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Lopatcong Center

390 Red School Lane, Phillipsburg, NJ 08865 · For profit - Limited Liability company · 153 certified beds · (908) 859-0200 Medicare & Medicaid certified

Call the home — (908) 859-0200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Feb 2024
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
409 Coventry Dr · (908) 213-0029 · Call to confirm hours
Pharmacy
96 Baltimore St · (908) 454-4352 · Call to confirm hours
Grocery
541 Congress St · (908) 454-1150 · Call to confirm hours
Park
Larry Holmes Dr · Typically dawn to dusk
Place of worship
810 Red School Ln · (908) 859-1230

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 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 2 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.6%8.7%15.4%better
Long-stay residents who lose too much weight2.9%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.7%0.6%0.9%better
Long-stay residents with a urinary tract infection0.5%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms6.2%12.1%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.3%2.3%3.3%typical
Long-stay residents whose ability to walk worsened10.2%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication30.1%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine94.9%97.2%95.3%typical
Long-stay residents with pressure ulcers6.0%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control24.7%15.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.0%12.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine49.7%80.1%79.4%worse
Short-stay residents rehospitalized after admission18.9%24.9%22.6%better
Short-stay residents with an outpatient ER visit6.9%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.352.071.67better
Long-stay outpatient ER visits per 1,000 resident days0.561.111.80better

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.

57.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 285 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.6%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
76.0%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 76.0% 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 129 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.6%CMS range 52.8–62.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 8.7–14.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge76.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge69.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge65.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 4.3–10.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.53
RN hours/ resident / day
0.80
LPN hours/ resident / day
1.74
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.43
RN hoursweekends
37.5%
Total nursing turnover
46.2%
RN turnover

