Merwick Care & Rehabilitation Center, LLC
100 Plainsboro Road, Plainsboro, NJ 08536 · For profit - Corporation · 200 certified beds · (609) 759-6000 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0568)
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.0% | 4.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.1% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 11.1% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.2% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.7% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.2% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.5% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 32.5% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.2% | 12.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 89.9% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.8% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.0% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.72 | 2.07 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.82 | 1.11 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.1% 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 316 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 69.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 99 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.1%CMS range 53.0–62.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 8.6–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 69.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 58.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 4.7–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 200 beds and averages 172.9 residents a day — about 86% occupied, or roughly 27 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 3.05 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 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 2.80 hrs/resident/day on weekends vs 3.15 on weekdays — 11% thinner on weekends. RN hours go from 0.77 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 10 most serious are shown; the remaining 21 are one tap away and print in full.
- Potential for harm · D2026-05-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint: 3015011Based on interviews, record review, and review of other pertinent facility documents it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by a) discharging a resident with a midline catheter (long, flexible catheter inserted into larger veins of the upper arm) in place without a physician order (PO) to do so; and b) removing a resident's midline catheter after the resident was discharged at the resident's home without a PO to do so. This deficient practice was identified for 1 out of 3 residents reviewed for the discharge process (Resident #2). This deficient practice was evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint: 3015011 Based on interviews, record review, and review of other pertinent facility documents it was determined that the facility failed to complete an incident report and thoroughly investigate after a resident was discharged from the facility with a midline catheter (long, flexible catheter inserted into larger veins of the upper arm) in place. This deficient practice was identified for 1 of 3 residents reviewed for the discharge process (Resident #2), and was evidenced by the following:Resident #2 was no longer at the facility. The closed medical record for Resident #2 was reviewed. A review of the admission record face sheet for Resident #2 revealed that the resident was admitted to the facility with diagnoses including but not limited to: pleural effusion (collection of fluid around the lungs), heart failure (heart muscle not pumping blood as well as it should), type 2 diabetes mellitus (body cannot use insulin correctly causing sugar build-up in the blood), malignant neoplasm of an unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 #:3015011 Based on interviews, record review, and review of pertinent documents, it was determined that the facility failed to ensure that the medical record accurately documented the care provided to a resident who was discharged home with a midline (long, flexible catheter inserted into larger veins of the upper arm) and had it removed in their home the next day by facility staff. This deficient practice occurred for 1 of 3 residents reviewed for discharge processes (Resident #2) and was evidenced by the following:Resident #2 was no longer in the facility. A closed record review was conducted. A review of the admission record face sheet for Resident #2 revealed that the resident was admitted to the facility with diagnoses including but not limited to: pleural effusion (collection of fluid around the lungs), heart failure (heart muscle not pumping blood as well as it should), type 2 diabetes mellitus (body cannot use insulin correctly causing sugar build-up in the blood), malignant neoplasm of an unspecified site of unspecified female breast (abnormal growth of cells that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-03 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
