Axia Care Center Of Orange
135 South Center Street, Orange, NJ 07050 · For profit - Individual · 188 certified beds · (973) 266-3000 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)
- it has an abuse, neglect, or exploitation citation (F0610), cited Jan 2025
- it has citations for mishandling residents’ money or property (F0569, F0570)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $124,800 in federal fines (most recent 2025-01-23)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 fell from 4 to 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.
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 | 8.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.1% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.2% | 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 | 0.5% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.1% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.9% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 13.0% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.5% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 66.2% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.0% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.3% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.69 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.36 | 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.
50.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 65 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 35.1% 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 94 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 43% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.1%CMS range 37.2–62.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.1%CMS range 9.0–17.4 | 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 | 35.1% | 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 | 38.3% | 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 | 33.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.4% | 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 | 96.8% | 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 | 93.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.1–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 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 188 beds and averages 160.0 residents a day — about 85% occupied, or roughly 28 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.14 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.78 hrs/resident/day on weekends vs 4.28 on weekdays — 12% thinner on weekends. RN hours go from 0.90 to 0.72 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · L2025-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespreadEnsure 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 Complaint NJ # 180392 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) ensure effective interventions were implemented and monitored for a resident (Resident #143) who resided in a piped-in oxygen room and was identified as a smoker and was observed smoking inside their room on 10/19/24. This deficient practice occurred for 1 of 1 residents reviewed for safe smoking. Observations on 1/15/25, 1/16/25, and 1/17/25, confirmed Resident #143 who resided in a piped-in oxygen room, kept their smoking materials in their room. The facility's failure to ensure all residents were protected from serious injury, harm or death from explosion or fire, from smoking inside of a room that had oxygen piped in through the walls resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/19/24, when Resident #143 was found by a Registered Nurse (RN #1) to be smoking in their room. From 1/15/25 through 1/17/25, 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.
- Actual harm · G2025-01-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 180392 Based on interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a thorough and complete investigation was completed to determine the causal factor of an injury of unknown origin to ensure that resident abuse or neglect had not occurred for a resident (Resident #264) who was in a persistent vegetative state (disorder of consciousness caused by brain damage), dependent on staff for all care, and required a mechanical ventilator for breathing. Resident #264 was found on 11/06/24, with a hematoma (blood filled injury) to the right eye, and ecchymosis (a bruise) to the right facial area measuring 16-centimeter (cm) x 10 cm. Resident #264 was transferred to the emergency room on [DATE], and was diagnosed with traumatic hematoma of the right eye. The deficient practice was identified for 1 of 2 residents reviewed for accidents and evidenced by the following: On 01/21/25 at 10:00 AM, the surveyor reviewed the closed electronic medical…
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 before2025-10-23 · 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 2641999, 2562115 Based on interview and record review and review of other pertinent facility documents on 10/23/25, it was determined that the facility failed to ensure that the nursing services were provided and documented consistently on the Treatment Administration Record (TAR) in accordance with professional standards of practice. This deficient practice was identified for 2 of 3 residents reviewed for standards of practice (Resident #1, Resident #2).The evidenced was as follows: Reference: The practice of nursing as a Licensed Practical Nurse is defined as performing tasks, and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a Registered Nurse, or otherwise legally authorized Physician or Dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice…
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 before2025-10-23 · 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
Based on interviews, medical record review, and review of pertinent facility documentation on 10/23/25, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) as being provided to residents for 2 of 4 residents reviewed for ADLs (Resident #1, Resident #2). The findings were as followed: A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to; morbid obesity, osteoarthritis, muscle weakness, and difficulty walking. A review Resident #1's comprehensive Minimum Data Set (MDS) an assessment tool dated 6/5/25 that the resident had a Brief Interview Mental Status (BIMS) score of 14 out of 15, indicating that the resident's cognition was intact. A review of Resident #1's June 2025 Documentation Survey Report v2, a form included blank spaces indicating that the task, were not completed as follows: Personal Hygiene on 6/11/25, and 6/23/25 on the day shift. On 6/8/25, 6/10/25, 6/18/25, 6/26/25, and 6/30/35 on the evening shift. On 6/13/25, 6/14/25, 6/15/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-15 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 #: NJ 185165 Based on observation, interview, record review and review of other facility documentation on 4/08/25 and 4/15/25, it was determined that the facility failed to implement and document an effective discharge plan to ensure a safe and effective transition of care for 1 of 3 residents reviewed for discharge planning, (Resident # 2). This deficient practice was evidenced by the following: The surveyor reviewed the admission Record of Resident #2 which revealed that the resident was admitted to the facility 02/2025 with diagnoses that included but not limited to: Spinal stenosis, Alzheimer's Disease, Repeated Falls, Muscle Weakness and Difficulty Walking. A review of Resident #2's admission Minimum Data Set (MDS) (an assessment tool) dated 03/28/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact. The Functional Status portion of the assessment specified that the resident required supervision 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.
