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Country Arch Care Center

114 Pittstown Road, Pittstown, NJ 08867 · For profit - Individual · 130 certified beds · (908) 735-6600 Medicare & Medicaid certified

Call the home — (908) 735-6600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0610) — most recent Oct 2023
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 21% of its spending goes to commonly-owned related companies

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS
Urgent care / clinic
22 Walmart Plaza, 2nd Level · (908) 847-5272 · Call to confirm hours
Pharmacy
30 Main St · (908) 735-5316 · Call to confirm hours
Grocery
ShopRite1.1 mi
50 Walmart Plz · (908) 730-6800 · Call to confirm hours
Park
Capoolong Creek Wildlife Management Area · (609) 984-0547 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 4 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 4 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 rating4★
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 increased11.3%8.7%15.4%better
Long-stay residents who lose too much weight5.4%4.6%5.4%typical
Long-stay residents with a catheter left in their bladder0.8%0.6%0.9%better
Long-stay residents with a urinary tract infection1.3%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.3%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%2.3%3.3%better
Long-stay residents whose ability to walk worsened7.3%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.6%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%97.2%95.3%typical
Long-stay residents with pressure ulcers4.1%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control22.5%15.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table16.4%12.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine91.1%80.1%79.4%better
Short-stay residents rehospitalized after admission23.8%24.9%22.6%typical
Short-stay residents with an outpatient ER visit5.2%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.132.071.67worse
Long-stay outpatient ER visits per 1,000 resident days0.981.111.80better

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.

55.8% 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 180 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.8%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
74.4%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 74.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 82 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 SNF55.8%CMS range 49.0–63.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.4–13.410.7%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 discharge74.4%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 discharge57.3%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 discharge62.2%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 identified98.5%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 setting100.0%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 discharge98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%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 worsened2.3%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 hospitalization7.8%CMS range 5.0–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.61
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.29
Aide hours/ resident / day
3.74
Total nurse hours/ resident / day
0.51
RN hoursweekends
39.7%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 114.9 residents a day — about 88% occupied, or roughly 15 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.51 hrs/resident/day on weekends vs 3.83 on weekdays — 8% thinner on weekends. RN hours go from 0.65 to 0.51 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

3
deficiencies at the latest standard inspection (2026-04-08)
0
at the previous standard inspection (2025-01-23)

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

Inspection deficiencies

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

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Fcited before2026-04-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 3/31/26 at 10:36 AM, the surveyor conducted an interview with the Regional Food Service Director (RFSD) and Registered Dietician (RD) prior to the initial tour of the kitchen. The RFSD and RD stated the following:-Dietary staff were required to wash their hands at the designated handwashing sink.-Dented cans were stored separately from the cans to be used for meals.-The dish machine was a low temperature dish machine that required a chemical sanitizer.-Dishware was required to be air dried.-The nursing unit pantries were maintained by nursing, dietary, and housekeeping.-Leftover food and food brought in by visitors should be labeled, dated, and stored for three days. On 3/31/26 at 10:58 AM, the surveyor, accompanied by the RFSD and RD, observed the following in the kitchen: 1. At the designated handwashing…

    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 · D2026-04-08 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote dignity and respect of the residents. This deficient practice was identified in 1 of 2 dining areas observed, (100 Unit) and was evidenced by the following: On 4/1/26 at 11:58 AM, the surveyor observed lunch in the 100 Unit dining area. The surveyor observed one (1) unsampled resident and Resident #30 sitting at the same table. A staff member was seated and feeding the unsampled resident their lunch. Resident #30 had not received their lunch tray. Resident #30 asked the surveyor, Miss, am I going to eat my noon meal? Resident #30's was not served their lunch until 12:09 PM. On 4/2/26 at 11:09 AM, the surveyor interviewed the Certified Nursing Assistant (CNA ) who stated that residents who are seated at the same table should receive their meal trays at the same time. The CNA further stated that staff should not start feeding other residents seated at the same table until all residents' trays are served their meal because it…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-08 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    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 provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 2 of 3 garbage dumpsters. This deficient practice was evidenced by the following: On 3/31/26 at 11:30 AM, the surveyor, accompanied by the Regional Food Service Director (RFSD) and Registered Dietician (RD), observed the facility's designated garbage disposal area. There were three garbage dumpsters that each had two lids. Two of the garbage dumpsters each had one lid open, exposing the trash bags inside. At that time the RFSD stated the garbage dumpster lids should be closed to prevent pests. On 4/7/26 at 11:12 AM, the surveyor, in the presence of the survey team, interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA stated that staff rounded the dumpster area throughout the day to ensure the dumpster lids were kept closed. A review of the facility's Dumpster Area Maintenance Protocol, dated 2/10/25,…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-11 · 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

