Waterfront Rehabilitation And Healthcare Center
633 State Route 28, Raritan, NJ 08869 · For profit - Corporation · 138 certified beds · (908) 526-8950 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
- 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
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 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 | 3.7% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.7% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 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 | 6.3% | 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 | 1.8% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.9% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.9% | 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 | 3.0% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.2% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.2% | 12.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.5% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.6% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 1.5% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.52 | 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.
50.4% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 89.5% 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 57 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 50.4%CMS range 40.0–63.6 | 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 | 8.3%CMS range 5.3–12.0 | 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 | 89.5% | 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 | 87.7% | 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 | 80.7% | 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 | 96.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 1.1% | 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 | 6.0%CMS range 3.2–11.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.25 | 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 138 beds and averages 132.2 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 2.97 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.78 hrs/resident/day on weekends vs 3.05 on weekdays — 9% thinner on weekends. RN hours go from 0.41 to 0.30 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%.
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 · Dcited before2025-11-24 · 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
Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 2 of 2 residents (Residents #31 and #76) reviewed for positioning and mobility, and was evidenced by the following: 1). On 9/25/2025 at 10:48 AM, the surveyor observed Resident #31 awake and alert, resting in bed on a low-air-loss mattress (a mattress used to prevent pressure ulcers), with the weight set between 250 and 280 pounds. On 9/26/2025 at 10:55 AM, the surveyor made a follow-up visit to the resident's room. Resident #31 was observed resting in bed on the low-air-loss mattress. The mattress weight setting was between 250 and 280 pounds. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to amyotrophic lateral sclerosis (a progressive neurodegenerative disease that affects motor neurons, leading to muscle weakness and eventually paralysis). A review…
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 before2025-11-24 · 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 and interviews, it was determined that the facility failed to store and maintain the ice scoopers in a sanitary manner.This deficient practice was identified on 3 out of nursing 4 wings that contained ice coolers (Wings #1, #3, and #4) and was evidenced by the following: On 9/29/2025 between 11:18 AM and 12:20 PM, the surveyor observed the following:Wing #1 had a blue ice cooler that had a white mesh bag attached to it. There was an ice scooper resting in the mesh bag. The bottom of the mesh bag contained a moderate amount of black residue.Wing #3 also had a blue ice cooler with a mesh bag attached to it. Inside of the mesh bag there was an ice scooper resting inside of a foam cup. Within the cup, the surveyor observed a yellow-tinged liquid with black residue. Wing #4 had a blue ice cooler that had a mesh bag attached to it. When opened, the mesh bag revealed an ice scooper that had been placed into a plastic bag, that was not self-draining as required.On 09/29/2025 at 12:21 PM, the surveyor and the Infection Preventionist (IP) toured the units together and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of other pertinent facility documentation on 4/22/25 and 4/23/2025, it was determined that the facility staff failed to a.) consistently document in the Documentation Survey Report v2 (DSR) and b.) follow the facility's Charting and Documentation policy. This deficient practice was identified for 1 of 3 residents (Resident #4) reviewed for documentation. This deficient practice was evidenced by the following: On 4/22/25, at 11:38 A.M., the surveyor observed Resident #4 seated in a wheelchair at the bedside. During interview the resident denied having any care issues at that time. According to the admission Record, Resident #4 was admitted with the following diagnoses, that were not limited to: neoplasm of prostate (growth or tumor in the prostate gland), anxiety disorder, and acute kidney failure. The resident's quarterly MDS, dated [DATE], revealed a BIMS of 12 out of 15 which indicated the resident was moderately cognitively impaired. 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 · Fcited before2024-05-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure food and beverages stored in one of one kitchen were dated and did not have expired manufacturer's use by dates. This had the potential to affect 114 of 116 residents who consumed food prepared in the facility's kitchen. Findings include: 1. Observation on 05/27/24 from 9:20 AM to 10:00 AM, during the initial kitchen inspection, with the Dietary Manager (DM) present, revealed the following: a. Observation of food and beverages stored in the kitchen's walk-in refrigerator revealed an opened one-gallon container of Russian dressing with an expired manufacturer's use by date of 09/25/23, four five-pound containers of cottage cheese with expired manufacturer's use by dates of 05/15/24, one five-pound container of cottage cheese with an expired manufacturer's use by date of 05/24/24, and 10 undated and thawed four-ounce cartons of nutritional shakes. During an interview on 05/27/24 at 9:30 AM, the DM confirmed the container of Russian dressing, and five containers of cottage cheese had expired…
