Meadowview Nursing And Rehabilitation Center
235 Dolphin Ave, Northfield, NJ 08225 · Government - County · 180 certified beds · (609) 645-5955 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0610), cited Aug 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,015 in federal fines (most recent 2025-06-05)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 | 23.3% | 8.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 4.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 7.6% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.4% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.3% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.3% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 22.3% | 8.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.8% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.0% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.1% | 15.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.1% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 25.0% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 30.1% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.3% | 8.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.56 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.49 | 1.11 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.9% 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 115 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.6% 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 76 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 61.9%CMS range 53.9–67.8 | 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 | 10.3%CMS range 7.2–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 52.6% | 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 | 54.0% | 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 | 56.6% | 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 | 100.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 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 | 4.5% | 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 | 6.0%CMS range 3.2–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 180 beds and averages 120.3 residents a day — about 67% occupied, or roughly 60 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 4.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.68 is at or above 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 3.91 hrs/resident/day on weekends vs 4.40 on weekdays — 11% thinner on weekends. RN hours go from 0.73 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · J2023-08-15 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ163798, NJ166210 Based on interviews, medical records, and review of other pertinent facility documentation on 7/31/23 and 8/1/23, it was determined that the facility failed to thoroughly investigate an alleged staff-to-resident physical and verbal abuse allegation that involved the Certified Nursing Aide (CNA #2) and Resident #2. The facility also failed to ensure its policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property was implemented during the alleged abuse allegation. On 4/23/23 at approximately 8:00 P.M., Resident #2 reported to a family member that CNA #2 had grabbed the resident by the wrist and was rough and had called him/her fat during care. Resident #2's daughter reported the abuse allegation to the Registered Nurse/Evening Supervisor (RN/ES) that same day , however, CNA #2 continued to provide direct resident care for the rest of the shift on 4/23/23. The CNA also provided direct resident care on 4/24/23. On 4/25/23, CNA #2 was in-serviced by the Director of Nursing (DON) about abuse on that day. The facility' failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2023-08-15 · tag F0835 — failed to run the facility competently — isolatedAdminister 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
Complaint #: NJ163793, NJ166210 Reference F610 Based on observation, interviews, medical record review, and review of other pertinent facility documentation during the on-site investigation on 8/7/23 and 8/8/23, it was determined that the facility's Licensed Nursing Home Administrator failed to ensure that the policies and procedures under the Abuse, Mistreatment, exploitation, Neglect, and Misappropriation of Property was implemented when Resident #2's family member reported he/she was grabbed by their wrist and shoved over their bed and called fat by the Certified Nursing Aide (CNA #2) on 4/23/23. The Administrator failed to report this incident along with an investigation to the New Jersey Department of Health. The Administrator also failed to ensure that all residents were free from abuse and a likelihood of harm when an alleged abuse allegation was made. The alleged CNA #2 continue to provide direct patient care after the allegation through the investigation period which was concluded on 4/25/23. The facility's failure to thoroughly investigate and follow its policies 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.
