .Under Chapter 2, Section 2.6-Required OBRA [Omnibus Budget Reconciliation Act] Assessments for the MDS revealed: .MDS Completion Date (Item Z0500B) No Later Than. 14th calendar day of the resident's admission (admission date + 13 calendar days) .Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain…

    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 before2026-02-09 · tag F0640 — isolated
    Encode 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

    REPEAT DEFICIENCY Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 2 of 36 residents (Resident #13 and #18) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 1/29/26 at 10:03 AM, the surveyor provided the MDS Coordinator/Registered Nurse (MDSC/RN) with the list of 2 residents who had completed an MDS assessment for Residents #13 and #18. The surveyor also requested a copy of the resident's final validation…

    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 before2026-02-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines, for 1 of 36 residents (Resident #15), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 1/29/26 at 8:57 AM, the surveyor observed Resident #15, who is seated in a motorized wheelchair, and stated that they would go down to smoke. The surveyor interviewed the Registered Nurse (RN), who stated that the resident is alert and oriented x3, and they can go by themselves to the smoking area. On 2/4/26 at 9:39 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #15, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #15 was admitted with diagnoses that included, but were not limited to, chronic obstructive pulmonary 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-09 · 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, record review, and review of facility polices, it was determined that the facility failed to document the non-compliance of the resident's fluid restriction. This deficient practice was identified for 1 (one) of 1 resident (Resident #11) reviewed for dialysis.The deficient practices were evidenced by the following: On 2/5/26 at 9:07 AM, the surveyor observed that the resident was not in the room. The staff stated that Resident #11 was on dialysis. The surveyor observed that the residents had 8 unopened cups of cranberry juice and 4 empty cups, for a total of 12 cups, on top of the overbed table. There are also 5 unopened bottles of bottled water (500 ml (milliliter) each) on top of the windowsill, 2 half-empty bottles of bottled water, and one 120 ml full bottle of water on top of the bedside table. On 2/5/26 at 11:51 AM, the surveyor reviewed the hybrid (paper and electronic) medical record for Resident #11, which revealed the following: A review of the Resident #11's admission Record (AR, an admission summary) documented that the resident 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-09 · 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

    Based on observation, interviews, and record review, it was determined that the facility failed to ensure the resident's designated smoking area was free from accident hazards, specifically by failing to clear snow and ice from the smoking area after the snow, to prevent slips and falls for 1 (one) of 2 residents (Resident #15), who were reviewed for smoking. This deficient practice was evidenced by the following: On 1/29/26 at 8:57 AM, the surveyor observed Resident #15, seated in a motorized wheelchair, who stated that they would go down to smoke to the 1st floor of the facility at the back patio. The surveyor interviewed the Registered Nurse (RN), who stated that the resident is alert and oriented x3, and they can go by themselves to the smoking area. The surveyor observed that the RN gave the vaping (handheld electronic device) device to Resident #15. On 1/29/26 at 9:03 AM, the surveyor went with Resident #15 to the first floor, to the back patio, to observe the resident vaping. The surveyor observed the No Smoking sign right in front of the automatic door. The surveyor observed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-09 · 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 ensure that a resident with an indwelling catheter (inserted into the urethra (tube) and draining urine to the bag) had a privacy bag for dignity. This deficient practice was identified in 1 (one) of 3 residents (Resident #18) who were reviewed for urinary catheter use. This deficient practice was evidenced by the following: On 1/28/26 at 9:50 AM, the surveyor observed Resident #18 in bed, asleep. It was observed that the resident's indwelling catheter, draining yellowish urine, was lying on the floor outside the privacy bag. The surveyor observed that there was a family member of the roommate inside the room. On the same day at 10:00 AM, the surveyor observed that the Licensed Practical Nurse (LPN) went inside the resident's room to give the resident's medication. The LPN left after he gave the medications to the resident. On the same day at 10:05 AM, the surveyor went back to Resident #18's room to observe the indwelling catheter. The surveyor observed the indwelling catheter bag with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-09 · tag F0880 — failed to prevent and control infections — isolated
    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 observation, interview, and record review it was determined that the facility failed to provide services in a manner to prevent or limit the spread of infection during a wound treatment observation. The deficient practice was observed for 1 resident (Resident #3) of 3 reviewed for pressure ulcers and other skin conditions and was evidenced by the following: The surveyor observed Resident #3 in bed with eyes closed on 1/28/26 at 10:02 AM and on 2/4/26 at 11:38 AM. A review of the resident's medical record revealed the following information. The 11/19/25 significant change in status Minimum Data Set (MDS) assessment tool indicated the resident had moderate cognitive impairment (brief interview for mental status score of 8). The MDS also indicated the resident had one pressure ulcer. The resident had a 1/22/26 physician's order for a sacral pressure ulcer as follows. Apply Santyl External Ointment 250 units/gram to sacrum topically every day shift for wound after cleansing with normal saline, pack with calcium alginate, and cover with dry dressing. The surveyor reviewed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Ecited before2024-10-10 · 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

