Ashbrook Care & Rehabilitation Center

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

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.

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.

49.2% 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 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 82.6% 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 46 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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.

Staffing

How full it usually is: this home is certified for 114 beds and averages 88.4 residents a day — about 78% occupied, or roughly 26 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 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.47 on weekdays — 12% thinner on weekends. RN hours go from 0.60 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 21% 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.

30 citations, most serious first. The 14 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · Jdisputed · IDR2025-05-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect 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

  Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to protect Resident #43, as well as all residents from abuse, when on 5/7/25, an alert and oriented resident (Resident #43) with a history of being abused, informed the surveyor that they reported an allegation of sexual abuse to staff that was not investigated. This deficient practice occurred for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. An additional interview on 5/7/25, Resident #43 reported to the surveyor that they could not recall the exact date that two female staff entered their room and inappropriately touched their buttocks and they reported the incident to an unidentified facility staff member. An interview on 5/7/25, with the Registered Nurse/Unit Manager (RN/UM #1), confirmed that Resident #43 was alert 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited beforedisputed · IDR2025-05-09 · tag F0609 — failed to report abuse allegations — isolated
  Timely 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

  Refer to F 600 and F 610 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of sexual abuse after Resident #43 reported to the Registered Nurse/Unit Manager (RN/UM #1) that sometime at the end of December 2024 or January 2025, their buttocks was inappropriately touched by two female staff members. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. An additional interview on 5/7/25, Resident #43 reported to the surveyor that they could not recall the exact date that two female staff entered their room and inappropriately touched their buttocks and they reported the incident to an unidentified facility staff member. An interview in 5/7/25, with the Registered…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jdisputed · IDR2025-05-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Refer to F 600 & F 609 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to initiate and complete a thorough investigation for an allegation of sexual abuse, after a resident (Resident #43) informed staff that two female staff members inappropriately touched their buttocks. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. An additional interview on 5/7/25, Resident #43 reported to the surveyor that they could not recall the exact date that two female staff entered their room and inappropriately touched their buttocks and they reported the incident to an unidentified facility staff member. An interview in 5/7/25, with the Registered Nurse/Unit Manager (RN/UM #1), confirmed that Resident #43 was alert and oriented to person, place, and time, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jdisputed · IDR2025-05-09 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Refer F 600, F 609, F 610 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) ensuring all residents were protected from abuse; b.) ensuring an allegation of sexual abuse was thoroughly investigated; and c.) reporting an allegation of sexual abuse to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. An additional interview on 5/7/25, Resident #43 reported to the surveyor that they could not recall the exact date that two female staff entered their room and inappropriately touched their buttocks and they reported 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-05-09 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 173967 REPEAT DEFICIENCY Based on observation and interview, it was determined that the facility failed to ensure the environment and common areas were maintained in a clean, homelike and sanitary manner. The deficient practice occurred on 2 of 2 resident units (North and South) and in the main dining room/activity room and was evidenced by the following: On 5/4/25 at 7:15 AM, the surveyor entered the main dining room and observed the wall air condition unit was missing molding around it, there were visible rips in the wall paper in several areas, the ceiling was cracked, the vents in the dining room were soiled with debris, the window air conditioning unit had debris inside the vent, and several chairs were visibly worn through the paint and at 7:19 AM, the surveyor interviewed the Infection Preventionist Licensed Practical Nurse who confirmed that the dining room was used daily. On 5/4/25 at 7:26 AM upon entering the North, Sub-Acute Unit, the surveyor observed a ceiling light fixture with 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and document review it was determined that the facility failed to store all potentially hazardous foods at appropriate temperatures and maintain the kitchen environment and equipment in a clean and sanitary manner to limit the potential for food borne illness. The deficient practice was evidenced by the following: On 05/04/25 at 6:29 AM, the surveyor completed a brief initial tour of the kitchen with the [NAME] and observed the following: 1. The can opener affixed to the metal table had embedded debris on the base, blade and metal shavings were visibly embedded in the debris and the insert on the base of the can opener. 2. The refrigerated sandwich preparation refrigerator contained a thermometer next to metal food containers with a reading of 60 degrees Fahrenheit (F) with a metal pan of sandwiches on top of and next to various containers including, but not limited to; metal containers labeled Tuna, 5/2-5/4; Swiss Cheese 4/27-5/3; Turkey 5/3-5/9. The surveyor asked the [NAME] to check the temperatures of the food items and the cook placed 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: LAW, [NAME] Complaint NJ # 173967 Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents who were dependent on staff assistance for care, by failing to provide: a) incontinence care, and b) nail care. This deficient practice was identified for 5 of 5 residents reviewed for ADL care (Resident #14 , #30, #31, #15 and Resident #33). Findings included: On 5/4/25 at 6:30 AM, Surveyor #1 assisted with a random Certified Nursing Aide (CNA) performed an incontinence care tour. The South Wing had a strong urine odor. 1. At 6:35 AM, Surveyor #1 noted the strong smell of urine and entered Resident #14's room. Surveyor #1 observed the 11:00 PM to 7:00 AM Certified Nurse Aide (CNA) assessed the resident for incontinence. Resident #14 was observed wearing an incontinence brief with a rolled up towel between the incontinence brief and the residents…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-09 · tag F0698 — failed to provide proper dialysis care — pattern
