Complete Care At Fair Lawn Edge
77 East 43rd Street, Paterson, NJ 07514 · For profit - Limited Liability company · 180 certified beds · (973) 754-6700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,036 in federal fines (most recent 2024-04-23)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 improved from 1 to 3 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 | 7.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.2% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.1% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.0% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.1% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.0% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.9% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.4% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.1% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.3% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 73.8% | 80.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.4% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 25.9% | 8.1% | 12.0% | worse |
‡ 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.
40.7% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.7% 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 47 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 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | 40.7%CMS range 28.4–55.5 | 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 | 9.7%CMS range 6.0–14.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 61.7% | 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 | 59.6% | 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 | 34.0% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 180 beds and averages 174.4 residents a day — about 97% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 2.72 hrs/resident/day on weekends vs 3.14 on weekdays — 13% thinner on weekends. RN hours go from 0.34 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · J2024-04-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ 165064 Complaint #NJ 166666 Based on interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to 1.) provide adequate supervision for a cognitively impaired, exit seeking resident and ensure exit doors were securely locked which resulted in Resident # 353 eloping from the facility on 06/15/2023 and 2.) follow facility elopement policy which resulted in Resident # 355 eloping from the facility on 08/17/2023. This deficient practice was identified for 2 of 3 residents (Resident # 353 and Resident # 355) reviewed for elopement. The facility failed to monitor and supervise a cognitively impaired, exit seeking resident from being able to exit the facility through an unsecured exit door. This posed a serious and immediate risk to the health, safety, and well-being of Resident #353. During an annual Recertification survey on 04/19/24, the survey team identified an Immediate Jeopardy (IJ) running from 06/15/23 at 8:53 PM, when the resident…
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 before2025-12-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # 2693362 Based on observation, interviews and review of other pertinent facility documents on 12/22/2025,12/23/2025 and 12/29/2025, it was determined that the facility failed to develop and implement a procedure to safely acquire and receive physician ordered Methadone, (a controlled Substance) from a third party clinic; by assigning an unlicensed staff a Certified Nursing Assistant (CNA #1) to travel to an outside third party clinic to pick up Methadone (a controlled substance) for Residents #6,#7 and #8. CNA #1 would take the locked box with the key which contained the Methadone and drive to the facility in her personal car. An interview with the third-party's clinic staff and with facility's CNA #1 confirmed that CNA #1 picked up Methadone from the outside clinic and had access to the key for the box with the Methadone. Review of document from the third-party clinic which was provided to the Department of Health (DOH) by the facility, stated that CNA #1 performed this function of picking up the Methadone for residents on 11/19/2025 until 12/15/2025. During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-18 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 2 of 2 units (3rd and 4th floors) and 2 of 2 shower rooms.This deficient practice was evidenced by the following:On 8/13/25 at 9:55 AM, the surveyor with the Housekeeping Director (HD) toured the 3rd floor and observed the following inside the shower room:-Upon entry, toward the right side of the shower room in the 1st cubicle, there was a shower chair with ripped chair cover, and across the 1st cubicle was a plastic tray. The 1st cubicle wall tiles and moldings with yellowish stain. The HD informed the surveyor that the plastic tray was part of a wheelchair that should have not on the floor. The HD confirmed that the tiles should have been cleaned.-The 2nd cubicle floor safety strips were peeling off. The HD stated that the safety strips were safety measures to prevent resident from falling while in shower and should have been fixed. Both the surveyor and the HD…