    Based on observation, interview, record review, and review of other facility's documentation, it was determined that the facility failed to ensure a.) the Professional Standards of Practice to assess a resident's pain at least each shift for significant changes in levels of chronic pain, b.) a physician order for administration with parameters was followed (Resident #131) and c.) a narcotic medication for pain was administered when documented as administered (Resident #367). The deficient practice was identified for one (1) of one (1), Resident #14, reviewed for pain management, one (1) of (4) four residents administered by one (1) of four (4) nurses observed during the medication administration, and for one (1) of (5) medication carts observed during the medication storage and labeling inspection. 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…

    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 · E2024-10-10 · 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

    Based on observation, interview, and record review it was determined that the facility failed to assess residents' vital signs and dialysis access site for complications upon return from the renal dialysis (RD) center for 2 of 2 residents reviewed for dialysis care, Resident #90 and 134. Evidence of the deficient practice is as follows. 1. The surveyor interviewed Resident #90 on 10/1/24 at 1:09 PM. The resident stated they had RD appointments on Monday, Wednesday, and Friday at 5:30 AM. The resident stated they are not assessed promptly when returning from RD. A review of the electronic medical record revealed the following information. The 8/15/24 quarterly Minimum Data Set (MDS) assessment tool, Section C - Cognitive Patterns, indicated the resident was cognitively intact (Brief Interview for Mental Status score 15 of 15). Section I - Active Diagnoses triggered for renal disease. Section O - Special Treatments, Procedures, and Programs indicated the resident received RD. The physician's 10/2024 Order Summary Report included the following RD-related orders. RD Monday, Wednesday,…

    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 · Edisputed · IDR2024-10-10 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift; (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 38 residents reviewed for accommodation of needs (Resident #59 and #127), and was evidenced by the following: On 10/1/24 at 11:34 AM, the surveyor observed Resident #59 in bed on a specialty mattress, with his/her eyes open. Resident #59 did not respond to the surveyor's greeting. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was intertwined with their roommates call bell cord and entangled in the bed electrical cords, not within his/her reach. The surveyor reviewed the medical record for Resident #59. A review of Resident #59's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis…

    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 · Dcited before2024-10-10 · tag F0640 — isolated
    Encode 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to start, complete and transmit the Minimum Data Set (MDS) for a Death in facility and a Discharge Return not Anticipated in accordance with federal guidelines. This deficient practice was identified for two (2) of 38 residents reviewed for Resident Assessment (Resident #144, and 54) and was evidenced by the following: 1. The surveyor reviewed the closed medical record for Resident #144. A review of the resident's admission Record (an admission summary) reflected that Resident #144 was admitted to the facility with diagnoses that included but was not limited to heart failure. On [DATE] at 10:14 AM, the surveyor reviewed the electronic Medical Record, Minimum Data Set (MDS) tab that reflected a Death in the facility tracking discharge was not completed and was 102 days overdue. On [DATE] at 10:28 AM, during an interview with the surveyor, the MDS-Director stated that the facility had 14 days to submit the death in the facility…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-10 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. On 10/1/24 at 11:45 AM, during the initial tour, Resident #25 was not in their room. A staff member identified Resident #25 in the dayroom asleep, not roused by the surveyor's voice, seated on a geri chair (geriatric chair or medical recliner; a large, padded chair with wheels, designed to assist seniors with limited mobility) with legs elevated and heels off-loaded (practice of reducing or removing pressure on a part of the body to help with healing or prevent wounds). The surveyor reviewed the medical record for Resident #25 According to the electronic Medical Record, Resident #25 had diagnoses which included, but were not limited to, unstageable pressure ulcer of unspecified site. Review of the quarterly Minimum Data Set, an assessment tool dated 6/28/24, reflected a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated a severely impaired cognition. Further review of the qMDS revealed Resident #25 had an unstageable deep tissue injury (DTI) that was not present upon admission.…