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure; a) Peritoneal Dialysis (PD - a procedure using the lining of the abdomen to filter out waste products from the blood) supplies were not stored directly on the floor in the room to avoid possible contamination; b) facility staff were trained and received competencies in PD; and c) staff were documenting the administration of PD. This deficient practice was identified for 1 of 1 resident (Resident #229) reviewed for PD and was evidenced as follows: A review of the admission Record (an admission summary) revealed that Resident #229 was admitted with diagnoses which included but were not limited to; End Stage Renal Disease, dependence of renal dialysis, and pneumonia. A review of the admission Minimum Data Set (MDS) a tool used to facilitate care, dated 4/30/25, included a Brief Interview for Mental Status (BIMS) of 03 out of 15 which indicated severely impaired cognition. The MDS further documented that Resident #229 had been admitted with being 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-09 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure 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 maintain a medication error rate below 5%. On 5/4/25 at 8:09 AM, 2 surveyors observed 2 nurses administered 25 doses of medication to 3 residents and there were 2 errors which resulted in a medication error rate of 8%. The deficient practice was evidenced by the following: On 5/4/25 at 8:09 AM Surveyor #1 observed the Registered Nurse (RN ) on the South Wing, administered the following medications to Resident #15: Pantoprazole 40 mg 1 tab medication to treat Gastroeosophageal reflex. Dutasteride 0.5 mg 1 tab medication to treat benign prostatic hyperplasia Metropolol 25 mg 1 tab,medication to treat hypertension Miralax 17 gm, medication to treat constipation. Verapamil 120 mg 1 tab medication to treat hypertension. Apixiban, 5 mg, ( not administered). medication to treat blood clot. The RN poured 5 milliliters ( ml) of the Miralax powder into a medication cup, then she added only 15 ml of water, stirred it and gave it to the resident. 1/2 of the medication was left in the medication…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-09 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to consistently follow medication hold parameters according to the physician's order. This deficient practice was identified for 1 of 3 residents reviewed for medications (Resident #1). The deficient practice was evidenced by the following: On 5/6/25 at 11:05 AM, the surveyor observed Resident #1 sitting in their bed. The Certified Nurse Aide (CNA) was present in resident's room. On 5/7/25 at 11:53 AM, the surveyor reviewed Resident #1's electric medical records (EMR) which revealed the following: The admission Record (AR; admission summary) revealed that Resident #1 had diagnoses which included but were not limited to: hypertension (high blood pressure), dementia and type 2 diabetes. A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate management of care, dated 3/22/25, revealed that Resident #1 had a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of severe 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-09 · tag F0814 — failed to dispose of garbage properly — isolated
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview it was determined that the facility failed to dispose of refuse in a manner to maintain a sanitary environment and prevent potential pests. The deficient practice was evidenced by the following: On 5/4/25 at 7:05 AM, the surveyor observed the dumpster area with the Food Service Director (FSD) and observed the garbage dumpster door was open and filled with garbage bags and the recycling dumpster was also open. The area adjacent to the dumpster had various debris, pallets, old garbage cans and various debris including various plastic, paper, and pallets were strewn in the wooded area behind the dumpster. The FSD stated the dumpsters should be closed and the area should not look like that and proceeded to close the dumpster doors. On 5/5/25 at 10:42 AM, the surveyor informed the Regional Licensed Nursing Home Administrator (RLNHA) and the Licensed Nursing Home Administrator (LNHA) of the debris and refuse outside of the open dumpsters and showed the pictures taken on 5/4/25. The RLNHA stated that he was not aware and it would be taken care of. NJAC…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-12-15 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and review of other facility pertinent documents, the facility failed to have a designated licensed Director of Nursing (DON) on a full time basis to oversee the care of all residents in the facility with 114 licensed beds. This failure increased the risk that all residents would not be provided with appropriate and accurate care and assessments from March 1, 2023, through July 10, 2023. This deficient practice was evidenced by the following: On 12/01/23 at 9:33 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), and the Infection Preventionist Nurse (IPN). The LNHA stated that the facility had 114 licensed beds. The ADON stated that she had been at the facility for three months. On that same date and time, the LNHA stated that there was no Director of Nursing (DON) at the moment and that the new DON will start on 12/11/23. The LNHA further stated that the previous DON #1 (DON#1) who had not been at the facility for a month had left. The surveyor asked for the DON timeline after 02/06/23 (the last…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-12-15 · tag F0756 — failed to review each resident's drug regimen — widespread
  Ensure 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