    Complaint# NJ00172367 Based on interviews, record review, and review of other pertinent facility documentation on 06/12/24, it was determined that the facility failed to maintain a complete Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident who was sent out to the Hospital. This deficient practice was identified for one resident (Resident #3), and was evidenced by the following: According to the admission Record, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: Dementia, Transient Cerebral Ischemic Attack, Muscle Weakness A review of the Resident #3's Progress Notes (PN) revealed that on 03/21/2024 at 12:53 A.M, Registered Nurse (RN) documented that Resident #3 needed to be sent out to the hospital for an injury near the right eye area. A further review of the Resident #3's PN, dated 03/21/2024 at 5:53A.M. and documented by LPN, revealed as follows: Return from E.R. 4:10am via stretcher accompanied by 2 EMT from Atlantic ambulance BP 136/76, pulse 78, respiration 19 and Pulse oximeter 97%…

    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 · Fcited before2023-10-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 record review, it was determined that the facility failed to a.) store foods in a manner intended to prevent the spread of food borne illness and b.) maintain a clean storage for food and cooking utensils as evidenced by the following: On 10/06/23 at 9:44 AM, the surveyor toured the kitchen with the Food Service Director (FSD), observed the following: 1. In the freezer the surveyor found; one opened box of carrots without an open and a use by date. The interior bag holding the carrots was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. 2. In the freezer the surveyor found; one opened box of chopped celery. The exterior of the box was unlabeled. The interior bag was unlabeled, wide open to the elements with large ice crystals. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. 3. In 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-10-19 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure: a) accurate documentation of the needed information in the Nurse Staffing Report, b) minimum State staffing requirements were met for 14 of 14 day shifts and on 3 of 14 overnight shifts reviewed, c) physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes (PN) at least once every sixty days in a timely manner, d) that nurse aides received the minimum required number of in-service hours, and e) LNHA and Medical Director attended the QAPI (Quality Assurance and Performance Improvement) meeting routinely necessary to provide for the needs of residents. This failure had the potential to affect all 105 residents who currently live in the facility. The evidence was as follows: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-10-19 · tag F0841 — widespread
    Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the interview, record review, and review of other pertinent facility documentation it was determined that the facility Medical Director (MD) failed to provide clinical oversight and guidance regarding resident care policies and procedures that affect resident care, medical care, and resident quality of life related to a) required physician visits and notes, b) attends mandatory quarterly QAPI (Quality Assurance and Performance Improvement) meetings, and c) minimum State staffing requirements were met. This failure had the potential to affect all 105 residents who currently live in the facility. This deficient practice was evidenced by the following: 1. A review of Resident #1's Progress Notes (PN) showed that the Physician Note's most recent documentation was a late entry on 7/23/23 for a date of service of 6/30/23. The following were other Physician Notes documented in the PN: 4/20/23 For date of 3/01/23 (late entry on 4/20/23) For date of 01/06/23 (late entry on 01/31/23) For date of 11/16/22 (late entry on 12/23/22) For date of 9/22/22 (late entry on 10/25/22) Further…

