Morristown Post Acute Rehab And Nursing Center
77 Madison Avenue, Morristown, NJ 07960 · For profit - Limited Liability company · 287 certified beds · (973) 540-9800 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 1.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.2% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 6.4% | 12.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.3% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.7% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 23.7% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.6% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.1% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.3% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 39.3% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.1% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.6% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.89 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.45 | 1.11 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
67.0% 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 630 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.5% 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 169 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 67.0%CMS range 62.8–70.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 8.2–11.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 67.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 5.3–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 287 beds and averages 205.3 residents a day — about 72% occupied, or roughly 82 beds typically open. It usually has some room. 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.39 hrs/resident/day on weekends vs 4.00 on weekdays — 15% thinner on weekends. RN hours go from 0.79 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · E2025-06-27 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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 review of other pertinent facility documents, it was determined that the facility failed to ensure implementation of interventions designed by the physical therapist to stimulate functional performance and prevent further decline. This deficient practice was identified for one (1) of three (3) resident reviewed for positioning and mobility (Resident #88) and was evidenced by the following: On 6/19/25 at 11:31 AM, during the initial tour of the second floor, the surveyor entered Resident #88's room. The resident was awake, alert, pleasant and had a breakfast tray in front of them with built up utensils (an adaptive eating utensils designed with molded plastic handles to assist individuals with limited or weakened grasping strength). No additional assistive device was observed on the resident. The surveyor reviewed the medical record for Resident #88. According to the admission Record, an admission summary, reflected that Resident #88 reflected diagnoses that included Parkinson's Disease (PD; a movement disorder of the nervous system that worsens…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0742 — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other pertinent facility documentation it was determined that the facility failed to ensure a resident with history of post-traumatic stress disorder (PTSD) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This deficient practice was identified for one (1) of five (5) residents (Resident #159) reviewed for unnecessary medications and was evidenced by the following: On 6/23/25 at 12:54 PM, the surveyor observed Resident #159 in bed and was reluctant to discuss their experience in the facility for fear of retaliation. The surveyor reviewed the medical record for Resident #159. According to the admission record, an admission summary, reflected that Resident #159 was admitted to the facility with diagnoses that included, major depressive disorder, mood disorder, anxiety disorder and (PTSD). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/28/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
4. The surveyor interviewed Resident #134 on 6/19/25 at 12:16 PM. The resident was seated in an armchair at the bedside and told the surveyor they received hemodialysis three times a week. A review of the electronic medical record revealed the following information. The 4/19/25 admission MDS assessment tool indicated the resident had no cognitive deficits as evidenced by a BIMS score of 14 of a possible 15. The June 2025 Order Summary Report included a 4/14/25 physician's order for Midodrine oral tablet (medication used to raise blood pressure) 5 mg. twice a day for hypotension (low blood pressure) hold for SBP (systolic blood pressure) above 130 millimeters of mercury (mmHg). A review of the April, May, and June 2025 Medication Administration Records included documentation by the administering nurse that Midodrine was administered 10 times when the SBP was above 130 mmHg or when a blood pressure was not documented. The surveyor interviewed the Licensed Practical Nurse Unit Manager on 6/25/25 at 10:21 AM. She confirmed nurses must follow the parameters for Midodrine to be held when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-27 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined that the facility failed to post the prior year's State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following: On 6/24/25 at 10:30 AM, the surveyor held the resident council meeting and 4 of 5 residents, who were in attendance, voiced that they did not know where the survey results were located. 