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Our Ladys Center For Rehabilitation & Healthcare

1100 Clematis Ave, Pleasantville, NJ 08232 · For profit - Limited Liability company · 214 certified beds · (609) 646-2450 Medicare & Medicaid certified

Call the home — (609) 646-2450 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 26 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 18% 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 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 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
932 S Main St, Pleasantville, NJ 08232 · (609) 383-0880 · Call to confirm hours
Pharmacy
912 S Main St · (609) 380-4846 · Call to confirm hours
Grocery
Friendly Deli, 151 New Jersey Ave · (609) 513-0743 · Call to confirm hours
Park
701 W Park Ave · 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 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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 increased4.8%8.7%15.4%better
Long-stay residents who lose too much weight11.2%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.4%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms79.9%12.1%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.0%2.3%3.3%better
Long-stay residents whose ability to walk worsened2.2%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.1%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine88.2%97.2%95.3%typical
Long-stay residents with pressure ulcers2.5%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control8.1%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table5.3%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine32.3%80.1%79.4%worse
Short-stay residents rehospitalized after admission22.8%24.9%22.6%typical
Short-stay residents with an outpatient ER visit13.1%8.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.862.071.67worse
Long-stay outpatient ER visits per 1,000 resident days2.571.111.80worse

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.0% 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 155 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.0%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
61.9%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 61.9% 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 134 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.0%CMS range 48.9–64.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.8–15.410.7%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 discharge61.9%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 discharge55.2%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 discharge57.5%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 identified100.0%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 setting98.9%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 discharge98.8%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 stay0.0%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 worsened1.3%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 hospitalization8.1%CMS range 5.1–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.451.02Oct 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
0.79
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.43
Total nurse hours/ resident / day
0.35
RN hoursweekends
33.8%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 214 beds and averages 182.0 residents a day — about 85% occupied, or roughly 32 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 3.43 hrs/resident/day is below 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 2.03 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 3.07 hrs/resident/day on weekends vs 3.57 on weekdays — 14% thinner on weekends. RN hours go from 0.72 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

8
deficiencies at the latest standard inspection (2024-12-31)
9
at the previous standard inspection (2023-11-22)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Ecited before2024-12-31 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 12/16/2024 at 10:08 AM during initial tour surveyor # 2 observed pillowcases tucked in the window of the bathroom on unit B room [ROOM NUMBER]. Also observed on unit B in room [ROOM NUMBER] A-side, surveyor # 2 observed the wall next to the bed with scratches and peeling paint. On 12/19/2024 at 09:54 AM during a tour of the Unit C and D nourishment room surveyor # 2 observed the following: 1. Under the sink there was a water bottle with a blue substance not labeled and a sponge open to air. 2. The ice machine was observed with white stains on the front and the tray was filled with water and rust was noted on the rack in the tray. 3. A stack of 3 paper cups were observed facing up and open to air. During an interview on 12/19/2024 at 09:57 AM with surveyor # 2, Registered Nurse/Unit manger #1 (RN/UM) said that the cups should be facing down to keep germs out. The RN/UM #1 also said that the blue substance was his/her own personal dish soap and that it should not have been in there. She removed the bottle 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 · E2024-12-31 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all medications and biologicals were stored and labeled properly in medication carts. The deficient practice was identified for 4 of 5 medication carts reviewed under the Medication Storage and Labeling Task. The deficient practice was evidenced by the following: On 12/16/2024 at 12:47 PM, the surveyor inspected the D-Hall medication cart. At that time, the surveyor observed two, loose tablets in the second drawer of the medication cart. Secondly, the surveyor observed one, multi-use vial of Insulin Lispro (fast-acting medication used to treat blood sugar levels) and one, multi-use vial of Lantus (long-acting medication used to treat blood sugar levels) undated. Lastly, the surveyor observed loose vials of Heparin (medication used to thin the blood) placed in a plastic basket with the insulins. At that time, during an interview with the surveyor, Licensed Practical Nurse (LPN) # 1 said they [insulins] should be dated. She also removed the Heparin vials…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-31 · 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