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 · E2024-05-30 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 observation, interview, record review, and facility policy review, the facility failed to ensure seven of eight residents (Resident (R)10, R77, R9, R45, R25, R57, and R83) reviewed for dignity were treated in a dignified manner out of 26 sampled residents. The facility failed to promote a dignified dining experience which included timely meal service, eating food at the same time as tablemates, and items served in non-disposable dishes for six of six residents (Resident (R)10, R77, R9, R45, R25, and R57) reviewed for dignity in dining. Additionally, the facility failed to honor R83's right to a dignified existence and self-determination by making her wear an identification wrist band after she made staff aware that she preferred not to wear the band. Findings include: 1. Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference Date ARD of 04/22/24, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 12 out 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 · E2024-05-30 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure there was an adequate supply of linens for 10 (R9, R25, R45, R75, R33, R7, R15, R94, R74, and a resident requesting to remain anonymous) out of 26 sampled and 25 supplemental residents. Specifically, there was an insufficient supply of towels to meet residents' needs. Findings include: 1. During the Resident Council Group interview on 05/28/24 at 10:00 AM, three of five residents who attended stated there was a problem with the availability of towels: -R9 and R25 stated there were not enough towels (bath towels and wash cloths) available. R9 and R25 stated they waited for the clean linen cart to be delivered to their halls and immediately got their own towels because if they did not, there would not be any towels available. -R45 stated he used his terry cloth bathrobe as a towel because he did not have any towels in his room. 2. During an interview on 05/29/24 at 9:31 AM, a resident who requested to remain anonymous stated there were not enough towels. The resident stated there were no towels currently…
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 · E2024-05-30 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, facility menu review, and facility policy review, the facility failed to ensure menus were prepared in advance which included a specific vegetable that was to be served for 39 of 56 lunch and supper meals on the facility's four-week menu cycle. This had the potential to affect 114 of 116 residents who consumed food prepared in the facility's kitchen. Findings include: 1. Review of R77's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/24, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R77 was cognitively intact. During an interview on 05/27/24 at 11:05 AM, R77 voiced a concern that the facility's menu frequently listed Vegetable of the Day instead of having a specific planned vegetable that was to be served at lunch and supper. R77 stated the same vegetables were served over and over at meals. R77 stated peas and carrots were often served at lunch and supper. During an interview on 05/29/24 at…
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 · E2024-05-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, test tray review, record review, review of Resident Council Minutes, and facility policy review, the facility failed to serve food that was palatable and at appetizing temperature for 13 of 13 residents (Resident (R) 26, R67, R81, R10, R86, R100, R105, R83, R84, R30, R45, R25, and R9) reviewed for food palatability out of 26 sampled residents. This failure had the potential to affect all 114 of 116 residents who consumed food prepared from the facility's kitchen. Findings include: 1. Review of R26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/24, located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated R26 was cognitively intact. During an interview on 05/27/24 at 11:48 AM, R26 stated at times meals were barely edible. R26 specified breakfast was not good and was not always hot when served. During an interview on 05/29/24 at 11:13 AM, R26 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-30 · 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 observation, interview, record review, and review of the facility's meal service times the facility served meals later than scheduled to residents who resided on four of five facility hallways which included five residents (Resident (R) 10, R57, R211, R30, and R25) of 26 sampled residents. This had the potential to affect 114 of 116 residents who consumed meals that were prepared from the kitchen. Findings include: Review of the facility's undated Meal service times schedule, provided by the Dietary Manager (DM) on 05/29/24, revealed meals were scheduled to be served at the following times: -Breakfast: Wing-5 (500 Hallway): 7:40 AM to 7:55 AM; Wing-1 (100 Hallway): 7:55 AM to 8:05 AM; Wing-2 (200 Hallway): 8:05 AM to 8:15 AM; Wing-3 (300 Hallway): 8:15 AM to 8:25 AM; Wing-4 (400 Hallway): 8:25 AM to 8:35 AM. -Lunch: Wing-5 (500 Hallway): 11:55 AM to 12:05 PM; Wing-1 (100 Hallway): 12:05 PM to 12:15 PM; Wing-2 (200 Hallway): 12:15 PM to 12:25 PM; Wing-3 (300 Hallway): 12:25 PM to 12:35 PM; Wing-4 (400 Hallway): 12:35 PM to 12:45 PM. 1. Review of R10's quarterly Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's 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 facility policy review, the facility failed to ensure guardianship documentation to support advanced directive decision making was in place for one of three residents (Resident (R) 66) reviewed for advanced directives of 26 sampled residents. R66 was not capable of making healthcare decisions and was documented as having a legal guardian. The facility did not have the guardianship documentation for R66. Findings include: Review of the undated admission Record, provided by the facility, revealed R66 was admitted on [DATE] with diagnoses including dementia, down syndrome, and aphasia (disorder resulting from damage to the brain affecting the ability to communicate). R66's family member (F) 66 was noted to be R66's responsible party and guardian. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/24 in the electronic medical record (EMR) under the MDS tab, revealed R66 was unable to complete the Brief Interview for Mental Status…
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 · D2024-05-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, interviews, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 24 reviewed for abuse was free from verbal abuse by a staff member of 26 sampled residents. This had the potential to affect resident safety at the facility. Findings include: Review of R24's admission Record, dated 05/30/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, congestive heart failure, bursitis of the left hip, anxiety, and chronic pain syndrome. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/24 and located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. The assessment indicated the resident was receiving both scheduled and as needed pain medications and the resident experienced…
