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Buckingham At Norwood, The

100 McClellan Street, Norwood, NJ 07648 · For profit - Limited Liability company · 240 certified beds · (201) 768-6222 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Nov 20242 immediate-jeopardy citations$76,226 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $76,226 in federal fines (most recent 2024-11-07)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing 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.

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

Location & what’s nearby

Hospital
Urgent care / clinic
220 Livingston St Ste 202 · (201) 768-9090 · Call to confirm hours
Pharmacy
220 Livingston St · (201) 322-9090 · Call to confirm hours
Grocery
45 Ver Valen St · (201) 367-9099 · Call to confirm hours
Park
414 Clinton Ave · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 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 held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.4%8.7%15.4%better
Long-stay residents who lose too much weight3.1%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.1%0.6%0.9%better
Long-stay residents with a urinary tract infection0.7%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms4.9%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.4%2.3%3.3%worse
Long-stay residents whose ability to walk worsened4.0%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.7%18.8%18.9%typical
Long-stay residents given the seasonal flu vaccine99.3%97.2%95.3%typical
Long-stay residents with pressure ulcers5.1%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control4.5%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.7%12.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine93.8%80.1%79.4%better
Short-stay residents rehospitalized after admission31.1%24.9%22.6%worse
Short-stay residents with an outpatient ER visit10.6%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days0.952.071.67better
Long-stay outpatient ER visits per 1,000 resident days1.631.111.80typical

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.

54.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 291 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.2%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
40.6%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 40.6% 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 123 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.2%CMS range 47.9–59.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 6.4–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge40.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge41.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.7–10.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.52
RN hours/ resident / day
0.80
LPN hours/ resident / day
1.89
Aide hours/ resident / day
3.21
Total nurse hours/ resident / day
0.40
RN hoursweekends
39.1%
Total nursing turnover
42.4%
RN turnover

How full it usually is: this home is certified for 240 beds and averages 179.5 residents a day — about 75% occupied, or roughly 60 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.99 hrs/resident/day on weekends vs 3.30 on weekdays — 10% thinner on weekends. RN hours go from 0.57 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% 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

