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CareOne At Madison Avenue

151 Madison Avenue, Morristown, NJ 07960 · For profit - Corporation · 178 certified beds · (973) 656-2700 Medicare & Medicaid certified

Call the home — (973) 656-2700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 21 lower-level deficiencies on record (see below)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
43 Maple Ave · (973) 993-9018 · Call to confirm hours
Pharmacy
203 South St · (973) 889-8901 · Call to confirm hours
Grocery
191 South St · (973) 898-4512 · Call to confirm hours
Park
137 James St · 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 fell from 5 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
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 increased14.0%8.7%15.4%typical
Long-stay residents who lose too much weight3.5%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%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 symptoms5.6%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%2.3%3.3%better
Long-stay residents whose ability to walk worsened8.2%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.3%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine92.4%97.2%95.3%typical
Long-stay residents with pressure ulcers5.4%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control17.6%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.2%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine88.0%80.1%79.4%better
Short-stay residents rehospitalized after admission19.6%24.9%22.6%better
Short-stay residents with an outpatient ER visit6.3%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.292.071.67worse
Long-stay outpatient ER visits per 1,000 resident days0.341.111.80better

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.

70.4% 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 377 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

70.4%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
70.2%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 70.2% 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 124 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% 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 SNF70.4%CMS range 64.1–77.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.8–13.010.7%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 discharge70.2%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 discharge69.3%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 discharge65.3%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 identified90.3%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 setting98.3%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 discharge95.3%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 stay0.0%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 worsened2.5%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 hospitalization6.5%CMS range 4.2–9.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 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

0.54
RN hours/ resident / day
1.33
LPN hours/ resident / day
2.16
Aide hours/ resident / day
4.03
Total nurse hours/ resident / day
0.30
RN hoursweekends
21.0%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 178 beds and averages 109.5 residents a day — about 62% occupied, or roughly 68 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.74 hrs/resident/day on weekends vs 4.15 on weekdays — 10% thinner on weekends. RN hours go from 0.63 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 21% is below 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

16
deficiencies at the latest standard inspection (2025-04-11)
3
at the previous standard inspection (2023-04-13)

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.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · F2025-04-11 · 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, record review and policy review, it was determined that the facility failed to a.) failed to ensure that the dish machine logs were completed and failed to ensure the dish machine was properly functioning and, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/3/25 at 11:14 AM, in the presence of the Food Services Director (FSD) and the Culinary Director (CD), the surveyor observed the following: 1. The surveyor observed the low temperature dish machine and the FSD used a test strip to measure the Parts Per Million (PPM) for the sanitizer portion of the machine. The FSD attempted to use the test strip and he was unable to use the test strip correctly, then the CD instructed the FSD with how to measure the PPM for the dish machine. The FSD stated that he should have known how to perform this test on the machine and he was covering today for his food service…

    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 · Fcited before2025-04-11 · tag F0880 — failed to prevent and control infections — widespread
    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 review of other facility documentation, it was determined that the facility failed to a.) follow Center for Disease Control recommendations and guidelines for Hand Hygiene for 2 of 2 Certified Nursing Assistants (CNA), b.) failed to dispose of waste appropriately in 1 of 3 residents rooms reviewed for Transmission Based Precautions (TBP) (Resident # 95) and, c.) failed to have signage for 1 of 3 residents reviewed for TBP (Resident # 95). Reference: According to the U.S. CDC guidelines for Transmission-Based Precautions dated 4/13/24, included the following recommendation details: -Contact Precaution; Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. -Droplet Precaution; Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space.…

    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 · E2025-04-11 · 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