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 · D2025-08-18 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and review of other facility documentation, it was determined that the facility failed to issue the Notice of Medicare Non-coverage (NOMNC, which is an official document issued by Medicare-certified healthcare providers and serves as a formal notice informing beneficiaries about the termination or denial of coverage for specific health care services) or Form CMS - 10123, required notice for 1 of 3 residents (Resident #182) reviewed for beneficiary notification. This deficient practice was evidenced by the following On 8/11/25 at 10:51 AM, the surveyor reviewed the NOMNC or Form CMS -10123 review completed by the facility for Resident #182 as follows: A review of the Progress Notes (PN) dated 4/9/25 at 4:19 PM stated that the resident was transferred to another health care facility. A review of the electronic Medical Records (eMR) revealed that there was no documented evidence that the NOMNC was done, nor the reason why it was not done. A review of the physician certification and re-certification form with a handwritten name of Resident #182 and with 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 · Dcited before2025-08-18 · 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 review of pertinent facility documents, it was determined that the facility failed to consistently follow standards of clinical practice by following a physician's order for the administration of medications and clarifying a physician's order for 2 of 5 residents (Resident #19 and #21). 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 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, 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 before2025-08-18 · 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
Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident receive treatment and care as specified by hospital discharge orders, in accordance with professional standards of practice and facility policies and procedures for 1 of 35 residents (Resident #169) reviewed. 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:…
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 before2025-08-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to ensure, a.) proper handling and storage of linen and laundry and b.) proper disposal of garbage to prevent the potential spread of infection in accordance with standards of clinical practice, and the facility's policy. This deficient practice was identified for 1 of 1 laundry area, 1 of 3 linen rooms, and 1 of 2 shower rooms observed during infection control tour.This deficient practice was evidenced by the following:On 8/13/25 at 9:38 AM, the surveyor toured the laundry area in the presence of the Laundry Staff (LS). Both the surveyor and the LS observed the following:-Upon entry to the laundry area, there was an electric fan on the floor blowing air toward the clean hung personal clothes of the residents. The electric fan with heavy accumulation of grayish substances and the personal clothes of the residents were uncovered. The LS confirmed that it was accumulation of dust that was in the electric fan and should have been…
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 before2024-04-23 · 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, record review and review of facility documents, it was determined that the facility failed to adhere to acceptable standards of nursing practice. This deficient practice was identified in 4 of 7 residents who had medication improperly prepared for administration, 1. Resident #86, #199, #73, #200, 2. facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 3 Residents reviewed for accurate dialysis scheduling of medication times, Resident #84, 3. failed to ensure that the oxygen rate was administered according to Physician's Order (PO), for 1 of 1 Residents reviewed for Oxygen use, Resident #2 4. facility failed to ensure recommendations made by the Registered Dietician was acted upon in a timely manner as per facility policy and in accordance with professional standards of clinical practice for one (1) of two (2) residents reviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain infection control practices to reduce the risk of infection during a pressure ulcer (PU) treatment; b.) to assess a resident for risk for pressure ulcer quarterly and c.) ensure a physician's order was administered as ordered consistently for preventative measures for skin for 1 of 2 residents (Resident #25) reviewed for PU/injury. This deficient practice was evidenced by the following: On 4/15/24 at 11:44 AM, the surveyor observed Resident #25 asleep in bed with resident's daughter at the bedside. The surveyor interviewed Resident #25's daughter who stated that the resident had a PU, and that the PU was getting better. Resident #25's daughter further stated that the staff turned and changed the resident. On 4/18/24 at 9:56 AM, the surveyor observed the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #1 perform Resident #25's PU treatment. The ADON and LPN #1 performed hand hygiene (HH) with an alcohol based…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-23 · tag F0711 — isolatedEnsure 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
3. On 4/22/24 at 12:23 PM, the surveyor reviewed Resident #352's hybrid medical records. The resident was discharged from the facility on 1/31/24. The admission Record (AR) documented that Resident #352 had diagnoses that included but were not limited, Acute Respiratory Failure, Pneumonia, Type II Diabetes Mellitus and Bipolar Disorder. A review of the physician progress notes (PN), revealed there were no notes written by Physician #1 from November 2023 to January 2024. 2. On 4/18/24 at 9:45 AM, the surveyor reviewed Resident #142's hybrid medical record which revealed that the resident's physician only documented one visit which was dated 4/11/24. There was not a documented physician's visit for Resident #142's admission and subsequent monthly visit for February 2024 and March 2024. On 4/18/24 at 9:47 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) of the second floor unit. The UM/LPN stated that Resident #142's physician visited residents a couple times a week but that she did not know how often the physician would write a note regarding the visit.…