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide reasonable accommodation of a resident, specifically by having the resident's call device on the floor while the resident was in bed. The deficient practice was identified for 1 of 4 residents (Resident # 320) reviewed under the Environmental Task. A review of Resident # 320's admission Record located in the Electronic Medical Record revealed a diagnoses of but not limited to, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region (Infection of the bone). On 12/16/2024 at 10:15 AM, the surveyor observed Resident # 320 in bed. At that time, their call device was on the floor, outside of reach of Resident # 320. On 12/20/2024 at 9:40 AM, the surveyor observed Resident # 320 in bed. At that time, their call device was on the floor, outside of reach of Resident # 320. On 12/23/2024 at 9:15 AM during an interview with the surveyor, the Licensed Nursing Home Administrator said the facility provided education regarding call devices to the Certified Nurse…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-31 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 record review, it was determined that the facility A.) failed to maintain medication records that were complete with staff signatures according to professional standards of clinical practice. This was identified for 1 of 32 residents reviewed (Resident #23) and it was determined that the facility B.) failed to follow the physician orders with regard to medications (meds) with parameters for 1 of 34 residents (Residents #51) reviewed. This deficient practice was identified by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide nail care to a resident who was unable to carry out activities of daily living (ADLs). This deficient practice occurred for 1 of 3 residents (Resident #122) reviewed for nail care and was evidenced by the following: On 12/17/24 at 12:38 PM, the surveyor observed Resident #122 sitting on the edge of their bed. The surveyor observed resident's both arms were shaking, and their nails were long, squared (Square shape) with sharp edges. On 12/18/24 at 11:47 AM, the surveyor observed Resident #122 sitting in their bed. Resident #122's nails were long, squared with sharp edges. Resident #122 stated I don't remember when my nails were cut last, and further stated, I am going to ask my family to bring me a nail cutter. On 12/18/24 at 11:54 AM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) stated his responsibilities included feeding, bathing, and providing ADL care, such as grooming, shaving the resident, and cleaning…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-31 · 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 ensure medication administration times were sequenced to accommodate a resident's hemodialysis (HD) schedule in accordance with professional standards of practice. This deficient practice was identified for 1 of 2 residents reviewed on hemodialysis (Resident #43), and was evidenced by the following: On 12/18/2024 at 09:17 AM, the surveyor observed Resident #43 in their room. Resident #43 stated that the facility gets him/her to dialysis on time. The surveyor reviewed the medical record for Resident #43. The medical reflected Resident # 43 had a primary diagnosis of but not limited to anemia and end stage renal disease. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/1/2024 which reflected that the resident had moderate cognitive impairment and that the resident received hemodialysis (a procedure that uses special equipment to clean the blood). The care plan reflected an intervention to confer with physician and/or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-31 · tag F0712 — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents A.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission, B.) were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 4 of 34 residents (Resident #51, #52, #119, and #122) reviewed for physician visits. This deficient practice was evidenced by the following: 1.) A review of Resident #51's hybrid (electronic and paper) medical records (MR) from May 2024 - December 2024 revealed the following: The admission Record reflected that the resident was admitted to the facility with diagnoses that included but weren't limited to hypertension (high blood pressure), End Stage Renal [kidney] disease, Schizophrenia, anxiety disorder, insomnia, and Anemia. A review of the quarterly…

    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 · Dcited before2024-12-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices specifically, by staff not wearing a personal-protective gown while entering a room under Contact Precautions. The deficient practice observed for 1 of 2 residents (Resident # 320) reviewed for Transmission-Based Precautions under the Infection Control task. The deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html A review of Resident # 320 admission Record located in the Electronic Medical Record (EMR) revealed a diagnoses of but not limited to, Methicillin Resistant Staphylococcus Aureus Infection as…

