Carnegie Post Acute Care At Princeton LLC
5000 Windrow Drive, Princeton, NJ 08540 · For profit - Limited Liability company · 180 certified beds · (609) 987-1221 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- a high number of inspection citations overall (28) — 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 payroll-based staffing rating is low (2/5)
- about 23% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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
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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 3 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.
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 | 4.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.5% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 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 | 6.8% | 12.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.9% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.2% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.4% | 18.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 99.2% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 5.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 18.7% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.8% | 12.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.0% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.6% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.6% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.61 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.59 | 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.
59.3% 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 166 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.6% 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 140 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% 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 | 59.3%CMS range 50.1–66.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.2–13.9 | 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 | 68.6% | 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 | 61.4% | 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 | 61.4% | 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 | 100.0% | 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 | 4.2% | 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 | 7.0%CMS range 4.1–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.29 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 180 beds and averages 152.3 residents a day — about 85% occupied, or roughly 28 beds typically open. It usually has some room. 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 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.13 hrs/resident/day on weekends vs 3.64 on weekdays — 14% thinner on weekends. RN hours go from 0.62 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · D2025-12-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # 2624594, 2593784, 2584559 Based on interviews, medical record review, and review of pertinent facility documents on 10/17/25, it was determined that the facility failed to initiate a wound care treatment as recommended for three days in accordance with professional standards of practice. This deficient practice was identified for 1 of 5 residents reviewed for wounds (Resident #5). The evidence was as follows: A review of the admission Record (AR) revealed that Resident #5 was admitted to facility with diagnoses that included but were not limited to, acute respiratory failure, hypertension, lack of coordination, and anxiety disorder. A review Resident #5's comprehensive Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview Mental Status (BIMS) score of 11 out of 15, indicating that the resident's cognition was moderately impaired. A review of Resident #5's Care Plan (CP) with a focus initiated on 7/1/25, revealed that the resident had a potential for skin breakdown.…
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 · E2025-02-25 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and review of facility documents, it was determined that the facility failed to maintain an ongoing review for their Antibiotic Stewardship (AS) Program. This deficient practice was evidenced by the following: On 2/20/25 at 1:54 PM, the surveyor interviewed the Chief Nursing Officer (CNO), who stated she was the acting Infection Preventionist (IP) since the last one had recently resigned. She stated she attended the quarterly Quality Assurance & Performance Improvement (QAPI) meeting and reports on infection control. The surveyor requested to review the AS. The CNO requested the Director of Nursing (DON) to join the meeting. At 2:19 PM, the DON joined the interview with 2 Antibiotic Stewardship binders, 2024 and 2025. The CNO stated the facility uses McGeer's Criteria (a set of guidelines used to define and diagnose healthcare associated infections (HIAs) in long-term care Facilities (LTCFs). The surveyor asked to be shown unsampled Resident #15's antibiotic tracking for January 2025. The DON…
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 · E2025-02-25 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and review of pertinent facility documents, it was determined that the facility failed to have a designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) and physically worked onsite in the facility. This deficient practice was evidenced by the following: Reference: According to the NJ Executive Directive 21-012 (revised 12/22/22) included The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. According to the CMS QSO-22-19-NH Memo dated 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022, Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to have at least a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-25 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the admission Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 2 residents (Residents #339) reviewed for timing of assessments and was evidenced by the following: This deficient practice was evidenced by the following: On 2/21/25 a review of the electronic health record (EHR) reflected that Resident #339 was admitted to the facility on [DATE]. The Comprehensive admission MDS was noted to be in progress. On 2/21/25 at 12:45 PM, the surveyor interviewed the MDS Coordinator, who stated the MDS assessment on a new admission was due within 14 days of admission. She further stated that she was working on this MDS now and that it should've been done the day before yesterday (2/19/25). A review of facility provided MDS Policy reviewed 10/2024…
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 · D2025-02-25 · 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, review of medical records and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete and electronically transmit the Minimum Data Set (MDS), an assessment tool, within 14 days of the resident's discharge. This deficient practice was identified for 1 of 1 resident, (Resident # 83) reviewed in the Resident Assessment Task for MDS record over 120 days old. On 2/18/25, the surveyor reviewed the MDS history in the electronic medical record (EMR), which revealed that Resident #83 was discharged on 12/2/2024. The surveyor was unable to locate a discharge MDS in Resident #83's EMR. On 2/18/25, the surveyor interviewed the MDS Coordinator, who stated the discharge MDS on Resident #83 should've been completed within 14 days of the discharge date . She also stated, I'm not sure what happened. On 2/25/25, after surveyor inquiry, the surveyor noted the discharge MDS was completed on 2/19/2025 and was transmitted on 02/20/2025 (completion was due by 12/16/2024 and transmission was due by 12/30/2024). A review of…
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 · D2025-02-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ 00179151 Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 31 residents reviewed (Resident #5, Resident #43, and Resident #53) for MDS accuracy. This deficient practice was evidenced by the following: 1. On 2/19/25 at 11:33 AM, the surveyor observed Resident #5, in a wheelchair, in the day room on the 2nd floor. The resident was noted with their head down and eyes closed. On 2/19/25 at 02:43 PM, the surveyor observed Resident #5, out of bed, in a wheelchair in the bedroom, yelling out for help. On 02/19/25 at 02:46 PM, the surveyor observed Resident #5, in a wheelchair in the 3rd floor dining room yelling help continually. A review of Resident #5's admission record reflected that the resident was admitted to the facility with diagnoses that included but were 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.