- Actual harm · Gcited before2025-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ186394 Based on interviews, review of the medical records, and other facility documentation, it was determined that the facility failed to ensure staff provided safe transfers with a two person assist from chair to bed when on 05/08/2025, a Certified Nursing Aide (CNA #1) transferred a resident (Resident #1) with a Hoyer lift (mechanical lift used to transfer) with no additional staff, and the resident complained of pain with noted bruising to the inner thigh and a swollen knee, that an x-ray identified that the resident sustained a fracture of the distal femoral shaft (thigh bone). This deficient practice was identified for 1 of 3 residents reviewed for accidents and hazards (Resident #1), and was evidenced by the following: A review of an incident report for Bruise dated 05/09/2025 at 5:30 AM, revealed that around 5:30 AM, the assigned CNA reported to this supervisor that she found bruises on the resident's right leg. Upon assessment, the resident was seen with a bruise measuring nine centimeters by four centimeters (9 cm x 4 cm) on the back of their right lower…
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 before2025-03-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 02/24/2025 from 09:43 to 10:09 AM, the surveyor, accompanied by the Food Service Manager (FSM), observed the following in the kitchen: 1. On the wall next to the solo standup solo freezer, a wall mounted knife container contained two knives with wooden handles. The wooden handles of the knives were exposed to the surveyor. They appeared to be old and had fine cracks in the handles on visual inspection, which would allow bacteria to remain in the wooden handles.When interviewed the FSM stated, Ok. I know that. The FSM removed the wooden knives from the wall monted knife container/holder. 2. The high temperature dish machine was observed to be in use and actively washing dishware on 02/24/2025 at 10:01 AM. The surveyor asked the FSM to provide the surveyor the dish machine…
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 · D2025-03-03 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 1 of 3 residents reviewed for Beneficiary Protection Notification, (Resident #92). This deficient practice was evidenced by the following: On 02/27/2025 at 8:38 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #92 as follows: A review of the SNFBPNR for Resident #92 indicated a Medicare Part A start date of 11/27/2024 and last covered day was 01/10/2025 and Resident #92 remained in the facility. A further review of the SNFBPNR revealed under 1. Was a SNFABN, Form CMS-10055 provided to the resident? No was checked. If no explain why the form was not provided: was handwritten stayed in the facility. Under 2. Was a Notice of Medicare Non-Coverage (NOMNC) (CMS 10123) provided to the resident? There was nothing marked to indicate whether the resident received the NOMNC or not. During an interview with the surveyor on 02/27/2025 at 9:23 AM, Social Worker (SW #1),…
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 before2025-03-03 · 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 interview, medical record review and review of other facility documentation, it was determined that the facility failed to develop and implement an individualized comprehensive care plan for a resident on antidepressant medication (medication used to treat clinical depression). This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #12) and was evidenced by the following: On 02/24/2025 at 10:16 AM, during the initial tour, Resident #12 was identified as being on antidepressant medication. A review of Resident #12's Electronic Medical Record (EMR) on 2/24/2025 at 2:01 PM, revealed the following: A review of the admission Record reflected the resident had diagnoses that included history of falling and depression. A review of the most recent comprehensive Minimum Data Set, an assessment tool dated 1/7/2025, revealed that the resident had a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. A further review of the MDS reflected use of antidepressant for Depression. A review of the Order…
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 · D2025-03-03 · 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
Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to update a resident care plan, specifically for newly identified wounds, for 1 of 30 residents reviewed for comprehensive person-centered care plans, (Resident #63). This deficient practice was evidenced by the following: During the initial tour of the facility on 02/24/2025 at 11:00 AM, Resident #63 was observed lying in bed with air mattress in place on the bed and bilateral heel booties in place. A review of the EMR on 02/24/2025 at 11:37 AM, revealed the following: According to the admission Record, Resident #63 was admitted to the facility with diagnoses including but not limited to: Palliative Care, Alzheimer's disease, and pressure ulcer left buttock stage 4. A review of the Quarterly Minimum Data Set, an assessment tool, dated 02/22/2025 revealed under section M Resident #63 had the following wounds; 1 stage 2, 1 stage 4 and 4 unstageable (Unstageable pressure ulcers are wounds that the bottom of the sore is…