    Complaint #NJ 00174418 Based on interview and record review it was determined that the facility failed to respond to residents' requests for assistance in a timely manner for 5 of 5 residents in attendance at the resident group meeting (Resident #8, 37, 51,60, 97) and 1 of 20 Residents (Resident #254) observed during a tour of the first floor Nursing Unit. This deficient practice was evidenced by the following: The surveyor conducted the resident group meeting on 4/7/25 at 10:30 AM. All 5 of 5 residents stated that the call bell response was slow on all shifts. The residents stated they wait between 30 minutes to an hour. The surveyor interviewed resident # 254 on 4/7/25 at 12:50 PM. The resident stated that on 4/6/25, they waited from 9:00 PM to 10:30 PM for their call bell to be answered. The resident stated that they were incontinent and were dependent on staff for personal care. A review of minutes from past resident council meetings included a 2/10/25 comment from residents stating that they would like to see faster call bell responses. On 4/7/35 at 2:45 PM, the surveyor…

    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 · E2025-04-11 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 #NJ 00174418 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 a.) 1 of 20 residents reviewed for Activities of Daily Living (ADL) care (Resident #254) and b.) 4 of 4 residents (Resident #17, 90, 255 and 256) observed for incontinence care on 1 of 3 Units (1st-floor Nursing Unit). This deficient practice was evidenced by the following: 1. On 4/7/25 at 12:50 PM, during a tour of the 1st floor Nursing Unit, Resident #254 stated that on 4/6/25 at 9:00 PM, the resident was incontinent of his/her bowels and used the call bell to summon staff for assistance. The Certified Nursing Assistant (CNA #1) did not respond until 10:30 PM. The Resident was in a soiled brief for 1.5 hours. A review of Resident #254's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were 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 · E2025-04-11 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management 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 2. The surveyor interviewed Resident #13 on 4/3/25 at 11:07 AM and on 4/7/25 at 10:25 AM in their room. The resident discussed their long term pain management for 3 herniated discs. The resident stated there was a time in October 2024 when a newly prescribed physician's order of oxycodone was not administered to the resident for 2 days. A review of the resident's medical record revealed the following information. The resident's admission Record included diagnoses of cervical disc degeneration, polyneuropathy, peripheral vascular disease, chronic pain, and Parkinson's disease. The 2/19/25 Annual Minimum Data Set (MDS) assessment tool indicated the resident had no cognitive deficits, utilized a manual wheelchair, experienced pain in the previous 5 days occasionally limiting day to day activities. The worst pain the resident experienced on a 0-10 scale (no pain to worst pain) in the previous pain was 3. The resident was coded to have taken opioid medicatons during the previous 7 days. The care plan for pain,…

    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 · E2025-04-11 · 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 clarify a physician's order for peritoneal site care and the assessment for sign and symptoms of infection for precaution. The deficient practice was identified for 1 of 1 resident reviewed for Peritoneal Dialysis (PD) and was evidenced by the following: The surveyor reviewed the closed record for Resident #26. 1. A review of the Resident admission Record (admission summary) reflected that Resident #26 was admitted , with diagnoses which included end stage renal disease, and peritonitis. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/27/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact and on admission, the resident was received PD. A review of the electronic Treatment Administration Record (eTAR) included a physician's order for Peritoneal Catheter (PC) site care every shift. Assess for signs and symptoms of infection every shift for precaution…