- Potential for harm · D2025-02-25 · tag F0712 — isolatedEnsure 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
Complaint #: NJ 00179151 Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every thirty days from April 2024 through January 2025 for 1 of 34 residents, (Resident #5) reviewed for physician visits. This deficient practice was evidenced by the following: On 2/19/25 at 11:33 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was noted with their head down and eyes closed. A review of Resident #5's admission record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke), major depressive disorder (depression), and type 2 diabetes (high blood sugar). A review of the comprehensive significant change Minimum Data Set (MDS), an assessment tool dated 1/24/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15,…
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 · D2025-02-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ 00179151 Based on observations, interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure adequate indication for a resident with behaviors prior to the administration of an antipsychotic medication (Seroquel). This deficient practice was identified for 1 of 6 residents (Resident #5) reviewed for unnecessary medications and was evidenced by the following: On 2/14/25 at 12:13 PM, the surveyor observed Resident #5 in a wheelchair with raised footrests in the 3rd floor dining room ready for lunch. On 2/19/25 at 9:55 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was sitting with their head down and eyes closed. On 2/19/25 at 10:28 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was sitting with their head down and eyes closed. On 2/19/25 at 11:33 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was sitting with their head down and eyes…
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 before2025-02-25 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of pertinent facility documentation, the facility failed to a.) ensure the required committee members, the Infection Preventionist (IP), was present for one of seven Quality Assurance and Performance Improvement (QAPI) meetings and b.) review of Antibiotic Stewardship (AS). This deficient practice was evidenced by the following: A review of the facility provided QAPI Meeting 3rd Quarter dated 10/17/24, did not reveal the Infection Preventionist (IP) signed in. A review of the facility provided QAPI Meeting 4rd Quarter dated 1/16/24, revealed the Infection Preventionist (IP) signed in. On 02/25/25 at 1:21 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) to review the facility's QAPI. The LNHA reviewed the QAPI sign in sheets dated 10/17/24 and verified he did not see where the IP had signed in. The surveyor asked the LNHA to show the AS Information that was reviewed with the committee. The LNHA reviewed the QAPI binder and was unable to locate the AS data, he…
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 before2025-02-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and a review of facility documentation, it was determined that the facility failed to ensure laundry staff had the proper personal protection equipment (PPE) necessary to handle linens to prevent the spread of infection. This deficient practice was evidenced by the following: On 02/20/25 at 2:34 PM, the surveyor toured the laundry room with the Director of Nursing (DON), the Chief Nursing Officer (CNO) and the Director of Housekeeping (DH). The surveyor observed 3 dryers in use and clean linens, which included patient johnny coats (hospital gowns), folded on a table. The tour continued into to the washing machine side. The surveyor observed empty linen carts. The surveyor did not observe any PPE. The surveyor asked the DH the process for sorting dirty laundry. He stated staff sorted the laundry by wearing gloves and a patient gown. He explained staff came in from the dryer side with the gown. He took the surveyor back to the dryer side and showed the surveyor the short-sleeved hospital gown. He stated staff wore the gown and then put it in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2024-10-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00178967 Based on interviews and review of pertinent facility documents on 10/31/24, it was determined that the facility failed to report an alleged violation of abuse and its subsequent findings to the New Jersey Department of Health state agency and follow their facility policy on Abuse, Neglect and Mistreatment of Residents for a resident (Resident #1). The deficient practice was evidenced by the following: According to Resident #1's admission Record (AR), Resident was admitted to the facility with diagnoses of that included but not limited to the following: Cerebral Infarction, Metabolic Encephalopathy, Hypertension, Respiratory Failure, and Glaucoma. According to Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities, dated [DATE], revealed Resident #1's Brief Interview for Mental Status (BIMS) score was 12 which indicated Resident's cognition was moderately impaired. Resident #1's MDS further showed Section…