How full it usually is: this home is certified for 153 beds and averages 130.1 residents a day — about 85% occupied, or roughly 23 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 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.74 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 2.78 hrs/resident/day on weekends vs 3.19 on weekdays — 13% thinner on weekends. RN hours go from 0.57 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 38% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-06-16)
13
at the previous standard inspection (2024-02-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · F2025-06-16 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
    Ensure 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 serve and document residents received a nourishing snack in the evening (HS) when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 6 of 6 residents (Resident #5, #14, #48, #54, #58, and #67) during the 6/11/25 resident council group meeting and evidenced by the following: On 6/11/25 at 10:32 AM, the surveyor conducted the resident council meeting with six residents (Residents #5, #14, #48, #54, #58, and #67) who were alert and oriented, and selected by the facility to attend the group meeting. All six residents stated that they were not offered nor received snacks in the evening. On 6/11/25 at 11:15 AM, the surveyor interviewed the Regional Food Service Director (RFSD), who stated the HS snacks are provided by the dietary department but are passed out and offered by the nursing staff. RFSD stated they were unaware of any issues with HS snacks not being passed out. On 6/11/25 at 11:30 AM, the surveyor spoke…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-06-16 · tag F0919 — failed to provide a working call system — widespread
    Make 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 observations and interviews on 06/13/2025 and 06/16/2025 in the presence of the Senior Maintenance Director (SMD) and the Maintenance Director (MD), it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning in accordance with State Operations Manual (SOM) Appendix PP Subsection 483.90 (g). This deficient practice had the potential to affect all residents and was evidenced by the following: An observation on 06/16/2025 at 10:26 AM revealed that resident room [ROOM NUMBER]-bathroom call bell did not activate the call bell light over the room door when tested. An observation on at 10:29 AM revealed that the resident call bell monitor at the second floor nurses station indicated that the resident bathroom call bells in rooms 219, 230, and the second floor shower room displayed a FAULT condition on the display screen. The date on the screen indicated that the Fault conditions had been active since 05/20/2025. Observations from…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-16 · tag F0552 — pattern
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving antipsychotic medications. This deficient practice was identified for 4 of 7 residents (Residents #27, 34, 60, and #72) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 6/9/25 at 10:25 AM, the surveyor observed Resident #27 lying in bed asleep. On 6/11/25 at 10:51 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #27, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #27 was admitted with diagnoses that included, but were not limited to, mood disorder and depression (a feeling of sadness). A review of the Significant Change Minimum Data Set (SC/MDS), (an assessment tool used to facilitate the management of care) dated 5/14/25…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed a.) to follow a Physician's Order and b.) create a Physicians Order for an oxygen dependent resident in accordance with professional standards of practice for 5 of 5 residents, (Resident #21, #28, #41, #68 and #109), 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…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-16 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews 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 1 of 26 residents (Resident #72), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 6/9/25 at 10:29 AM, the surveyor observed Resident #72 asleep in bed. On 6/11/25 at 11:39 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #72, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #72 was admitted with diagnoses that included, but were not limited to, mood swings and anxiety (feeling of worry or nervousness). A review of the Annual Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care), dated 4/25/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included refusal of care. This deficient practice was identified for 1 of 26 residents (Resident #60) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 6/9/25, at 10:35 AM, the surveyor observed Resident #60 out of bed and in a wheelchair, able to respond to the surveyor's questions. Although Resident #60 was scheduled for a shower today, they mentioned that they sometimes refuse to take a shower because they do not feel like it. On 6/11/25 at 12:58 PM, the surveyor reviewed the electronic Health Record (eHR)/hybrid medical record (paper and electronic) of Resident #60, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #60 was admitted with diagnoses that included, but were not limited to, mood swings and anxiety (feeling of worry or nervousness). A review of the recent quarterly Minimum Data Set…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Repeat Deficiency. Based on observations, interviews, record reviews, and other facility documentation, it was determined that the facility failed 1.)failed to follow infection control procedures with 3 of 5 residents on Oxygen (O2) Therapy and 2.) failed to follow appropriate hand hygiene procedures during medication administration. This deficient practice was identified 3 of 5 residents (Resident #21, Resident #28 and Resident # 109) reviewed for O2 therapy and 1 (one) of 3 nurses who was observed during medication administration. 1. On 6/9/25 at 10:25 AM, the surveyor observed and interviewed Resident #28 awake in bed, with oxygen (O2) via nasal cannula (NC) (medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 1.5 liters/minute (LPM), O2 running. The surveyor further observed the O2 tubing laying directly on the floor of the resident's room. The surveyor reviewed the admission Record (AR; or face sheet; an admission summary) which revealed that the resident had 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C #: NJ00173585 Based on interviews, medical record review, and review of other pertinent facility documents on 6/25/24 it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policies and procedures for 1 of 4 residents (Resident #3) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #3 was admitted on [DATE], with diagnoses that included but were not limited to: Fracture of Unspecified Part of the Neck of the Right Femur, Parkinson Disease, and History of fall. The Minimum Data Set (MDS), an assessment tool, dated 2/5/24, revealed a Brief Interview of Mental Status (BIMS) of 0 which indicated the resident's cognition was severely impaired and the resident needed assistance with ADLs including toileting, eating, and transfer. A Care Plan (CP), initiated on 1/31/24…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-06 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FRI NJ00162201 Based on observation, interview, and record review of pertinent documentation, it was determined that the facility failed to implement their abuse policy and written regulations based on protecting their residents after the abuse investigation. This deficient practice was identified for one of two residents (Resident #91) reviewed for following the facility's abuse policy. The deficient practice was evidenced by the following: The surveyor investigated the Facility Reported Incident (FRI) sent in by the Executive Director, Licensed Nursing Home Administrator (LNHA) to the Department of Health (DOH) on 3/8/23 based on a resident to resident altercation between the Resident #91 and the Resident #39, which revealed the following: The facility reported that on 3/8/23, a staff member heard yelling from room [ROOM NUMBER]. Upon responding, the staff found Resident #91 (room [ROOM NUMBER]) walking out of Resident #39's (room [ROOM NUMBER]) room and stated, I didn't do anything get out of my way. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-06 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 facility documentations, it was determined that the facility failed to evaluate the basis use or discontinuation of a gastrostomy tube device consistent with the resident's goals and wishes. This deficient practice was identified for one of two residents (Resident #83) reviewed. This deficient practice was evidenced by the following: On 1/30/24 at 11:20 AM, the surveyor observed the resident lying in bed. The resident stated, I have a tube, but I have not been using it for a long time. I have been asking them to remove it since I was admitted here about 2 1/2 years ago, everyone knows but they told me they can't find a doctor who can remove it because of my insurance. On 1/30/24 at 1:20 PM, the surveyor interviewed the Unit Manager (UM), License Practical Nurse (LPN) on the first floor, she stated, The resident does not use the tube, it's there because of the stroke the resident had in the past. The tube gets water flushes only. The resident and son does want the tube out but as per Social Worker, it's hard…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2024-02-06 · tag F0711 — pattern
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to: a) assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 18 of 27 residents reviewed (Resident #110, 57, 4, 72, 9, 40, 69, 1, 91, 83, 48, 103, 62, 74, 10, 35, 79, and 102); and b) wrote physician progress notes (PPN) at least every 60 days with alternating nurse practitioner (NP) visits for 2 of 27 residents reviewed (#35 and #79). The deficient practices were evidenced by the following: 1. The surveyor reviewed the Order Summary Report (OSR) for Resident #110 which revealed that the physician did not sign and date the monthly OSR for the month of December 2023. 2. The surveyor reviewed the OSR for Resident #57 which revealed that the physician did not sign and date the monthly OSR for the month of January 2024. 3. Resident #4's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2023…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-06 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint NJ00163544 and NJ00161527 Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift; (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-06 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) clarification of a physician's order for the frequency of the application time of a medicated patch (Lidocaine) (an anesthetic medicated patch applied to relieve pain) for one (1) of five (5) residents, (Resident #53), observed during the medication administration observation, b.) vital parameters, blood pressure and heart rate, were obtained just prior to administration of medications that had physician's orders that based the results of the parameters on whether to administer the medications for (2) of five (5) residents, (Resident #53 and #113), observed during medication administration observation and c.) accurate documentation on the electronic medication administration records for four (4) of five (5) residents, (Resident #53, #84, #99 and #182), during the medication administration observation for two (2) of two (2) nurses observed during the medication administration observation.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-06 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, it was determined that the Consultant Pharmacist (CP) failed to report irregularities found in the medical records to the facility. This deficient practice was observed for the following residents: 1. On 2/2/24 at 11:15 AM, the surveyor reviewed the electronic medication administration records (eMAR) of Resident #74. Resident #74 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease (a condition where the kidney does not function properly resulting in increased blood pressure). The surveyor reviewed the December 2023 eMAR and the current Physician's Order sheet which reflected an order for Midodrine 2.5 milligrams (mg) (a medication that is used to increase blood pressure) give one (1) tablet three (3) times a day for Hypotension (low blood pressure) with a starting date of 12/15/23. Review of the medication administration…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-06 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 all medications were administered without error of 5% or more. During the medication administration observation on 2/1/24, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 34 opportunities, and five (5) errors were observed which calculated to a medication administration error rate of 14.7%. This deficient practice was identified for three (3) of five (5) residents, (Resident #99, #111 and #182), that were administered medications by two (2) of two (2) nurses that were observed. The deficient practice was evidenced by the following: 1. On 2/1/24 at 8:40 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer medications to Resident #99 which included a 25 milligram (MG)/100 MG tablet of Carbidopa-Levodopa (Sinemet) (a medication used to treat movement disorders) and a 325 MG tablet of Ferrous Sulfate (Iron) (a supplement). At that time, the LPN stated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 follow appropriate measures to prevent and control the spread of infection during a Covid-19 outbreak on the ground floor of the facility for: a.) failure to properly wear N95/respirator masks for 4 of 4 staff members observed on the ground unit, and b.) failure to wear a fit tested N95/respirator mask for 2 of 4 staff members observed on the ground unit. The deficient practices were evidenced by the following: On 2/6/24 at 2:00 PM, the surveyor toured the ground floor unit. At the nurse's station, the surveyor observed Licensed Practical Nurse (LPN) who was wearing a DS-N95-1 mask with the straps cut, tied and the straps were then tied behind her ears. The surveyor asked the LPN why the N95 mask was worn that way and the LPN stated the mask was uncomfortable, so I cut, tied it and wore it like that. She stated she was fit tested for this mask and should have worn it the way she learned during fit testing. At 2:05…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0582 — isolated
    Give 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