Complaint #: 2680813Based on record review, staff interviews, and review of pertinent facility documentation on 12/3/2025, it was determined that the facility failed to ensure the individualized comprehensive care plan reflected a resident's current physician ordered diet. This deficient practice was identified for 3 of 3 residents (Resident #1, Resident #2, and Resident #4). The findings were as followed:1.According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: atrial fibrillation (irregular heart rhythm), dementia, and depression. According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 11/14/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident's cognition was severely impaired. Resident #1 was no longer at the facility at the time of the survey.A review of Resident #1's Order Summary Sheet (OSR) with active orders as of 11/7/2025 revealed the following physician order (PO):Vegetarian diet, pureed texture, thin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility documents, it was determined that the facility failed to a.) sanitize, store, and maintain kitchen equipment to prevent microbial growth, b.) store, label and date potentially hazardous foods to prevent food borne illness, and c.) discard potentially hazardous food past the use by date. The deficient practice was evidenced by the following: On 4/21/2025 from 9:36 AM to 10:05 AM, the surveyor, who was accompanied by the Assistant Food Service Director (AFSD), observed the following in the kitchen: 1. In the walk-in refrigerator, there was a 5-pound container of ricotta cheese with lid ajar and opened date of 4/8/2025. The packaging indicated to use within 7 days of opening. The AFSD confirmed it needed to be discarded. 2. In the walk-in refrigerator, there were 3 Styrofoam cups of brownish liquid covered with plastic lids with no label and use by date. The AFSD confirmed they were coffee and that they needed to be labeled and dated. 3. In the walk-in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-25 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
4.) On 4/21/25 at 10:08 AM during the initial tour of the facility, surveyor #4 observed an oxygen concentrator (a device that enriches air with oxygen by removing nitrogen) in Resident # 70's room with a nasal cannula oxygen tubing (small flexible tube with two prongs that delivers oxygen into the nose) connected to the concentrator. The nasal cannula tubing was found on the floor under the bedside table. A review of the admission Record, an admission summary, revealed that Resident #70 had medical diagnoses which included but were not limited to: Chronic Kidney Disease, contractures and hypoglycemia. A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 4/1/25, identified that the resident had a Significant Change, and included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was placed on Hospice 4/3/25. In addition, under section O Special Treatments, Procedures, and Programs, it was indicated that the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-25 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promotes his/her quality of life. This deficient practice was identified for 1 of 32 residents (Resident #123) reviewed for resident rights. Upon initial tour of the facility on 04/21/2025 at 11:15 AM, the surveyor was speaking with Resident #123 in their room with the door closed. While speaking with the resident, the door opened and Registered Nurse #1 (RN#1) attempted to enter. Resident #132 shook their head, looked at the surveyor, and stated no knock. This surveyor stated that they were speaking with the resident and RN #1 exited the room. Approximately 5 minutes later, RN #1 knocked, immediately entered the room, walked past the surveyor and began to set up wound care supplies. This surveyor explained that they were with the Department of Health and would like to speak with the resident. RN #1 stated that they had to set up for wound care. The surveyor requested RN #1 three different times to exit the room to allow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined the facility failed to maintain the resident's living environment in a clean, sanitary, and homelike manner that included a wall-mounted call device input (Resident #13) and soap dispensers (Resident #17 and #49). This deficient practice was identified for 2 of 4 nursing units observed for environment. This deficient practice was evidence by the following: 1. During the initial tour of the facility on 4/21/25 at 10:16 AM, the Surveyor #1 observed a call device input system taped to the wall above the resident's bed in room [ROOM NUMBER] bed #2. On 4/22/25 at 9:15 AM, the surveyor interviewed Resident #13's family member that stated that the call device input box had been taped to the wall for at least a month and that the Maintenance Department was aware of it and waiting on a new system to replace it. The family member confirmed that the call device had been functioning properly. During an interview with the surveyor on 4/24/25 at 12:34 PM, the Licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-25 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 2 of 2 residents reviewed for resident assessment (Resident #9 and Resident # 147). This deficient practice was evidenced by: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS no later than 14 days after assessment being completed. After transmitting of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. The following residents were identified that the MDS were not transmitted timely: 1. Resident #9: the discharge return anticipated MDS was completed on 12/21/2024 and was due to be transmitted no later than 01/04/2025. It was transmitted 04/23/2025. 