- Potential for harm · D2025-04-15 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ00185165 Based on interviews, medical record reviews, and review of other pertinent facility documents on 04/08/25, it was determined that the facility's Director of Social Services (DSS) failed assist a resident in obtaining needed community services, as required by the Job Description for Social Services Director. The DSS also failed to follow the facility's Discharge Policy policy for 1 of 3 residents (Resident #2). This deficient practice was evidenced by the following: Review of the Electronic Medical Records (EMRs) is as follows: The surveyor reviewed the admission Record of Resident #2 which revealed that the resident was admitted to the facility 02/2025 with diagnoses that included but not limited to: Spinal stenosis, Alzheimer's Disease, fall from bed, muscle weakness and difficulty walking. A review of Resident #2's admission Minimum Data Set (MDS) (an assessment tool) dated 03/28/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact. The Functional Status portion 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 · F2025-01-23 · tag F0569 — widespreadNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) that approached the limit that could jeopardize a resident's eligibility for Medicaid or Supplimental Security Income (SSI). This deficient practice was identified for all residents who maintained Personal Needs Accounts at the facility and was evidenced by: A review of the Funds Balance Report for 01/15/2025 revealed a list of eighty five active resident names with a balance of $84, 036.27 Due to patients. There were twenty -one residents listed with PNA funds that range from $1,852.93 to $3,997.38. On 01/21/25 at 10:32 AM, the surveyor, in the presence of the survey team interviewed the Certified Social Worker (CSW) regarding the PNA accounts and if the CSW was involved with the PNA. The CSW stated that the business office handled the PNA. The CSW stated the business office will send a list of residents with PNA money, and the Certified Nurse Aide or family would let us know if the resident needed anything and the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-23 · tag F0570 — widespreadAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review it was determined that the facility failed to ensure that a Surety Bond was in place to protect all resident funds held by the facility. This deficient practice affected all residents who maintained a Personal Needs Account with the facility and was evidenced by the following: On 01/15/25 at 2:08 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the facility's surety bond and a list of all the resident funds held by the facility. On 01/15/25 at 2:37 PM, the LNHA provided a copy of a Certificate of Liability Insurance Date: 01/15/2025 (the survey entrance date) with Crime- Including Burglery listed as the type of insurance coverage provided. The surveyor questioned the LNHA regarding the policy that he provided and he stated, this is what they (corporate oversight) gave me. A review of the Funds Balance Report for 01/15/2025 revealed a list of eighty five active resident names with a balance of $84, 036.27 Due to patients. On 01/17/25 at 8:38 AM, the surveyor asked the LNHA about the residents funds and if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-23 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
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 review of pertinent documents it was determined that the facility failed to maintain an effective comprehensive data driven Quality Assurance and Performance Improvement program by failing to review all services provided including to ensure significant events were reviewed to determine root cause to prevent further occurrences. This deficient practice occurred for residents with a history of smoking in their room, holding drug paraphernalia and a lighter in their room (Resident #143 and Resident #34), and for a resident (Resident # 264) who was dependent on staff for all care, and sustained an injury of unknown origin that required hospitalization on 11/06/24. This deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: Refer to 689L, 610G a. During the survey, a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR Part 483.25(d)(2) F 689 as the facility failed to follow their smoking policy 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 · E2025-01-23 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ 168201, # NJ 179357 Based on observations, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that a resident call light was readily accessible and within reach on 01/15/25, 01/16/25, and 01/21/25. The deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for accommodation of needs and was evidenced by the following: On 01/15/25 at 10:45 AM, during an initial tour, the surveyor observed Resident #43 watching television (TV) in the bed. The resident stated, I am paralyzed (unable to move) from a stroke and not able to move my right arm. The surveyor observed resident's left hand elevated on a pillow. The surveyor observed the resident's call bell (a round disk-shaped flat device with a red cross in the middle) was placed close to their right shoulder. Resident #43 stated, I am not able to use my call bell and have asked them (staff) to place it on more towards left side. On 01/16/25 at 11:57 AM, the surveyor observed Resident #43 watching TV in the bed and the call…