6
deficiencies at the latest standard inspection (2026-04-02)
15
at the previous standard inspection (2024-11-07)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · L2024-11-07 · tag F0728 — failed to protect against nurse-aide misconduct — widespread
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and a review of pertinent facility documents, it was determined that the facility failed to ensure that a non-certified Nursing Aide (NA #1) received the required training and competencies needed prior to receiving their own assignment and rendering resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming. This was identified for 1 of 9 NAs reviewed (NA#1) who provided direct care to residents on 5 of 5 nursing units. NA #1 was hired on 6/17/24, as a Hospitality Aide. NA #1 began independent resident care assignments on 7/03/24, and was enrolled in a state approved Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP) that began on 7/15/24, and worked 69 shifts with no evidence of completing the required skills and competencies prior to providing resident care. The facility's failure to ensure all NAs were trained with the appropriate competencies and skills required prior to receiving an independent resident care assignment posed a likelihood that serious…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2023-07-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and policy review, the facility failed to clean and disinfect glucometers per the manufacturer's recommendation. This facility failure to properly clean and disinfect multi-use glucometers has the potential to increase the likelihood of transmission of blood-borne pathogens for two of 30 residents (Resident (R) 351 and R 11) receiving blood sugar monitoring. On 7/13/23 at 2:59 PM, the Administrator and the Director of Nursing (DON) were notified of immediate jeopardy (IJ) in the following area: at F880-: Infection Control. The Immediate Jeopardy began on 07/13/23 when the licensed nursing staff failed to properly clean and disinfect multi-use glucometers for R351 observed on 07/12/23 and R11 observed on 07/13/23. The facility provided an acceptable plan for removal of the immediate jeopardy at F880 on 07/14/23 at 1:45 PM. On 07/14/23 at 3:00 PM, the immediacy was removed after the plan was verified to have been implemented. The deficient practice remained at a scope and severity of a D (Isolated, no actual harm with potential for more than minimal…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-02 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #2790946Based on observation, interview and record review it was determined that the facility failed to accurately document and administer pharmaceuticals in accordance with physicians' orders for 4 residents (#14, 67, 108, 156) of 32 reviewed. Specifically, Resident #14 received late administration of insulin, Resident #67 received late administration of pain medications, Resident #108 had documentation discrepancies regarding the administration of antianxiety medication, and Resident #156 had documentation discrepancies regarding the administration of narcotic pain medication. The findings are as follows.1.On 3/26/26 at 10:37 am, the surveyor observed Resident #67 awake in bed. Two certified nursing assistants were assisting the resident with morning personal care. The resident appeared agitated. On 3/30/26 at 11:00 am and 3/31/26 at 10:34 am, the surveyor again observed the resident in bed. The resident was calm, conversant, and denied discomfort. On 3/26/26 at 10:40 am, the surveyor observed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined that the facility failed to ensure call devices were positioned within reach of a resident who was at risk for falls. The deficient practice was cited for 1 resident (Resident #59) and evidenced by the following. On 3/26/26 at 11:30 am, the surveyor observed Resident #59 standing in the doorway of their room next to their bed. The resident told the surveyor that they needed help because there was spilled water in the room. The surveyor inquired whether the resident pushed the call device to summon help. The resident replied she did not know where the device was. The call device was observed on the floor under the bed near the roommate's bed.On 3/27/2026 at 10:37 am, the surveyor observed the resident lying on their bed. The surveyor observed the call device under the bed near the roommate's bed. When asked by the surveyor where the call bell was, the resident replied they did not know. On 3/30/26 at 9:50 am, the surveyor observed the resident lying on their bed. The surveyor observed the call device on the floor…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to continue to assess a resident after a fall to ensure the resident had no adverse effects from the event in 1 of 3 residents reviewed for falls (Resident #80).This deficient practice was evidenced by the following:On 3/26/26 at 10:52 AM, the surveyor observed Resident # 80 in room seated in chair, interviewable, and stated that they are pleased with the care. A review of the Resident # 80's electronic health record (EHR) reflects the resident was admitted with diagnoses that included but were not limited to a fracture of the right femur, dementia, difficulty walking and unsteadiness on feet.A review of Resident #80's annual Minimum Data Set (MDS), dated [DATE], an assessment tool, reflected that the resident is moderately cognitively impaired. The MDS reflected that the resident used a wheelchair for mobility and needed assistance with transfers.A review of the progress notes for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to monitor the nutritional status for 1 of 1 residents reviewed for nutritional status (Resident #137), by not following a physician's orders for monitoring of the resident's weight.The deficient practice was evidenced by the following:On 3/26/26 at 10:46 AM, the surveyor observed resident in bed, awake and responsive with the call bell placed within the resident's reach. A review of Resident #137's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; type 2 diabetes, obesity, essential hypertension (high blood pressure) and urinary retention.A review of Resident #137's annual Minimum Data Set (MDS), an assessment tool dated 2/20/26, reflected that the resident was moderately cognitively impaired.A review of the resident's Physician Order Summary report reflected the following physician's order (PO): Weigh resident daily and notify provider if resident gains more than 3 lbs. in 24 hour…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to clarify oxygen therapy orders to ensure a resident was provided with care, consistent with professional standards of practice, for 1 of 1 resident (Resident #16) reviewed for respiratory care. The deficient practice was evidenced by the following:On 3/26/26 at 11:11 AM, the surveyor observed Resident #16 sitting in a wheelchair, alert and sitting with other residents at a table for a recreational activity. The resident was not on any oxygen therapy and there were no observed concerns.On 4/1/26 at 9:09 AM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #16.The admission Record (a summary of important resident information) revealed Resident #16 had diagnoses that included but were not limited to, hemiplegia (a paralysis or severe weakness affecting one side of the body), and dementia.A Quarterly Minimum Data Set assessment, a tool used to facilitate management of care, dated 1/26/26, indicated the facility assessed the resident's cognition using a Brief Interview…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-02 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516.This deficient practice was evidenced by the following:According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:(a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements:(1) Compliance with title XVIII of the Act and applicable Medicare regulations.(2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies the provider or…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-07 · tag F0868 — widespread
    Have 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 review of pertinent facility documentation, the facility failed to have the Infection Preventionist present for three (3) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 156 residents who currently live in the facility. The deficient practice was evidenced by the following: On 10/29/24 at 11:02 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and the Registered Nurse/Unit Manager during an Entrance Conference meeting. The LNHA confirmed that day census (total number of residents) of 156. The LNHA stated that it was the Regional Infection Preventionist Nurse (RIPN) the facility's Infection Preventionist (IP), and the LNHA was unsure when the RIPN started to be the IP. The surveyor asked for the IP timeline since the last recertification (7/14/23), and the LNHA responded that he would get back to the surveyor. On 11/06/24 at 01:48 PM, the Director of Nursing (DON) provided the last three-quarters of QAPI Attendance sheets 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for five (5) out of eight (8) newly hired staff prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed eight randomly selected new employee files. The review for reference checks for five of the eight new employees revealed the following: -Staff #1's file, a Registered Nurse (RN) who was hired on 5/27/24, revealed only 1 reference check in their file. -Staff #2's file, a RN who was hired on 9/10/24, revealed only 1 reference check in their file. - Staff #3's file, a Certified Nursing Assistant (CNA) who was hired on 10/30/23, revealed no reference checks in their file. - Staff #4's file, a CNA, who was hired on 10/16/23, revealed no reference checks in their file. - Staff #5's file, a CNA, who was hired on 10/16/23, revealed no reference checks in their file. On 11/06/24 at 01:21 PM, the surveyor interviewed the Human Resources Regional Director (HRRD)…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    4. On 10/29/24 at 10:21 AM, the surveyor observed posted signs outside Resident # 140's room for oxygen (O2) in use, EBP (enhanced barrier precautions), and PPE (personal protective equipment) box hung outside the door. The resident was lying in bed with a nasal cannula (a device that delivers extra O2 through a tube and into the nose) and O2 at 2LPM (liters per minute) attached to the concentrator (a device for O2). The surveyor reviewed the hybrid medical records of Resident #140. The AR revealed that the resident was admitted to the facility that included a medical diagnosis that was not limited to essential hypertension (high blood pressure that is not due to another medical condition), chronic kidney disease, and DM. According to the comprehensive Minimum Data Set (cMDS) with an ARD of 10/12/24, Section C Cognitive Patterns revealed a BIMS score of 11 out of 15 which reflected that the resident's cognitive status was moderately impaired. A review of the PO with an order date of 10/23/24 for Midodrine HCl oral tab 5 mg give 1 tab via G-Tube (gastrostomy tube) three times a day…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly store medication (med) for one (1) of 38 residents, Resident #210, and b.) ensure that medications (meds) were stored and labeled appropriately for two (2) of four (4) med carts inspected and two (2) of four (4) med storage rooms inspected located on four (4) of five (5) nursing units according to facility's policy and standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-11-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of residents' quality of life specifically by not providing a.) breakfast meal in a timely manner for one (1) of nine (9) residents in 2 South dining area and b.) privacy during eye consultation and/or treatment for one (1) of eight (8) residents in 1 South dining area. The deficient practice was evidenced by the following: 1. On 10/31/24 at 8:25 AM, the surveyor observed the breakfast in the 2 South dining room. The surveyor observed nine residents inside