    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 · Fcited before2023-11-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY F812 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/14/2023 at 9:20 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the walk-in refrigerator a previously opened box contained shelled eggs. The box was open, and the eggs were exposed. The box was sitting on the floor of the walk-in refrigerator. 2.- In addition, a bulk bottle of Ranch dressing and a bottle of bulk BBQ sauce were previously opened. The bottles did not have an open or use by date. A pan contained Jello and was covered with clear plastic wrap. The pan of Jello was undated, and the plastic wrap did not completely cover the Jello, exposing it to the air. 3. On a middle shelf of the walk-in refrigerator a white…

    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 · Ecited before2023-11-22 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, safe and sanitary environment. This was identified for 3 of 4 units and was evidenced by the following: During the initial tour of B hall on 11/14/2023 at 10:58 AM the surveyor observed the following; -privacy curtain between the beds in room B 09 had dark stains on it. -The floor at foot of A bed had a dark orange/brown stain. -The floor was observed to have brown pieces of debris scattered on it. -There was no foot board on A bed. On 11/15/23 at 9:23 AM, the surveyor observed the radiator cover between rooms [ROOM NUMBERS] on B hall in disrepair, with chipped paint. Multiple doorways into resident rooms on B hall observed with chipped paint. During a tour of A hall on 11/17/2023 at 9:19 AM, the surveyor observed the following: -A Hall door jams where they meet floor were observed to have dark areas for rooms 3, 4, 5, 6, 7, 8, 9, 10 11, 12, and 14. -The privacy curtain 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · E2023-11-22 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests by failing to remove insect traps filled with carcasses from a resident's room and failing to remove dead insect carcasses from a resident dining area. The deficient practice was observed for 1 of 8 residents (resident # 71) and 1 of 2 Dining Areas under the Environmental Task. The deficient practiced was evidenced by the following: On 11/14/2023 at 10:37 AM during the initial tour, the surveyor met Resident # 71 in his/her room. At that time, the resident said he/she that insects were observed in the room on multiple occasions. At that time, the surveyor observed two insect traps underneath the baseboard heater. The traps mechanism for action was a sticky substance that prevents the insects from moving out of the trap. The traps were filled with insect carcasses. The majority of the insects in the trap appeared to be but not limited to cockroaches. On 11/15/2023 at 8:15 AM, the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to implement a comprehensive, person-centered care plan to prevent fall and fall related injury for 1 of 34 residents reviewed (Resident #52). This deficient practice was evidenced by: On 11/14/2023 at 10:50 AM during initial tour, the surveyor observed Resident #52 resting in bed. There was no floor mat on the floor. On 11/17/2023 at 08:10 AM, the surveyor observed Resident #52 resting in bed and watching TV. The floor mat was not on the floor. During that time, the surveyor observed Resident #52's room and did not see the floor mat. The surveyor also observed a bed alarm pad placed underneath Resident #52, with gray cord extending on the floor and not connected to the powering device (a box with batteries which makes the alarm work). On 11/20/2023 at 08:38 AM, the surveyor observed Resident #52 sleeping in bed. The floor mat was not on the floor by Resident #52's bed. A review of admission Record found in the Electronic Medical Record (EMR) indicated that Resident #52's diagnosis…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-22 · 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

    Resident #133 Based on observation, interview, review of the medical record (MR) and review of other pertinent facility documents, it was determined that the facility failed to consistently ensure communication with a contracted dialysis facility according to facility policy and procedure. This deficient practice was evidenced for 1 of 1 resident (Resident #133) investigated for dialysis. This deficient practice was evidenced by the following: On 11/16/2023 at 09:06 AM Resident #133 stated to the surveyor that they had attended dialysis for approximately (1) year and is transported via the facility contracted transportation service. Resident #133 stated that he/she had no issues with transportation. Resident #133 also stated that he/she does not take a communication binder when attending dialysis and does not recall staff checking his/her dialysis site upon return to the facility. According to the admission Record, Resident #133 was admitted to the facility with the following but not limited to diagnoses: Calculus in bladder (bladder stones), heart failure, acute respiratory…

