Family Of Caring At Park Ridge LLC
120 Noyes Drive, Park Ridge, NJ 07656 · For profit - Limited Liability company · 210 certified beds · (201) 505-1777 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has 2 actual-harm citations
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $133,120 in federal fines (most recent 2025-01-10)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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 | 12.7% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.5% | 4.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.6% | 0.9% | typical |
| 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 | 3.2% | 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 | 3.5% | 2.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 11.4% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.6% | 18.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 66.5% | 97.2% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 7.2% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 9.1% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.2% | 12.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 54.8% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.2% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.0% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.88 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.20 | 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.
54.9% 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 369 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.4% 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 233 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 50% 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 | 54.9%CMS range 49.1–59.5 | 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 | 10.4%CMS range 8.3–13.0 | 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 | 64.4% | 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 | 60.5% | 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 | 52.4% | 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 | 96.5% | 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 | 98.8% | 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 | 98.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 4.1–9.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 210 beds and averages 183.7 residents a day — about 87% occupied, or roughly 26 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 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 1.87 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 2.97 hrs/resident/day on weekends vs 3.39 on weekdays — 12% thinner on weekends. RN hours go from 0.56 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% 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.
32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2025-01-10 · 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 other pertinent facility documentation, it was determined that the facility failed to a.) identify, assess, and implement interventions for a resident (Resident #35) with an unplanned significant weight loss of 7 pounds (lbs) or 5.1% in one month and 25.2 lbs or 25.71% significant weight loss in six months from 4/12/24 through 10/7/24, b.) identify, assess, and implement interventions for a resident (Resident #92) with a significant weight loss of 14 lbs. or 10.03% in one month for 48 days; c.) identify, assess, and implement interventions for a resident (Resident #3) with a significant weight loss of 18 lbs. or 13.4% in one month; d.) obtain, record, and monitor weights in accordance with physician's orders; e.) obtain re-weights to verify a significant weight change; and f.) monitor the effectiveness of interventions for a resident with a significant weight loss. The deficient practice was identified in 3 of 7 residents (Residents #3, #35, and #92)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2021-06-30 · 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 C#NJ00145520 Based on interview and record review, it was determined that the facility failed to a.) promptly notify the physician of a change in condition and provide timely service; b.) monitor and document the change of condition; c.) document the assessment of a Registered Nurse; and d.) ensure that staff were aware of the physician's written transfer order. This deficient practice was identified for 1 of 2 residents (Resident #223) reviewed for hospitalization, according to the standards of clinical practice. Resident #223 was hospitalized on [DATE] with a diagnosis of Stroke [Cerebrovascular Accident (CVA) occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients; This is a medical emergency, and prompt treatment is crucial]. 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…
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 · D2026-06-29 · 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
COMPLAINT #2720685 Based on interviews, review of medical records, and pertinent facility documentation, it was determined that the facility failed to notify the Resident's Representative of a change in condition for 1 of 1 sampled residents reviewed (Resident #183). This deficient practice was evidenced by the following:On 6/10/26 at 1:08 PM, the surveyor reviewed Resident #183's closed hybrid (paper and electronic) medical record.A review of Resident #183's admission record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia (an umbrella term for a decline in mental ability that is severe enough to interfere with everyday life) and hypertension (high blood pressure).A review of Resident #183's most recent discharge return anticipated Minimum Data Set (MDS) reflected that the resident's cognitive skills for daily decision making was severely impaired. Further review reflected that the resident had an unstageable pressure ulcer/injury which was not present on admission (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 · Ecited before2025-10-23 · 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
Complaint #2611374Based on interview, record review, and review of other pertinent facility provided documentation, the facility failed to follow appropriate tuberculosis (TB) testing and documentation for 3 of 3 residents, Residents #1, #2, and #3 according to the standard of clinical practice and facility's policies. 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. The Nurse Practice Act for the State of New Jersey states: 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 before2025-10-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NJ#2578488Based on interview, review of medical record, and other pertinent documentation, it was determined that the facility failed to; a.) ensure skin conditions and impairments were addressed appropriately, b.) obtain and follow physician order for skin impairments, c.) document reason as to why the order was not followed, and c.) ensure Certified Nursing Aide (CNA) documented provided care to the resident, for 1 of 3 residents, Resident #3 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…