the dining room, one Recreation Aide (RA), one Director of Recreation (DoR), and one Quality Assurance Corporate Aide (QACA). The three facility staff were all standing, the DoR and the QACA were talking inside the dining room. Upon entry to the dining room, there was a resident on one table with no breakfast tray seated in a wheelchair, next table were four residents with no breakfast…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the interview and record review, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within the 14th calendar day of the resident's admission (admission date plus 13 calendar days) in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for three (3) of 38 residents (Resident #125, #132, and #212) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. On 11/04/24 at 9:50 AM, the surveyor observed Resident #125 lying in bed with eyes open and unable to answer the surveyor's inquiry. On 11/04/24 at 11:00 AM, the surveyor reviewed the hybrid (paper and medical) records of Resident #125 and revealed: The admission Record (AR; an admission summary) documented that Resident #125 was admitted to the facility with diagnoses that included but were not limited to encephalopathy (a disease that affects the brain). The most…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for two (2) of 38 residents (Resident #125, and #212) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 11/04/24 at 9:50 AM, the surveyor observed Resident #125 lying in bed with eyes open and unable to answer the surveyor's inquiry. On 11/04/24 at 11:00 AM, the surveyor reviewed the hybrid (paper and medical) records of Resident #125 and revealed: The admission Record (AR; an admission summary) documented that Resident #125 was admitted to the facility with diagnoses that included but were not limited to encephalopathy (a disease that affects the brain). Resident #125's most recent comprehensive MDS (cMDS), with an Assessment Reference Date (ARD; the last day of the observation period) of 02/04/24,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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, record review, and review of facility provided documents, it was determined that the facility's interdisciplinary team (IDT) failed to ensure the facility policy was followed to ensure the person-centered care plan was revised to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and to ensure the resident was (invited to participate) involved in the care planning process. The deficient practice was identified for one (1) of 38 residents reviewed for care planning (Resident #131) and was evidenced by the following: On 10/29/24 at 10:29 AM, during initial tour, the surveyor observed Resident #131 lying in bed in their room. Resident #131 expressed concern with their discharge (d/c) plans. The resident explained that they had been in the facility for several months, was there to receive rehabilitation (rehab) therapy, and did not have a place to stay outside the facility. Resident #131 stated that they had completed rehab therapy and was independent with activities of daily living. The resident 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint # NJ167164 and #167919 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and facility policies and procedures for one (1) of 38 residents, Resident #360, reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen and nebulizer, according to the standard of clinical practice and the facility's policy and procedure, specifically a.) that respiratory equipment was stored in accordance with facility policy and infection control measures for two (2) of two (2) residents reviewed for respiratory care, Resident #210 and #213, b.) clarify the oxygen therapy order and ensure staff followed the appropriate hand hygiene and use of personal protective equipment (PPE) for a resident with contact precautions and oxygen posted sign for one (1) of one (1) of resident, Resident #213, reviewed for tracheostomy care. 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…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) sufficient nursing staff and b.) incontinence care was provided for two (2) of two (2) residents (Residents #67 and #214) in a timely manner, during the incontinence tour. This deficient practice was evidenced by the following: 1. On 10/29/24 at 9:04 AM, the survey team entered the facility and met with the Receptionist. The surveyor observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 10/29/24 Day Shift, 7:00 AM-3:00 PM (7-3), current Census 158, total of 13 CNAs, and staff to resident ratio of 1 CNA:12.2 Residents. On 10/29/24 at 10:21 AM, the surveyor observed Resident #140 lying on the bed with the responsible party (RP) at the bedside. The RP informed the surveyor that there were no care issues except that the facility was short of staff. The RP stated that yesterday morning, only one Certified Nursing Aide (CNA) worked in the unit (Penthouse) for a total of 18 residents. The RP further stated that it had…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for three (3) of seven (7) days. This failure could affect the knowledge of the availability of staff to care for the residents, resident representative, and visitors. This deficient practice was evidenced by the following: On 10/29/24 at 9:04 AM, the survey team entered the facility and met with the Receptionist who instructed surveyors to use the stand-alone thermometer and fill out the paper for COVID screening. The surveyor observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 10/29/24 Day Shift, 7 AM-3 PM, current census of 158 that included 13 CNAs (Certified Nursing Aides) with staff to resident ratio of 1 CNA:12.2 Residents. On 10/29/24 at 9:20 AM, the Registered Nurse Supervisor (RNS) informed the surveyor in the presence of the survey team that the census (total number of residents) was 156. On 10/30/24 at 8:17 AM, the surveyor entered the facility and met 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer the medication to Resident #45 due