    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 · D2023-11-22 · tag F0868 — isolated
    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

    Based on interview and review of pertinent facility documents, it was determined that the facility failed to have a Quality Assurance and Process Improvement Committee (QAPI) and Quality Assurance Assessment (QAA) that consisted of the minimum required members by failing to include the facility's Medical Director in any of the provided attendance sheets. The Medical Director's attendance was not documented on 10 of 10 attendance sheets provided by the facility. The deficient practice was evidenced by the following: On 11/20/2023 at 12:24 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) said that the facility-provided Quality Assurance Meeting signature sheets are the same signature sheets for QAPI Committee. A review of the signature sheets the facility provided to the surveyor did not include the Medical Director's signature as proof of attendance to any meetings held during 2023, specifically from January through October. On 11/21/2023 at 11:24 AM during an interview with the surveyor, the Medical Director stated he attends the facility'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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-22 · 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 pertinent facility documents, it was determined that the facility failed to use appropriate hand hygiene and proper disinfection while providing wound care to residents. The deficient practice was observed A.) for 1 of 1 resident (Resident # 85) investigated for Pressure Ulcers/Injury and B.) 1 of 2 residents (Resident #109) investigated for Skin Condition. The deficient practices were evident by the following: A.) A review of Resident # 85's Electronic Medical Record (EMR) revealed a Nutrition Note in the progress notes dated 11/3/2023. The Nutrition Note revealed that Resident # 85 had an unstageable pressure ulcer to the sacral area. A review of Resident # 85's Significant Change 5-Day Minimum Data Set (MDS) dated [DATE] revealed under section, M that Resident # 85 was at risk for pressure ulcers/injury. The MDS did not reveal that he/she had a pressure ulcer or injury at that time. A review of Resident # 85's medical diagnoses located in the EMR revealed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-22 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    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 interview, record review and review of other pertinent facility documents, it was determined that the facility failed to ensure documentation in the resident's medical record of the information provided regarding the benefits and risks of immunization and the administration or the refusal of the vaccine, specifically the pneumococcal vaccination (vaccine used to prevent pneumonia). This deficient practice was identified for 3 of 5 residents (Resident # 135, Resident #63, & Resident # 109) reviewed for immunization status. This deficient practice was evidenced by the following: 1.) A review of the Electronic Medical Record (EMR) revealed that Resident #135 had diagnoses including but not limited to: Diabetes Mellitus type 2 (a disease of inadequate control of blood levels of glucose), dysphagia (difficulty swallowing), hyperlipidemia (high cholesterol). Resident #135 is over the age of 65. A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 10/29/2023,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-22 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure resident call devices where within reach of the residents for 2 of 32 sampled residents, (Resident #99 and Resident #201). This deficient practice was evidenced by the following: 1.) During the initial tour of the facility on 11/14/2023 at 10:58 AM, Resident #99 was observed lying in bed and the call bell was observed on the floor, under the overbed table and under a can out of the reach of the resident. Resident did not respond when asked if he/she uses the call bell. On 11/15/2023 at 9:22 AM, Resident #99 was observed to be lying in bed and the call bell was observed to be inside the top drawer of the dresser that was next to the bed. The call bell was not in reach of the resident. On 11/20/2023 at 8:29 AM, Resident #99 was observed lying in bed and the call bell was observed to be draped over top of the dresser. The call bell was out of reach of the resident. A review 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Complaint # NJ163585 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide the needed care and services in accordance to professional standards of practice that met the resident's physical needs by not obtaining laboratory diagnostics, specifically a blood test as ordered by the physician for the next day. The deficient practice was discovered for 1 of 3 residents (Resident # 355) investigated for Change of Condition. The deficient practice was evident by the following: A review of Resident # 355's Electronic Medical Record (EMR) revealed that he/she had diagnoses of but not limited to a fracture of unspecified part of right clavicle, subsequent encounter for fracture with routine healing, paroxysmal atrial fibrillation (irregular heart rhythm), and chronic obstructive pulmonary disease (lung disease). A review of Resident # 355's Physician Orders revealed an order to Send to ER [Emergency Room] re: critical lab result 3/24/2023 and that the resident is a Full Code (provide life sustaining measures).…