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 · E2023-08-03 · 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 Complaint #NJ00146686 Based on observation, interview, medical record review, and review of other pertinent facility documentation on 08/02/23 and 08/03/23, it was determined that facility staff failed to consistently document in the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the residents. In addition, the facility staff failed to follow the facility's policy titled Activities of Daily Living for 4 of 4 residents (Resident #1, #2, #4, and #5) reviewed for documentation. The deficient practice was evidenced by the following: 1. On 08/02/23 at 09:47 AM, the surveyor observed Resident #1 in their bed with their family member at their bedside. Resident #1 did not respond to the surveyor's greeting. A family member was interviewed at this time, and revealed they visited the facility every day. They also indicated that the facility staff cared for resident 's ADL needs in a timely manner. According to the admission Record (AR), Resident #1 was admitted to the facility…
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 before2023-01-31 · 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
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 a.) develop a comprehensive, person-centered care plan to address dementia care for Resident #16, b.) develop a comprehensive, person-centered care plan to address a sacral pressure ulcer for Resident #83, c.) develop a comprehensive, person-centered care plan to address the use of an antibiotic for Resident #109 and d.) develop a comprehensive, person-centered care plan to address pain management for Resident #122. This deficient practice was identified for 4 of 29 residents reviewed for comprehensive care plans and was evidenced by the following: 1. On 1/20/23 at 12:25 PM, the surveyor observed Resident #16 in the dining room in a recliner. The resident was alert but did not respond to the surveyor's inquiries. A review of the resident's medical record reflected the following: Review of the residents admission Record (an admission summary) reflected that he/she was admitted with diagnoses that included but 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.
- Potential for harm · Ecited before2023-01-31 · 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
Based on observation, interview, and record review, it was determined that the facility failed to a.) follow physician orders for Dilantin and Keppra (anti-epileptic medications used to control seizures) levels every three months since 8/9/2021 for Resident #13. This deficient practice was identified for 1 of 28 residents (Resident # 13) reviewed for physician orders; b.) act upon the Urology Consultation's recommnedation according to professional standards of clinical practice for Resident #90. This deficient practice was evidenced for 1 of 2 residents (Resident #90) reviewed for catheters. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of…
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 · E2023-01-31 · tag F0698 — failed to provide proper dialysis care — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to a.) consistently monitor fluid restriction instructions in accordance with the physician's order and professional standards of care and b.) carry out a dietitian recommendation for 1 of 2 residents (Resident #71) reviewed for dialysis care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11.…
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 · E2023-01-31 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards a.)accurately document the administration of a controlled medication for Resident #11; and b.) ensure that a resident was administered all their medications for Resident #11. This deficient practice was identified for one (1) of three (3) residents, Resident #11 and one (1) of two (2) nurses during medication observation pass; and failed to c.) maintain the availability of two topical analgesic medications (Diclofenac 1% gel and Biofreeze 4% gel ) for (1) one of (6) six residents interviewed during resident council, Resident #103. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual…
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 · E2023-01-31 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 1/26/23, the surveyor observed three (3) nurses administer medications to three (3) residents. There were 29 opportunities, and three (3) errors were observed, which calculated to a medication administration error rate of 10.34 %. This deficient practice was identified for two (2) of three (3) residents, (Resident #11 and #73), that were administered medications by two (2) of three (3) nurses. The deficient practice was evidenced by the following: On 1/26/22 at 9:05 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN #1) in the room of Resident #11. The surveyor observed LPN #1 checking the resident's identification bracelet and informing Resident #11 that she will be administering the resident's medications. The surveyor observed that the resident just finished eating breakfast. On 1/26/23 at 9:05 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.