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 F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ2611374 and NJ2621276Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to: a) follow the care plan and appropriate safety precautions to provide a two person assist with bed mobility to prevent a fall incident for 1 of 2 residents reviewed for falls (Resident #2) and b) follow a resident's plan of care for two person assist with use of Hoyer lift transfer to ensure safety, for a resident who had a limited physical mobility related to right hemiplegia, for 1 of 2 residents reviewed for accidents (Resident #1). This deficient practice was evidenced by the following: 1. On 10/23/25 at 9:19 AM, Surveyor #1 (S #1) requested from the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) a list of residents with falls in the last six months. On 10/23/25 at 10:23 AM, the LNHA provided the list of residents who had fall incidents in the last six months which included Resident #2, who had one fall event which occurred on 9/8/25. On 10/23/25 at 10:49 AM, S #1 reviewed the electronic…
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 · F2025-01-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/6/25 at 11:16 am, the surveyor in the presence of the Assistant Food Service Director (AFSD) observed the following during the kitchen tour: 1. The surveyor observed in storage container 5 open bags of bread: 1 gluten free bread, 1 whole wheat bread, 2 rye breads, and 1 white bread all were missing open and use by labels. The AFSD could not state why the opened bags of bread were missing labels but acknowledged all opened items need to have an open and use by label. 2. The surveyor observed in dry storage room [ROOM NUMBER], one 6 pound (lb.) 10 ounce (oz) can of fruit mix with a large dent. The can was in the regular rotation with 5 other cans of fruit mix. The AFSD stated any dented cans should be removed from the regular rotation of canned…
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 · E2025-01-10 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 3 of 4 medication carts and 2 of 2 refrigerators observed on the 2nd and 3rd floors of the facility. 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 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 licensed or otherwise legally authorized physician or dentist. On 1/8/25 at 11:24 AM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following: 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 · E2025-01-10 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and review of facility documentation, it was determined that the facility failed to ensure that a Certified Nurse Aide (CNA) received at least 12 hours of mandatory in-service training for 4 of 5 CNA education reviewed (CNA #1, CNA #2, CNA #3, and CNA #4). The deficient practice was evidenced by the following: On 1/9/25 at 1:26 PM, the surveyor reviewed the provided in-service education for five randomly selected CNAs for the 2024 year, which revealed the following: CNA #1 with a date of hire (doh) on 11/15/21, had 1 hour and 50 minutes of in-service training from date of hire anniversary dates. CNA #2 with a doh on 7/15/23, had 5 hours and 55 minutes of in-service training from date of hire anniversary dates. CNA #3 with a doh on 11/2/23, had 8 hours and 20 minutes of education from date of hire anniversary dates. CNA #3 was on leave between 9/16/24 to 11/11/24. CNA #4 with a doh on 6/5/23, had 8 hours and 20 minutes of education from date of hire anniversary dates. On 1/9/25 at 1:54 PM, the surveyor interviewed the Assistant Administrator (AA) about CNA…
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 · D2025-01-10 · 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
Based on observation, interview, and review of facility-provided documents, it was determined that the facility failed to ensure that a.) meals were consistently provided in a dignified and homelike manner. The deficient practice was observed in the recreation dining area for 2 of 6 residents (Residents #103 & #147). The deficient practice was evidenced by the following: The surveyor reviewed the electronic medical records (EMR) for Resident #103 and Resident #147. Resident #103: The admission Record (AR; an admission summary), revealed that the resident was admitted with diagnoses which included but are not limited to, type 2 diabetes and essential hypertension (also called primary hypertension, or idiopathic hypertension) is a form of hypertension without an identifiable physiologic cause). A comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 10/09/24, indicated the facility assessed the resident's cognition using a Brief Interview for Mental Status (BIMS) test, Resident #103 scored a 15…
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 · D2025-01-10 · 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 COMPLAINT #NJ172916 Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding for 3 of 35 residents reviewed, Resident #2, #121 and #109. The deficient practice was evidenced by the following: 1. On 1/8/25 at 9:59 AM, the surveyor and the 3 [NAME] Unit Manager (UM) observed in room [ROOM NUMBER]-D Resident #2 sitting on the wheelchair (w/c), privacy curtain was missing, and a black, portable fan on top of the bedside table was on with a large amount of dust accumulation on the front grill. The surveyor and UM observed 411-W Resident #121 sitting on the w/c. The surveyor and the UM observed in the room [ROOM NUMBER] the broken shade by the window; the bottom part of the two overbed tables with splattered white substances; the bathroom soap dispenser broken off the wall and laying on the garbage can; the floors in the residents' room and bathroom with dark black stains. The UM completed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, it was determined that the facility failed to transmit the completed Minimum Data Set (MDS), an assessment tool used to facilitate the management of care within fourteen days as required for 2 of 3 residents, Residents #110 and #155 reviewed for system selected for MDS over 120 days, and 1 of 38 residents, Resident #589, in accordance with federal guidelines. This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #110 and revealed: The admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to, muscle weakness, essential (primary) hypertension (abnormally high blood pressure that is not the result of a medical condition), and adjustment disorder with depressed mood. The most recent Discharge Return Not Anticipated (DRNA) MDS revealed that the assessment was completed but not…
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.
