Valley View Rehabilitation And Healthcare Ctr
1 Summit Avenue, Newton, NJ 07860 · For profit - Limited Liability company · 31 certified beds · (973) 383-1450 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- 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
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 2 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 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.
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 | 29.2% | 8.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 21.3% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 5.2% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 12.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 2.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 28.6% | 8.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.2% | 18.8% | 18.9% | better |
| Long-stay residents with pressure ulcers | 8.9% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.2% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 12.7% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 20.7% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.8% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.7% | 8.1% | 12.0% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
65.0% 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 76 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.0% 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 20 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | 65.0%CMS range 54.8–75.1 | 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 | 10.8%CMS range 7.9–16.5 | 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 | 55.0% | 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 | 45.0% | 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 | 60.0% | 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 | 94.1% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.0% | 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 | 0.0% | 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 | 6.4%CMS range 3.6–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 31 beds and averages 16.8 residents a day — about 54% occupied, or roughly 14 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 4.19 hrs/resident/day on weekends vs 4.26 on weekdays — 2% thinner on weekends. RN hours go from 0.98 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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 · Fcited before2025-04-24 · tag F0658 — failed to meet professional standards of care — widespreadEnsure 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 4. On 4/21/25 at 10:00 AM, the surveyor observed Resident #3 in the facility activity room. The resident was seated in a chair with their walker next to them. The resident was dressed and groomed, and the surveyor observed no oxygen being used by the resident. On 04/21/25 at 11:00 AM, the surveyor inspected the resident's room and found no oxygen concentrator. On 4/21/25 at 11:20 AM, the reviewed the hybrid medical chart for Resident #3, which revealed the following: A review of the Resident #3's AR documented that the resident was admitted to the facility with diagnoses that included but were not limited to: anemia (low levels of healthy red blood cells), major depressive disorder (persistent depressed mood), anxiety disorder (feelings excessive fear or worry) and Alzheimer's disease (a progressive, degenerative brain disorder that causes memory loss). A review of the Annual MDS dated [DATE] revealed, under Section C, a BIMS score of 5 out of 15, which indicated severe cognitive impairment. The AMDS 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.
- Potential for harm · F2025-04-24 · tag F0712 — widespreadEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 4/21/25 at 10:00 AM, the surveyor observed Resident #3 in the facility activity room. The resident was seated in a chair with their walker next to them. The resident was alert and showed no signs of behaviors. The resident was participating in activities with other residents. On 4/21/25 at 11:20 AM, the surveyor reviewed the hybrid (paper and electronic) medical chart for Resident #3 which revealed the following: A review of the Resident #3's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: anemia, major depressive disorder, anxiety disorder and Alzheimer's disease. A review of the Annual MDS dated [DATE], revealed under Section C, a BIMS score of 5 out of 15 which indicated that the resident had severe cognitive impairment. A review of the resident's facility Progress Notes (PN) revealed no notes from the resident's primary physician from 11/1/24 until 04/21/25. 4. On 04/21/25 at 12:20 PM, the surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-24 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of the Nurse Staffing Report it was determined that the facility failed to ensure that a required Registered Nurse (RN) was present at the facility 7 days a week for at least 8 consecutive hours a day for 5 of 14 days reviewed. This deficient practice was evidenced by the following: Per the Interpretive Guidance §483.35(b) Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week. However, per Facility Assessment requirements at F838, §483.70(e), facilities are expected to identify when they may require the services of an RN for more than 8 hours a day based on the acuity level of the resident population. If it is determined the services of an RN are required for more than 8 hours a day. Facilities may choose to have differing tours of duty (e.g. 8 hour- or 12-hour shifts) for their licensed nursing staff. Regardless of the approach, the facility is responsible for ensuring the 8 hours worked by the RN are consecutive within each 24-hour period. Review of the Nurse Staffing Report…