- Potential for harm · Ecited before2023-01-31 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 4 of 5 medication carts inspected. This deficient practice was evidenced by the following: On 1/27/23 at 11:25 AM, the surveyor inspected the 3rd floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened and undated bottle of Morphine 20 mg/ml solution (medication for pain). The surveyor interviewed LPN #1 who stated that once a bottle of Morphine solution was opened that it should be dated because once opened it only had a 90-day expiration date. On 1/27/23 at 11:30 AM, the surveyor inspected the 3rd floor medication cart #2 in the presence of LPN #2. The surveyor observed an opened bottle of blood Glucose test strips (a product to test the blood sugar levels) that was not dated. The surveyor interviewed LPN #2 who stated that an opened bottle of blood Glucose test strips should have been dated. On 1/27/23 at 11:45 AM, the surveyor inspected the 2nd floor medication cart #2 in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-31 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 the safe and appetizing temperatures of food and drink served to the residents. This deficient practice was identified by 6 of 6 residents, who during the 1/23/23 Resident Council group meeting stated that hot foods were received cold, and confirmed during the lunch time meal service on 1/27/23 on 1 of 3 nursing units (third floor) tested for food temperatures by two surveyors, and was evidenced by the following: On 1/23/23 at 10:26 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. All six residents stated that hot foods were received cold at meals. On 1/27/23 at 11:44 AM in the presence of the survey team, the surveyor ensured that a state issued digital thermometer was calibrated (Calibration ensures that the thermometer is accurate and precise for the measurement of food temperatures) to the reading of 32 degrees Fahrenheit (F) via the ice bath method. On…
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 · E2023-01-31 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of pertinent facility documents, it was determined that the facility failed to consistently serve residents a nourishing snack when there was more than a 14-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for 6 of 6 residents (Resident's #2, #27, #30, #46, #63 and #103) during resident council meeting and was evidenced by the following: On 1/23/23 at 10:26 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. Four of six residents stated that they did not receive a bedtime snack even when they asked. One resident stated that I didn't know they had snacks, so I didn't know to ask for it. On 1/25/23 at 9:31 AM, in the presence of the survey team the Licensed Nursing Home Administrator (LNHA) stated that he reviewed and provided copies to the surveyor of the snack accountabilities logs from the electronic medical record for Resident's #2, #27, #30, #46, #63 and #103. He acknowledged that there were holes in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-01-31 · tag F0868 — patternHave 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 provide documentation to account for the Infection Control Preventionist attendance for 2 of 3 Quarterly Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings. This deficient practice was evidenced by the following: On 1/24/23 at 9:42 AM, the surveyor interviewed the Interim Infection Control Preventionist (ICP) in the presence of the survey team. The Interim ICP stated that she was responsible for the facility's infection prevention control program. She also stated that she had been coming in and out of the facility. However, she stated that she had been working full time in the facility, 50 hours per week for the past 3 weeks. She informed the surveyor that prior to her, the facility hired an ICP on 2 separate occasion and neither of which remained in the facility. During the interview, the surveyor asked the Interim ICP if she attended the Quarterly QAPI committee meetings. She stated that she had not attended the QAA…
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 before2023-01-31 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of other pertinent documentation, it was determined that the facility failed to ensure a.) staff adhered to standards of infection control practices for the appropriate disposal of a soiled incontinence brief and b.) practiced appropriate hand hygiene in accordance with the Centers for Disease Control (CDC). This deficient practice was identified for (1) one staff member on one (1) of three (3) units. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines, Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 01/18/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together…
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 before2020-10-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review, and review of other facility documentation, it was determined that the facility failed to: a.) transcribe orders to the electronic physician's orders and medication administration record (eMAR), for 2 of 3 residents reviewed for oxygen, (Resident #25 and #30); b.) check for placement of an enteral feeding tube prior to a bolus feed; and c.) label and date a resident specific multi-use gallon of water for an enteral tube flush for 1 of 2 residents (Resident #50) reviewed for tube feeding. 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 case finding, health teaching, health counseling, and provision of care…