    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 issue the proper required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 1 of 3 residents (Resident #71) reviewed for facility change notifications. The deficient practice is as follows: The facility presented the surveyor with a list of residents who were discharged from the facility within 6 months and should have received Beneficiary Notices. The surveyor reviewed Resident #71's Beneficiary Notification list which indicated that the resident was discharged from a Medicare Part A stay at the facility and was documented as having a discontinuation of their Medicare Part A insurance payment to the facility. Resident # 71 was admitted to the facility on [DATE]. The last documented covered day of coverage for Medicare Part A service was 1/11/24. The facility did not present the resident with the proper required SNFABN form to notify them of the termination of insurance. On 2/2/24 at 11:45 AM, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to accurately assess a resident utilizing the Minimum Data Set (MDS) assessment tool. The deficient practice was identified for 1 (#57) of 30 residents reviewed for accuracy of assessment and is detailed as follows. On 1/30/24 at 11:36 AM, the surveyor observed Resident #57 seated in a wheelchair in the nursing unit hallway. The surveyor again observed the resident on 01/31/24 at 09:45 AM seated in a wheelchair in the day room. A review of the electronic medical record revealed the following information. The resident was admitted to the facility receiving hospice services and continued receiving services without interruption up to the time of the Standard survey. A review of the 12/31/23 Quarterly MDS, Section O, indicated the resident was no longer receiving hospice services. On 02/05/24 at 09:42 AM, the Director of Nursing confirmed that the resident continued to receive hospice services during the assessment period for the 12/31/23 MDS. A corrected MDS was submitted on 2/5/24 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for 1 of 27 residents reviewed for comprehensive care plans (Resident #79). This deficient practice was evidenced by the following: On 1/30/24 at 11:40 AM, the surveyor observed Resident #79 out of bed to a wheelchair, watching TV. The resident's room front door had a signage stop instructing the use of specific personal protective equipment (PPE) during care and before entering the room. Outside the resident's room are two plastic storage carts containing a box of gloves, gowns, masks, and goggles. The surveyor reviewed Resident #79 hybrid medical record (paper and electronic) which revealed the following: According to the admission Record (an admission summary), Resident #79 was admitted to the facility with diagnoses that included but were not limited to personal history of other infectious and parasitic (organism that lives in a host) diseases and Cerebral Infarction (disrupted blood flow to the brain). The Annual Minimum Data…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to revise a resident's care plan to reflect their current needs related to a fall and fracture. The deficient practice was cited for 1 of 30 residents (#57) reviewed for comprehensive resident-centered care planning and is evidenced by the following. On 1/30/24 at 11:36 AM the surveyor observed Resident #57 seated in a wheelchair in the nursing unit hallway. The surveyor again observed the resident on 01/31/24 at 09:45 AM seated in a wheelchair in the day room. A review of the electronic medical record revealed the following information. An 11/2/23 progress noted written at 17:50 revealed the resident fell from their wheelchair while self-propelling the chair in the hallway of the nursing unit. The surveyor reviewed the resident's current comprehensive care plan provided by the Director of Nursing (DON) on 2/1/24 at 11/30/24. The focus area of the fall care plan initiated on 6/30/23 and revised on 10/10/23 indicated the resident was at risk for falls due to cognitive loss and lack of safety…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary respiratory care and services of residents in accordance with professional standards of practice for one of two residents, (Resident #1) reviewed for respiratory care. This deficient practice was evidenced by the following: On 1/30/24 at 11:30 AM, the surveyor observed the oxygen signage by the door of Resident #1. The surveyor observed Resident #1 lying in bed, the oxygen concentrator by the left side of the bed with oxygen at 2 1/2 liters/minute, nasal cannula laying on the side of the mattress, no shortness of breath noted, oxygen tubing dated 1/19/24. The resident stated, I use my oxygen on and off every day. On 1/31/24 at 10:20 AM, observed the resident lying in bed with oxygen use on 2 1/2 liters/minute via nasal cannula and tubing dated 1/19/24. On 1/31/24 10:34 AM, the surveyor interviewed the primary nurse License Practical Nurse…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-01 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care to address the treatment