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Forest Hills Center For Rehabilitation And Healing

497 Mt Prospect Ave, Newark, NJ 07104 · For profit - Limited Liability company · 120 certified beds · (973) 482-5000 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 immediate-jeopardy citation$37,580 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $37,580 in federal fines (most recent 2023-12-12)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 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
467 Mount Prospect Ave · (973) 483-2800 · Call to confirm hours
Pharmacy
519 Broadway · (973) 482-4968 · Call to confirm hours
Grocery
441 Mt Prospect Ave · (973) 350-0116 · Call to confirm hours
Park
Branch Brook Park Dr · (973) 268-3500 · 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 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased7.1%8.7%15.4%better
Long-stay residents who lose too much weight5.3%4.6%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.7%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms8.1%12.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.9%2.3%3.3%better
Long-stay residents whose ability to walk worsened7.4%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.9%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%97.2%95.3%typical
Long-stay residents with pressure ulcers4.1%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control16.1%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table5.9%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine92.0%80.1%79.4%better
Short-stay residents rehospitalized after admission32.0%24.9%22.6%worse
Short-stay residents with an outpatient ER visit6.0%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days0.712.071.67better
Long-stay outpatient ER visits per 1,000 resident days0.161.111.80better

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.

50.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.1%U.S. median 51.5%
Got home and stayed home
15.1%U.S. median 10.7%
Went back to hospital
65.2%U.S. median 56.6%
Met the expected recovery
0.44U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 65.2% 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 92 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 0.44 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 SNF50.1%CMS range 42.2–56.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF15.1%CMS range 10.7–19.810.7%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 discharge65.2%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 discharge70.7%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 discharge54.4%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 identified68.1%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 setting91.1%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 discharge93.8%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 hospitalization7.2%CMS range 4.4–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.461.02Oct 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

0.58
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.54
RN hoursweekends
32.0%
Total nursing turnover
31.6%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 110.5 residents a day — about 92% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.22 hrs/resident/day on weekends vs 3.45 on weekdays — 7% thinner on weekends. RN hours go from 0.59 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% 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

17
deficiencies at the latest standard inspection (2025-08-05)
9
at the previous standard inspection (2023-12-12)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