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 before2025-01-23 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 167555 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 2 of 2 residents (Resident #33 and Resident #8) reviewed for Activities of Daily Living. The deficient practice was evidenced by the following: 1. On 1/15/25 at 9:45 AM, the surveyor observed Resident #33 in bed and a strong urine odor was observed in the room. The resident was able to answer questions and informed the surveyor that they had not been changed since last night. On 1/15/25 at 10:15 AM, the surveyor returned to the room and observed the resident in the same position. The resident indicated that they had not had incontinence care. On 1/15/25 at 10:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had Resident #33 on her assignment. The CNA revealed that she reported to work at 7:00 AM this morning, she delivered the breakfast tray and she had not yet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-23 · tag F0687 — failed to care for feet properly — patternProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure there was no delay in treatment for a resident who required podiatry care that was ordered on 12/04/2024 and the podiatrist consult was completed 01/20/25, and the resident wore pressure relieving boots as per physician order. This deficient practice was identified for 1 of 1 resident (Resident #38) reviewed for foot care and was evidenced by the following: On 1/15/25 at 10:07 AM, the surveyor observed Resident #38 was in awake and alert in bed, with feet outside of covers and were not off loaded or in boots. Both feet were observed to be encrusted with a thick yellow, cracked and dry skin. The right foot had approximately a dime sized round black area above the right heel on the sole of the foot. The left foot had what appeared to be a black pencil eraser sized area on the ball of the foot. There were various colored flakes of what appeared to be skin scattered on the bed sheet by the resident's feet. On 01/22/25 at 8:00 AM, the surveyor reviewed 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.
Show the remaining 19 citations
- Potential for harm · D2025-01-23 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of pertinent documentation, it was determined that the facility failed to provide residents with a dignified environment by not providing bed linens, and not consistently emptying multiple urinals. This deficient practice was identified for 2 of 2 residents (Resident #113 and Resident #91) reviewed for dignity and was evidenced by the following: a. On 01/15/25 at 10:10 AM, Surveyor #1 observed Resident #113 in their room and in their bed, wearing a hospital type gown. There were no linens, pillows, or blankets on the bed and crumbs were observed in the bed. On 01/15/25 at 10:49 AM, Surveyor #1 and Surveyor #2 went to Resident #113's room. Both surveyors observed the resident was still sitting on the bed with no linens, pillows, or blankets on the bed as observed by the surveyor approximately 40 minutes prior. On 01/16/25 at 8:19 AM, Surveyor #1 observed Resident #113 sitting in a wheelchair in the room. There were no linens, pillows, or blankets on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 # NJ 177957, # NJ 180392 Based on interviews, record review, and pertinent facility documents provided by the facility from 01/15/25 through 1/22/25, it was determined that the facility failed to notify the family/responsible party when a resident (Resident #264) had a change in condition and required transport to the emergency room. This deficient practice occurred for 1 of 1 closed medical records reviewed for resident (Resident #264) who had a change in condition. The deficient practice was evidenced by the following: According to Resident #264's admission Record, the Resident was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Acute and chronic respiratory failure hypoxia, Epilepsy, tracheostomy status and dependence on respiratory ventilators. The Discharge assessment dated [DATE], reflected that Resident #264 was severely cognitively impaired and totally dependent on staff for all activities of daily living (ADLs). Review of Resident #264's Care Plan…
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 · D2025-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to maintain safe handrails on 1 of 5 Resident Units. This deficient practice was evidenced by the following: On 1/15/25 at 9:53 AM, the surveyor toured the 3rd floor and observed the following: Outside of room [ROOM NUMBER], the corner handrail was not securely connected to the next piece of handrail. Outside of room [ROOM NUMBER], the handrail was cracked. By the soiled linen room, the handrail was not secure. Across from room [ROOM NUMBER], the handrail was not secure to the wall. Outside of room [ROOM NUMBER], the handrail was not connected to the next piece. In the out cove by the telephone for resident use, the handrail was not secure to the wall. Outside of room [ROOM NUMBER], the handrail was cracked and not secure. Outside of room [ROOM NUMBER], the corner piece of handrail was loose from the connecting piece. On 1/15/25 at 10:00 AM, a maintenance worker was on the 3rd Floor Unit. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 36 residents (Resident #143 and Resident #26) reviewed for accuracy of MDS coding. The deficient practice was evidenced as follows: On 1/15/25 at 9:39 AM, during initial tour, Surveyor #1 observed a sign posted on the wall outside of Resident #143's room, No Smoking (in red), Piped in Oxygen in Use. Upon entrance to Resident #143's room, the surveyor observed the resident watching television (TV) in bed. The surveyor observed a pack of cigars on the table next to the resident and asked the resident what that was. The resident took a cigar out of the case and stated it's a cigar while showing it to Surveyor #1. On 1/16/25 at 8:50 AM, the surveyor reviewed the medical record for Resident #143. According to the admission Record (AR), Resident #143 was admitted to the facility 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 · Dcited before2025-01-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, it was determined that the facility failed to administer medication in accordance with the physician order and professional standards of nursing practice. This deficient practice was observed for one of 1 of 1 residents (Resident #60) reviewed for medications during the initial tour conducted on 01/15/25 and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-23 · 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 pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician order, and ensure oxygen equipment was stored properly. This deficient practice was identified for 1 of 3 residents (Resident #47) reviewed for respiratory care and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey 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.
- Potential for harm · D2025-01-23 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, it was determined that the facility failed to ensure residents had cognitive ability before signing arbitration agreements. This deficient practice was identified for 1 of 3 residents (Resident #61) reviewed for arbitration agreements. This had the potential to result in resident representatives not being able to resolve disputes with the facility in a court of law. The deficient practice was evidenced by the following: On 1/15/25 at 10:18 AM, Surveyor #4 observed Resident #61 in bed. The resident did not respond to the surveyor when spoken to. A staff member was entering the room and stated the resident could not see. On 1/15/25 at 11:12 AM, the Licensed Nursing Home Administrator (LNHA) informed Surveyor #1 that the facility utilized arbitration agreements which were part of the admission agreement. The facility provided a list of residents who had signed arbitration agreements. On 01/16/25 at 11:06 AM, during a phone conversation with Surveyor #1, Resident #61's representative explained the resident was legally blind. The representative…
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 · D2025-01-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of pertinent documentation, it was determined that the facility failed to prevent the spread of potential infection by failing to don (put on) Personal Protective Equipment (PPE) prior to entering the room of residents on contact precautions. This deficient practice was identified for 2 of 2 residents (Resident #144 and Resident #147) reviewed for Transmission-based Precautions (TBP). The deficient practice was evidenced by the following: 1. On 01/15/25 at 8:57 AM, the surveyor observed Resident #144's room with signage outside the door alerting all to stop, Contact Precautions everyone must: . put on gown before room entry, put on gloves before room entry . There was a three-drawer plastic bin outside of the door with PPE gowns and gloves. At that time, the Registered Nurse Unit Manager (RN/UM) walked past the Licensed Practical Nurse (LPN) who was outside the door and into Resident #144's room. The RN/UM did not don a PPE gown or gloves. The RN/UM…
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 before2023-09-18 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to follow acceptable standards of clinical practice with regards to 1. accurately following a physician's order (PO) in administering pain medication to treat varying pain levels (Resident #15, Resident #108); 2. ensure the positioning mobility to prevent contracture was applied prior to signing the administration record (Resident #15); 3. accurately documenting the urinary output for residents with a suprapubic catheter (Resident #39, Resident #78). 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…