1 of 5 of the resident's stated that they thought the survey results were at the receptionist desk. On 6/24/25 at 11:30 AM, the surveyor could not locate survey results near the receptionists desk and could not locate them throughout he facility and the receptionist stated that they did not know where the survey results were located. On 6/24/25 at 1:40 PM, the Surveyor met with Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and surveyor voiced concerns that previous years survey results could not be located. The LNHA stated the results were at the reception area desk and that they were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and United States (U.S.) Food and Drug Administration (FDA) dish sanitation recommendations, the facility failed to ensure 1 of 1 dish machine and 1 of 1 three-compartment sink were utilized in accordance with FDA guidance to minimize the potential for foodborne illness. Specifically, the facility failed to ensure the low-temperature dish machine achieved recommended temperatures, failed to ensure sanitizer testing supplies were not expired, and failed to maintain the chemical concentration of sanitizer in the three-compartment sink. The failed practices had the potential to affect 194 residents who received meals from the dietary department out of a total census of 199 residents. Findings included: Chapter 4 of the U.S. FDA 2022 Food Code indicated, 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature (B) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 49°C [Celsius] (120°F. [Fahrenheit]). The Food Code also specified, 4-501.114 Manual and Mechanical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-08 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, record review, interview, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and (&) Oversight Group (QSOG) memoranda, the facility failed to ensure CDC guidance and the facility's infection prevention and control (IPC) policies were promptly and consistently implemented, as evidenced by: 1) failure to ensure staff donned the appropriate personal protective equipment (PPE) while caring for 3 (Residents #1, #2, and #3) of 3 residents reviewed for enhanced barrier precautions (EBP. 2) failure to ensure staff donned the appropriate PPE when entering the room to deliver and set up a meal tray for 1 (Resident #4) of 3 residents reviewed for transmission-based precautions and failed to perform appropriate hand hygiene between delivering meals to Residents #4, #5, and #6. 3) failure to ensure a vaccination was promptly administered after consent was obtained for 1 (Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-07 · tag F0773 — patternProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 #: NJ00178715 Based on interview, record review, and review of facility's pertinent documentation on 11/06/2024, it was determined that the facility failed to obtain physician orders for laboratory services performed on 3 of 4 residents (Resident #1, Resident #2, and Resident #3) reviewed for laboratory services and physician orders. The deficient practice was evidenced by the following: 1. According to Resident #1's admission Record (AR), Resident was admitted to the facility with the following diagnoses that included but not limited to: Urinary Tract Infection, Hydronephrosis with Renal and Urethral Calculous Obstruction, Hypertension, Hyperlipidemia, Anxiety Disorder, Depression, Benign Prostatic Hyperplasia, and Congestive Heart Failure. According to the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 04/09/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident's cognition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY COMPLAINT # NJ176547 CENSUS: 192 SAMPLE SIZE: 3 Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate incontinence care and double diapering a dependent resident who required staff assistance. This deficient practice was identified for 1 of 3 residents reviewed for bladder and bowel incontinence (Resident #2) and was evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Traumatic Subdural Hemorrhage without loss of Consciousness, [NAME] Syndrome, Acute and Chronic Respiratory Failure with Hypoxia, Persistent Vegetative State, Cerebral Stroke Syndrome, Gastrostomy Status, Tracheostomy Status, Essential Primary Hypertension. According to the Minimum Data Set (MDS), an assessment tool dated 6/4/2024, Resident #2 had a Brief Interview for Mental Status (BIMS) of 99, indicating that Resident # 2's cognition was unable to be assessed. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-09 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to identify the need for a new Preadmission Screening and Resident Review (PASARR-a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness) when a resident had a new diagnosis of mental illness for one (Resident (R) 23) of three sampled residents in a total sample of 42. This failure placed the residents at risk of not receiving necessary services. Findings included. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R23 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and major depressive disorder. The resident did not have diagnosis of Alzheimer and/or dementia. Review of the Medical Diagnosis list located in the Medical Diagnosis tab of the EMR revealed the following mental illness 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.