    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 · F2023-10-19 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of pertinent facility documentation, the facility failed to have: a) the Medical Director (MD) present for two out of three Quality Assurance and Performance Improvement (QAPI) meetings, b) the Licensed Nursing Home Administrator (LNHA) present for three out of three QAPI meetings, and c) set QAPI meeting schedule. This failure had the potential to affect all 105 residents who currently live in the facility. The deficient practice was evidenced by the following: On [DATE] at 8:57 AM, the survey team entered the facility and met with the Receptionist who instructed the surveyors to use the touchless thermometer attached to a wall to check the surveyors' temperature, log in the binder temperature, and answer the COVID-19 screening questions. Later on, an employee introduced herself to the survey team as the facility's Administrator in Training and a Registered Nurse (AiT/RN). The AiT/RN provided a business card that included her name with the title of Administrator. On [DATE] at 9:54…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-19 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an incident/accident: a) on 6/23/23 that resulted in a nose fracture for Resident #27 and b) Resident 208. This deficient practice was identified for two (2) of six (6) residents reviewed for accident and was evidenced by the following: 1. On 10/10/23 at 11:44 AM, the surveyor observed Resident #27 sitting in their room and could not be interviewed as the resident spoke in [dialect redacted]. At that time, the activities/translator was at the activities area, attending to other [dialect redacted] speaking residents. On 10/10/23 at 12:47 PM, the surveyor observed the resident was not in the room and found the Certified Nursing Assistant (CNA) in the room instead. In the presence of the surveyor and Licensed Practical Nurse (LPN), the CNA stated that she was waiting for the resident to call her from the bathroom. At that time, the LPN stated 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-19 · tag F0712 — pattern
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes (PN) at least once every sixty days in a timely manner. This deficient practice was identified for three (3) of six (6) residents reviewed for physician visits, Residents #1, #8, and #18. This deficient practice was evidenced by the following: 1. On 10/17/23 at 8:51 AM, the surveyor and the Licensed Practical Nurse both observed Resident #1 lying on the bed. The surveyor reviewed Resident #1's medical records. The admission Record (AR; or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (or MS; resulting nerve damage disrupts communication between the brain and the body. MS causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination), other muscle spasm, and quadriplegia (a symptom of paralysis that affects all a person'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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · E2023-10-19 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to: a) identify residents in need of, offer a Pneumococcal vaccine for four (4) of six (6) residents, (Residents #13, #82, #84, and 95), and offer the subsequent Pneumococcal vaccine for two (2) of six (6) residents, (Residents #28 and #30) and b) follow the facility Pneumococcal vaccine policy in accordance with the Advisory Committee on Immunization Practices and the CDC (Centers for Disease Control and Prevention) guidelines. This deficient practice was evidenced by the following: Reference: A review of the CDC guidelines for Pneumococcal vaccination included: Age 65 years or older who have: -Not previously received a dose of PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15…

    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 · D2023-10-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility provided documents it was determined that the facility failed to provide a physically impaired resident a specialized call bell according to the resident's limitation and preference. This deficient practice was identified for Resident #1, one (1) of two (2) residents reviewed for the limited range of motion, and was evidenced by the following: On 10/13/23 at 11:47 AM, during the courtesy meeting with the facility's Volunteer Advocate (VA), the VA informed the survey team that she was the one who recommended to the facility for the resident to have a specialized call bell due to the resident's limitations to upper extremities as per resident's preference. The surveyor reviewed Resident #1's medical records. The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (or MS; resulting nerve damage disrupts…

    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 · D2023-10-19 · tag F0559 — isolated
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and other pertinent facility documentation, it was determined that the facility failed to a) notify in advance and in writing of a resident's new roommate change for a cognitively impaired resident in accordance with federal and state regulations. This deficient practice was identified for one (1) of three (3) residents reviewed for room change (Resident #81) and was evidenced by the following: On 10/17/23 at 10:07 AM, the surveyor interviewed the Director of Social Services (DSS) who stated the process for a resident's room change were discussed during the morning clinical meeting with the Interdisciplinary team. The team was comprised of the Certified Nursing Assistant (CNA) to the resident, Social Services, the Licensed Practical Nurse (LPN) or the Registered Nurse (RN) assigned to the resident, the Infection Preventionist (IP), the Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA). The conversation involved discussing the resident's personality differences, comfort. We also wanted the resident in the room to be…

    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 · D2023-10-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 pertinent facility documentation it was identified that the facility failed to provide residents with a clean, safe, comfortable, and home like environment. This deficient practice was identified in one (1) of two (2) dining areas where morning activities for the English-speaking residents were also held. A review of the Material Safe Data Sheet for [brand name redacted] under Section 7: Handling and Storage included the following: Provide good ventilation. Do not use in confined spaces without adequate ventilation and/or respirator. Avoid contact with skin and eyes. Do not eat, drink, or smoke when using the product. Methods of Clean-up: Small spillages: Absorb with sand or other inert absorbent. Large spillages: Dam and absorb. Collect spillage in containers, seal securely and deliver for disposal according to local regulations. Wear necessary protective equipment. Storage: Keep separate from food, feedstuffs, fertilizers and other sensitive material. Store in closed original container at temperatures between 5°Cand 30°C/ 40°F and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for three (3) of nine (9) newly hired staff reviewed, (Staff #1, #4, and #6) and was evidenced by the following: On 10/18/23 at 9:16 AM, the surveyor reviewed nine randomly selected new employee files for license verification which revealed the following: Staff #1, a Certified Nursing Assistant (CNA), hired 7/06/23, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. Staff #4, a Speech Therapist, hired 01/01/23, did not have a New Jersey Division Consumer Affairs license verification printout for license verification. There was no documented evidence that Staff #4's license was verified. Staff #6, a CNA, hired 3/21/23, had a NJDOH…