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- Potential for harm · D2025-01-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on 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 4 of 38 residents, (Residents #38, #118, #176, and #188), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: A review of the latest version of the MDS 3.0 Manual (updated October 2024), Chapter 1, page 1-5, revealed .An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment . Chapter 3, page A-42-43, revealed Item…
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 · D2025-01-10 · 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 the comprehensive care plans (CP) for 1 of 35 residents reviewed (Resident #118). This deficient practice was identified by the following: On 1/6/25 at 12:03 PM, the surveyor observed Resident #118 in bed, with eyes closed. The surveyor further observed the resident using an air mattress (a specialized mattress that is used to prevent or treat pressure injuries). The surveyor reviewed Resident #118's hybrid (computer and paper chart) medical records. The admission Record reflected that Resident #118 was admitted to the facility with medical diagnoses which included but not limited to, Alzheimer's Disease, Type 2 Diabetes Mellitus, Acute Kidney Failure. A review of the Quarterly Assessment Minimum Data Set, an assessment tool used to facilitate the management of care, dated 12/13/24 reflected that the resident had a Brief Interview for Mental Status score of 7 out of 15 indicating that the resident had severely impaired cognition. A review of the January 2025 Order Summary Report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview, record review, and review of pertinent documents it was determined that the facility failed to ensure residents who were discharged to the community had a discharge order, discharge summary, and care plan. This deficient practice was identified for 2 of 5 residents, Residents #110 and #176, reviewed. This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #110 and revealed: The admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to, muscle weakness, essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition), and adjustment disorder with depressed mood. A review of the most recent Discharge Return Not Anticipated (DRNA) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, of Resident #110 revealed in Section A Identification Information that the discharge (d/c) status was coded…
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 before2025-01-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview, review of medical record, and other pertinent documentation, it was determined that the facility failed to ensure skin conditions were addressed by professional standards by failing to: a.) document a surgical wound on the admission assessment, obtain a physician order to assess, document and monitor the surgical site, develop a care plan which addressed the surgical site and ensure surgical follow up for the removal of the staples for 1 of 5 residents, Resident #119, reviewed for skin impairment and b.) failed to set the air mattress (AM) (a specialized mattress that is used to prevent or treat pressure injuries) to reflect the weight of Resident #118 to ensure proper support and comfort. This deficient practice was evidenced by the following: 1. On 1/7/25 at 10:00 AM, the surveyor observed Resident #119 lying in a low bed against the wall in their private room. According to the admission Record (AR; or face sheet, an admission summary), Resident #119 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure that a new intervention was implemented and documented in the resident's care plan after a resident's fall, in order to prevent any additional falls for 1 of 3 residents reviewed for falls (Resident #26). This deficient practice was evidenced by the following: On 1/6/25 at 11:57 AM, the surveyor observed Resident #26 seated in a wheelchair (w/c) in the resident's room. The surveyor observed that Resident #26's bed had one side against the wall and was in the low position. The surveyor did not observe a floor mat in the room. A review of Resident #26's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebrovascular disease (a general term for a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · 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 observations, interviews, record review, and review of pertinent facility documents, the facility failed to: a.) obtain an order and develop a care plan that included interventions for a resident that had an indwelling catheter and was placed on enhanced barrier precautions (EBP) based on current professional standards of practice for 2 of 5 residents reviewed for urinary catheter care or urinary tract infection (UTI), Residents #40 and #115 and b.) ensure an indwelling urinary catheter drainage bag and tubing did not touch the floor for 1 of 5 residents, Resident #289, reviewed for urinary catheter. This deficient practice was evidenced by the following: 1. On 1/6/25 at 12:03 PM, the surveyor observed Resident #40 seated in a wheelchair in the resident's room, had a urinary catheter that was in a blue privacy bag. The surveyor observed that there was a sign outside Resident #40's room that indicated the resident was on EBP. A review of Resident #40's admission Record (AR; or face sheet; admission summary) indicated that the resident 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 before2025-01-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to follow a Physician's Order in accordance with professional standards of practice for 2 of 4 residents, Resident #58 and Resident #105), reviewed for respiratory care. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed…
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 · D2025-01-10 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