    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 before2024-10-10 · 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 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 10 residents (Resident #59, #82 and #29), observed for incontinence care on 1 of 2 units (B1 Unit). This deficient practice was evidenced by the following: On 10/1/24 at 11:34 AM, the surveyor observed Resident #59 in bed on a specialty mattress, with his/her eyes open. Resident #59 did not respond to the surveyor's greeting. The surveyor observed a strong unpleasant odor in the resident's room. On 10/1/24 at 11:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had been assigned to Resident #59's care for the 7AM-3:00 PM shift. During the interview, the CNA stated that she had 10 residents on her assignment and that this was the first opportunity she had to provide care to Resident #59. The surveyor asked the CNA how often she provided incontinence care 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ 177694, NJ 176286 Based on interviews and record review and review of pertinent facility documentation, the facility failed to ensure an abnormal urine lab result was communicated to the physician, received treatment and care, in a timely manner, and in accordance with professional standards of practice that meet the resident's physical, mental and psychosocial needs. This deficient practice was identified for one (1) of two (2) residents reviewed for abuse and neglect, (Resident #319) and was evidenced by the following: The surveyor reviewed the closed record for Resident #319. According to the admission Record, Resident #319 was admitted to the facility with diagnoses which included but were not limited to chronic kidney disease (gradual loss of kidney function), heart failure (a condition when the heart does not pump enough blood to meet the body's needs) and hyperparathyroidism (excessive secretion of parathyroid hormone resulting in abnormally high levels of calcium). Review of the quarterly…

    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 · D2024-10-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 consistently follow a physician's order for placement of an orthopedic device for 1 of 3 residents reviewed for positioning and mobility, Resident #77. The deficient practice is evidenced by the following. The surveyor observed the door to Resident #77's room was closed on 10/1/24 at 11:19 AM. The surveyor knocked and entered the room to see the resident had completed receiving morning care from the Certified Nursing Assistant (CNA). The CNA stated she was done with care and left the room. The surveyor observed a blue hand splint placed on the over bed table. The surveyor returned to the resident's room later the same day at 1:03 PM. The splint was observed on the over bed table. The resident was seated in a geri-chair (a reclining lounge-type chair) at the bedside. A review of the electronic medical record revealed the following information. An admission Record noting the resident was admitted with a diagnosis of a right-hand contracture. A 4/26/24 Physician's Order for the application…