- Potential for harm · D2024-01-09 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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, the facility failed to ensure the PASARR (Pre-admission Screening and Resident Review-a screening process for residents who have indicators of intellectual disability, related disability, or serious mental illness) was followed for one (Resident (R) 43) of three sampled residents in a total sample of 42. The facility failed to ensure a PASARR Level 1 was corrected to include serious mental illness to determine if a Level II (a more in-depth screening) was required. This failure placed the resident at risk of not receiving the mental health services needed and placed him at risk for a diminished quality of life. Findings included. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R43 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder (a disorder associated with episode of mood swings ranging from depressive lows to manic highs.) and adjustment disorder 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.
Show the remaining 18 citations
- Potential for harm · Dcited before2024-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility policies, the facility failed to ensure one resident (Resident (R) 118)'s out of four residents' had appropriate fall prevention interventions to prevent potential accident hazards. Findings include: Review of an undated policy provided by the facility titled, Fall Risk Assessment indicated .The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of R118's electronic medical record (EMR) titled, admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. Review of R118's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/23, located under the MDS tab indicated the staff was unable 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.
- Potential for harm · D2024-01-09 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (Resident (R) 15) of four sampled residents who were fed via a gastrostomy tube had the enteral feeding container labeled, dated, and timed, as required. This failure placed the resident at risk for having received expired and/or inaccurate enteral nutrition. Findings included. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R15 was admitted to the facility on [DATE] with diagnoses that included a non-traumatic bleeding on the brain, one-sided paralysis, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of [DATE] revealed R15 had a staff assessed Brief Interview of Mental Status (BIMS) score of 2 out of 15 that indicated he was moderately impaired in cognition and was administered all of his nutrition via a gastrostomy tube. During an initial observation on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control standards were performed during intravenous (IV) medication administration for one (Resident (R) 196) of one resident reviewed for IV antibiotic medications. The facility failed to ensure proper glove use was used during IV medication administration. This failure placed the resident at risk for cross contamination from infectious agents. Findings included. Review of the facility policy's titled, Infection Control (IC) Guidelines For All Nursing Procedures, dated 02/2023, revealed, .It is the policy of this facility to adhere to infection control (IC) guidelines to limit or prevent the spread of infection between residents and/or staff . Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R196 was admitted to the facility on [DATE] with diagnoses that included a kidney infection, a urinary tract infection (UTI), was resistant to multiple antibiotics, and had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0837 — isolatedEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
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 # NJ00168549 and NJ00168552 Based on observation, interview, and review of pertinent facility documentation on [DATE], it was determined that the facility failed to implement its policy on Administering Medications and Physician Medication Orders for 4 of 4 resident residents (Resident #1, Resident #2, Resident #3, and Resident #4). This deficient practice was evidenced by the following: During the entrance conference on [DATE] at 9:40 a.m., the Licensed Nursing Home Administrator (LNHA) revealed that LPN #1 was the previous unit manager of XX floor and was currently acting as the facility's Infection Control Preventionist (ICP). During the tour of the XX floor on [DATE] at 9:59 a.m. the Surveyor interviewed LPN #1. LPN #1 introduced herself as the floor LPN/Unit Manager (UM) and the facility's ICP. LPN #1 revealed that she has been in the UM position since last year and 4 weeks for the ICP position. LPN #1 explained that as the floor UM, her job was to make sure that the residents were being taken…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2021-08-06 · tag F0677 — failed to help fully-dependent residents with daily care — widespreadProvide 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 3.) On 07/27/21 at 9:39 AM, Surveyor #2 observed Resident #63 in a wheelchair in his/her room. Surveyor #2 observed the resident's finger nails were visibly long and extended above his/her finger tips, with a visible dark debris under all ten nails. Resident #63 stated to Surveyor #2 that he/she would like to have his/her finger nails cut but couldn't recall if he/she had ever asked any of the staff. On 07/28/21 at 10:48 AM, Surveyor #2 made a second observation of Resident #63 while the resident was sitting in a wheelchair in their room. Resident #63's finger nails remained visibly long with debris observed under the nails. On 07/29/21 at 10:03 AM, Surveyor #2 made a third observation of Resident #63 while sitting in a wheelchair in his/her room. Surveyor #2 observed Resident #63's nails remained visibly long with debris observed under the nails. The resident stated that he/she wanted them cut but nobody would do it. The resident further stated he/she didn't recall if anyone asked him/her if he/she would like…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2021-08-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, it was determined that the facility failed to maintain the kitchen in a clean and sanitary manner, and properly store potentially hazardous foods to ensure they are not used by a safe use by date to prevent the development of food borne illness. The deficient practice was evidenced by the following: On 07/27/21 from 8:50 AM to 10:32 AM the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) and observed the following: 1. A walk in refrigeration unit, box #3, had stored items which included plastic bins of 4 ounce pre- packaged thin juices, thickened juices, 4 ounce yogurts and wrapped pre-made sandwiches. The FSD stated the refrigeration unit was used primarily for tray line items and was currently in operation. There was a puddle of liquid observed on the floor of the refrigeration unit and the air temperature felt warm. The FSD stated the cold items should be stored at 32 degrees Fahrenheit (F) or less and the surveyor and the FSD checked the temperature of 4 ounces of apple juice and the container of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2021-08-06 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 facility documentation, it was determined that the facility failed to follow facility policy and Centers for Disease Control and Prevention (CDC) guidelines to limit the potential spread of infection by failing to: a) maintain a system of infection surveillance, per facility policy, to identify and monitor facility infections for all residents who resided on 4 of 4 nursing units, b.) ensure physician ordered transmission based precautions (TBP) for 2 of 2 residents (Resident #306 & #307) were implemented and followed, c.) perform appropriate hand hygiene as indicated during a medication observation, upon doffing (removing) personal protective equipment (PPE), during a meal observation, and as observed in a resident's room, d.) maintain a consistent COVID-19 screening process upon facility entry, e.) maintain respiratory suctioning equipment in a clean, sanitary manner for 1 of 2 residents reviewed (Resident #92) and e.) maintain 4 out of 4 multi-use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-06 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records and review of other pertinent documentation, it was determined that the facility failed to treat all residents in a dignified manner by: a.) applying multiple incontinent briefs to incontinent residents, b.) failing to provide incontinence care to a resident assessed to be dependent on staff for activities of daily living (ADL's ), c.) transporting a resident in a recliner chair backwards, d.) failing to clean blood off a resident's face, and e.) failing to maintain a resident's clothing, blanket, and wheelchair in a clean manner. This deficient practice was identified for 7 of 8 residents reviewed for dignity (Residents #29, #33, #45, #75, #76, #112, #129) on 2 of 4 nursing units and was evidenced by the following. a.) On 07/29/21 at 11:10 AM, surveyor #3 observed Resident #76, who resided on the 3rd floor, lying in bed with a hospital gown over top of a regular shirt with pieces of food lying on his/her chest. The resident's hair appeared greasy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-06 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and review of pertinent documents, it was determined that the facility failed to follow the facility abuse policy by failing to: a.) thoroughly investigate an allegation of a staff member injuring a resident as potential abuse, and b.) failed to investigate