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 before2025-04-24 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Repeat Deficiency Based on observations, interview, review of facility job descriptions, it was determined that the facility failed to employ either a full time Registered Dietitian (RD) or a Dietary Manager (DM) that meets the qualifications to function as a director of food and nutrition services. This deficient practice was evidenced as follow: On 4/21/25 at 9:15 AM, the surveyor interviewed the Food Service Director (FSD #1), who is the FSD from another facility, but is covering for the facility FSD #2 today. FSD #1 revealed they work in a regional FSD capacity but does not come to the facility often. Per FSD #1, FSD #2 does not have any current dietary certifications, ServSafe, Certified Dietary Manager (CDM), and/or Certified Food Protection Professional (CFPP). FSD #1 further stated they would expect a FSD to have one or more of those certifications. On 4/22/25 at 9:39 AM, the surveyor interviewed FSD #2 who stated this was their first job as an FSD and was hired on 6/2/24, their ServSafe certification expired on 3/2024, and does not have any further certifications. FSD #2…
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 · F2025-04-24 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 4 of 4 residents (Resident # 1, # 6, #15, and #16), during the 4/22/25 Resident Council group meeting and evidenced by the following: On 4/22/25 at 10:27 AM, the surveyor conducted the resident council meeting with four resident (Resident # 1, # 6, #15, and #16), who were alert and oriented, and selected by the facility to attend the group meeting. All four residents stated that they were not offered or received snacks in the evening. On 4/22/25 at 10:51 AM, the surveyor interviewed the Regional Director of Recreation (RDR) and Director of Activities (DA) who evening snacks are provided by the Dietary Department. On 4/22/25 at 10:58 AM, the surveyor interviewed the Food Service Director (FSD) who stated the Recreation Department provides evening snacks. On 4/22/25 at 11:05 AM, 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 · Fcited before2025-04-24 · 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
Repeat deficency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. On 04/21/25 at 09:15 AM, the surveyor in the presence of the Food Service Director (FSD#1), observed the following during the kitchen tour: 1. The clipboard on wall contained the weekly food temperature log, the surveyor observed that no temperatures had been taken for dinner from 4/14/25 through 4/17/25 and 4/19/25. FSD#1 acknowledged the missing temperatures and stated they should have been recorded. 2. On the bread shelf, the surveyor observed a 28 ounce (oz) whole wheat bread with an open date of 4/8/25, without a use by date. Also observed was an open bag of flour tortilla without an open or use by date. FSD #1 stated bread should be kept for three days after opening and the tortilla bag should have been labeled with an open and use by date. 3. On a shelf on the chef preparatory table the surveyor observed a 16oz can of corn starch, a 24oz can of B'gan brand beef…
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 · F2025-04-24 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was physically present and actively involved by providing daily oversight to ensure all policies and procedures were implemented. The evidence was as follows: On 4/21/25 at 9:30 AM, during entrance conference the surveyor met with the facility administrative team that included the Director of Nursing (DON) and the Regional Licensed Nursing Home Administrator (RLNHA). The TC was informed by the facility that the facility LNHA was not at the facility because of a religious holiday. Throughout the survey that lasted from 04/21/25 through 04/24/25, the LNHA was not observed in the building. On 4/24/25 at 9:15 AM, the surveyor reviewed the facility's Quality Assurance and Performance Improvement (QAPI) book which included signed in log sheets which revealed that the LNHA was not present in 5 of 5 QAPI meetings reviewed. A review of the facility's Administrator Job Description, which was provided…
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 · F2025-04-24 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of pertinent facility provided documents, it was determined that the facility failed to ensure the facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies was reviewed and updated, as necessary, and at least annually. This deficient practice was evidenced by the following: On 04/21/25 at 09:30 AM, during the entrance conference held with the facility administration, the surveyor requested a copy of the Facility Assessment (FA). On 4/24/25 at 10: 30 AM, the surveyor was reviewing the FA that was provided by Regional Licensed Nursing Home Administrator (RLNHA). The FA was not signed and had a date of 4/25/25 and they were no evidence that the FA was conducted or reviewed prior to the surveyor team entering the building. On 04/24/25 at 10:40 AM, the surveyor interviewed the RLNHA regarding the FA not being signed or dated correctly and no explanation was provided. On 4/24/25 at 10:45 AM, the surveyor requested the last FA for 2024 from the RLNHA and Director…
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 · E2025-04-24 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and record review, it was determined that the facility failed to assure the Licensed Nursing Home Administrator (LNHA) attended the quarterly Quality Assurance (QA) meetings. This was identified for 5 of the 5 QA meetings reviewed. This deficient practice was evidenced by the following: On 4/24/25 at 9:16 AM, the Director of Nursing (DON) provided the surveyor with the sign-in sheets for the last five QA meetings and showed the following: on 4/10/2024, 7/17/2024, 10/9/2024, 1/20/2025, and 4/2025 the LNHA failed to attend the QA meeting. On 4/24/25 at 9:45 AM, the DON provided the surveyor with the facility Quality Assurance & Performance Improvement (QAPI) Plan. Under the section titled, Governance and Leadership - Responsibility, the QAPI Committee meets at least quarterly and is composed of the following individuals: Administrator, Director of Nursing, Medical Director, Director of Activities, Director of Social Services, Director of Administrative Manager, and Director of Rehab Services. On 4/24/25 at 11:58 AM, the surveyor interviewed the DON, who stated…