  • Immediate jeopardy · Kcited before2023-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other pertinent facility documents on 12/4/2023, it was determined that the facility failed to provide four of ten residents with a prescribed pureed diet, which should have been smooth, soft, and homogenous in consistency. The pureed mashed potatoes served to the residents from the kitchen on 12/4/23, were served with several chunks of potato mixed into the mashed potatoes. The facility's failure to prepare and provide the proper pureed food consistency and, failure of the nursing staff to report the improper food consistency, placed Resident #61, #28, #31 and #69, as well as all other residents, at risk of aspiration and choking which could cause serious harm, impairment or death. This resulted in an Immediate Jeopardy (IJ) situation that began on 12/4/23. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 12/4/23 at 4:18 PM. An acceptable written Removal Plan was received on 12/5/23 at 10:00 AM. The Removal Plan was verified by the survey team onsite on 12/5/23 at 1:10 PM, lifting the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-05 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews and review of pertinent facility documents, it was determined that the facility failed to provide food at a safe and appetizing temperature. The deficient practice was identified for 6 of 6 residents (Residents #1, #19, #20, #29, #69 and #78) that participated in the Resident Council Meeting and was evidenced by the following:On 7/31/25 at 10:30 AM, while participating in Resident council meeting 6 of 6 residents verbalized, they receive food that is cold at meals. On 8/5/25 at 10:15 AM, the surveyor interviewed Unit Manager (UM) for 5th floor. The UM confirmed occasionally residents ask for their food to be heated because it arrived cold. The UM further stated cold food gets heated up on the unit in a microwave. UM stated staff starts passing trays as soon as they are on the floor and acknowledged there are some delays at times getting trays to floor caused by elevators. On 8/5/25 at 10:20AM, the surveyor interviewed CNA #1. CNA#1 verbalized that residents complain of cold food sometimes and stated the elevators slow down the food arrival time…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-05 · tag F0806 — failed to honor food preferences — widespread
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 6 of 6 residents (Resident #2, #8, #25, #69, #94, and #116) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows:1. On 7/30/25 at 12:17 PM, the surveyor was observing the lunch meal on 4th floor unit. The surveyor observed Resident #69's tray, per the tray ticket, Resident #69 was supposed to receive coffee, strawberry short cake and health shake supplement, all three items were missing from the tray. 2. On 7/30/25 at 12:23 PM, the surveyor was observing the lunch meal on 4th floor unit. The surveyor observed Resident #25's tray, per the tray ticket, Resident #25 was supposed to receive sour cream and diet health shake supplement, both items were missing from the tray. 3. On 7/30/25 at 12:29 PM, the surveyor was observing the lunch…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.This deficient practice was observed and evidenced by the following:On 7/29/25 at 9:37 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and observed the following: 1. In the bread storage area, the surveyor observed one loaf of sliced white bread, one loaf of sliced whole wheat bread, one bag of 12 hotdog buns, and one loaf of rye bread all opened and without open/use by labels. The FSD stated they use the manufacturers use by dates.2. On a dry storage shelf the surveyor observed an open bag of penne pasta with an open date of 3/26/25 without a use by label. The FSD stated open pasta can be used for 90 days after opening and further acknowledged the pasta was past the 90 days from opening.3. On the Chef preparatory table, the surveyor observed three opened containers of seasoning: 16 ounce (oz) granulated garlic, 5 oz Italian seasoning, and 16 oz red…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-05 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris.This deficient practice was observed and evidenced by the following:On 7/29/25 at 9:37 AM, the surveyor in the presence of the Food Service Director (FSD) toured the kitchen and garbage area; and found the following. There was garbage debris that included food wrappers, food containers, cups, gloves, paper products, and plastic utensil around the dumpster and surrounding areas. The FSD stated that the area should have been cleaned by the maintenance and dietary departments.On 7/30/25 at 1:00 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Disposal of Refuge with a reviewed date of 5/2025. Under the interpretation and implementation section of the policy revealed, 4. Outside dumpsters or compactors provided by waste management services will be kept closed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-05 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and review of facility policies it was determined that the facility failed to a.) ensure residents with significant weight changes (a weight change of 5% in 30 days and/or 10% in 180 days) were addressed by the Registered Dietitian (RD#1) in a timely fashion and b.) ensure that a resident was weighed weekly in accordance with physician's orders and facility policy. This deficient practice was identified for 2 of 2 residents (Resident #8 and #64) reviewed for significant weights changes. The deficient practice was evidence by the following:1. On 7/29/25 at 11:18 AM, the surveyor interviewed Resident #64 in their room. Resident #64 stated they are on a pureed diet and had lost weight over the past year, but unable to state how much. A review of Resident #64 Face Sheet ((FS) an admission record) revealed that the resident had diagnosis that included but were not limited to unspecified protein-calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things), type 2 diabetes mellitus…

    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 · E2025-08-05 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to provide appropriate incontinence care to dependent residents. This deficient practice occurred for 3 of 4 residents reviewed for sufficient staffing (Resident # 47, #63, and #64) and was evidenced by the following:Refer to F677Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/1/21: (1) One Certified Nurse Aide (CNA) to every eight residents for the day shift. (2) One direct staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-05 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 7/30/25 and 7/31/25, the surveyor observed three (3) nurses administer medications to six (6) residents. There were 25 opportunities, and six (6) errors were observed which calculated to a medication administration error rate of 24%. The deficient practice was identified for two (2) of six (6) residents, (Resident #16 and #89), that were administered medications by two (2) of three (3) nurses that were observed.The deficient practices were evidenced by the following:1). On 7/30/25 at 8:48 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN#1) in the room of Resident #16. The surveyor observed LPN#1 informing Resident #16 that she would be administering the resident's medications. The surveyor observed the resident who was in…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and other facility documentation, it was determined that the facility failed to a.) maintain a sanitary clean environment; b.) minimize the potential spread of infection to residents during medication administration for 1of 3 nurses observed during medication pass on 1 of 2 nursing units and c.) follow the Centers for Disease Control recommendations and guidelines for Hand Hygiene for 3 of 3 staff members.This deficient practice was evidenced by the following. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24, Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1. On 07/30/25 at 8:52 AM,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-05 · 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 observations, interviews, and a review of pertinent facility documents, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promotes their quality of life. The deficient practice and violation of privacy were identified for 3 of 28 residents (Resident #70, #71 and Resident #123) reviewed for residents' rights and was evidenced by the following: On 7/30/25 at 11:30 AM, the surveyor was interviewing Resident #70. At that time, the surveyor observed a maintenance worker enter the room without knocking or announcing themselves. The maintenance worker opened a step ladder and inspected the privacy curtain and then exited the room.On 7/30/25 at 11:40 AM, the surveyor observed the same maintenance worker enter the room of Resident #71, without knocking, waiting for permission or introducing themselves before entering the room.At that time, the surveyor interviewed the maintenance worker who stated that they should have knocked, announced themselves and attempted to get permission before entering the room. On 7/30/25 at 11:45…