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 before2025-03-03 · 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 review of the Electronic Medical Record (EMR), and review of other facility documents it was determined that the facility 1.) failed to perform a reweigh for a resident with greater than 5% weight loss in 30 day period for 1 of 3 residents investigated for nutrition (Resident #50) and 2.) failed to follow an order for wound vac dressing change for 1 (Resident #351) of 1 resident investigated for skin conditions. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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 regimes as prescribed by a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-03 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the electronic medical record (EMR), and review of other facility documentation, it was determined that the facility failed to consistently apply a hand splint as recommended by therapy. This deficient practice was identified for 1 of 1 resident reviewed for range of motion (Resident #1), and was evidenced by the following: During the initial tour on 02/24/2025 at 11:53 AM, the surveyor observed Resident #1 awake, non-verbal, lying in bed, with his/her right hand clenched in a fist position and pulled up toward the chest. There was no splint or hand roll in place at that time. The resident was cognitively impaired and was unable to provide health history or answer questions. On 2/25/25 at 1:23 PM, surveyor observed Resident #1 with no splint on right hand. On 2/26/25 at 9:29 AM, surveyor observed Resident #1 with no splint on right hand. A review of the Electronic Medical Record (EMR) on 02/24/2025, revealed the following: Resident #1 had a medical diagnoses that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to a.) ensure there was a physician order for the use of a Foley catheter and care plan, b.) ensure a resident with a catheter had the catheter bag in a privacy bag for dignity, and c.) failed to ensure a catheter bag did not come in contact with the floor to prevention possible contamination. This deficient practice was identified for 3 of 3 Residents reviewed for catheter use (Resident #6, Resident # 17, and Resident #348) and was evidenced by the following: On 02/25/2025 at 12:57 PM, Surveyor #1 observed Resident #17 lying in bed with their catheter bag hanging from the bed frame. The catheter bag was not in a privacy bag and was visible from the hallway. On 02/25/2025 at 03:14 PM, a review of the EMR revealed the following: According to the admission Record, Resident #17 was admitted to the facility with diagnoses including but not limited to:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure respiratory tubing, and nasal cannula were stored properly, and c.) obtain physician order for oxygen administration. This deficient practice was identified for 2 of 2 residents (Residents #75 and #349) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. The deficient practice was evidenced by the following: 1.) Upon initial tour of the facility on 02/24/2025 at 10:19 AM, Surveyor #1 observed Resident #75 using oxygen through a nasal cannula connected to an oxygen concentrator that provides extra oxygen to those who have difficulty breathing. However, the oxygen tubing was not labeled. Additionally, another nasal cannula was found resting on the seat of the resident's wheelchair, connected to a portable oxygen tank that was also unlabeled and exposed to the environment. On 02/25/2025 at 10:56 AM, Surveyor #1…
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 before2025-03-03 · 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
Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to ensure accurate accountability of controlled drugs to prevent loss or diversion. This deficiency was identified for 2 of 4 medication carts inspected. This deficient practice was evidenced by the following: On 02/26/2025 at 11:30 AM, the surveyor inspected F-Hall medication cart in the presence of the Registered Nurse/Unit Manager #1 (RN/UM #1). A review of the shift-to-shift Narcotic Record Controlled Count Sign Sheet (NRCCSS), which is used in healthcare settings to track the administration and accountability of controlled substances, revealed missing signatures for the following dates and shifts: 2/01/2025 for the outgoing nurse (7:00 AM - 3:00 PM), and 2/09/2025, for both the incoming and outgoing nurses (11:00 PM - 7:00 AM). On 02/26/2025 at 11:38 AM, the surveyor inspected E-Hall medication cart in the presence of the RN/UM #1. A review of the shift-to-shift NRCCSS revealed missing signatures on the following dates and shifts: 02/05/2025 for both…
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 · D2025-03-03 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to follow through on recommendations made by the Consultant Pharmacist (CP) during their monthly medication review regimen (MRR) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident # 66) and was evidenced by the following: During the Initial Tour of the facility on 02/24/2025 at 10:57 AM, Resident #66 was observed in a high back wheelchair in his/her room clean and groomed. Resident requested and received a cup of coffee. A review of the EMR on 02/24/2025 at 10:00 AM, revealed the following: According to the admission Record, Resident #66 was admitted to the facility with diagnoses including but not limited to: unspecified dementia with other behavioral disturbances. According to the most recent quarterly Minimum Data Set, an assessment tool dated 12/22/2024 revealed the resident had a Brief Interview for Mental Status of 6/15 MDS which…