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 · D2024-05-30 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure a Level One PASARR (Pre-admission Screening and Resident Review) was revised for one of two residents (Resident (R) 16) reviewed for PASARR after the resident was newly diagnosed with a major mental illness (MMI) of 26 sampled residents. This failure created the potential for residents to receive inadequate mental health services. Findings include: Review of R16's admission Record, located in the electronic medical record (EMR) under the Admission tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure and anxiety. A diagnosis of bipolar disorder was added to the resident's diagnoses list on 10/15/20 (approximately five months after the resident's original admission to the facility. Review of R16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/24 and located in the EMR under the MDS tab, indicated a Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure that two of 26 sampled residents (Residents (R) 9 and R100) care plans were revised to reflect the residents care needs. R9's care plan was not revised to reflect the physician ordered emergency dialysis dressing supplies to be maintained at the resident's bedside. Additionally, R100 was not allowed to participate in the scheduled care plan meetings. Findings include: 1. Review of R9's undated admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with hemodialysis. Review of R9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/23 and located in the resident's EMR MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score 15 out 15 which indicated the resident had intact cognition. The section for special treatments and procedures revealed the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident reviewed for activities (Resident (R) 74) was provided with a meaningful activity program of 26 sampled residents. An assessment of R74's activity preferences was lacking; the care plan was not specific to R74's interests, and R74 was not provided with sufficient activities to prevent boredom. Findings include: Review of the undated admission Record, provided by the facility, revealed R74 was admitted to the facility on [DATE]. During an interview on 05/27/24 at 11:55 AM, R74 stated he was a chess player and liked to play dominoes. R74 stated he enjoyed intellectual activities; however, there were not any people at the facility to play chess or dominoes with. R74 stated he stayed in his room with the TV on all the time and he had no activity beyond TV. R74 stated he was bored and getting weaker from doing nothing and asked, What am I supposed to do, walk up and down the hall? R74 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 facility policy review, the facility failed to change an indwelling urinary catheter every month as ordered for one of three residents (Resident (R) 26) reviewed for urinary catheter care out of 26 sampled residents. Failure to provide urinary catheter care as ordered can result in a resident developing a urinary tract infection. Findings include: Review of R26's undated Medical Diagnosis sheet, located under the Med Diag [Medical Diagnosis] tab of the electronic medical record (EMR), revealed R26 was admitted to the facility on [DATE] and had diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of R26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/24, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R26 was cognitively intact. The MDS also indicated R26 had an indwelling urinary…
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 · D2024-05-30 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure that one of one resident (Resident (R) 9) reviewed for dialysis of 26 sampled residents had emergency dressing supplies at the bedside according to the physician orders. The failure has the potential to delayed response to resident bleeding excessively from the dialysis port. Findings include: Review of R9's undated admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with hemodialysis and diabetes mellitus type II. Review of R9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/23 located in the resident's EMR MDS tab revealed the section for special treatments and procedures identified the resident was assessed to receive dialysis. Review of R9's quarterly MDS with an ARD of 05/11/24 located in the resident's EMR MDS tab revealed special treatment and procedures identified the resident was 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 · D2024-05-30 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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, interviews, and facility policy review, the facility failed to ensure one of six residents (Resident (R) 105) reviewed for accidents had appropriate physicians' orders, was provided informed consent, and was appropriately assessed for his use of side rails of 26 sampled residents. This failure had the potential to affect resident safety at the facility. Findings include: Review of R105's admission Record, dated 05/30/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including bilateral primary osteoarthritis of hip, pain in left hip, muscle weakness, cognitive communication deficit, dementia, and repeated falls. Review of R105's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/24 and located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident had moderately impaired…
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 · D2024-05-30 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure one of five residents reviewed for unnecessary medications (Resident (R58)) had a documented response to the Pharmacist's recommendations. Specifically, the Pharmacist made recommendations for dose reductions of an antidepressant medication, Lexapro, for R58 due to an irregularity. The Physician failed to document that the identified irregularity had been reviewed and what, if any, action was taken to address it, or the rationale to make no changes to the medication. Findings include: Review of the undated admission Record, provided by the facility, revealed R58 was admitted to the facility on [DATE] and had a diagnosis of depressive episodes. Review of the Order Summary, dated 02/13/24 in the electronic medical record (EMR) under the Orders tab, revealed a prescription for Lexapro [anti-depressant] Oral Tablet 20 milligrams (mg), one tablet by mouth in the morning for depression. Review of the Consultant Pharmacist'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.