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 before2024-04-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility failed to properly store and accurately label medications found during the initial unit inspection. This deficient practice was observed for 1 of 3 facility units examined, as evidenced by the following: On 4/15/24 at 12:50 PM, the surveyor inspected the 2nd floor low medication cart. Within the low medication cart the surveyor observed an opened 10ml bottle of Acetylcysteine 20% that was not labeled. Further examination of the bottle of Acetylcysteine revealed that the bottle did not have any documentation of a date or time the bottle was opened. Inspection of the bottle of Acetylcysteine 20% indicated on the label, Store in refrigerator after opening. and Discard opened vial after 96 hours. The surveyor interviewed the 2nd floor UM/LPN#1 who stated that it might belong to Resident #146 who does have an order for Acetylcysteine. The UM/LPN#1 confirmed that the medication should not have been stored without a label, date/time opened. Review of the facility admission Sheet for Resident #146…
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 15 citations
- Potential for harm · D2024-04-23 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to provide the mandatory annual dental care services. This deficient practice was observed for 1 of 31 residents reviewed for dental care services, Resident #56, as evidenced by the following: On 04/15/24 12:27 PM, the surveyor observed the resident in bed, awake and alert. A review of the admission Record for Resident #56 reflected that the resident was admitted to the facility with diagnoses that included but not limited to Depression, Post Traumatic Stress Disorder, Anorexia, Hypertension and Fracture of the left femur. A review of Resident #56's Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 1/11/24, reflected that the Brief Interview for Mental Status score of 15 of 15 indicating that the resident had intact cognition. The resident was admitted in the facility on 2/9/2023 and was recipient of Medicaid effective 3/19/23 and should have had at least an annual examination and treatment by a Dentist. The surveyor could not find any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-23 · 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 policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/15/24 at 09:21 AM, the surveyor in the presence of the entered the Food Service Director (FSD) observed the following during the kitchen tour: 1. During the kitchen inspection, the surveyor observed inside walk-in freezer, multiple boxed items stacked above 18 inches from ceiling. FSD stated he will do rearrange the boxes, so they are stored below the 18 inches from the ceiling. 2. On 4/16/24 at 10:38 AM, during the lunch meal preparation, the surveyor observed the Dietary Chef (DC), check the temperature of ground pork with a non-disinfected thermometer. The FSD had given the thermometer to the DC, who opened the thermometer probe and inserted the thermometer into the ground pork without disinfecting. The surveyor asked the chef why they did not disinfect 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 before2024-04-23 · 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 observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices to mitigate the spread of infection for 2 of 3 Nurses observed during medication administration, and [NAME] statement observed during wound treatment. The deficient practice was observed on 2 (3rd and 4th floor) out of 3 nurses observed during medpass or facility floors during medication administration observation. This deficient practice was evidenced by the following: 1. On 4/18/24 at 8:39 AM, the surveyor observed medication administration (med pass) performed on the 3rd floor, performed by a Licensed Practical Nurse (LPN) #3. The State Surveyor observed LPN#3 put his soapy hands immediately under the running water without scrubbing away from the water first. LPN#3 could not explain why he did not scrub his soapy hands away from the running water prior to rinsing the soap off. 2. On 4/18/23 at 8:52 AM, the surveyor observed med pass performed on the 4th floor, performed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-02-23 · 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
On 2/16/22 at 10:20 AM, Surveyor #4 reviewed the Behavior Monitoring Forms for Resident #89 for January 2022 which included the following: The Behavior Monitoring Form for the psychoactive medication Risperdal 3 mg twice a day (BID) had indicated that the behavioral symptoms of delusions were to have been monitored and documented daily on all three shifts. A review of the Behavioral Monitoring Form reflected that the symptom of delusions was only documented for the 7 AM to 3 PM shift and on the 3 PM to 11 PM shift each day for the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. On 2/17/22 at 11:45 AM, Surveyor #4 reviewed Resident #89's Behavior Monitoring Form for January 2022 again and additional information was added to the forms which included the following: The Behavior Monitoring Form for Risperdal 3 mg BID had the behavioral symptom of delusions documented for the 11 PM to 7 AM shift for each day of the month of January. On 2/16/22 at 11:14 AM, Surveyor #4 reviewed Resident #84's Behavior Monitoring Forms for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-02-23 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 7. On 2/16/22 at 10:13 AM, surveyor #4 observed Resident#79 lying in bed, awake and alert, calm and soft spoken but with clear speech and was able to answer questions appropriately. A review of the admission Record reflected that the resident was admitted on [DATE] and was readmitted to the facility from the hospital on [DATE]. A review of the 1/6/22, admission MDS indicated a BIMS score of 11, which reflected that the resident's cognition was moderately impaired. A review of the POS reflected physician orders for Mirtazapine Tablet 15 MG, Give 1 tablet via G-Tube at bedtime for Depression and Escitalopram Oxalate Tablet 10 MG, Give 1 tablet via PEG-Tube one time a day for Depression. On 2/17/22 at 12:22 PM, the surveyors observed a black binder titled 3RD FLOOR-HIGH SIDE with Behavior Monitoring Form(s) in the binder and Resident #79's form could not be located in the binder. Registered Nurse/Supervisor (RN/S) informed the surveyors that residents' BMF should be in the 3rd floor low side binder. While the RN/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 · Dcited before2022-02-23 · 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
Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to maintain a residents wheelchair and cushion in a clean and homelike manner. This deficient practice was identified for 1 of 3 residents reviewed for care of equipment and maintenance, Resident #63 and was evidenced by the following: The surveyor toured the 400's Unit on 2/11/2022 at 11:30 AM and observed Resident #63 siting on the bed, he/she did not acknowledged the surveyor when the surveyor entered the room. Next to the bed the surveyor observed a ripped and torn wheelchair, the cushion was torn in several places exposing the yellow foam. Some particles and food like debris were noted on the torn cushion. On 2/14/2022 at 11:45 AM, the surveyor observed Resident #63 sitting in the room, the wheelchair was noted at the bedside, ripped and torn in different places. The cushion was ripped and also torn in different areas. The surveyor reviewed Resident #63's medical record on 2/26/2022. The admission Face Sheet revealed that Resident #63 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 · D2022-02-23 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and review of facility provided documentation, it was determined that the facility failed to complete a Comprehensive admission 14-day Minimum Data Set (MDS) assessment or Comprehensive Annual MDS assessment as required according to the Resident Assessment Instrument (RAI) for 5 of 24 residents reviewed for MDS completion (Resident #2, #4, #5, #8 and #363). The deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than once every 12…
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 · D2022-02-23 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and review of facility provided documents, it was determined that the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment, a periodic and federally mandated, standardized assessment tool, within the required time frame, according to the Resident Assessment Instrument (RAI) for 15 of 24 residents reviewed for MDS completion (Resident #1, #3, #6, #7, #9, #10, #11, #19, #23, #25, #27, #28, #29, #30 and #50). The deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and; 2). 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 · D2022-02-23 · 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
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 provide personal grooming care to a resident that was dependent on the staff for hygiene for 1 of 23 residents, Resident #63. This deficient practice was evidenced by the following: On 2/17/22 at 10:19 AM, the surveyor observed Resident #63 in the room, awake and was seated on the bed. The resident did not look at the surveyor or speak when spoken to. The resident's fingernails on both hands were long and extended beyond the fingertips. The surveyor also observed Resident #63 with a long, scattered facial hair. The surveyor reviewed the admission record that indicated Resident #63 was admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's Disease, Depression and Schizophrenia. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate care management dated 11/18/21, indicated a Brief Interview for Mental Status scored at 03, which indicated that 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 before2022-02-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility staff failed to follow the physician orders for the administration of Ozempic (an anti-diabetic medication) for the treatment of type 2 diabetes mellitus creating a delay in treatment, and failed to assess the resident for first dose response. This deficient practice was identified for Resident #37, one of 23 residents reviewed and was evidenced by the following: Resident #37 was admitted to the facility with diagnoses which included unspecified atrial fibrillation, type 2 diabetes mellitus with hyperglycemia (elevated blood sugar), chronic kidney disease and unspecified glaucoma. The Annual Minimum Data Set (MDS - an assessment tool) dated 02/02/22, revealed that Resident #37 had a Brief Interview for Mental Status (BIMS) score of 07/15 which indicated the resident was moderately cognitively impaired. During the medication pass observation on 02/14/22 at 9:10 AM, the Registered Nurse (RN) informed the surveyor that she had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-23 · 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 other pertinent documents provided by the facility, it was determined that the facility failed to post cautionary signage to indicate that oxygen therapy was in use and to administer oxygen therapy according to the physician's order. This deficient practice was identified for one of two residents reviewed for respiratory care (Resident #24), and was evidenced by the following: Resident #24 was admitted to the facility with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), acute kidney failure, diabetes mellitus, and mild intermittent asthma. A review of the most recent Quarterly Minimum Data Set (MDS - an assessment tool) dated 01/08/2022, revealed that Resident #24 was coded as being dependent on staff for some activities of daily living and was coded as having received Oxygen care. Resident #24 was coded a 12 on the Brief Interview for Mental Status which indicated intact cognition. During the initial tour on 2/11/2022 at 12:04 PM, the surveyor observed Resident #24 in bed, with oxygen running via…