    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 before2024-10-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 2 of 4 residents, (Resident #29 and #136). This deficient practice was evidenced by the following: 1. On 10/1/24 at 12:46 PM, the surveyor observed Resident #29 in bed. The resident did not respond to the surveyor. The surveyor observed Resident #29 wearing a nasal cannula (NC) with a portable oxygen tank on and the gauge was set at 2 liters per minute (LPM). On 10/4/24 at 7:38 AM, the surveyor observed Resident #29 in bed with the head of the bed positioned at approximately 45 degrees with a tube feeding running via a machine at 65 mililiters (mls) per hour. The resident did not respond to the surveyor. The surveyor observed Resident #29 was wearing a NC with a portable oxygen tank on and the gauge was set at 1 LPM. A review of Resident #29's admission Record revealed Resident #29 was admitted to the facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-25 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, review of facility documents and review of facility policy, the Quality Assurance (QA) committee failed to ensure required members of the committee attended the quarterly meetings. This failure had the potential to affect all 175 residents who currently live in the facility. Findings include: Review of the undated facility's policy titled, Quality Assurance Performance Improvement [QAPI] Program, revealed, .The Administrator, or designee is responsible for assuring that all QAPI activities and required documentation is completed and/or up-to-date [sic]. Review of the facility's policy titled, Quality Assessment and Assurance Plan, dated December 2009, revealed, .Authority: 2. The Administrator is responsible for assuring that his facility's Quality Assessment and Assurance Program complies with federal, state, and local regulatory agency requirements. The facility was unable to provide documentation of who attended the third quarter Quality Assurance Performance Improvement Meeting, dated 07/22/22. Interview on 07/20/23 at 4:55 PM, the Administrator 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 observations, interview, record review, and policy review the facility failed to provide a safe, clean, and homelike environment for its residents. Specifically, two residents (Resident (R)106 and (R)40) windows were found to be dirty and broken and a request for bed replacement for R40 had not been fulfilled; and R23's room was found to have leaking insulated ceiling pipes. This deficient practice had the potential to affect three out of 175 residents. In addition, the facility failed to exercise reasonable care for the protection of a resident's (R40) property from damage or theft for one out of one resident sampled for missing items. The deficiency had the potential to significantly impact the residents' quality of life, safety, and overall well-being. The lack of a safe, clean, and homelike environment compromised the residents' sense of dignity and comfort. Findings include: 1. Review of R40's undated admission Record located in R40's electronic medical record (EMR) located under the Profile tab…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ165572, NJ155763 Based on interview, record review, and facility policy review the facility failed to report timely, within two hours and not later than 24 hours for initial notification to the state survey agency (SSA), a witnessed resident to resident altercation for one of one sampled resident (R)21 and an injury of unknown origin for R122 reviewed for facility reported incidents (FRIs). Failure to report resident to resident altercations or injuries of unknown origin could potentially lead to continued abuse and neglect. Findings include: 1. Review of R122's admission Record from the facility electronic medical record (EMR) under the Profile tab showed an admission date of 06/08/21, readmission on [DATE], with medical diagnoses that included moderate dementia with mood disturbance, sepsis, and metabolic encephalopathy. Review of R122's EMR Progress Notes tab showed a practitioner's note on 07/06/23 at 12:48 PM that stated, .Chief Complaint .Patient was noted with a bruise behind left ear. I 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure the Resident Representative and two residents (Resident (R)122 and R154) of two residents reviewed for facility initiated emergent hospital transfer were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information required on the transfer notice. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: 1. Review of R122's admission Record from the facility electronic medical record (EMR) Profile tab showed an admission date of 06/08/21, readmission on [DATE], Review of R122's EMR Progress Notes tab showed a practitioner's note on 07/06/23 at 12:48 PM that stated, .Chief Complaint .Patient was noted with a bruise behind left ear. I was noted this morning. Will send patient to hospital for…

    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 · Dcited before2023-07-25 · tag F0640 — isolated
    Encode 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 record review, interview and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident (Resident (R)150), reviewed for not having a Minimum Data Set ([MDS) discharge assessment transmitted to Centers for Medicaid and Medicare Services (CMS) in a timely manner, in that the MDS was not transmitted until 120 days after the resident was discharged from the facility This failure has the potential to have Medicare or Medicaid services denied due to the payment system having the R149 as being a nursing facility resident. Findings include: Review of R150's admission Record from the electronic medical record (EMR) showed a facility admission date of 02/08/23. Review of R150's EMR Orders tab showed an order on 03/24/23 to discharge to home. Review of R150's EMR MDS tab showed a discharge return not anticipated (DCRNA) with an assessment reference date of 03/26/23. Review of the history of the assessment showed an accepted status date of 07/17/23. In an interview on 07/19/23 at 3:14 PM regarding the MDS history screen in the EMR, 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 · Dcited before2023-07-25 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately assess] and encode the Minimum Data Set [MDS] related to the presence of an indwelling catheter for one of six residents reviewed for urinary catheters. for one of six residents (Resident (R)15) reviewed for urinary catheter or urinary tract infection (UTI). This failure could lead to inaccurate care planning and/or care provision for the resident. Findings include: Review of R15's admission Record from the electronic medical record (EMR) showed a facility admission date of 01/08/20, readmission date of 05/09/23, with medical diagnoses that included cancer of the bladder and colon, colostomy, bacteremia, and sepsis. Review of R15's EMR Orders tab showed orders for colostomy care, but nothing regarding a catheter. Review of R15's EMR Minimum Data Set (MDS) under the MDS tab showed an admission MDS, with an assessment reference date (ARD) 05/16/23 that did not show a catheter coded; however, the 5-day MDS with an ARD of 06/01/23 showed R15 coded as having…