needs for Resident #64 and Fall Risk for Resident #600, 2 of 23 residents reviewed. The deficient practice was evidenced by the following: 1. On 10/15/21 at 12:16 PM, surveyor observed Resident #64 in bed with Oxygen going at 2 liters/minute (l/m) via a nasal cannual. The resident was awake watching television. There was a pressure relieving mattress on the resident's bed. The resident's lower extremities were wrapped with ace bandages. The surveyor reviewed Resident #64's electronic medical record (EMR) that revealed the following: According to the admission Record, Resident #64 was admitted to the facility with diagnoses that included Cellulitis of the right lower limb, Lymphedema, Type II Diabetes Mellitus, and Morbid Obesity. The Annual Minimum Data Set (MDS) an assessment tool dated 9/4/21 indicated that the facility performed a Brief Interview for Mental Status and the results showed a score of 15 out of 15 which indicated 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of practice by not documenting that a resident was receiving oxygen and not monitoring oxygen saturation (O2 sats)levels according to the physician's orders for 1 of 2 residents (Resident #37) reviewed. This deficient practice was evidenced by the following: On 10/13/21 at 10:23 AM, the surveyor observed Resident #37 sitting on the bed with oxygen (O2) on via nasal cannula at 2 liters/minute (l/m). On 10/14/21 11:37 AM, the surveyor observed Resident #37 lying across the bed with oxygen running at 2 l/m via nasal cannula, watching television. The resident informed the surveyor that the resident uses the oxygen all the time. The surveyor reviewed Resident #37's electronic medical records that revealed the following: According to the admission Record, Resident #37 was admitted to the facility with diagnoses that included Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Obesity. The Quarterly Minimum Data Set an assessment tool dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and review of pertinent facility documentation, it was determined that the facility staff failed to follow appropriate infection control guidelines for Personal Protective Equipment (PPE), handwashing, and disinfection of shared medical equipment for 1 of 3 nurses observed during medication pass observation. This deficient practice was evidenced by the following: On 10/18/21 at 8:20 AM, the surveyor observed a Registered Nurse (RN) during medication pass observation on the ground floor of the facility. The RN was wearing a N 95 mask (a filtering facepiece respirator) with the two straps of the face mask around her neck. At 8:28, the RN entered the room of Resident #550 and donned (put on) clean gloves. The RN administered oral medications to the resident, gave the resident a Lovenox injection (a medication that helps prevent the formation of blood clots) in the abdomen, and applied a Lidocaine Patch 5% (an anesthetic used to prevent and treat pain) to the resident's right thigh. The RN doffed (removed) gloves and immediately donned new gloves. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to GENESIS HEALTHCARE — 184 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 53.5+1.5 vs chain
The other 183 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Alexandria Care CenterLos Angeles, CA 1 of 5Bay Crest Care CenterTorrance, CA 1 of 5Bethlehem North Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bethlehem South Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bridgeville Rehabilitation & Care CenterBridgeville, PA 1 of 5Brightwood CenterFollansbee, WV 1 of 5Carlisle Skilled Nursing And Rehabilitation CenterCarlisle, PA 1 of 5Casa De Oro CenterLas Cruces, NM 1 of 5Devonshire Care CenterHemet, CA 1 of 5Gettysburg CenterGettysburg, PA 1 of 5Glenwood CenterFlorence, AL 1 of 5Heritage CenterHuntington, WV 1 of 5Hidden Valley CenterOak Hill, WV 1 of 5Inners Creek Skilled Nursing And Rehabilitation CeDallastown, PA 1 of 5Jersey Shore Skilled Nursing And Rehabilitation CeJersey Shore, PA 1 of 5Kingston Court Skilled Nursing And RehabilitationYork, PA 1 of 5Las Palomas CenterAlbuquerque, NM 1 of 5Lebanon Center, Genesis HealthCareLebanon, NH 1 of 5Lebanon Skilled Nursing And Rehabilitation CenterLebanon, PA 1 of 5Linden Grove Health Care CenterPuyallup, WA 1 of 5Magnolia RidgeGardendale, AL 1 of 5Marmet CenterMarmet, WV 1 of 5Meridian CenterHigh Point, NC 1 of 5Merry Wood LodgeElmore, AL 1 of 5Mount Olive CenterMount Olive, NC 1 of 5Mountain Ridge Center, Genesis HealthCareFranklin, NH 1 of 5Oak Grove CenterWaterville, ME 1 of 5Oceanside Skilled Nursing And RehabilitationHampton, NH 1 of 5Orchard Park Health Care & Rehab CenterTacoma, WA 1 of 5Parkersburg CenterParkersburg, WV 1 of 5Pembroke CenterPembroke, NC 1 of 5Pine LodgeBeckley, WV 1 of 5Playa Del Rey CenterPlaya del Rey, CA 1 of 5Pocahontas CenterMarlinton, WV 1 of 5Pottstown Skilled Nursing and Rehabilitation CentePottstown, PA 1 of 5Putnam CenterHurricane, WV 1 of 5Ridgewood CenterRidgewood, NJ 1 of 5Rio Rancho CenterRio Rancho, NM 1 of 5River City CenterDecatur, AL 1 of 5River Ridge CenterKennebunk, ME