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 19 citations
- Potential for harm · Dcited before2025-03-03 · 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, interviews, record review, and review of facility documentation, it was determined that the facility failed to follow enhanced barrier precautions (EBP), a set of infection control measures aimed at reducing the risk of transmitting infectious agents. This deficiency was observed for 1 of 1 resident (Resident #49) reviewed for EBP. This deficient practice was evidenced by the following: On 02/24/2025 at 10:38 AM, upon initial tour of the facility the surveyor observed the Home Health Aide (HHA#1) giving a bed bath to Resident #49 in their bedroom, while the resident was in bed, without wearing personal protective equipment (PPE), despite a sign on the outside of the door indicating EBP and the proper PPE required for contact. A review of Resident #49's Order Summary Report located in the Electronic Medical Record revealed an order to maintain EBP due to the presence of a urinary drainage tube, a medical device used to drain urine from the bladder and a history of Extended-Spectrum Beta-Lactamase (ESBL) in the wound, a bacteria resistant to many commonly used…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-02 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY COMPLAINT #NJ00175651 Based on observation, interview, and record review, on 08/02/24, it was determined that the facility failed to notify a resident in writing of a resident room change for 2 of 2 residents (Resident #1 and Resident #2). This deficient practice was identified and was evidenced by the following: 1). On 08/02/24 at 11:45 A.M., the surveyor observed Resident #1 awake in bed, watching television. The surveyor asked how long the resident had been in this room and the resident stated that he/she had been there for about three weeks. The resident stated that the unit manager [of the previous unit] and the social worker informed his/her that the resident was moving due to, something to do with my kidneys. The resident further stated that he/she had not received anything in writing prior to the move. Review of Resident #1's admission Record (AR) face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included, but were not limited to: hypertension,…
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 before2023-08-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint#: NJ163798, NJ166210 Based on observation, interview, and review of pertinent facility documents on 8/7/2023 and 8/8/23, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of abuse when a resident (Resident#2) reported to a familiy member that he/she was grabbed by their wrist and shoved over their bed and called fat by the Certified Nurse Aide (CNA) while providing care. This deficient practice was identified for 1 of 3 residents reviewed for reportable events. This deficient practice was evidenced by the following. During an interview on 8/7/2023 at 2:38 P.M., the Administrator stated he received a phone call from the RN/ES that night around approximately 9:39 P.M., advising him of the incident that had occurred between a CNA and Resident #2. I told the RN/ES that I would communicate with Resident #2's family member. The Administrator continue to state,I told the RN/ES that night to immediately obtain witness statements from the CNA's. I was off on Monday (4/24/2023) and on Tuesday (4/25/2023), I spoke with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
Complaint #: NJ163793, NJ166210 Based on observations, interviews, a review of the medical record, and other pertinent facility documents on 8/7/23 and 8/8/23, it was determined that the facility failed to provide documented evidence of care provided to a resident (Resident #2). The facility also failed to follow the Certified Nursing Assistant's job discreption and its policies titled, CNA Care Delivery, ADLs for 1of 3 residents (Resident #2) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the AR Resident #2 was admitted on with 3/28/23 with diagnoses which included but were not limited Obstructive Sleep Apnea, Morbid (Severe) Obesity Due to Excess Calories, Difficulty Walking, and Anxiety Disorder, Unspecified. According to the Minimum Data Set (MDS), an assessment tool dated 7/5/23, Resident # 2 had a BIMS score of 15/15, which indicated the Resident #2 was cognitively intact. The MDS also showed Resident #2 needed total assistance and two-person physical assistance with most Activities…
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 before2022-12-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