2. Resident #147: the discharge return not anticipated MDS was completed on 12/20/2024 and was due to be transmitted no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and pertinent facility documentation, it was determined that the facility nursing staff failed to document on the Treatment Administration Record (TAR) to indicate that treatments were administered according to the Physician Orders (PO) and acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes. The deficient practice was identified for 1 of 41 residents (Resident #49). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · Dcited before2025-04-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to A). store oxygen equipment in a sanitary manner B.) develop a comprehensive care plan for a resident receiving oxygen therapy and a resident who self suctioned; C.) label and date oxygen tubing according to professional standards and failed to obtain a physician order for a resident receiving oxygen therapy. This deficient practice was identified in 3 of 4 residents (Resident #70; Resident #152; Resident #472) reviewed for respiratory care and was evidenced by the following: A.) On 4/21/25 at 10:08 AM during the initial tour of the facility, surveyor # 1 observed an oxygen concentrator (a device that enriches air with oxygen by removing nitrogen) in Resident # 70's room with a nasal cannula oxygen tubing (small flexible tube with two prongs that delivers oxygen into the nose) connected to the concentrator. The nasal cannula tubing was found on the floor under the bedside table. A review of the admission Record, an admission summary, revealed that Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure accurate accountability of controlled drugs to prevent loss or diversion. The deficient practice was identified for 1 of 5 medication carts inspected. This deficient practice was evidenced by the following: On 04/23/2025 at 09:59 AM, the surveyor inspected the Luxor Unit medication cart in the presence of the Registered Nurse #1 (RN#1). A review of the shift-to-shift Narcotic and Controlled Drug Count Verification Record, (NCDCVR) which is used in healthcare settings to track the administration and accountability of controlled substances, revealed missing signatures for the following dates and shifts: 04/02/2025 for the outgoing nurse (11:00PM) 04/04/2025 for the outgoing nurse (11:00PM) 04/06/2025 for the incoming nurse (11:00PM) 04/07/2025 for the outgoing nurse (7:00AM) 04/09/2025 for the incoming nurse (3:00PM) and outgoing nurse (11:00PM) 04/11/2025 for the incoming nurse (3:00PM) and outgoing nurse (11:00PM) 04/12/2025 for the outgoing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-22 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ00158378 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) follow a physician's order to obtain weekly weights for 1 of 5 residents (Resident #251) investigated for nutrition b.) notify a physician of a resident's medication refusal for 1 of 4 residents (Resident #254) investigated for accidents c.) follow a physician's order (PO) to notify if a resident's blood sugar fell below 100 for 1 of 30 residents (Resident #58) reviewed for medications d.) enter a progress note related to an unwitnessed fall for 1 of 4 residents (Resident #58), investigated for accidents and incidents and e.) document the administration of medication on the resident's electronic medication administration record (eMAR) for 1 of 30 residents (Resident #292) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-22 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 154800, NJ 154946, NJ 158378 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to a.) ensure that incontinence care was provided to dependent residents in a timely manner for 7 of 9 residents (Resident #3, #25, #103, #75, #48, #95, and #127) observed for incontinence care on 2 of 4 units ([NAME] and Luxor 1) and b.) provide nail care to residents that required extensive assistance from the staff for activities of daily living (ADLs) for 2 of 4 residents, (Resident #127 and #75) reviewed for ADLs. This deficient practice was evidenced by the following: 1. On 11/15/23 at 12:46 PM, during an interview with the surveyor, RN/UM #2 and LPN #2 identified residents as being dependent on staff for care. On 11/16/23 at 7:36 AM, the surveyor completed an incontinence tour on the [NAME] Unit and observed the following: a. On 11/16/23 at 8:00 AM, the surveyor accompanied by Registered Nurse (RN) #2 observed Resident #3 in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-22 · tag F0725 — failed to have enough nursing staff — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ00155975; NJ00158378; NJ00154946; NJ154800 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide adequate staff to ensure all residents were provided with timely: a.) incontinent care, and b.) nail care for residents that required extensive assistance for activities of daily living (ADLs). This deficient practice occurred for 7 of 9 residents reviewed for incontinence care (Resident #3, #25, #103, #75, #48, #95 and #127 on 2 of 4 units ([NAME] and