    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 · D2023-10-19 · 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 Complaints # NJ00158985, NJ00156816 Based on observation, interview, record review, and review of pertinent facility documentation, 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, for three (3) of 21 residents, (Resident #26, Resident #208, Resident #209) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified October.20.2023, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 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; and b.) ensure an individualized comprehensive care plan interventions were developed and implemented to a Stage 1 pressure injury wound; and c.) ensure an individualized comprehensive care plan with interventions were developed and implemented in a timely manner after a skin impairment occurred for one (1) of three (3) residents reviewed for PU (Resident #81). This deficient practice was evidenced by the following: On 10/16/23 at 10:00 AM, the surveyor observed Resident #81's assigned Licensed Practical Nurse (LPN #1) perform a wound treatment. Prior to handwashing (HW), LPN #1 pulled the lever on the paper towel dispenser downward and upward multiple times to dispense the paper towel. LPN #1 then performed HW for 20 seconds. After LPN #1 dried her hands with 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review and review of other pertinent facility provided documentation, the facility failed to implement and document in the resident's care plan a new intervention after each fall in order to prevent any additional falls for one (1) of five (5) residents reviewed for falls (Resident #22). This deficient practice was evidenced by the following: On 10/10/23 at 12:12 PM, the surveyor observed resident #22 in their room, seated in a wheelchair eating lunch. Resident #22 did not want to be bothered at this time. The surveyor reviewed Resident #22's medical records. The admission Record (or face sheet; an admission summary) reflected that Resident #22 was admitted to the facility with diagnoses that included but not limited to asthma (a chronic condition that inflames and narrows the airways in the lungs), atherosclerosis heart disease (or hardening of the arteries -- is the leading cause of heart attacks, strokes, and peripheral vascular disease.), unspecified systolic (congestive) heart failure (a specific type of heart failure that occurs in 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · 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 review of other pertinent provided facility documents, it was determined that the facility failed to ensure that tracheostomy (trach) care and services were provided according to the standard of clinical practice for one (1) of one (1) resident (Resident #18) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/06/23 at 10:37 AM, the surveyor observed Resident #18 seated in a geri chair (a specialized seating solution designed specifically for seniors and individuals with limited mobility) in their room eyes open, nonverbal, with trach (an incision in the windpipe made to relieve an obstruction to breathing) and oxygen (O2) in use. The surveyor reviewed the medical records of Resident #18. The resident's admission Record (or face sheet; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dependence on supplemental oxygen, gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach) status, hypoxic…

    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 · D2023-10-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to: a) consistently monitor the resident's vital signs (VS) and dialysis access site and b) complete the Hemodialysis Communication Record (HCR) according to the facility's policy and standard of clinical practice. This deficient practice was observed for one (1) of one (1) resident reviewed. The deficient practice was evidenced by the following: On 10/06/23 at 9:48 AM, the surveyor observed that Resident #60 was not in their room. The Unit Clerk stated that the resident was at the dialysis center. On 10/10/23 11:48 AM, the surveyor observed the resident in bed asleep. The surveyor reviewed the hybrid medical records (a combination of paper, scanned, and computer generated record) of Resident #60. The admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to end stage renal disease (ESRD) (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · tag F0728 — failed to protect against nurse-aide misconduct — isolated
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and review of pertinent facility documentation, it was determined that the facility allowed one (1) of one (1) Non-Certified Nursing Aides (NA) to continue working as an NA after the specified 120 days. This deficient practice was identified during new hire employee review. This deficient practice was evidenced by the following: On 10/18/23 at 9:16 AM, the surveyor reviewed the facility provided new hire employee files. The review included the following: The NA had a date of hire (doh) 5/11/23. The NA completed a Certified Nurses Aide (CNA) Program on 4/14/23. The NA passed the Skills Evaluation on 4/17/23. There was no documented evidence that the NA was licensed as a Certified Nursing Assistant. On 10/18/23 at 11:13 AM, the surveyor interviewed the Human Resources Director (HRD) and the Director of Nursing (DON) regarding the NA. The HRD stated that the NA was under the 190 days after her skills test. She added that when a NA came from the school that the school told us that the NA could work for 190 days after the skills test. The HRD stated that the NA 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review it was determined that the facility failed to provide the mandatory annual dental care services. This deficient practice was observed for two (2) of 21 residents, (Resident #26, Resident #209) reviewed for dental care services, and was evidenced by the following: 1. On 10/18/23 at 12:17, PM the surveyor observed the resident had jagged teeth and brown discoloration when Resident #26 smiled. The resident stated that there was not any pain at this time. The surveyor asked the resident if he/she had seen a dentist or had been offered since the resident was admitted . The resident stated no, neither. On 10/16/23 at 11:46 AM, surveyor interviewed the Certified Nursing assistant (CNA). The CNA informed the surveyor that Resident #26 was a set-up for morning (AM) care including care for resident's teeth. She further stated that the resident had no complete set of teeth and with some broken teeth. On 10/10/23 at 9:45 AM, the surveyor reviewed Resident #26's electronic…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently identified and implemented for one (1) of six (6) residents (Resident #8) reviewed for dietary preferences. This deficient practice was evidenced as follows: On 10/06/23 at 11:04 AM, the surveyor observed Resident #8 inside their room with a Certified Nursing Assistant providing care. On 10/11/23 at 9:04 AM, the surveyor observed the resident seated on a specialized air mattress, covered with a blanket, and with water on top of a tray table in front of the resident. The resident stated that the resident had a concern with food because the resident was not being provided with a menu in advance to choose what the resident likes to eat. The resident further stated that the resident was not provided with an option to choose their meals. On that same date and time, the surveyor asked the resident if the resident informed the facility management and if the Dietician was aware of 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-19 · 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 Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) appropriate use of personal protective equipment (PPE) for two (2) of three (3) staff observed during meal observation and b) linen carts were maintained and cleaned for proper storage of clean supplies for four (4) out of five (5) linen carts according to facility policy and Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: According to the CDC, Appendix D - Linen and laundry management, last reviewed May 4, 2023, Best practices for management of clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Each floor/ward should have a designated room for sorting and storing clean linens. Transport clean linens to patient care areas on designated carts or within designated containers that are regularly (e.g.,…