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 · Ecited before2025-04-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to a) provide appropriate care and services of urinary catheter care to prevent urinary tract infections, b) performed hand hygiene after urinary catheter care, c) no Transmission-Based Precautions (TBP) or Enhanced Barrier Precautions (EBP) signage outside the resident's door, and d) no Personal Protective Equipment (PPE) accessible observed with 1 of 2 residents reviewed for infection control practices (Resident #4). This deficient practice was evidenced by the following: On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake and sitting in bed with an indwelling urinary catheter inside the privacy bag (a tube placed inside the bladder to facilitate urine flow) lying on top of the bed. The surveyor observed that there was no TBP sign or use of EBP outside the resident's room, and there was no available PPE. On 4/21/25 at 12:21 PM, the Director of Nursing (DON) went to the Resident #4 room after seeing the urinary catheter on top of the bed. The surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2025-04-24 · 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 ensure that the State of New Jersey inspection results were readily accessible for residents who resided in the facility. This deficient practice was identified for 4 of 4 residents (Resident #1, #6 #15, and #16) during the 4/22/25 Resident Council group meeting and evidenced by the following: On 4/21/25 at 9:00 AM, the surveyor observed that the State Survey results were located near the front entrance on the first floor. On 4/22/25 at 10:27 AM, the surveyor conducted the resident council meeting with four resident who (Resident #1, #6 #15, and #16) were alert and oriented, and selected by the facility to attend the group meeting. All four residents stated that they were not aware of the existence or location of the State Survey results. The surveyor reviewed the 2/11/25, 3/11/25, and 4/15/25 Resident Council meeting minutes. The minutes did not address the location of the State Survey results. On 4/22/25 at 10:51 AM, the surveyor interviewed the Regional Director of Recreation (RDR) and Director 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 · D2025-04-24 · tag F0640 — isolatedEncode 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 complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 2 (two) of 8 residents (Resident #5 and #15) This deficient practice was evidenced by the following: The MDS is a comprehensive tool, federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 4/22/25 at 10:07 AM, the surveyor interviewed the Director of Nursing (DON) about the MDS Coordinator/Registered Nurse (MDSC/RN). The DON stated that the MDSC/RN worked remotely and does not go to the facility. The surveyor provided the DON with the list of 2 residents who had not completed an MDS in over 14…
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 · D2025-04-24 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines for 2 of 8 residents (Residents #4 and #15) reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed with oxygen (O2) at 2 lpm (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). Resident #4 stated that they also used oxygen at night and during activities at home. On 4/22/25 at 1:22 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A review of the admission Record (an admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 and implement a comprehensive person-centered care plan (CP) that included anticoagulant, antidepressant, and oxygen use. This deficient practice was identified for 3 of 8 residents (Resident #4, #5, and #15) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed on oxygen (O2) at 2 lpm (liters per minute) via nasal cannula (N/C, a medical device that provides supplemental O2 therapy, the device that has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). The resident has an indwelling urinary catheter inside the privacy bag (a tube placed inside the bladder to facilitate urine flow). On 4/22/25 at 1:22 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A 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 · Dcited before2025-04-24 · 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
Repeat Deficiency Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) follow a physician's order, and b) place signage of oxygen (O2) therapy use according to standards of clinical practice and facility policy and procedure for 2 (two) of 2 residents, (Resident #4 and #15) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 4/21/25 at 12:17 PM, the surveyor observed Resident #4 awake sitting in bed on oxygen (O2 at 2 liters per minute (lpm) via nasal cannula (N/C), a medical device that provides supplemental O2 therapy, the device has two prongs and sits below the nose. The two prongs deliver O2 directly into nostrils) connected to a portable oxygen concentrator (a device that supply an O2). Resident #4 stated that they used oxygen at night and during activities, and also added that they used it at home. The surveyor noted there is no signage outside the room for oxygen use. On 4/22/25 at 1:22 PM, the surveyor reviewed the hybrid medical record…
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 before2025-04-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 3 (three) of 5 (five) residents (Resident #1, Resident #10, and Resident #18) observed during the 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 dentist. Reference:…