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 kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice occurred on 2 of 3-unit nourishment rooms (unit 1 and unit 2) and was evidenced by the following: On 12/6/2022 from 9:19 AM to 9:37 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM) observed the following on the 2nd unit nourishment room: 1. In an upper cabinet the surveyor observed (9) 4 oz (ounce) nectar thickened cranberry juices. The thickened cranberry juices had a best if used by date of 19 [DATE]. In addition, an upper cabinet above the microwave had (2) 46 Fl oz (fluid ounce) containers of orange juice concentrate. The orange juice containers had a use by date of 08/16/2022. On interview the LPN/UM stated that, Maintenance is responsible for monitoring the dates of foods in the nourishment room. 2. On 12/6/2022 at 9:37 AM, 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 · E2022-12-22 · tag F0888 — patternEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of other facility documentation, it was determined that the facility failed to accurately track and document facility and contracted staff vaccination status to include primary series and boosters when eligible. This deficient practice was evidenced by the following: On 12/1/2022, during entrance conference, the facility was asked to provide documentation of their staff and contracted staff vaccination status. On 12/2/2022 the facility provided a spread sheet for the facility staff. A review of the facility staff vaccination spread sheet showed that 3 staff members were eligible/due for their booster in June of 2022. There was no documentation provided to indicate the boosters were received. On 12/5/2022 the facility provided a spread sheet for the contracted staff who provide services at the facility. A review of the spread sheet did not include documentation of the dates that 8 of the 12 Independent Licensed Practioners received the initial covid vaccines. The spread sheet also revealed that 2 of 21 Therapy Department, Dietician, Security,…
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 · D2022-12-22 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review and review of other facility documentation, it was determined that the facility failed to ensure the accurate assessment of a resident's feeding tube and a pressure ulcer was documented in the Minimum Data Set (MDS), an assessment tool. This deficient practice was identified for 2 of 21 resident's reviewed for MDS accuracy (Resident #85 and #71), and was evidenced by the following: A. On 12/1/2022 at 10:56 AM, during the initial tour of the facility, the surveyor observed Resident #85 in their wheelchair getting dressed. Resident #85 stated he/she had a feeding tube and they wanted it removed. The surveyor questioned if the resident was able to eat by mouth. Resident #85 responded, Yes. The surveyor asked how long the feeding tube had been in place. The resident responded, Too long. I want it out. A review of the admission Record revealed that Resident #85 was admitted to the facility with the diagnoses including but not limited to: vascular dementia, and dysphagia, oropharyngeal phase (difficulty initiating a swallow). 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.
- Potential for harm · Dcited before2022-12-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review and review of other facility documentation, it was determined that the facility failed to ensure that the residents had a comprehensive person-centered care plan that addressed all the resident's medical needs and diagnosis. This deficient practice was identified for 2 of 21 sampled residents, (Resident #30, Resident #15) and was evidenced by the following: 1. On 12/1/2022 at 10:47 AM, Resident #30 was observed in bed and not responsive to surveyor's presence. A review of the medical record indicated that Resident #30 was admitted to the facility with diagnosis which included, but not limited to: Heart Failure, Type 2 Diabetes Mellitus, and Complete Traumatic Amputation of the Toe. A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate care dated 11/17/2022, identified Resident #30 as severely impaired cognition. According to the resident's electronic medical record, Resident #30 was discharged to the hospital with a change 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.
- Potential for harm · Dcited before2022-12-22 · 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
Based on observation, interview, review of the medical record, and other facility documentation it was determined that the facility failed to follow acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes by not maintaining medication records that were complete with staff signatures for 1 of 22 sampled residents (Resident # 47). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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. According to the admission Record, Resident #47 was admitted to the facility with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to update a resident care plan post fall and to follow their own policy titled Accidents & Incidents, Resident for 1 of 3 Residents reviewed for Accidents, (Resident #15). This deficient practice was evidenced by the following: During the initial tour of the Garden Unit on 12/1/2022 at 11:14 AM, Resident #15 was observed in the hallway with a chair alarm in place. Resident said hi and denied any complaints. A review of the admission Record revealed resident admitted to facility diagnosis of cerebral infarction (stroke), Alzheimer's dementia and Atrial fibrillation (A fib) (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart.) A review of the annual Minimum Data Set, dated [DATE], an assessment tool used to facilitate resident care, revealed a Brief Interview for Mental Status Interview score of 7/15 indicating Resident #15 had moderately…