    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 · E2022-02-09 · tag F0550 — failed to protect resident dignity and rights — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents were provided with the assurance of receiving care and related services per the Federal and State laws and regulations by: 1.) having residents sign a COVID-19 RIDER- New Jersey to waive care and services and 2.) failing to have a policy, procedure and process in place for the use of the COVID-19 RIDER- New Jersey. This deficient practice occurred for 38 of 135 residents (Resident #107, #108, #224, #225 and #475, and 36 unsampled residents who were admitted between 01/01/22 and 1/31/22, and 2 residents who presently resided at the facility (Resident #1 and #71). The deficient practice was evidenced by the following: On 01/31/22, the facility provided the survey team with an Admission/Discharge To/From Report, Admissions 01/01/2022 to 01/31/2022. The report was Dated: [DATE] and Timed: 11:25:37. On 01/31/22 at 11:30 AM, the Surveyor reviewed the electronic medical…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-02-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner. This deficient practice was evidenced by the following: On 1/31/2022 from 9:38 to 10:27 AM the surveyor, accompanied by the Regional Director of Dietary (RDOD) observed the following in the kitchen: 1. On a middle shelf in the walk-in freezer, a Tupperware style container was labeled Hispanic Pork. The container had a label that read 5/18. The pork showed signs of freezer burn with excessive ice crystal buildup on the pork. On interview the RDOD stated, That's old. We usually go 6 months on frozen foods. I'm throwing it in the trash. 2. A cleaned and sanitized meat slicer on a prep shelf in the cook's area was uncovered and not in use. In addition, a cleaned and sanitized Buffalo chopper (a machine that chops or emulsifies food by rotating it in a bowl under spinning blades) was not in use and was not…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that 1) assistive devices to protect the skin and prevent contractures were in place as required by the physician's order, and 2) assistive devices were in place prior to signing the Treatment Administration Record (TAR). This deficient practice was identified for Resident #22, one of the 32 sampled residents reviewed for care and services and was evidenced by the following: Reference: New Jersey Statutes, 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 case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimes as prescribed by a licensed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    Based on observation, staff interviews and clinical record reviews, it was determined that the facility failed to provide personal care for 1 of 32 residents reviewed for their ability to independently carry out activities of daily living (ADL's), Resident # 22. The deficient practice was evidenced by the following: On 01/31/2021 at 9:54 AM, the surveyor toured the B Hall of the facility and observed Resident #22 lying in bed. The 1st, 2nd, 3rd and 4th fingers of the resident's right hand were observed curled into the palm of that hand. The fingertips of the contracted fingers could not be observed. When the resident was asked if the fingers could be straightened, he opened both hands and the fingernails were observed to be long with a dark coated substance approximately of ½ inch underneath the nails. Another observation on 02/01/2021 at 9:25 AM, revealed Resident #22 lying in bed. The 1st, 2nd, 3rd and 4th fingers of the resident's right hand were observed curled into the palm of that hand. The surveyor observed no palm protector in place or splint applied to prevent 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-09 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure a resident (Resident #19) received the ordered rate of nutritional formula according to the physician's order for 1 of 3 resident reviewed for tube feeding (Resident #19). The deficient practice was evidenced by the following: On 1/31/22 at 10:57 AM, during the initial tour, Resident #19 was observed in bed receiving nutritional formula via a tube feeding pump (Pump designed to deliver formula through a tube placed in a stomach). The pumps electronic display showed the formula was being delivered at 75mL (milliliters)/hour. On 2/1/22 at 9:25 AM, Resident #19 was observed in bed receiving nutritional formula via the tube feeding pump. The pumps electronic display showed the formula was being delivered at 75mL/hour. A review of the Electronic Medical Record (EMR) revealed under Medical Diagnosis revealed Resident #19 was diagnosed with but not limited to, dysphagia (difficulty swallowing) and paralytic ileus (condition where 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 · D2022-02-09 · 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, medical record review and review of other facility documentation, it was determined that the facility failed to a) administer oxygen at the prescribed liter per minute (L/PM) per the physician's order, and b) contain oxygen/nebulizer and medication delivery systems in protective coverings for 2 of 3 residents reviewed for respiratory care, (Resident #9 and #24). This deficient practice was evidenced by the following: 1. On 2/1/2022 at 11:29 AM, the surveyor observed Resident #24 sitting in their room in a wheelchair (w/c) watching television. The surveyor observed the resident was not wearing oxygen and there was no oxygen source in the room. The surveyor further observed the oxygen tubing and nasal cannula were draped across the dresser out of the resident's reach and not in a protective covering. At that time, Resident #24 stated the oxygen was somewhere, but he/she was not sure where. A review of the facility provided medical records for Resident #24 included: An admission Record that revealed Resident #24 was admitted with diagnoses which…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility documentation, it was determined that the facility failed to properly wear Personal Protective Equipment (PPE) while on the COVID-19 positive unit which the facility identified as the Red Zone unit. This deficient practice was identified for 2 staff members and was evidenced by the following: On 01/31/22 at 9:29 AM, the regional temporary Licensed Nursing Home Administrator (LNHA) stated the required PPE in the facility on the COVID-19 positive, RED zone unit was that staff were to wear N95 masks, eye protection, and PPE gowns in the hall and were to wear gloves when entering the resident's rooms. On the Persons Under Investigation (PUI) YELLOW zone, staff were to wear eye protection, N95 mask, and gown and gloves when entering the resident's rooms. On the GREEN zone well residents, staff were to wear surgical mask or N95 mask and eye protection. On 01/31/22 at 9:58 AM, the surveyor approached the closed double doors of the COVID-19 positive Red Zone and observed through the glass, a housekeeper in the hall wearing a KN95 mask…