to unavailability of the medication. The deficient practice was identified for one (1) of four (4) residents (Resident #45) observed during medication administration. The Resident did not received medication for mood disorder at the prescribed time. The deficient practice was evidenced by the following: On 11/04/24 at 7:50 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepared medication (med) of Resident #45. The LPN was unable to administer the med Seroquel 12.5 mg (milligram) to the Resident due to unavailability. The LPN acknowledged that the Seroquel 12.5 mg was not available in the med cart. The LPN informed the surveyor that she would call the pharmacy to deliver the med as soon as possible (ASAP). The surveyor reviewed the medical record of Resident #45. The admission Record revealed that the resident 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 ensure that the resident did not receive an unnecessary medication for one (1) of five (5) residents reviewed, (Resident #73). The deficient practice was evidenced by the following: The surveyor reviewed Resident #73's electronic medical record (EMR) which revealed the following: Resident #73's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic kidney disease, (when the kidneys are damaged and can't filter blood the way they should) and urinary tract infection. Resident #73's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/15/24, reflected that the resident had a Brief Interview for Mental Status (BIMS), a tool used to screen and identify cognitive condition, score of 0 out of 15, which indicated that Resident #73 was severely cognitively impaired. The resident's list 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to accurately assess one of 32 residents (Resident (R) 101) functional range of motion. Failure to code the MDS correctly can lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: During observation on 07/10/23 at 3:24 PM, R101 was sitting in the wheelchair located in the resident's room. R101 was observed with contractures of the right upper extremity wrist and elbow. A splinting device was not observed on the resident. R101 was not interviewable. Review of R101's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed an admission date of 09/17/20 with diagnoses that included history of a cerebral vascular accident with a right upper extremity contracture. Review of R101's electronic quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR with an Assessment Reference Date (ARD) date of 06/24/23, documented R101 had no impairment of the upper extremities. On 07/12/23 at 3:08 PM,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to develop and implement a care plan for one of 32 sampled residents (Resident (R) 101) with measurable goals and interventions to care for and manage the resident's right upper extremity contracture. Findings include: During observation of R101 on 07/10/23 at 3:24 PM, resident was sitting in the wheelchair located in the resident's room. R101 was observed with contractures of the right upper extremity wrist and elbow. A splinting device was not observed on the resident. Review of R101's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed an admission date of 09/17/20 with diagnoses that included history of a cerebral vascular accident with a right upper extremity contracture. Review of the 10/20/20 Physician Progress Notes located in the Progress Notes tab of the EMR revealed a Rehabilitation Initial Evaluation which documented that R101 had a history of a cerebral vascular accident (CVA) with a right upper extremity contracture. Under Assessment and Plan the physician…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined the facility failed to accurately assess and implement interventions for the care and management of contractures for one of one resident (Resident (R) 101) reviewed for position, mobility. This failure created the potential for further preventable decline in range of motion. Findings include: During observation of R101 on 07/10/23 at 3:24 PM, R101 was sitting in the wheelchair located in the resident's room. R101 was observed with contractures of the right upper extremity wrist and elbow. A splinting device was not observed on the resident. R101 was not interviewable. Review of R101's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed an admission date of 09/17/20 with diagnoses that included history of a cerebral vascular accident with a right upper extremity contracture. Review of the 10/20/20 Physician Progress Notes located in the Progress Notes tab of the EMR revealed the Rehabilitation Initial Evaluation which documented R101 had a history of a cerebral vascular…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$76,226 in federal fines across 1 penalty.

  • $76,226 — penalty dated 2024-11-07

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

Part of a chain

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

RatingThis homeChain avg
Overall 2 of 52.3-0.3 vs chain
Health inspection 2 of 51.9+0.1 vs chain
Staffing 2 of 52.6-0.6 vs chain
Quality measures 3 of 54.5-1.5 vs chain
The other 7 homes this chain runs (chain average 2.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
JACOBS, HYMANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST95%since 01/18/2002
JACOBS, LIVIAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 01/18/2002
DUBLIN, TREVORIndividualW-2 MANAGING EMPLOYEEsince 12/03/2018
METTERNICH, CHRISTOPHERIndividualCORPORATE OFFICERsince 08/17/2017

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.

$19.2M
Net patient revenuemost recent cost report
-8.2%
Operating marginrevenue minus expenses
$2.8M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 79%Medicare 8%Other / private 13%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$381per resident / day
operating cost
$11,580per month
≈ monthly operating cost
$352per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315290. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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