Showing 40 of 183; 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 / managerTypeRoleShareSince
GENESIS OPERATIONS IV LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/31/2011
FC-GEN OPERATIONS INVESTMENT LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2011
GEN OPERATIONS I LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2011
GEN OPERATIONS II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2011
GENESIS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2011
GENESIS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GHC HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/01/2011
SUN HEALTHCARE GROUP INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
WHITMAN, ARNOLDIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/31/2011
BERG, MICHAELIndividualCORPORATE OFFICERsince 12/01/2012
BRIDGEFORD, LAURAIndividualCORPORATE OFFICERsince 01/01/2024
MENDELSON, AVIIndividualCORPORATE OFFICERsince 01/01/2024
AVERSA, THADDEUSIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2002
SCHEIER, BARRYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2025
GENESIS ADMINISTRATIVE SERVICES LLCOrganizationADP OF THE SNFsince 02/01/2019
POWERBACK REHABILITATION LLCOrganizationADP OF THE SNFsince 02/01/2023

CMS files one row per role, so the 19 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

11 organizational owners 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.

$14.6M
Net patient revenuemost recent cost report
+4.0%
Operating marginrevenue minus expenses
$1.7M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 14%Other / private 19%

This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$344per resident / day
operating cost
$10,454per month
≈ monthly operating cost
$358per day
avg. revenue, all payers

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

What families pay in NJ

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315202. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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