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 · D2022-02-23 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 and review of pertinent facility documentation, it was determined that the facility failed to seek clarification of a medication order from the Medical Director (MD) when unable to reach a resident's ordering physician. This deficient practice was identified for Resident #37, one of nine residents reviewed during medication administration observation. The deficient practice was evidenced by the following: On 02/14/22 at 9:01 AM, the surveyor observed the Registered Nurse (RN) on the 4th floor, administering medications to residents including Resident #37. The RN opened a box with a pen injector of Ozempic (an anti-diabetic medication). The RN reviewed the physician order and was unsure of how to use the delivery system pen injector and asked the Unit Manager for assistance. The RN administered the Ozempic. The box which contained the medication revealed in large print that the medication was a once weekly dose. Review of the February 2022 Medication Administration Record (MAR)…
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 before2022-02-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate pharmaceutical services, which included ensuring accurate administering of all drugs, in accordance with professional standards of practice. This deficient practice was identified for 2 of 23 residents reviewed (Resident #76 and #37) and was evidenced by the following: 1.) The surveyor reviewed the medical record for Resident #76. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included Epilepsy, Cerebral Palsy, Quadriplegia and Gastrostomy Status (G-Tube), a tube inserted into the stomach that allows nutrition to be directly administered into the stomach. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/4/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident was severely cognitively impaired. A review of the resident's individualized,…
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 before2022-02-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, it was determined that the facility failed to ensure that biological drugs and supplies were removed from the crash cart when expired. This deficient practice was identified on one of two units and was evidenced by the following: On 02/14/2022 at 10:30 a.m., the surveyor inspected the 400's Unit crash cart with the Unit Manager Registered Nnurse (UM/RN) and noted 3 bottles of normal saline solution with an expiration date of 03/2021. The Ambu bag (a self inflating, hand held device commonly used to provide ventilations to patients who are not breathing ) with a used by date of 04/2021. An interview with the nurse on 2/14/2021 at 11:30 a.m., revealed that the night supervisor was responsible to check the crash cart. The nurse could not provide any rationale regarding the expired saline solution bottles and the Ambu bag still on the crash cart for use in an emergency. The facility was made aware of the above issue on 2/21/2022 at 1:15 p.m. On 2/23/2022 at 10:15 a.m.; the Director of Nursing (DON) stated that the expired saline and 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 before2022-02-23 · 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
Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to 1) store respiratory care equipments in a manner to prevent infections, 2) adhere to infections control practices for hand hygiene according to CDC (Center for Disease Control) and the facility policy, and 3) failed to properly wear an N95 fitted respiratory mask. This deficient practice was identified for three staff members on two units. The deficient practice was evidenced by the following: 1) On 2/11/2022 at 12:04 PM, the surveyor toured the 400's Unit and observed Resident # 24 in bed. The oxygen concentrator (an oxygen delivery system) was set to deliver oxygen therapy at 3 Liters via (by way of) nasal cannula (tubing that is applied to the nose that delivers oxygen). The oxygen tubing and the nasal cannula were not labeled or dated and were observed on top of the concentrator not in any protective covering. On 2/14/2022 at 8:15 AM, the surveyor observed Resident #24 in bed, the oxygen concentrator was turned off. The nasal cannula 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.
“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
$10,036 in federal fines across 1 penalty.
- $10,036 — penalty dated 2024-04-23
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 COMPLETE CARE — 85 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 | 3 of 5 | 3.1 | -0.1 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 84 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 84; lowest-rated first.
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 |
|---|---|---|---|---|
| CCM AT PASSAIC HOLDING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/15/2017 |
| SCHWARTZ, HERSHEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 10% | since 06/15/2017 |
| STERN, SAMUEL | Individual | CORPORATE OFFICER | — | since 06/15/2017 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 89% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 315331. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-18, 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 →
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