- Potential for harm · D2024-05-30 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility served known food allergies and food dislikes to three of four residents (Resident (R) 102, R77, and R81) reviewed for food allergies and food choices out of 26 sampled residents. Findings include: 1. Review of R102's undated Medical Diagnosis sheet, located under the Med Diag [Medical Diagnosis] tab of the electronic medical record (EMR), revealed R102 was admitted to the facility on [DATE] and had an allergy to melon. Review of R102's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/24, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R102 was cognitively intact. Review of R102's care plan, with an initiation date of 02/28/24, located under the Care Plan tab of the EMR, contained the following Focus which specified, I have a nutritional problem or a potential nutritional problem r/t [related to] .Food Allergy. 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 · Dcited before2024-05-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review, the facility failed to ensure proper infection control for one of two residents (Resident (R) 107) reviewed for respiratory services of 26 sampled residents. R107's oxygen tubing and humidification cannister were not changed weekly to ensure sanitary administration of the resident's oxygen. Findings include: Review of R107's admission Record, dated 05/30/24 and located in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis and acute respiratory failure with hypoxia. Review of R107's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/02/24 and located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated the resident had severely impaired cognition. The assessment did not indicate the resident was receiving oxygen at the time 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 · E2022-03-22 · tag F0640 — patternEncode 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 interviews, review of medical records and other facility documentation, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS, an assessment tool), within 14 days of completing the resident's assessment. This deficient practice was identified for 13 of 16 residents reviewed (Residents #16, #20, #15, #2, #9, #12, #14, #1, #8, #4, #3, #11, #10), from system selected for MDS over 120 days for late submissions and for 2 of 28 residents reviewed (Residents #25, #24) for MDS completion and transmission. This deficient practice was evidenced by the following: During an interview with the surveyor on 03/04/22 at 11:50 AM, the Licensed Nursing Home Administrator (LNHA) stated that the MDS Coordinator left the facility a few months ago and he was unable to fill the position despite posting it. He stated that a Regional MDS Coordinator completed them in the interim and provided the surveyor with her contact information and an additional preferred contact. During a phone interview on 03/04/22 at 12:03 PM, the surveyor phoned the LNHA'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.
- Potential for harm · D2022-03-22 · 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
Based on interviews, review of medical records an other facility documentation, it was determined that the facility failed to complete the Comprehensive Minimum Data Set assessment in a timely manner for 3 of 16 residents reviewed (Residents #7, #13 and #17) for system selected MDS over 120 days for late submissions. This deficient practice was evidenced by: During an interview with the surveyor on 03/04/22 at 11:50 AM, the Licensed Nursing Home Administrator (LNHA) stated that the MDS Coordinator left the facility a few months ago and he was unable to fill the position despite posting it. He stated that a Regional MDS Coordinator completed them in the interim and provided the surveyor with her contact information and an additional preferred contact. During a phone interview on 03/04/22 at 12:03 PM, the surveyor phoned the LNHA's preferred contact who identified herself as an MDS Consultant. She stated that when the previous MDS Coordinator left, it became apparent that the MDS were backed up and they had been working weekly to resolve the issue and tried to catch up. She stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan for the use of oxygen for 1 of 2 residents reviewed for oxygen therapy, Resident # 57. This deficient practice was evidenced by the following: On 02/24/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident # 57,in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to an oxygen concentrator that was set at 2 lpm (liters per minute). On 03/01/22 at 12:50 PM the surveyor observed Resident #57 in bed with oxygen delivered through a nasal cannula at 2 lpm. A review of the admission Records (an admission summary) indicated Resident # 57 was admitted to the facility 02/2021 and had diagnoses, which included but were not limited to; Atherosclerotic Hearth Disease (build up in and on artery walls), Covid-19 (viral infection), and Hypertension (high blood pressure). A review of the Quarterly Minimum Data Set (MDS), an assessment tool used 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 · D2022-03-22 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility documents, it was determined that the facility failed to obtain physician orders to provide oxygen for 2 of 2 residents, Resident # 57 and #136, reviewed for oxygen in accordance with nursing professional standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: 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 a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The 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.