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 · D2023-09-18 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 address a Full code status (code status that indicates a patient wants all resuscitation procedures to be provided to keep them alive in case of a medical emergency) order signed by the resident's family with no follow up from the Physician. This deficient practice was identified for 1 of 32 residents, Resident #15 reviewed for advanced directives. This deficient practice was evidenced by the following: On 9/5/23 at 11:14 AM, the resident was observed in the day room seated in a reclining Geri-chair watching TV. The surveyor reviewed Resident #15's hybrid medical record. Resident #15 was admitted to the facility with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Hypertension. A review of the Social Services progress notes revealed documentation on 1/11/23, 1/12/23 and 1/13/23 that the resident's family member (listed in the admission Record as one of the emergency contacts) requested that Resident #15's advance…
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 before2023-09-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 32 residents (Resident # 147, and #15) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 9/12/23 at 1:18 PM, the surveyor reviewed the closed medical chart for Resident #147 who was MDS coded for hospitalization. The surveyor reviewed the Discharge Summary (DS) created on 7/31/23 by the Social Worker (SW) for Resident #147. The DS documented that Resident #147 was discharged home per their family's request. Review of the 7/29/2023 Nursing Progress Note (PN), indicated that Resident #147 was discharged at 1:15 PM with their family member, without any distress or discomfort, all discharge papers ready and signed by the resident. Review of Resident #147's Face Sheet (FS) (a one-page summary of important information about…
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 · D2023-09-18 · 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, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan (CCP) for 2 of 32 residents reviewed, Resident #127 and Resident #106. This deficient practice was identified by the following: 1. On 9/5/23 at 11:00 AM, the surveyor observed Resident #127 in the day room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #127's hybrid medical records. The admission Record (AR) reflected that Resident #127 was admitted to the facility with medical diagnoses which included but not limited to Congestive Heart Failure, Type 2 Diabetes Mellitus, Acute Kidney Failure and Hypertension. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/10/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 14 indicating that the resident was cognitively intact. A review of the form titled; Wound Evaluation & Management Summary dated 8/17/23 revealed that Resident #127 had a Stage…
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 · D2023-09-18 · 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
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain a urinary catheter and provide services in a manner consistent with standards of practice for 2 of 3 residents reviewed for urinary catheter care (Resident #108, and #78). This deficient practice was evidenced by the following: 1. On 9/5/23 at 11:01 AM, Resident #108 was observed lying in bed, alert and able to communicate their needs. The resident was observed with a urinary catheter attached to a drainage bag hanging at their bedside. The surveyor smelled a strong urine odor at the resident's bedside. The resident verbalized no concerns. The surveyor reviewed the electronic health record (EHR) of Resident #108 which revealed the following: According to the admission Record, Resident #108 was admitted with diagnoses that included but were not limited to Acute and Chronic Respiratory Failure with Hypoxia, neuromuscular dysfunction of the bladder, and unspecified injury at unspecified level of cervical spinal cord. Review of the 7/31/23…
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 · D2023-09-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 facility policy, it was determined that the facility failed to 1. enter weekly weights in the electronic medical record (EMR) for 3 of 4 residents, Resident #133, #16, and #85, 2. Address the cause(s) between current medical condition and significant (sig) weight losses for 4 of 4 residents, Resident #133, #16, #31 and #85 and 3. address identified actual or possible reasons of significant weight losses in the resident's care plan for 4 of 4 residents, Resident #133, #16, #31 and # 85, all reviewed for weight loss per facility policy. This deficient practice was evidenced by the following: 1. On 9/5/2023 at 10:35 AM, the surveyor observed Resident #133 in bed with a Tube Feeding (TF) (tube feeding is a flexible tube that goes through the nose or belly area and delivers liquid nutrition directly into the stomach or small intestine) Glucerna 1.5 (a diabetic based tube feeding formula) running at 65 milliliter per hour (ml/hr.) delivering nutritional…
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 · D2023-09-18 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility polices it was determined that the facility failed to maintain proper kitchen sanitation practices. This deficient practice was evidenced by the following: On 9/5/23 from 9:35 AM through 10:20 AM, the surveyor completed the initial kitchen tour with the Food Service Director (FSD) and Regional Registered Dietitian (RRD). Upon entering the dish room, the surveyor observed a dietary aide (DA) using the dish washing machine, that was filled with soiled breakfast dishes. The surveyor observed the wash and rinse cycle reaching 114 degrees Fahrenheit (F). The FSD stated, the dish machine is a low temperature machine. The wash and rinse cycles should be 120 F. The FSD ran the dish machine two more times, with the wash and rinse cycle temperature maintaining 114 F. The RRD provided the temperature log showing the dish machine temperature readings of 120 F from 9/1-9/5/23. The FSD informed the surveyor that the temperature of the dishwashing machine is checked with the initial use of the machine. Neither the DA, FSD, or RRD could…