    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 · D2025-08-05 · 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, interview, and review of other facility documentation, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for a.) 1 of 2 Nursing Units reviewed for environment; b.) ensure clean linens were provided daily for 6 of 6 residents who attended the resident group meeting (Resident #1, 19, 20, 29, 69 and 78); c.) ensure equipment was kept in a clean, sanitary manner for 2 of 2 residents, (Resident #113 and #70) and e). ensure privacy curtains were clean and in working order for 2 of 2 Residents (Resident #47 and #13)). This deficient practice was evidenced by the following: 1. On 7/30/25 at 9:14 AM, Surveyor #1 (S#1) and the Director of Maintenance and Housekeeping (DMH) toured the 4th floor unit and observed the following: The clean linen room was observed with the door closed, upon entry there was a metal rack uncovered with clean folded towels. On top was a vent with heavy accumulation of grayish substance and 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
Show the remaining 19 citations
  • Potential for harm · D2025-08-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 4 residents (Resident #47, 63 and 64) observed for incontinence care on 1 of 2 units (4th-floor Nursing Unit).This deficient practice was evidenced by the following:On 7/31/25 at 8:15 AM, the surveyor completed an incontinence tour on the 4th floor Nursing Unit and observed the following:1. On 7/31/25 at 8:25 AM, the surveyor, accompanied by the Licensed Practical Nurse/ Unit Manager, observed Resident #64 in bed. The LPN/UM exposed Resident #64's incontinence brief, and the surveyor observed that it was saturated with urine. The LPN/UM confirmed that the brief was saturated with urine.A review of Resident #64's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to, diabetes mellitus and dementia. A review 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 · Dcited before2025-08-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide a safe smoking environment for 2 of 2 residents (Resident #3 and #72). This deficient practice was identified in the smoking area by the entrance to the facility, and was identified by the following:On 7/29/25 at 9:15 AM, the surveyor observed that the area near the facility's covered entryway had extinguished cigarettes on the ground in several areas. The surveyor observed that there were no receptacles or ashtrays in the area to safely extinguish cigarettes. The surveyor also observed that there were no fire extinguishers or fire blankets.1. On 7/29/25 at 10:50 AM, the surveyor observed Resident #3 in their room. The alert and oriented Resident stated that he/she was an independent smoker, and the facility staff permitted him/her to keep their cigarettes and lighters locked in their top drawer.On 7/30/25 at 11:00 AM, the surveyors observed Resident #3 in the portico near the front…

    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 · D2025-08-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure a urinary drainage bag was secured in a manner to prevent contamination, infection control, and to enhance dignity for 1 of 1 resident reviewed for urinary catheter care.The deficient practice was evidenced by the following: On 8/4/25, at 9:45 AM, the surveyor observed Resident #113's urinary drainage bag not in a privacy bag and visible from the hallway. A review of Resident #113's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; urinary retention, chronic obstructive pulmonary disease, and gastrostomy status (a feeding tube inserted through the abdominal wall into the stomach to deliver nutrition). A review of the current Order Summary Report and transcribed onto the Treatment Administration Record (TAR) reflected a physician order to check urinary catheter (a flexible, plastic tube inserted into the bladder to drain urine) for proper placement, provide…

    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 · D2025-08-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure oxygen nasal cannula tubing was stored in accordance with infection control measures for 1 of 1 residents (Resident #113) reviewed for Oxygen Therapy. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative 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…

    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 · D2025-08-05 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure that medication was administered according to the physician's order (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in one (1) of six (6) residents (Resident #16) during medication observation pass. The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-05 · 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 interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in the resident's medical record to the facility staff and attending physician. This deficient practice was identified for one (1) of six (6) residents observed during medication administration pass, (Resident #89) for medication management and was evidenced by the following: On 07/31/25 at 8:30 AM, during medication administration pass the surveyor observed a Registered Nurse (RN#1) entered into Resident #89 room. The resident was observed sitting up in bed and eating breakfast.RN #1 informed the resident that she would be taking their vitals and then would be administering their medications.On 7/31/25 at 8:32 AM, the surveyor observed RN#1 preparing to administer five (5) medications for Resident #89 which included aspirin 81 milligram (mg) chewable tablet (coronary artery disease), Januvia 50 mg (medication to lower blood sugar), Ferrous Sulfate 325 mg (anemia), Metformin…