    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 · E2025-04-11 · 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, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) disposition (destruction), reconciliation, and accountability of the returned controlled dangerous substance (narcotic; medications, with high potential for abuse, were tracked with detail) for 1 of 1 automatic dispensing system (ADS), b.) opened saline solution bottle was dated, to indicate expiration, which was identified during an observation of a resident on enhanced barrier precautions (EBP), and c.) a medication was stored in accordance with manufacturer's specifications identified in 1 of 4 medication carts inspected. On [DATE] at 11:24 AM, during an interview with the surveyor, the Director of Nursing stated that she had access to the website to review different types of reports. The DON stated she compared the reports and destroyed the returned narcotic medication with another 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 · E2025-04-11 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. On 4/7/25 at 12:20 PM, on the lower level (LL), the surveyor observed that in the bathroom of 2 unsampled residents in rooms #17, and #21, the emergency calling device's pull cords were wrapped around the grab bars. At 12:38 PM, the surveyor showed the concerns to the Registered Nurse (RN). The RN stated that the pull cords should not be wrapped around the grab bars and the paper product should not be placed inside the call device. The RN stated that the resident's on the LL mostly require assistance with toileting and showering and would not be in the bathroom without a staff member. 3. On 04/07/25 at 12:45 PM, on the first floor, the surveyor observed that in the bathroom of an unsampled resident's room, (room116), the emergency calling device cord above the toilet was missing. At 3:15 PM, the surveyor showed the CNA the concern. The CNA stated that the cord should be there. At 3:20 PM, the surveyor showed the concern to the Registered Nurse/ Unit Manager (RN/UM). The RN/UM confirmed that the cord should be there so that the residents could use it to summon help. NJAC 8:39-31.8…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined that the facility failed to maintain the dignity of an unsampled resident on the 3rd floor. This deficient practice was found with 1 of 2 Certified Nursing Aides (CNA) observed on the 3rd floor during the survey. The deficient practice was evidenced by the following: On 4/8/25 at 12:14 PM, the surveyor observed an unsampled resident who self-propelled in their wheelchair down the hallway, the surveyor then overheard the CNA say to the unsampled resident, you can't be moving around in the hallway because people are eating in their room, and then the CNA went behind the resident's wheelchair and push their wheelchair down the hallway toward the unsampled resident's room. At 1:00 PM, the surveyor interviewed the CNA, who stated that he was not regularly on the unit and was concerned that the resident might try to enter other resident's rooms while they ate their lunch. At 1:35 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the unsampled resident was allowed to self propel around 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 · D2025-04-11 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 executed living will and durable power of attorney for health care was maintained in the same section of the resident's medical record readily retrievable by any facility staff, follow up on a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, and determine the code status. This deficient practice was identified for 1 of 3 residents reviewed for advanced directives (Resident #52), and was evidenced by the following: On 4/3/25 at 10:18 AM, the surveyor observed Resident #52 asleep wearing a short sleeve shirt, the right upper arm had a small bandage near the arteriovenous (AV) fistula (surgically created connection between the artery and the vein primarily used for hemodialysis). On 4/4/25 at 9:10 AM, the surveyor observed Resident #52 laying on their side, asleep. The surveyor reviewed the medical record for Resident #52. A review of the Resident admission Record (admission summary) reflected that Resident #52 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2025-04-11 · 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 observation and interview, it was determined the facility failed to maintain the residents' living environment and the outside of the facility in a clean, sanitary, and homelike manner for 1 unsampled resident (room [ROOM NUMBER]) and the area on the 2nd floor outside of the elevator doors. The deficient practice was evidenced by the following: 1. On 4/3/25 at 11:10 AM, on the 2nd floor, outside of the elevator the floor, the surveyor observed 2 broken pieces in the floorboards, where double doors closed. 2. At 11:35 AM, the surveyor observed the garbage area outside of the facility and observed 1 pair of plastic gloves, a plastic knife, a few pieces of paper napkins, and a few clear pieces of plastic on the ground around the garbage dumpsters. 3. On 4/8/25 at 12:08 PM, the surveyor observed an unsampled resident inside of room [ROOM NUMBER]. The surveyor observed that the latch at the top of the door was broken and twisted. The door was unable to close completely when the surveyor pulled it closed. At…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-11 · 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 observation, interview, 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 5 residents, Resident #29, 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 10/26/24, included the following. The CDC recommended administration of Pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults 50 years or older who have received PCV 13 only at any age. The surveyor observed Resident #29 on 4/3/25 at 10:47 AM awake in bed. A review of the 1/20/25 Quarterly MDS Section O0300, indicated the resident's pneumococcal vaccination was up to date. A review of the resident's immunization schedule revealed the resident received the pneumococcal polysaccharide vaccine (PPSV23) on 10/18/21. The surveyor interviewed the Infection…

    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 · D2025-04-11 · 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, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 Residents (Resident #1) reviewed for care and services for pressure ulcers. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of…

    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 · D2025-04-11 · 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