    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 · D2022-02-09 · tag F0888 — isolated
    Ensure staff are vaccinated for COVID-19
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of Covid-19 a contagious respiratory infection. This deficient practice was identified for 1 of 1 partially vaccinated staff, Licensed Practical Nurse (LPN #1) and was evidenced by the following: On 2/1/2022 at 11:10 AM, the surveyor observed Licensed Practical Nurse (LPN#1)wearing a KN95 mask as well eye protection. During an interview at that time, LPN #1 said this was her second day of work at the facility. She went on to say she was vaccinated 1 week ago and that she was due for her second vaccine on 2/13/2022. On the same day at 11:23 AM, LPN #1 was observed standing in the doorway of room B6. LPN #1 said she bought the KN95 by herself and that they (facility) gave her another mask to wear, but it gave her a migraine. She stated the mask she was wearing was like the surveyors (N95) with 2 straps. LPN #1 went to her locker to show it to the surveyor but couldn't find it. During 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CENTER MANAGEMENT GROUP — 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 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 3 of 51.8+1.2 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 15 homes this chain runs (chain average 3.2★, 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
PLEASANTVILLE VENTURES LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 12/01/2015
BOEHM, CAROLINEIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
GROS, CHARLES-EDOUARDIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/01/2015
GREYSTONE FUNDING COMPANY LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 08/01/2020
BABROFF, SHERRIIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/15/2015
DELANEY, DIANEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/14/2025
LEVI, SHLOMOIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2022
FLANCIA, MARIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/17/2022
KLEIN, BARUCHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2015
THADHANI, RAMCHANDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2016
VINITSKY, AVROHOMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2022

CMS files one row per role, so the 24 rows in the source record cover these 11 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.

$20.3M
Net patient revenuemost recent cost report
+2.2%
Operating marginrevenue minus expenses
$3.5M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 62%Medicare 14%Other / private 24%

This home reported $3.5M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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

$346per resident / day
operating cost
$10,506per month
≈ monthly operating cost
$353per 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 315054. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-31, 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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