    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 · D2025-08-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 properly dispose of medications which was observed for one (1) of three (3) nurses during medication administration pass. This deficient practice was evidenced by the following:On 7/30/25 at 8:48 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN#1) in the room of Resident #16. The surveyor observed LPN#1 informing Resident #16 that she would be administering the resident's medications. The surveyor observed the resident in bed and eating breakfast.On 07/30/25 at 8:52 AM, the surveyor observed LPN#1 preparing to administer nine (9) medications to Resident #16 which included Carvedilol 6.25 mg (medication for lowering blood pressure), Levocarnitine 330 mg tablet (to prevent and treat low blood levels of carnitine), Hydralazine 25 mg tablet (medication for lowering blood pressure), Vitamin C 250 mg tablet (supplement), Aspirin 81 mg (coronary artery disease),…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-12-12 · tag F0711 — widespread
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 20 of 22 residents (Resident #86, 14, 31, 34, 48, 54, 152, 22, 28, 49, 1, 4, 12, 56, 58, 16, 40, 61, 69, and #73) reviewed. Some of the residents had not had physician signed orders since December 2022. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the residents' primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents chart. In addition, there were no electronic signatures under the physician's orders in the electronic medical record for the following residents: 1. Resident #86's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-12 · 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 follow Professional Standards of Practice by failing to assess a weight change for 2 of 3 residents reviewed for nutritional status which did not contribute to harm, Resident #73 and #58. 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. 1. On 11/29/23 at 11:11 AM, the surveyor interviewed Resident #73, who stated that he/she had not lost weight and that he/she looks the same. The resident stated that he/she had no issues with appetite and is happy with his/her weight. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-12 · 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 interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis scheduled times and documenting accurate medication administration times from October until December surveyor inquiry. This deficient practice was identified for one (1) of (1) resident, (Resident #22), reviewed for dialysis services and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey…

    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 · D2023-12-12 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the interview and record review, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment for 5 of 22 residents, (Resident #6, 28, 4, 56, and #58) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. Resident #6 was observed to have an Annual MDS with an Assessment Reference Date (ARD) on 10/20/23 and was due to be transmitted no later than 11/9/23. The Annual MDS was not transmitted until 11/30/23. 2. Resident #28 had an Annual MDS with an ARD on 10/18/23. The assessment was completed and was due to be transmitted no later than 11/7/23. The Annual MDS was not transmitted until 11/30/23. 3. Resident #4 was observed to have a Significant Change MDS with an ARD on 11/23/22 and was due to be transmitted no later than 12/14/23. The Significant Change MDS was not transmitted until 1/6/23. 4. Resident #4 was observed to have a Quarterly MDS with an ARD on 8/26/23. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan for a resident using an oxygen and bilevel-positive airway pressure (BIPAP - a device that helps with breathing). This deficient practice was identified for 1 of 22 residents (Resident #12) reviewed for a comprehensive Care Plan (CP) and was evidenced by the following: On 11/29/23 at 10:32 AM, the surveyor observed Resident #12 resting in bed in their room. Resident #12 received oxygen via a nasal cannula (NC- a plastic prong attached to a tube inserted into the nostrils that oxygen flows through) connected to a concentrator (an oxygen delivery system). The concentrator was set at 3 LPM (liters per minute). The surveyor observed a BIPAP machine in the resident's left drawer. On 12/1/23 at 10:28 AM, the surveyor observed Resident #12 out of bed in a wheelchair. The resident received oxygen via NC attached to an oxygen tank set at 2 LPM. The surveyor reviewed the Electronic Health Record (EHR) of Resident #12, which revealed the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-12 · 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 interview and record review, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) recommendations were acted upon in a timely manner regarding adjusting the timing of medications to be administered when a resident was available in the facility. The deficient practice was identified for one of 21 residents (Resident #22) reviewed for CP recommendations and was evidenced by the following: On 12/1/23 at 11:56 AM, the surveyor interviewed Resident #22. The resident stated that he/she had been in the facility almost three months and went out for dialysis (a procedure that uses special equipment to clean the blood when the kidneys can no longer perform the function naturally) on Mondays, Wednesdays and Fridays in the afternoon around 3:00 PM. The resident also stated that he/she had previously gone to dialysis later in the evening, but the time was changed. The surveyor reviewed the medical record for Resident #22. A review of the admission Record (an admission summary) reflected diagnoses that included chronic kidney disease, Stage 4 (Severe),…