    Based on observation, interview and record review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from February 2025 until surveyor inquiry for 1 of 5 residents (Resident #71) reviewed for medication management. The deficient practice was evidenced by the following. The surveyor observed Resident #71 on 4/03/25 at 10:43 AM laying in a low bed to the floor with cushioned mats on each side of the bed. The resident was calling out in a foreign language and appeared confused. A review of the medical record revealed the following information. The admission Record included the diagnosis of dementia with mood disturbance. The resident was receiving Hospice services. The April 2025 Medication Administration Record (MAR) included the following pain-related physician orders: Pain score every shift; 0=no pain; 1,2,3,4=mild pain, 5,6,7=moderate pain; 8,9,10=severe pain. Acetaminophen (Tylenol) 325 mg. Give 2 tablets by mouth every 6 hours as needed for mild pain (1-4). Morphine Sulfate Solution 20 mg./ml. Give…

    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 · D2025-04-11 · 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 observation, interview, 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 medication administration observation on 4/7/25 and 4/8/25, the surveyor observed five (5) nurses administer medications to five (5) residents. There were 27 opportunities, and two (2) errors were observed which resulted in a medication error rate of 7.41%. This deficient practice was identified for two (2) of five (5) residents (Resident #37 and 64), that was administered by two (2) of five (5) nurses. This deficient practice was evidenced by the following: 1. On 4/7/25 at 8:38 AM, the surveyor observed Licensed Practical Nurse (LPN #1) who was assigned to the second-floor low side medication cart, knocked on Resident #37's door. The greeted the resident who was seated on the edge of their bed facing their breakfast tray on the bedside table. At 8:44 AM, the surveyor observed LPN #1 prepare medications for Resident #37. The medications prepared included a physician's order of Voltaren Gel 1% apply 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 · D2025-04-11 · 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

    Based on observation, interview, and record review, it was determined that the facility failed to ensure pneumococcal vaccination was offered according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations for Resident #29. This deficient practice was identified for 1 of 5 residents reviewed for immunization status. The deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 9/12/24, included the following. The CDC recommends a single dose of PCV21 (pneumococcal 21-valent conjugate vaccine; Capvaxive), PCV20 (pneumococcal 20-valent conjugate vaccine), or PCV15 (pneumococcal 15-valent conjugate vaccine) greater than or equal to 1 year after the last PPSV23 (pneumococcal 23-valent polysaccharide vaccine; Pneumovax23) dose. Reference [previous guidelines] A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine…

    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 · D2023-04-13 · 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 complete and transmit Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) 3.0 Manual guidelines. This deficient practice was identified for 2 of 24 residents reviewed for resident assessment (Residents #23, and #65). This deficient practice was evidenced by the following: 1. On 4/04/2023 at 1:03 PM, the surveyor reviewed the admission Record (AR) for Resident #23 which revealed that Resident #23 was admitted to the facility on [DATE] with diagnosis that included but were not limited to noninfective gastroenteritis and colitis (inflammation of the intestine). The admission MDS assessment, Assessment Reference Date (ARD) dated 3/27/23 was completed on 4/03/23 and was due for submission by 4/02/23. The MDS was not submitted until 4/06/23. 2. On 4/06/2023 at 11:21 AM, the surveyor reviewed the AR for Resident #65 which revealed that Resident #65 was admitted to the facility with a diagnosis…

    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 before2023-04-13 · 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 Based on observation, interview, and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, in accordance with the federal guidelines. This deficient practice was identified for 2 of 24 residents reviewed for resident assessment (Resident #14, and Resident #68). This deficient practice was evidenced by the following: 1. During the initial facility tour on 3/30/23 at 12:25 PM, the surveyor observed Resident #14 watching tv wearing a hearing aid to her left ear. The surveyor reviewed the medical records of Resident #14 which revealed the following: The admission MDS (AMDS) dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated that the resident's cognition was intact. The AMDS Section B Hearing, Speech, Vision of Resident #14 Hearing aid was coded 0 (zero) or No, which did not reflect the resident's current use of a hearing aid.…

    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 before2023-04-13 · 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