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 before2022-12-22 · 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 and record review, it was determined that the facility failed to ensure that transmission-based precautions were followed to prevent spread of infections to include hand washing. This deficient practice was identified for 1 Certified Nursing Assistant (CNA #2) and 2 Laundry Staff (LS#1 and LS#2) who did not properly utilize personal protective equipment (PPE) while handling equipment or items that were likely contaminated with infectious bodily fluids. 1. On 12/7/2022 at 09:19 AM, the surveyor observed the Garden Unit on the ground floor. The surveyor observed a resident room with a Stop Sign at the entrance that read Enhanced Barrier Precautions: Everyone Must: Clean their hands including before entering and when leaving the room. Providers and Staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering; Transferring; Changing linens; Providing Hygiene; Changing briefs or assisting with toileting; device care or use: central line urinary catheter, feeding tube, tracheostomy; wound care:…
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 · E2020-10-07 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a) address and implement appropriate interventions for resident's with a significant weight gain or loss, and, b) provide a comprehensive nutritional assessment to identify the nutritional needs of a resident newly admitted to the facility. This deficient practice was identified for 4 of 6 residents reviewed for nutrition (Resident #8, #33, #37 and #204), and was evidenced by the following: 1. On 10/1/ 2020 at 12:39 PM, the surveyor observed Resident #204 sitting in their wheelchair in his/her room waiting for lunch. The resident stated that they recently had surgery, pointed to their abdominal region, and said they still had some pain in that area. The resident stated that since they were in some pain, they probably would not eat lunch. The resident stated that they ate when they wanted to. The surveyor questioned the resident if they had lost weight since admission to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2020-10-07 · tag F0801 — patternEmploy 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 observation, interview, and record review, it was determined that the facility failed to employ a Registered Dietitian and was evidenced by the following: On 9/29/2020 at 11:41 AM, the Food Service Manager (FSM) informed the surveyor that the facility currently did not have a Registered Dietitian (RD) employed. The FSM stated that the facility had a full-time RD, but was unsure when the RD left the facility. The FSM informed the surveyor that the Licensed Nursing Home Administrator (LNHA) could provide any additional information. On 9/30/2020 at 8:29 AM, the LNHA informed the survey team that the facility's RD resigned in April of 2020. The LNHA stated that the facility was a Civil Service Environment (government position) and the job required a Civil Service list. The List was posted, but only one person was on that list who had not met the facility's expectations. The facility posted the position and received no applicants. The facility re-posted the position and now had two applicants scheduled to be interviewed. The LNHA stated that during Novel Corona Virus 19 (COVID),…
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 before2020-10-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, review of medical record (MR), and other facility documentation, it was determined that the facility failed to report an elopement of a resident that occurred on 7/29/20, to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 1 resident's (Resident #304) and was evidenced by the following: According to the facility admission Record, Resident #304 was admitted in 9/2015 with diagnoses which included, but not limited to, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), Parkinson's Disease (a nervous system disorder that affects movement), and unsteady on his/her feet. On 10/5/20 at 10:21 AM, the surveyor reviewed the facility investigation dated 7/29/20 that was prepared by the Infection Prevention/Staff Development/Supervisor of Nursing and included the following: Resident #304 left the facility to go to a local fast food restaurant to get pancakes. The Resident wandered down the road on which the facility was located and turned onto an adjacent road. Resident #304 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-10-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to follow a physician order for a wound treatment. This deficient practice was identified for 1 of 1 resident's (Resident #73) observed for wound care and was evidenced by the following: On 9/29/20 at 11:08 AM, the surveyor observed Resident #73 in bed and lying on their right side with the head of bed slightly elevated. The resident wouldn't speak specifically to the surveyor's inquiry as he/she mentioned they were tired. The resident stated that they had a wound and demonstrated by pointing to their lower back. On 10/01/20 at 10:02 AM, the Licensed Practical Nurse (LPN) confirmed the physician order on the Treatment Administration Record (TAR) in the presence of the surveyor. The LPN removed the Dakins solution (an antiseptic) 0.125% and dermal wound cleanser from the treatment cart and placed the items on the clean field (an area kept free from microorganisms) located on Resident #73's overbed table. At 10:08 AM, Resident #73 was lying in bed…