    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 · D2023-10-19 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 the interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) for three (3) of three (3) staff in accordance with the facility policy and Centers for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 21-012 (revised [DATE]) included ii. The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. According to the CMS QSO-22-19-NH Memo dated [DATE] and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated [DATE], effective date on [DATE] Overview of New and Updated…

    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 · D2023-10-19 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of facility provided documents, it was determined that the facility failed to ensure that all Certified Nursing Assistant (CNA) received the mandated 12-hours annual competency training as required. This deficient practice was identified in five (5) of five (5) CNAs reviewed and was evidenced by the following: On 10/17/23 at 02:25 PM, the surveyor asked the Director of Nursing (DON) for the mandated education and annual competency training of five (5) randomly chosen CNA. On 10/18/23 at 9:16 AM, the Human Resource Director provided the requested mandatory education and annual competency training documents that included the following: CNA #1 was hired 01/02/1999; total of eight hours of education CNA #2 was hired 09/24/2021; total of eight hours of education CNA #3 was hired 04/01/2007; total of eight hours of education CNA #4 was hired 03/24/2016; total of 6.5 hours of education CAN #5 was hired 12/29/2022; total of eight hours of education Further review of the above documents showed that the five CNAs did not have mandated 12-hours annual competency…

    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
  • No harm found · C2023-10-19 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that the facility failed to provide written notification of the emergency transfer to the resident representative and the Office of the Long-Term Care Ombudsman (LTCO) for one (1) of two (2) residents (Resident #46), reviewed for hospitalizations. This deficient practice was evidenced by the following: On 10/06/23 at 10:58 AM, the surveyor observed Resident #46 inside their room seated on a bed. The resident stated that there was no concern with care. The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #46. The admission Record (or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), gastro-esophageal reflux disease without esophagitis…

    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

“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 THE ROSENBERG FAMILY — 16 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 5 of 52.7+2.3 vs chain
Health inspection 4 of 52.2+1.8 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 15 homes this chain runs (chain average 2.7★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
COUNTRY ARCH CARE CENTER, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 04/01/2001
ROSENBERG, ESTHERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 04/01/2001
ROSENBERG, JONATHANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 04/01/2001
COUNTRY MOUNTAIN LLCOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 04/01/2001
STERN, SAMUELIndividualCORPORATE OFFICERsince 12/01/2016
FREY, REBECCAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/18/2025
GOLUB, LARISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2001

CMS files one row per role, so the 18 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$14.0M
Net patient revenuemost recent cost report
-1.7%
Operating marginrevenue minus expenses
$3.0M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 12%Other / private 17%

About 71% 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 $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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

$367per resident / day
operating cost
$11,160per month
≈ monthly operating cost
$361per 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 315433. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-08, 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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