an injury of unknown origin. This deficient practice occurred for 2 of 2 residents investigated for abuse (Resident's #45 & #255) and was evidenced by the following: 1. On 08/03/21 at 10:44 AM, the surveyor observed Resident #45 in bed, the resident did not initially respond, held his/her head down and appeared guarded. At 10:49 AM the Certified Nurse Aide (CNA) assigned to Resident #45 entered the room. The CNA stated she completed all care for the resident except for feeding and the resident did not like to be touched. A review of the medical record for Resident #45 revealed the following: The admission Record revealed the resident had diagnoses including Downs Syndrome (a genetic disorder associated with mild to moderate intellectual disability) and major depressive disorder. An annual Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-06 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure a resident who left the facility for hemodialysis treatments received physician ordered medications in coordination with the hemodialysis schedule, and in accordance with physician prescribed orders, b.) assess a resident who had a change in condition, and c.) ensure medications were administered, parameters were monitored as ordered, and the physician was notified regarding medications that were not administered per policy. The deficient practice occurred for 1 of 3 residents reviewed for hemodialyis (Resident #7), 1 of 32 residents reviewed for quality of care (Resident #112) and 1 of 1 closed records reviewed for resident death (Resident #155). The deficient practice was evidenced by the following: a.) On 07/27/21 at 10:45 AM, Surveyor #1 interviewed Resident #7 in his/her room. The resident stated that he/she went to dialysis on Tuesday, Thursday, and Saturday…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 pertinent facility documentation, it was identified that the facility failed to a.) assess and document the development of a facility acquired pressure ulcer, b.) notify the physician of the development of the facility acquired pressure ulcer, and c.) obtain a physician ordered treatment for a facility acquired pressure ulcer. This deficient practice was identified for one of two resident's reviewed pressure ulcers, (Resident #129) and was evidenced by the following: Resident #129 was admitted to the facility with diagnoses which included, enterocolitis (inflammation of the digestive tract), diabetes mellitus, difficulty in walking, unspecified abnormality of gait (walking) and mobility, need for assistance with personal care. The admission Minimum Data Set (MDS ) a resident assessment tool, dated 06/29/2021, revealed that Resident #129 was alert and able to make his/her needs known. Resident #129 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-06 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent facility documentation it was determined, that the facility failed to: a.) maintain adequate monitoring of a resident post dialysis treatment and b.) consistently document post dialysis treatment on the hemodialysis communication record. This deficient practice was identified for one of three residents reviewed, (Resident #7) for dialysis care and services and was evidenced by the following: On 07/27/21 at 10:45 AM, the surveyor observed Resident #7 in his/her room. The resident stated that he/she went to dialysis on Tuesday's, Thursday's, and Saturdays, was picked up by transport around 11:00 AM and would return to the facility around 5:00 PM. The resident showed the surveyor his/her fistula (a surgically made passage between an artery and a vein that functions as a dialysis access site) on his/her left forearm. The surveyor observed that the fistula site was clean and dry. The surveyor reviewed the medical record for Resident #7. Review of the resident's admission Record reflected that the resident had resided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-06 · tag F0725 — failed to have enough nursing staff — patternProvide 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
Complaint #NJ 00146254 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment and b.) provide sufficient staffing numbers to meet minimum staffing requirements. This deficient practice was observed on 4 of 4 nursing units and for eight of 30 residents' reviewed, (Resident #7, #33, #45, #54, #63, #75, #76, and #129) for care related to staffing. Refer to F677, The deficient practice was evidenced by the following: 1.) On 07/27/21 at 11:03 AM, on 07/28/21 at 11:52 AM, and on 07/29/21 at 8:49 AM, Surveyor #1 observed that the fingernails on Resident #54's bilateral hands were contorted and disfigured. The resident's fingernails were observed to be long and jagged with a black substance underneath of them. 2.) On 07/27/21 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.