Luxor 1) and for 2 of 4 residents, (Resident #38 and #218) reviewed for ADLs and was evidenced by the following: Refer to F677E Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-22 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) follow appropriate hand hygiene practices for 4 of 5 staff observed and b.) handle and store linens and resident's garbage in accordance with facility policy. This deficient practice was evidenced by the following: 1. On 11/13/23 at 1:50 PM, the surveyor observed Registered Nurse (RN) #1 don (put on) a disposable gown, and gloves and entered room [ROOM NUMBER] which had signage indicating the resident was on transmission-based precautions. On 11/13/23 at 1:55 PM, the surveyor observed RN #1 preparing to exit room [ROOM NUMBER], RN #1 doffed (took off) her gown and gloves and exited the room. The surveyor observed that RN #1 did not sanitize or wash her hands after she removed her gloves. On 11/16/23 at 7:57 AM, during incontinence rounds, the surveyor observed RN #2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-22 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #NJ00156125 Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) for 1 of 5 residents reviewed for investigations and was evidence by the following: A review of Resident #296's admission Record Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis which included ileostomy (surgery where the small intestines is diverted through an opening of the abdomen), multiple sclerosis (a chronic disease of the central nervous system) and depression. A review of Resident #296's admission Minimum Data Set (MDS), an assessment tool, dated 6/16/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. On 11/20/23 at 1:15 PM, the surveyor reviewed a facility document dated 6/24/22 titled Resolution to Resident Grievance/Complaint Form for Resident #296. The grievance form revealed that on 6/17/22 that the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan. This deficient practice was identified for 1 of 30 residents (Resident #124) reviewed for care plans and evidenced by the following: On 11/13/2023 at 12:47 PM, the surveyor observed Resident #124 with an unidentifiable mass on the forehead. The surveyor also observed that there was blood on the bedsheets. The surveyor reviewed the medical record for Resident #124: A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included displaced fracture of surgical neck of left humerus and schizophrenia. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 08/11/2023, reflected a brief interview for mental status (BIMS) score of 9 out of 15, which demonstrated moderately impaired cognition. A review of the individualized comprehensive care plan (ICCP) failed to include a focus area 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.
- Potential for harm · D2023-11-22 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to consistently complete the dialysis communication form for one (1) of two (2) residents, (Resident # 239) reviewed for dialysis. This deficient practice was evidenced by the following: On 11/17/23 at 10:01 AM, the surveyor observed the resident seated in a wheelchair in their room. Resident #239 stated that he/she goes to dialysis on Mondays, Wednesdays, and Fridays. A review of Resident #239's admission record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: acute kidney failure, osteomyelitis of the vertebra (infection of the bone), and low back pain. A review of the admission Minimum Data Set (MDS), an assessment tool dated 11/7/23 reflected a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated an intact cognition. A further review of the resident's MDS, Section O - Special Treatment and Procedures, reflected that the resident received hemodialysis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-22 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage compactor free of garbage and debris. On 11/13/23 at 9:59 AM, the surveyor, in the presence of the Food Service Supervisor (FSS) toured the kitchen and the designated garbage area and observed the following: There was garbage debris that included food, gloves, cups, paper products, plastic bags, and card board surrounding the garbage compactor. The FSS stated that the area should have been clean by the maintenance, housekeeping, and dietary departments. On 11/20/23 at 2:19 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and was informed of the findings. The LNHA stated the garbage compactor was replaced prior to survey and the maintenance department and housekeeping should ensured the area was clean. A review of the facility policy titled Dispose of Garbage and Refuse, dated 8/17, indicated that the Dining Services Director coordinates…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-12-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 pertinent facility documentation, it was determined that the facility failed to: a.) obtain the appropriate physician orders for the care of a resident with a tracheostomy, b.) appropriately label and date oxygen tubing, c.) obtain a physician's order for the use of oxygen and continuous positive airway pressure (CPAP) and d.) failed to follow their facility's policy and procedure for the use and storage of oxygen and respiratory equipment. This deficient practice