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 before2025-04-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 label, store, and dispose of medications in one (1) of two (2) medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 11:38 AM, the surveyor inspected the high-side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened Advair 250/50 inhaler with an opened date of [DATE] that was expired. At that time, the surveyor reviewed the manufacturer information on the inhaler in the presence of LPN#1. LPN#1 acknowledge that once opened the inhaler have an expiration date of 30-days. LPN#1 stated that the Advair inhaler was opened over 30-days ago and should have been removed from the medication cart. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Advair inhaler once opened have an expiration date of 30-days. On [DATE] at 12:30PM, the surveyor presented the above concerns…
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 before2025-04-24 · tag F0851 — isolatedElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Repeat deficiency Based on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of three PBJ Report submissions reviewed, (Fiscal Year Quarter 1 2025, October 1 - December 31) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the third fiscal year quarter to CMS. The dates of the first quarter 2025 included October 1, 2024, through December 31, 2024. On 04/22/25 at 10:00 AM, the surveyor interviewed the Staffing Coordinator (SC) who stated she was responsible for the nursing staff scheduling as well as reporting staffing daily to the Department of Health (DOH) website. She stated that she submitted the staffing reports to CMS and that she will provide them to the surveyor. On 04/23/25 at 10:15 AM, the surveyor rreviewed the facilities CMS submission reports (PBJ submitter…
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 before2023-11-22 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, review of the facility assessment tool and facility job descriptions, it was determined that the facility failed to employ either a full time Registered Dietitian (RD) or a Dietary Manager (DM) that meets the qualifications to function as a director of food and nutrition services. This deficient practice was evidenced as follow: Refer to F812 F and E0015 F. On 11/15/2023 at 10:25 AM, the surveyor interviewed the Food Service Director (FSD) in the presence of a second surveyor. He stated that he had a Servsafe certification and started the position on 11/6/23. On 11/16/23 at 10:46 AM, the surveyor interviewed the FSD Consultant (FSDC) in the presence of the survey team. She stated that her credentials were Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP), and Servsafe certified . In addition, she stated that she was responsible to train the FSD. She acknowledged that today was the first day she was at the facility with the FSD. On 11/17/23 at 10:37 AM, the surveyor interviewed the Registered Dietitian (RD) in 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 · Fcited before2023-11-22 · 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 record review, it was determined that the facility failed to a.) store foods in a sanitary manner, b.) ensure the kitchen environment and equipment was maintained in a clean and sanitary manner, and c.) handle dishware in a manner to prevent cross contamination, to limit potential bacteria growth and potential food borne illness. The deficient practice was evidenced by the following: On 11/15/2023 at 10:25 AM through 12:28 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD) in presence of a second surveyor. At 10:26 AM, the surveyor observed a dish machine temperature log which was filled out for the entire day (afternoon and dinner time). The [NAME] stated, it was a mistake, usually I check the temperatures and then log them in. At 10:27 AM, the surveyors continued the tour with FSD. The surveyor observed a single door, white reach in freezer and identified several opened foods with no opened date and were not labeled. The FSD identified the following items and stated that, items should have been labeled and 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.
- Potential for harm · Fcited before2023-11-22 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
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 submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of three PBJ Report submissions reviewed, (Fiscal Year Quarter 3 2023, April 1 - June 30) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the third fiscal year quarter to CMS. The dates of the third quarter included April 1, 2023, through June 30, 2023. On 11/20/23 at 12:09 PM, the surveyor interviewed the Administrative Assistant (AA) in presence of a second surveyor. She stated, she was responsible for the nursing staff scheduling as well as reporting staffing daily to the Department of Health (DOH) website. On 11/21/23 at 10:25 AM, the surveyor interviewed the AA, who stated that she submitted staffing to the DOH daily and to CMS on a quarterly basis. She stated staffing must be submitted to CMS quarterly.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise a comprehensive care plan post fall for a resident who fell and sustained a left radial fracture. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for falls. This deficient practice was evidenced by the following: On 11/16/23 at 11:44 AM, the surveyor observed the resident in his/her room seated in a chair combing his/her hair. The resident was able to tell the surveyor that he/she had a fall sometime in September in the bathroom and broke his/her wrist. The resident stated, I slipped and fell and showed the surveyor a yellow bracelet on his/her wrist which indicated fall risk. The surveyor reviewed the medical record for Resident #7. A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but not limited to: pneumonia, unspecified organism, unspecified fracture of the lower end of left radius, initial encounter…