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 a.) complete the Hemodialysis Communication Record, pre dialysis and/or post dialysis treatment for 7 of 16 days and b.) ensure a resident was placed on a fluid restriction as recommended by the dialysis center or documented the reason the recommendation was not followed for 1 of 1 resident reviewed for dialysis, Resident #76. This deficient practice was evidenced by the following: On 1/6/25 at 11:43 AM, the surveyor interviewed Resident #76 who was seated in a wheelchair in the resident's room. Resident #76 stated that they received dialysis services 3 times a week. The surveyor asked Resident #76 if they were on a fluid restriction. Resident #76 stated yes. A review of Resident #76's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to end stage renal disease (a condition where the kidneys have permanently…
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 · D2025-01-10 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days from September 2023 through December 2024 according to the facility's policy and procedure. This deficient practice was identified for 1 of 38 residents, Resident #187 was reviewed for physician visits and was evidenced by the following: The surveyor reviewed the closed hybrid (paper and electronic) medical records of Resident #187 and revealed: Resident#187's admission Record (or face sheet; an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to Alzheimer's disease with late onset (a common form of dementia that starts after the age of 65 and can cause memory and cognition issues, impaired judgment, and other symptoms as it progresses), unspecified osteoarthritis unspecified, and unspecified dementia (a term used to describe a group of symptoms affecting memory,…
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 · D2025-01-10 · tag F0732 — isolatedPost 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 ensure the daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 2 of 5 days during the survey. This deficient practice was evidenced by the following: On 1/6/25 at 11:03 AM, upon entry to the facility, Surveyor #1 observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main entrance. The NHRCSR posted was dated 12/16/24, for the [7:00 AM to 3:00 PM] day shift. There was no NHRCSR for 1/6/25 posted. On 1/7/25 at 8:29 AM, upon entry to the facility, Surveyor #2 observed a NHRSCR posted at the front desk by the main entrance. The NHRCSR posted was dated 1/5/25 for the day shift. There was no NHRCSR for 1/7/25 posted. On 1/8/25 at 11:32 AM, Surveyor #1 interviewed the staffing coordinator (SC). The SC stated when she came into work around 7:00 AM, she would confirm if any callouts, would update staffing data in the computer for 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 · D2025-01-10 · tag F0809 — failed to serve meals on a reasonable schedule — isolatedEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure bedtime (HS) snacks were offered. This deficient practice was identified for 5 of 5 residents (Resident #124, Resident #53, Resident #140, Resident #70, Resident #189) during the Resident Council group meeting and was evidenced by the following: On 1/7/25 at 12:49 PM, the surveyor conducted a resident group meeting with five residents who were alert and oriented and were selected by the facility to attend the group meeting. All five residents at the group meeting stated that the HS snacks were not offered. All five residents also stated they would like to have a HS snack. The surveyor reviewed the Resident Council meeting minutes in the last 3 months from October 2024 through December 2024. The minutes did not address HS snacks. On 1/8/25 at 1:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and Director of Nursing (DON) to discuss the above concern. The LNHA stated HS snacks must be offered to the residents…
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 before2025-01-10 · 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 observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 4 of 11 staff (3 Housekeepers and 1 Certified Nursing Aide) and b.) ensure nebulizer machine was properly stored and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After…
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 before2025-01-10 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
REPEAT DEFICIENCY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure resident call devices were within reach of the residents for 1 of 35 sampled residents (Resident #79). This deficient practice was evidenced by the following: On 1/8/2025 at 9:21 AM, the surveyor observed Resident #79 lying in bed with the call bell tied to the right side rails out of the resident's reach. The Licensed Practical Nurse (LPN#1) stated that the call device should be within the resident's reach. On 1/8/25 at 12:36 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #79, which revealed the following: A review of the admission Record (an admission summary) reflected that Resident #79 was admitted with diagnoses that included but were not limited to a non-displaced fracture of the anterior wall of the left acetabulum (a break in the hip socket, which is part of the pelvis) subsequent encounter for fracture with routine healing, and unspecified fall subsequent encounter. A review of the recent…