    Complaint #NJ00149914 Based on observation, interview, review of facility records, and other pertinent facility documents on 4/4/23, it was determined that the facility failed to follow a Professional Standards of Practice by not transcribing an order for medication appropriately. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: A review of the admission Record for the Resident # 103 reflected that the resident was admitted to the facility with diagnoses which included but were not limited to cellulitis of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-04-27 · 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, and record review, it was determined that the facility failed to hold the prescribed medication Midodrine (a medication to treat low blood pressure) for 2 of 2 Resident's reviewed (Resident #39 & #80). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) wear the appropriate personal protective equipment (PPE) inside a resident's room on Transmission Based Precautions (TBP) and, b.) conduct hand hygiene between tasks and after the removal of gloves for 1 of 6 residents (Resident #135) reviewed on TBP. This deficient practice was evidenced by the following: On 4/16/21 beginning at 10:21 AM, the surveyor conducted the Entrance Conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) when the Cohort Plan for the building was revealed as follows: Green Zone - Naïve, negative, recovered, and vaccinated. Staff were to wear goggles or face shield and surgical mask at minimum. Yellow Zone - Unknown or potentially incubating, New Admission/re-admission and not COVID-19 recovered. Staff were to wear a N95 or KN95, no need to cover with surgical mask, face shield or goggles and a gown 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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to CAREONE — 37 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 3 of 53.4-0.4 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 36 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Care One At MillburyMillbury, MA 1 of 5Care One At RandolphRandolph, MA 1 of 5Careone At OradellOradell, NJ 2 of 5Care One At BrooklineBrookline, MA 2 of 5Care One At NewtonNewton, MA 2 of 5Care One At RedstoneEast Longmeadow, MA 2 of 5Care One At WeymouthWeymouth, MA 2 of 5CareOne At Hanover TownshipWhippany, NJ 2 of 5Careone At MiddletownAtlantic Highlands, NJ 2 of 5Rehab & Nursing Ctr Greater PittsburghGreensburg, PA 3 of 5Care One At LexingtonLexington, MA 3 of 5Care One At LowellLowell, MA 3 of 5Care One At New BedfordNew Bedford, MA 3 of 5CareOne At MoorestownMoorestown, NJ 3 of 5CareOne at New MilfordNew Milford, NJ 3 of 5Careone At East BrunswickEast Brunswick, NJ 3 of 5Careone At Ridgewood AvenueParamus, NJ 3 of 5Careone At WellingtonHackensack, NJ 4 of 5Care One At ConcordW Concord, MA 4 of 5Care One At Essex ParkBeverly, MA 4 of 5Care One At NorthamptonNorthampton, MA 4 of 5CareOne At TeaneckTeaneck, NJ 4 of 5CareOne at The HighlandsEdison, NJ 4 of 5Careone At CresskillCresskill, NJ 4 of 5Careone At EveshamMarlton, NJ 4 of 5Careone At LivingstonLivingston, NJ 4 of 5Careone At ParsippanyParsippany Troy Hill, NJ 4 of 5Careone At Somerset ValleyBound Brook, NJ 5 of 5Care One At HolyokeHolyoke, MA 5 of 5Care One At PeabodyPeabody, MA 5 of 5Care One At WilmingtonWilmington, MA 5 of 5CareOne At WallWall, NJ 5 of 5Careone At HolmdelHolmdel, NJ 5 of 5Careone At ValleyWestwood, NJ 5 of 5Careone At WayneWayne, NJ 5 of 5River Glen Health Care CenterSouthbury, CT

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 / managerTypeRoleShareSince
CARE ONE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2004
DES 2009 GST TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST18%since 01/25/2017
DES HOLDING CO., INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST24%since 01/25/2017
DES-C 2009 GRATOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/26/2009
STRAUS, DANIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2004
BARUCH, DAVIDIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/01/2021
CARE ONE MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2004
HEALTHBRIDGE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/25/2008

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$15.9M
Net patient revenuemost recent cost report
-15.7%
Operating marginrevenue minus expenses
$942K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 19%Other / private 31%

This home reported $942K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$498per resident / day
operating cost
$15,126per month
≈ monthly operating cost
$430per 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 315488. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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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