- Potential for harm · E2021-08-06 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent facility documentation, it was identified that the facility failed to ensure that an insulin medication was administered to a resident within an appropriate time frame according to: a.) physician's order and b.) manufacturer specifications. This deficient practice was identified for 1 of 1 resident, (Resident #7) reviewed for the administration of an insulin medication, and was evidenced by the following: On 07/27/21 at 10:45 AM, the surveyor observed Resident #7 in his/her room. The resident stated that he/she went to dialysis on Tuesday's, Thursday's, and Saturdays, was picked up by transport around 11:00 AM and would return to the facility around 5:00 PM. The resident further stated that he/she had diabetes (a chronic condition which affects the way the body processes sugar) and liked to bring a snack with him/her to dialysis incase his/her blood sugar (amount of circulating glucose in the body; normal values are between 70 - 100) dropped. On 08/03/21 at 10:05 AM, the surveyor observed the resident in his/her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-06 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 documentation, it was determined the facility failed to ensure residents received the correct physician ordered thickened liquids. This deficient practice was identified for 5 of 10 residents (Resident #30, #69, #93, #104, #112) on the third floor unit, reviewed for therapeutic diets. The deficient practice was evidenced by the following: On 07/30/21 at 8:41 AM, the surveyor observed a Styrofoam cup sitting on the the bedside table in Resident #69's room with the date of 07/30/21 written on it. Resident #69 was lying in bed and unable to reach the cup. The Director of Nursing (DON) was at the third floor unit nurse's desk at that time. The DON accompanied the surveyor to Resident #69's room and observed the Styrofoam cup sitting on Resident #69's bedside table. The DON picked up and examined the Styrofoam cup and acknowledged the contents was thin ice water and the cup was full. The DON stated Resident #69 was on thickened liquids and should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-08-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain a safe environment during medication administration. This deficient practice was identified for 1 of 32 residents reviewed (Resident #132). The deficient practice was evidenced by the following: Resident #132 was admitted to the facility with diagnoses which included, unspecified convulsions, hypertension, adjustment disorder, congestive heart failure and end stage renal disease. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 04/2021 and the Annual assessment dated 10/2021, revealed that Resident #132 was awake and alert. Resident #132 scored 15 on the Brief Interview for Mental Status (BIMS ) which indicated the resident was cognitively intact. On 07/30/2021 at 8:10 AM, the surveyor observed the nurse in the hallway at the medication cart. The surveyor entered Resident #132's room and observed a cup with medications on the bedside table. The resident stated I am waiting for the breakfast tray to take my medications. Resident #132 shared a room with another Resident. One housekeeping…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-08-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
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 store urinary catheter drainage bags appropriately to limit the development of infection. This deficient practice was identified for 2 of 3 residents reviewed, (Resident #86 & Resident #106) for urinary catheter care, and was evidenced by the following: 1.) On 07/27/21 at 9:52 AM, surveyor #1 observed Resident #106 seated upright in a wheelchair in his/her room. The resident stated that he/she had resided at the facility for, awhile and had an indwelling urinary catheter. The resident then lifted his/her left pant leg and showed the surveyor a drainage bag attached to his/her left leg which contained clear, yellow urine. The surveyor entered the resident's bathroom and observed an indwelling urinary catheter drainage bag stored in a plastic bag that was tied onto the handrail in the resident's bathroom. The surveyor observed that the tubing to the resident's indwelling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-08-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and other document review, it was determined, that the facility failed to a.) administer the correct amount of oxygen (O2) to residents per the physician's order, b.) document the administration of O2 per physician's order, and c.) failed to date and sign the O2 tubing to verify that it was changed. This deficient practice was identified for 1 of 2 residents reviewed (Resident #130) for respiratory care and was evidenced by the following: According to admission Record (AR), Resident # 130 was admitted to the facility with the diagnoses that included but were not limited to: malignant neoplasm (cancer) of the rectum, diabetes mellitus (DM) and obesity. The admission Minimum Data Set (MDS) an assessment tool dated 06/30/21, indicated that Resident # 130 was cognitively intact, required extensive assistance with activities of daily living (ADLs) an required the use of O2 continuously. On 07/27/21 at 10:57 AM, the surveyor observed Resident # 130 in bed with O2 infusing by way of (via) nasal cannula (Soft plastic tubes that can be fitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ALLAIRE HEALTH SERVICES — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.6 | +2.4 vs chain |
| Health inspection | 4 of 5 | 2.2 | +1.8 vs chain |
| Staffing | 4 of 5 | 3.1 | +0.9 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 19 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| FREUND, ELIYAHU | Individual | W-2 MANAGING EMPLOYEE | since 03/17/2020 |
| KURLAND, BENJAMIN | Individual | CORPORATE DIRECTOR | since 03/17/2020 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $5.0M 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315157. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-27, 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.