- Potential for harm · Dcited before2022-03-22 · 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 Based on interviews, record review, and review of facility policy, it was determined the facility failed to implement a physician's order for wound care to prevent the worsening of a left heel pressure ulcer and sacral pressure ulcer for 1 of 1 residents reviewed for pressure ulcers, Resident #122. This deficient practice was evidenced by the following: According the admission Record, Resident #122 was admitted to the facility in 1/2022 for rehabilitation. On 2/9/22 the resident was sent to an acute hospital and was readmitted on [DATE]. The resident had diagnoses that included, but were not limited to; hemiparesis (paralysis on one side of the body) following cerebral infarction (stroke), peripheral vascular disease (narrowing of arteries which results in reduced blood flow to head, arms, stomach and legs), and diabetes mellitus with diabetic polyneuropathy (the condition of nerve damage caused due to persistently high blood sugar level). A review of the admission Minimum Data Set (MDS), an assessment tool,…
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 before2022-03-22 · 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 observations, interviews, and review of other facility documentation, it was determined that the facility failed to a.) properly label and date food products stored in the walk-in refrigerator/freezer and b.) ensure that kitchen staff wore a hair restraint that fully covered their hair during food preparation in the kitchen in order to prevent foodborne illness for 1 of 1 staff member observed with improper hair restraint usage. This deficient practice was evidenced by: On 02/24/22 from 09:39 AM until 10:16 AM, the surveyor observed the following in the presence of the Director of Dining (DOD): 1. In the walk-in freezer: a. On the second shelf from the top of a four-tiered wired rack, the clear plastic outer packaging of a block of Swiss cheese was not secured and the cheese was opened and exposed to the air within the freezer. The DOD stated that he would re-wrap it correctly. b. On the second shelf from the top of a three-tiered wired rack, a previously opened package of frozen hamburger patties was wrapped in clear plastic, and was not dated. c. On the bottom shelf of 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 · Dcited before2022-03-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to maintain appropriate infection control practices for a.) maintaining the cleanliness of an oxygen concentrator and a feeding tube pump pole, for 1 of 2 residents reviewed for oxygen, Resident #57 and b.) the use of required personal protective equipment (PPE) on 1 of 5 units. This deficient practice was evidenced by the following: 1. On 02/24/22 at 01:20 PM, during the initial tour of the facility, the surveyor observed Resident # 57 in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to an oxygen concentrator that was set at 2 lpm (liters per minute). There was a feeding pump pole next to the oxygen concentrator. The resident was 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…
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 · D2022-03-22 · tag F0888 — isolatedEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, 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 3 of 3 partially vaccinated staff, and 1 of 2 unvaccinated staff, and was evidenced by the following: On 03/07/22 at 11:33 AM, the surveyor observed a Licensed Practical Nurse (LPN) working on unit 2 wearing a surgical mask and goggles. During an interview at that time, the LPN stated that she believed she was scheduled to receive her second dose of the vaccine on 3/18/22. On 03/07/22 at 11:46 AM, the surveyor observed a Certified Nursing Assistant (CNA), working on unit 3 wearing a surgical mask and goggles. During an interview at that time, the CNA stated that she was scheduled to receive her second dose of the vaccine on 03/20/22. On 03/08/22 09:42 AM, the surveyor observed the receptionist, sitting behind the plastic barrier at the desk, wearing a surgical mask, no goggles/face shield. She…
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 ATLAS HEALTHCARE — 29 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 | 5 of 5 | 3.6 | +1.4 vs chain |
| Health inspection | 4 of 5 | 3.1 | +0.9 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 28 homes this chain runs (chain average 3.6★, 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 |
|---|---|---|---|---|
| RIVERS EDGE HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2023 |
| COPPER NJ TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| GOLD NJ TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| MALT FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| NJ MAZEL PARENTCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| NJ NOBLE PARENTCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| SGS 2010 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| SILVER NJ TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| TYH 2017 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| MEISNER, ROBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/01/2023 |
| GOLDBERGER, SHLOMO | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2023 |
| BAK, PINCHOS | Individual | CORPORATE OFFICER | — | since 04/01/2023 |
9 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 85% 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 $533K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 315140. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-24, 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.