was identified for 3 of 3 resident's, (Resident #81, Resident #94 and Resident #140), reviewed for respiratory care for 1 of 2 residents, (Resident #145) reviewed for closed medical records. The deficient practice was evidenced by the following: 1. On 12/1/21 at 11:16 AM, the surveyor observed Resident # 81 in bed sleeping. The resident was observed with a Tracheostomy (trach) with humidified oxygen in use. The tracheostomy collar and dressing observed to be clean. The head of the bed was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-12-15 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 Based on observation, interview and record review, it was determined that the facility failed to maintain complete, accurate and readily accessible medical records. This deficient practice was identified for 1 of 30 residents reviewed (Resident #37) for a period of 7 months and was evidenced by the following: On 12/01/21 at 11:33 AM, during the initial tour of the facility, the surveyor observed Resident #37, seated in a wheelchair in the resident's room. Resident #37 had three complaints: swollen feet, poor vision with missing eyeglasses, and missing dentures. Review of the resident's medical record revealed the following information: The resident's Face Sheet (an admission summary) disclosed that Resident #37 was admitted with diagnoses that included, but were not limited to dysphagia (difficulty or discomfort in swallowing) and glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight). Review of the resident's Significant Change Minimum Data Set (MDS), dated [DATE], an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-12-15 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) appropriate infection control practices were followed in accordance with the Center for Disease Control guidance (CDC) and facility guidelines for 2 of 2 housekeeping staff observed on 1 of 4 nursing units and b.) Transmission-Based Precautions (TBP) were followed for 1 of 11 residents (unsampled resident #1) on TBP's on 1 of 4 nursing units and c.) proper handwashing technique for 3 of 4 nurses during the medication pass on 3 of 4 units. The evidence was as follows: According to the U.S. CDC guidelines for Hand Hygiene in Healthcare Settings Hand Hygiene Guidance, updated 1/30/20, included Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-12-15 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer a resident the influenza and pneumonia vaccination. This deficient practice was identified for 1 of 5 residents, (Resident #74) reviewed for vaccination status and was evidenced by the following: On 12/01/2021 at 11:42 AM, the surveyor observed Resident #74 lying in bed on an air mattress reading a book that was written in the resident's native language. At that time, the surveyor attempted to interview the resident and the resident stated that his/her English was not so good. The surveyor reviewed Resident #74's medical record. A review of the resident's admission Record reflected that the resident was admitted to the facility in June 2021 and had diagnoses which included but were not limited to muscle weakness, high blood pressure, other recurrent depressive episodes, cognitive communication deficit, and encounter for surgical aftercare following surgery on the digestive system. A review of the resident's most recent quarterly Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 other facility documents, it was determined that the facility failed to maintain the call bell within reach of 1 of 28 residents (Resident #91) reviewed. This deficient practice was evidenced by the following: On 12/01/21 at 12:30 PM, during the initial tour of the facility, the surveyor observed Resident #91, whose room was located towards the end of the hallway, far from the nurse's station. Resident #91 was out of bed and seated in a Geri-chair in his/her room. The resident was leaning to the left side with no pillows or cushions on the Geri-recliner for comfort and proper positioning. When asked, Resident #91 stated, in a very soft voice, that he/she was very uncomfortable. The resident was not in reach of the call bell, which was wrapped around a bar on the bed frame to the left of the resident's Geri-recliner. On that same day and time, a Certified Nursing Assistant (CNA #1) entered the resident's room and repositioned the resident with a pillow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and a review of facility documents, it was determined that the facility failed to a.) maintain kitchen floors and baseboards in a sanitary manner and in good repair and b.) provide clean, sanitary floor mats in 3 of 4 resident rooms on 1 wing of 1 Nursing Unit (Grace Garden Unit 2, high side hallway). This deficient practice was evidenced by the following: 1. On 12/01/21 at 09:42 AM, during the initial tour of the kitchen in the presence of the Account Manager (AM), the surveyor observed the following: a.) There was an accumulation of dirt along the floor to wall junctures throughout the kitchen and dish room. There was some debris behind the double ovens. Most notably, the kitchen floor was severely worn in several areas near the cooking equipment and throughout the dish room. Therefore, the kitchen floor was not a smooth surface and was difficult to clean. The AM acknowledged the poor condition of the kitchen floor and stated, It's a big project. To patch it up, we would have to replace the entire floor. Once it starts pitting, it doesn't stop. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to clarify a Physician's Orders (PO) for code status (the type of emergent Cardio Pulmonary Resuscitation treatment a person would receive if their heart or breathing were to stop). This deficient practice was identified for 1 of 30 residents, (Resident #36) reviewed for code status related to professional standards of nursing practice and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to provide Activity of Daily Living (ADL) care to dependent residents. This deficient practice was identified for 2 of 2 residents, (Resident #8 and Resident #21) reviewed for ADLs and was evidenced by the following: 1. On 12/01/2021 at 10:22 AM, the surveyor observed Resident #8 lying in bed. The surveyor observed that the fingernails on both hands extended approximately ¼ inch above his/her fingertips. On 12/06/2021 at 12:35 PM, the surveyor observed the resident lying in bed. The resident's left hand was observed to be curled inward. The surveyor further observed that the resident's fingernails extended approximately ¼ inch above his/her fingertips on both hands. On 12/08/2021 at 9:45 AM, the surveyor observed Resident #8 fingernails in the presence of the resident's assigned Certified Nursing Aide (CNA). The resident's CNA stated that the resident's fingernails were, very…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to apply a physician ordered splinting device to a resident with contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that cause the joints to shorten and become stiff). This deficient practice was identified for 1 of 5 residents's (Resident #21) reviewed for position and mobility and was evidenced by the following: On 12/01/2021 at 11:07 AM, the surveyor observed Resident #21 lying in bed with his/her hands resting on his/her lap. The surveyor observed that both resident's hands were contracted, and the resident was not wearing a splinting device on his/her hands. On 12/02/2021 at 12:23 PM, the surveyor observed the resident in his/her room being fed lunch by the Certified Nursing Aide (CNA). The resident was smiling and listening to soft music as he/she was being fed. The surveyor observed that the resident's hands were placed on his/her lap. The surveyor further observed that the resident's hands were contracted, 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.
- Potential for harm · D2021-12-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) accurately assess a new admission weight for a resident; b.) follow and obtain weekly weights for 4 weeks as per facility's weight schedule for newly admitted residents in accordance with facility policy and procedure and c.) obtain a re-weight in a timely manner for 1 of 5 residents (Resident #53) reviewed for nutrition. This deficient practice was evidenced by the following: On 12/1/21 at 11:34 AM, the surveyor observed Resident #53 was on contact precautions. The resident was in bed awake and speaking with his/her physician inside the resident's room. On 12/3/21 at 10:55 AM, the surveyor observed the resident in bed awake with oxygen in use at 3 liters per minute via nasal cannula and wearing eyeglasses. The resident verbalized that he/she goes to hemodialysis three times a week. The resident verbalized that the food is ok, and that his/her appetite varies day to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2021-12-15 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to provide a resident with their quarterly Personal Needs Allowance (PNA) statement. This deficient practice was identified for 1 of 30 residents, (Resident #76) reviewed for accounting and records of personal funds. The deficient practice was evidenced by the following. On 12/06/2021 at 12:28 PM, Resident #76 was observed seated in a wheelchair in the main dining room on the long-term care unit on the first floor. The resident stopped the surveyor and requested if the surveyor could help him/her obtain the money that was entitled to him/her every month from the facility. The resident further stated that he/she thought the allowance was $52.00 a month. On 12/07/2021 at 9:43 AM, the surveyor interviewed the Director of Social Services (DOSS) who stated that it was the first time she was hearing that the resident was requesting money. The DOSS further stated that it was a combination of activities, the business office, and social services to work…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 2 of 5 | 2.6 | -0.6 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| JACOBS, HYMAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 95% | since 08/22/2007 |
| JACOBS, LIVIA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 08/22/2007 |
| JOSEPH, JEAN | Individual | W-2 MANAGING EMPLOYEE | — | since 12/03/2018 |
| METTERNICH, CHRISTOPHER | Individual | CORPORATE OFFICER | — | since 08/17/2017 |
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 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 $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315001. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, 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.