    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 before2023-07-25 · 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 Based on observation, interview, record review, and policy review, the facility failed to provide assistance with facial grooming, and preserve and promote the dignity of two (Residents (R)84 and R117) of two residents reviewed for activities of daily living out of 39 sampled residents. This failure resulted in residents' appearing in a manner that failed to preserve the residents' dignity. Findings include: 1. Review of R84's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R84 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, muscle wasting and atrophy, and anxiety disorder. Review of R84's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/23, located in the EMR under the MDS tab, revealed R84 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. The MDS indicated R84 required extensive assistance of one staff member for personal hygiene.…

    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 before2023-07-25 · tag F0880 — failed to prevent and control infections — isolated
    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 review of facility policy, observations, and staff interviews, the facility failed to follow appropriate infection control practices for hand hygiene and glove wearing for one (Resident (R120) of one resident observed during resident care. Findings include: Observation on 07/20/23 at 8:52 AM revealed Certified Nurse Aide (CNA)5 with R120. There was blood on R120's sheet due to R120 scratching herself. CNA5 donned a right-hand glove only and lifted R120's left leg to find the source of the bleeding. When told she was only wearing one glove, CNA5 stepped into the hallway to obtain another glove and donned it on her left hand without performing hand hygiene. On 07/20/23 at 08:57 AM, CNA5 removed her gloves, did not perform hand hygiene, and walked down the hall to R68's room. CNA5 touched R68's shoulder and hands and exited R68's room, still without performing hand hygiene. Continued observation on 07/20/23 at 9:01 AM CNA5 entered the activities/dining area and assisted R173 to drink by lifting her cup of thickened juice and touching R173's shoulder, without performing hand…

    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 · D2023-07-25 · 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 interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure that five of five residents (Resident (R) R8, R9, R113, R117, and R132) reviewed for pneumococcal vaccinations were up to date with their pneumococcal vaccines per CDC guidelines out a total sample of 39. This practice had the potential to increase the risk for these residents to contract pneumonia. Findings include: 1. Review of R8's quarterly Minimum Data Set (MDS) located in the Electronic Medical Record (EMR) under the MDS tab with an Assessment Reference Date (ARD) of 04/05/23 revealed R8 was admitted to the facility on [DATE] R8 was over the age of sixty-five at the time of her admission to the facility. Review of R8's immunization record located under the Immunization tab of the EMR revealed R8 received a dose of the Prevnar13 pneumococcal vaccine on 05/13/21 The record failed to reveal that R8 had received any further pneumococcal…

    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
  • No harm found · C2023-07-25 · tag F0949 — failed to train staff on dementia and abuse — widespread
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, facility policy review and review of facility assessment, the facility failed to ensure three Certified Nurse Aides (CNAs) (CNA1, CNA2, and CNA3) of three CNAs and one Registered Nurses (RN)1 of one RN reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses indicated on the facility assessment. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present. Findings include: Review of the Facility Assessment, reviewed 02/20/23, showed: Purpose The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. This assessment will be used to make decisions about the direct care staff needs, as well as the capabilities to provide services to our residents. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable…

    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

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

No federal fines in the current CMS record.

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 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 2 of 51.8+0.2 vs chain
Quality measures 5 of 54.3+0.7 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
BOEHM, CAROLINEIndividualDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNFsince 11/30/2023
GROS, CHARLES-EDOUARDIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/30/2023
KLEIN, MIRIAMIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/30/2023
NEWPORT REAL ESTATE CAPITAL LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 12/31/2012
CHMURA- SAEZ, PATRICIAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/10/2025
LEVI, SHLOMOIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2019
STAUM, STEVEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/04/2024
BARRAVECCHIO, ANTHONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2013
FLEMING, DONNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/03/2019
KLEIN, BARUCHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
VINITSKY, AVROHOMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/11/2013

CMS files one row per role, so the 25 rows in the source record cover these 11 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.

$28.5M
Net patient revenuemost recent cost report
+3.7%
Operating marginrevenue minus expenses
$4.6M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 53%Medicare 33%Other / private 14%

This home reported $4.6M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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

$429per resident / day
operating cost
$13,029per month
≈ monthly operating cost
$445per 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 315042. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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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