    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 · D2023-12-12 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that the facility failed to ensure that dietary staff were following the meal tickets for three (3) of 10 residents reviewed for puree diets. This deficient practice was evidenced by the following: On 12/4/23 at 12:20 PM, the surveyor observed the pureed lunch meal for residents who were prescribed a pureed diet. The surveyor observed that the lunch tray tickets for Resident # 28, # 31 and # 69 indicated that the residents were to receive boiled rice (pureed) but all three (3) of the resident's actually received pureed mashed potatoes on their trays instead. At 12:45 PM, the surveyor interviewed the Dietary Director (DD), who stated that the lunch tray tickets indicated that all the residents who received a puree diet were supposed to receive boiled rice (pureed). The DD added that all the residents actually received pureed mashed potatoes and he was not sure why that occurred. At 4:18 PM, the surveyor discussed the above concerns with the Administrator and Director of Nursing, who did not provide any further…

    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 · Dcited before2023-12-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined the facility failed to accurately document in the medical record the status of a resident who left the faciity on a pass. The concern was cited for 1 (Resident #154) of 22 residents reviewed and is evidenced by the following. The surveyor observed Resident #154 in bed with eyes closed on 11/29/23 at 11:27 AM. The surveyor observed the resident's room on 11/30/23 at 10:38 AM and the resident was not in the room. The bed linens had been removed, and no personal items were visible. A review of the electronic medical record revealed the following information in the Progress Notes. The admission Record indicated the resident was admitted to the facility on Hospice services. Diagnoses included but were not limited to, acute respiratory failure with hypoxia (low oxygen) and a mass and swelling of the neck. The Minimum Data Set (MDS) assessment tool indicated the resident was discharged on 11/30/23 with an anticipated return to the facility. Electronic Progress Notes reflected on 11/29/23 at 1 PM, the resident went out 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) assessed and pronounced a deceased resident in accordance with nursing standards of clinical practice. This deficient practice was identified for Resident #69, 1 of 1 resident reviewed for the deceased closed record, and 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 stated, 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. Reference: New Jersey Administrative Code, Title 13, Law and Public Safety, Chapter…

    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 before2021-07-27 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure that: a.) the physician responsible for supervising the care of resident's signed and dated monthly physician's orders for 4 of 18 residents reviewed, Residents #3, #38, #44 and #51; and, b.) the facility physician failed to accurately assess and evaluate residents for 1 of 18 residents reviewed, Resident # 61. The deficient practice was evidenced by the following: 1. On 7/19/21 at 12:15 PM, the surveyor, observed Resident #3 seated in a wheelchair. Resident #3 was seen on the 3rd-floor dining room eating lunch independently. The surveyor greeted the resident, who responded with a smile. The surveyor reviewed the admission Record Face Sheet (FS) (a one-page summary of important information about a resident) for Resident #3. The resident was admitted to the facility on [DATE], with the diagnosis included but was not limited to Acute Respiratory Failure, Diabetes Mellitus, Dementia, and Chronic Kidney Disease.…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 maintain complete, accurate, and readily accessible medical records (Physician Progress notes from June 2021 through July 2021). This deficient practice was identified for 1 of 23 residents reviewed, Resident #44, and was evidenced by the following: On 7/16/2021 at 10:15 AM, during the facility tour, the surveyor observed Resident #44 in the room, awake and in bed at the lowest position. The resident was also observed with continuous oxygen via nasal cannula at 3 liters per minute. The resident was alert with confusion. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to, Pneumonia, Hypertension, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease. A review of the Medicare 5-day Minimum Data Set Assessment, a tool used to facilitate care management dated…

    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 before2021-07-27 · 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 facility documents, it was determined that the facility failed to practice appropriate use of personal protective equipment (PPE) in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This was identified for 3 of 21 residents reviewed for Transmission Based Precautions (TBP), Resident #170, #219, #171. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, included 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2: Personal Protective Equipment-HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95…

    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

$37,580 in federal fines across 1 penalty.

  • $37,580 — penalty dated 2023-12-12

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to INFINITE CARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.0≈ chain avg
Health inspection 1 of 51.5-0.5 vs chain
Staffing 3 of 52.4+0.6 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 7 homes this chain runs (chain average 2.0★, 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 / managerTypeRoleShareSince
FOREST HILL SNF OPERATIONS HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2022
CH FOREST HILL HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2022
CW FOREST HILL HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2022
SEAM TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2022
SK FOREST HILL HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/01/2022
MERVINE, GEORGEIndividualW-2 MANAGING EMPLOYEEsince 05/01/2022
KLEIN, SOLOMONIndividualCORPORATE OFFICERsince 05/01/2022

5 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.

$15.0M
Net patient revenuemost recent cost report
+6.8%
Operating marginrevenue minus expenses
$2.3M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 62%Medicare 26%Other / private 12%

This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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

$377per resident / day
operating cost
$11,451per month
≈ monthly operating cost
$404per 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 315375. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-05, 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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