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 before2023-11-22 · 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 and record review, it was determined that the facility failed to clarify a Physician's Order (PO) for oxygen administration in accordance with professional standards of practice for 1 of 1 resident reviewed for respiratory care (Resident #70). The deficient practice was evidenced by the following: On 11/15/23 at 11:41 AM, the surveyor observed Resident #70 in the facility activity room. Resident #70 was seated in a wheelchair and was participating in activities. The resident was receiving oxygen via nasal cannula. The oxygen concentrator was set at three liters per minute (LPM). On 11/16/23 at 11:10 AM, the surveyor observed Resident #70 in bed receiving oxygen via a nasal cannula. The oxygen concentrator was set at three LPM. The surveyor reviewed the medical record of Resident #70. Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in November of 2023 with diagnoses which included but was not limited to; chronic obstructive pulmonary disease (COPD, (a group of diseases that cause airflow…
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 before2023-11-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 6 (six) residents (Resident #9) observed during the 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 dentist.…
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 before2023-11-22 · 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
Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility staff failed to follow appropriate infection control practices for appropriately performing hand hygiene and sanitizing a blood pressure cuff between 2 of 2 residents observed during the medication pass, (Resident#5 and Resident #10). These deficient practices were evidenced by the following: On 11/17/23 at 8:35 AM, during the medication pass, the surveyor observed the Licensed Practical Nurse (LPN) obtaining Resident #10's vital signs. The LPN brought the electronic blood pressure cuff into the resident's room and took the resident's blood pressure. The LPN then returned to the medication cart which was in the hall. The surveyor observed the LPN placing the electronic blood pressure cuff on the medication cart. The surveyor did not observe the LPN sanitize the electronic blood pressure cuff or perform hand hygiene. The surveyor observed the LPN prepare medication for Resident #10 and then observed her entering the resident's room and administering 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 · Dcited before2021-07-29 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 observation, interview, and record review, it has been determined that the facility failed to consistently maintain professional standards of nursing practice regarding a) obtaining a physician's order for hemodialysis (HD) for 1 of 1 resident, Resident #5, reviewed for dialysis and b) documenting on the Electronic Treatment Administration Record (ETAR) for 1 of 10 residents, Resident #13, reviewed. The deficient practice is 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 casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized…
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 before2021-07-29 · 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 and record review, it was determined that the facility failed to maintain the necessary respiratory care and services. This deficient practice was identified for 2 of 2 residents (Resident #13 and Resident # 18) reviewed for respiratory care and was evidenced by the following: 1. On 07/27/21 at 9:53 AM, the surveyor saw Resident #13's nasal cannula placed on the bed beside the resident. The surveyor asked if the resident needed to have the oxygen on. Resident #13 stated that he/she should wear it and put it the nasal cannula on. The oxygen was running at 3 liters per minute (lpm). The surveyor reviewed Resident #13's Electronic Medical Record which indicated the following: According to the admission Record, the resident was admitted with diagnoses that included Heart Failure and Chronic Obstructive Pulmonary Disease. According to the July 2021 Physician's Orders, Resident #13 had an oxygen order to be delivered at 3.5 lpm via nasal cannula continuously as needed for shortness of breath or oxygen saturation less than 92%. The order date was 6/3/2021.…
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 before2021-07-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 review of facility policies, it was determined that the facility failed to label and store multi dose vials in accordance with manufacturer specifications. This was found in 1 of 2 medication carts and 1 of 1 medication refrigerator. The deficient practice was evidenced by the following: On [DATE] at 10:27 AM the surveyor inspected the Long Term Care medication cart with the Licensed Practical Nurse (LPN). Inside of the medication cart there was a vial of Humalog insulin that was open and undated. There was a container that held the insulin vial. The container was dated [DATE]. The LPN confirmed the vial was not dated and that it should have been. There was also a vial of Lantus insulin that was open. The label attached to the vial read house stock. The vial had an open date written on it of [DATE]. The vial had been opened 56 days prior. According to the manufacturer, Lantus insulin should have been discarded 28 days after opening. The surveyor then inspected the medication…
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AM 145 HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 37% | since 03/15/2022 |
| THE WHITE MAPLE CORPORATION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 9% | since 03/15/2022 |
| HERSH, ISAAC | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 19% | since 03/15/2022 |
| LERNER, URI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 9% | since 03/15/2022 |
| STERN, RONALD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 9% | since 03/15/2022 |
| DEITEL, ARTHUR | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 9% | since 03/15/2022 |
| LANDA, BENJAMIN | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/15/2022 |
CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
This home reported $158K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 315409. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-24, 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.