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 · D2025-01-10 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #NJ172916 Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in 1 of 1 laundry room in accordance with the facility procedures. This deficient practice was evidenced by the following: On 1/10/25 at 8:40 AM, Surveyor #1 (S#1) toured the laundry area on the 1st floor and there were four staff. The surveyor observed the folding area for personal clothing with two personal cellphones on top of the clean folded clothing and there was a radio/cassette recorder on top of the clean folded linens and incontinent pads (cloth). On that same date and time, during the tour with the Housekeeping Aide (HA), the surveyor observed used gloves on top of personal clothing washer, white gown, face towel, linen on the floor next to a big washer. There was an accumulation of grayish substances on the floor and dried brownish substances, as per the HA, the floor was dusty and was not sure about the brownish discoloration on the floor, and the white gown, face towel,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, document review, and facility policy review the facility failed to ensure the accurate code status was documented and available for reference for two of 27 sampled residents (Resident (R)23 and R40). This deficient practice could result in not following the specific resident wishes documented in the advanced directive. Findings include: 1. Review of R23's Admission record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of [DATE]. Review of the header information for R23 in the EMR revealed the code status was not identified. The space was left blank for code status. Review of the paper chart for R23 revealed the chart lacked documentation of the New Jersey Practitioner Orders for Life Sustaining Treatment (POLST on green paper) to indicate resident choice for code status (Cardiopulmonary Resuscitation CPR or Do Not Resuscitate DNR). There was a form dated [DATE] from the Medical Society of New Jersey with the bold capitol…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to assess and document lower extremity edema for one of one resident (Resident (R) 90) reviewed for edema out of 27 sample residents. Findings include: Review of the admission Record located under the Profile tab of the electronic medical record (EMR) revealed that R90 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, right sided hemiplegia, and hypertension. Review of R90's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/13/23, revealed R90's Brief Interview for Mental Status (BIMS) score was 13 out of 15 indicating resident was cognitively intact. Review of the Care Plan initiated on 12/09/22 located in the EMR under the Care Plan tab revealed that R90 has altered cardiovascular status related to hypertension. Interventions included Monitor/document/report PRN [as needed] any s/sx [signs/symptoms] of CAD [coronary artery disease]:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · 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, record review, interviews, and facility policy review, the facility failed to administer oxygen as ordered by the physician and failed to document the administration of oxygen for one of one (Resident (R16) reviewed for oxygen out of 27 sample residents. Findings include: Review of R16's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R16 was admitted to the facility on [DATE]. Review of R16's electronic quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/23 revealed a Brief Interview for Mental Status (BIMS) was not able to be completed due to the resident was rarely/never understood. The resident was totally dependent on staff for bed mobility, transfer, toilet use and eating. Active diagnoses included heart failure and dementia. The resident was receiving hospice care. Review of R16's physician's Order Summary Report, dated 08/23, located under the Orders tab of the EMR revealed that the resident had an order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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, record review, interviews, and review of facility policy, the facility failed to ensure a call was functioning for one of six residents (Resident R) 90) reviewed for environment out of 27 sample residents. Findings include: Review of R90's electronic admission Record located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, right side hemiplegia and dysphagia. Review of R90's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/13/23, revealed R90's Brief Interview for Mental Status (BIMS) score was 13 out of 15 indicating resident was cognitively intact. Review of R90's Care Plan initiated on 03/30/23 located under the Care Plan tab of the EMR revealed resident was at risk for falls related to Parkinson's disease and poor balance with the goal to minimize risk for falls. Interventions included encouraging 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 · Ecited before2021-06-30 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) appropriate infection control practices were followed in accordance with the Center for Disease Control guidance (CDC) and facility guidelines for 1 of 4 housekeeping staff observed on 1 of 3 nursing units; b.) store an indwelling urinary catheter drainage bag to prevent the transmission of infection for 1 of 1 resident (Resident #40) reviewed for catheter care; and c.) follow appropriate infection control practices for the administration of medications for 1 of 3 nurses during the medication observation pass. The evidence was as follows: According to the U.S. CDC guidelines for Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, updated 1/30/20, included Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling…
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.
- No harm found · C2025-01-10 · tag F0836 — widespreadEnsure 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
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 supplier type will furnish and bill Medicare. (3) Not employing 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.
“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
$133,120 in federal fines across 1 penalty.
- $133,120 — penalty dated 2025-01-10
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315438. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-10, 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.