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 before2020-10-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review other facility documentation, it was determined that the facility failed to a.) ensure a care plan was developed timely for a resident who was receiving oxygen and b.) to ensure a fall intervention was implemented after a resident had a fall. This was identified for 2 of 21 residents reviewed for care plans (Resident #30 and #89). This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #30 was admitted in 07/2020 with diagnosis which included but were not limited to; Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of Resident #30's admission Minimum Data Set (MDS), an assessment tool dated 07/16/20, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident's cognition was intact. The MDS also revealed that the resident used oxygen. On 10/20/20 at 11:30 AM, the surveyor observed an oxygen concentrator connected 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 · Dcited before2020-10-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility documents, it was determined the facility failed to remove an expired medication and maintain a clean, orderly medication cart for 2 of the 3 carts inspected. This deficient practice was evidenced by the following: On [DATE] at 12:27 PM, in the presence of the Unit Manager (UM), the surveyor inspected the second floor medication cart (Cart #2) and observed the following: in the first bin of the third drawer, there was one pink tablet and one green tablet which were unwrapped and unmarked. In the second bin of the third drawer, there were two orange tablets, one pink tablet, one yellow tablet, two white tablets, and one-half white table which were unwrapped and unmarked. When interviewed at that time, the UM stated the med cart drawers were cleaned before and after every shift and as needed for spills. The UM further stated loose medications were destroyed by the nurse using a drug destroyer and that the nurse checked expiration dates for safety to avoid 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 · D2020-10-27 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 10/20/20 at 9:35 AM, during the initial tour of the kitchen, the surveyor who was accompanied by the Food Service Director (FSD), observed the following in the kitchen: In the dry storage room: 1. A 20-pound opened bag of [NAME] was not labeled with a received or opened date. 2. A 10-pound opened bag of Tri-Color Rotini was not labeled with a received or opened date. In the walk-in freezer: 1. An opened bag of potato skins was not labeled with a received or opened date. 2. A 10-pound opened undated box of precooked lasagna sheets in an opened plastic bag opened and not dated as to when the bag was opened. The FSD stated that all food that came into the building needed to be labeled with a received date. The FSD stated the unlabeled foods…
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 · B2023-01-31 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to provide written notification of the emergency transfer to the resident, resident representative, and the Office of the Long-Term Care Ombudsman (LTCO) for two (2) of two (2) residents (Resident # 88 and Resident # 113), reviewed for hospitalizations. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical records of Resident # 88. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to functional quadriplegia, epilepsy, unspecified, and gastrostomy status. Review of the New Jersey Universal Transfer Form (NJUTF) dated 8/31/22, indicated the resident was transferred to the hospital for fever. Review of the Minimum Data Set (MDS) dated [DATE], indicated the resident had a discharge assessment with return anticipated. Review of the NJUTF dated 10/3/22, indicated the resident was transferred 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 · B2023-01-31 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to provide residents and/or their representatives with the facility's notice of bed hold policy. This deficient practice was identified for two (2) of two (2) resident (Resident # 88 and Resident # 113), reviewed for hospitalization. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical records of Resident # 88. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to functional quadriplegia, epilepsy, unspecified, and gastrostomy status. Review of the New Jersey Universal Transfer Form (NJUTF) dated 8/31/22, indicated the resident was transferred to the hospital for fever. Review of the Minimum Data Set (MDS) dated [DATE], indicated the resident had a discharge assessment with return anticipated. Review of the NJUTF dated 10/3/22, indicated the resident was transferred to the hospital for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 MB HEALTHCARE — 12 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 | 4 of 5 | 3.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 3.1 | -0.1 vs chain |
| Staffing | 2 of 5 | 2.9 | -0.9 vs chain |
| Quality measures | 5 of 5 | 4.6 | +0.4 vs chain |
The other 11 homes this chain runs (chain average 3.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| JOES BEACH LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 14% | since 06/14/2023 |
| BRODT, MOSHE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 51% | since 06/14/2023 |
| FRANKL, CINDIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 6% | since 06/14/2023 |
| THE BEACH IS BACK TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 14% | since 06/14/2023 |
| SOMMERS, DOVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/14/2023 |
| CZAPNIK, CHAIM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/14/2023 |
| PILLER, MENDY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 11/29/2025 |
| SCHLOSS, DEBORAH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/08/2025 |
| MB HEALTHCARE SERVICES LLC | Organization | ADP OF THE SNF | — | since 06/14/2023 |
| DORFMAN, YAAKOV | Individual | ADP OF THE SNF | — | since 06/14/2023 |
| PECORA, JOSEPH | Individual | ADP OF THE SNF | — | since 06/14/2023 |
CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 23% 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 315370. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-25, 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.