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 · F2022-01-13 · tag F0711 — widespreadEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that the residents primary physician sign and date monthly physician orders to ensure that the residents current medical regimen was appropriate. This deficient practice was observed for 21 of 30 residents (Resident #17, #58, #39, #2, #37, #61, #86, #75, #38, #96, #131, #130, #120, #49, #67, #114, #76, #82, #105, #10, and #74) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the residents primary physician had not hand sign the Order Summary Reports (monthly physician's orders) located in the residents chart. In addition there were no electronic signatures under the physician's orders for the following residents: 1. Resident #2's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for October 2021, November 2021 and December 2021 monthly physician's…
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 · D2022-01-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan for floor maintenance program (FMP) and failed to revise restorative nursing program (RNP) care plan after the RNP was discontinued. The deficient practice occurred for 1 of 1 resident (Resident #86) reviewed for limited range of motion. On 1/6/22 at 10:00 AM, the surveyor observed Resident #86 lying in bed with eyes closed attached to a ventilator via a tracheostomy and had tube feeding infusing via a gastrostomy tube (feeding tube through the stomach area). Heel lifts were on both feet to keep pressure off the heels. The surveyor observed hand rolls in both hands and bilateral elbow splints. The surveyor reviewed Resident #86's hybrid medical records (paper and electronic) that revealed the following. According to the admission Record, Resident #86 was admitted with diagnoses that included Acute and Chronic Respiratory Failure and Encephalopathy. The resident was ventilator dependent via tracheostomy tube (a surgical incision in the windpipe too allow…
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 before2022-01-13 · 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, and record review, it was determined that the facility failed to follow accepted nursing standards of practice while 1.) administering an oral inhaler medication and 2.) applying splints without a physician's order. The deficient practice was identified for 1of 5 nurses observed during the Medication Administration task and 1 of 1 residents (Resident #86) reviewed for limited Range of Motion. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes…
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 before2022-01-13 · 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
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 follow the physician's order for the administration of oxygen. This was found with 1 of 5 residents reviewed for respiratory care, Resident # 120. The deficient practice was evidenced by the following: On 1/5/22 at 12:02 PM, the surveyor observed Resident #120 in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to wall oxygen set at 4 lpm (liters per minute). The surveyor reviewed the resident's record which revealed the following: An admission Record with diagnoses which included Respiratory Failure, and Shortness of Breath. A Physician's Order Sheet (POS) with an order that read Oxygen inhalation via nasal cannula @ 3 lpm every shift. Check every shift. The order was dated 11/24/21. The same order was repeated by the physician when the resident was re-admitted from the hospital on [DATE], then on 1/2/22.…
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
$124,800 in federal fines across 1 penalty.
- $124,800 — penalty dated 2025-01-23
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 ALARIS HEALTH — 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 3.1 | -2.1 vs chain |
| Health inspection | 1 of 5 | 2.9 | -1.9 vs chain |
| Staffing | 4 of 5 | 2.4 | +1.6 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 7 homes this chain runs (chain average 3.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ZELMANOVITZ, JOSEPH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 99% | since 07/28/2005 |
| ZELMANOVITZ, GITI | Individual | DIRECT OWNERSHIP INTEREST | — | since 07/28/2005 |
| STERN, SAMUEL | Individual | CORPORATE OFFICER | — | since 12/01/2003 |
| ROMAN, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/16/2026 |
| SAMUEL, RAMEZ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/15/2026 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
About 80% 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. 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 315352. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-23, 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.