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 before2020-10-07 · 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
Based on observation, interview and record review, it was determined that the facility failed to: a) accurately document the administration of controlled medication for Residents #2, #28, #60, and #61 and; b) maintain a system of record keeping that ensures an accurate inventory of controlled medications. This deficient practice was identified on 3 of 4 medication carts reviewed and evidenced by the following: 1. On 09/29/20 at 10:40 AM, the surveyor, in the presence of the Licensed Practical Nurse #1 (LPN#1), inspected the A-Hall cart. A review of the reconciliation of the narcotics stored in the secured and locked narcotic box to the declining inventory sheet revealed Resident #28's lorazepam 0.5 milligram (mg) tablets, a medication used for anxiety, did not match. The blister pack contained 12 half tablets and the declining inventory sheet accounted for 13 tablets administered. LPN #1 stated that she forgot to sign the declining inventory sheet for the dose she had given that morning. She further acknowledged she should have recorded on the declining inventory sheet immediately…
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 · D2020-10-07 · 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
Based on observation, interview and review of other facility documentation, it was determined that the facility failed to; properly store, label and dispose of medications in 3 of 4 medication carts and 1 of 2 medication refrigerators inspected This deficient practice was evidenced by the following: On 9/29/20 at 10:40 AM, the surveyor, in the presence of the Licensed Practical Nurse #1 (LPN #1) inspected the A-Hall medication cart. The inspection revealed four loose pills in drawer two and drawer three. A further review of the controlled substance inventory secured in the narcotic box revealed medications being stored that were awaiting destruction were as follows; Resident #5's lorazepam 0.5 milligram (mg) tablets, a medication used for anxiety, order had been discontinued but remained on the active medication cart. Resident #254 passed away July of 2020, tramadol 50 mg tablets, a medication used for pain, as well as lorazepam 1 mg tablets remained on the active medication cart. Resident #255 passed away in July of 2020, tramadol 50 mg tablets, and morphine sulfate solution, both…
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 · D2020-10-07 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure 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: a) provide an individualized assessment of possible food related weight changes by a qualified nutritional professional and failed to offer residents an individualized nutritionally equivalent food substitute/nourishment; b) ensure their Enhanced Calorie Program provided a super cookie calorically equivalent to their policy; and c) periodically update and ensure the adequacy of their the Enhanced Calorie Program by a qualified nutritional professional. This deficient practice was evidenced by the following: On 10/2/2020 at 9:23 AM, the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that the facility currently had no Registered Dietitian (RD) so the nurses were reviewing resident's weight loss. The RN/UM stated that if a resident was losing weight, they spoke to the resident's primary care physician (PCP) to determine if the resident should be placed on the facility's Enhanced Calorie Program (ECP). This program included foods that contained higher calories to increase 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 before2020-10-07 · 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 facility documentation, it was determined that the facility failed to maintain proper infection control procedures to address the risk of the spread of infection, for 2 of 25 Residents (Resident #33 and #73) observed and the annual review of the facility Antibiotic Stewardship Program (ASP). This deficient practice was evidenced by the following: 1. On 10/6/2020 at 12:22 PM, the surveyor observed Resident #33 sitting in a wheelchair by the door to their room. There was a sign outside the door that read, Stop, see nurse before entering the room. Resident #33 had an indwelling urinary catheter that was in a blue privacy bag and was secured to the left side of the residents wheelchair frame. The surveyor observed there was shared bathroom with the unoccupied room next door. There was a urinal in a bag that was secured to the grab bar. There was a small pink plastic bedpan that was not labeled or in a storage bag tucked behind the bathroom grab bar and a white plastic urine measuring device that was not labeled or in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$14,015 in federal fines across 1 penalty.
- $14,015 — penalty dated 2025-06-05
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SAVAGE, MICHELLE | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2009 |
| LEVINSON, DENNIS | Individual | CORPORATE DIRECTOR | since 01/01/2000 |
| DELROSSO, GERALD | Individual | CORPORATE OFFICER | since 01/01/2000 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 315358. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-03, 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.