  Based on interviews and a review of pertinent facility documents, it was determined that the facility failed to provide oversight by a licensed Consultant Pharmacist (CP), to review the resident's medication regimen and medical record to identify and report irregularities for 17 out of 20 residents, (Residents #1, #11, #16, #17, #18, #24, #26, #38, #39, #43, #56, #61, #65, #72, #76, #87, and #90) reviewed during Medication Regimen Review (MRR), according to facility's policy and procedure. This deficient practice was evidenced by the following: 1. On 12/01/23 at 9:12 AM, the surveyor observed Resident #1 sitting on edge of bed eating breakfast and dressed appropriately. The surveyor reviewed the hybrid (a combination of paper-based and electronic medical records that primarily involves tracking and storing a patient's health records in several formats and places) medical records of Resident #1. Resident #1's admission Record (AR; or face sheet, an admission summary) reflected that that resident was a long-term care (LTC) resident at the facility and had diagnoses which included but…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-12-15 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in 11 out of 17 resident rooms and one (1) of one (1) shower room observed during environmental rounds. This deficient practice was evidenced by the following: On 12/05/23 at 10:39 AM, the surveyor observed the wound care treatment of Resident # 39 that was done by the Licensed Practical Nurse (LPN) and was assisted by the Registered Nurse/Unit Manager (RN/UM). The LPN performed handwashing inside the toilet room, the toilet room was adjoined (a toilet room that is accessed from and used exclusively by the occupants of two adjacent sleeping units) and the toilet tissue paper holder dispenser was broken. The two rooms with the adjoined toilet were for rooms [ROOM NUMBERS]. Resident #39 was in room [ROOM NUMBER]. After the wound treatment, the LPN went outside 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$89,583 in federal fines across 12 penalties.

• $44,486 — penalty dated 2025-05-09
• $4,587 — penalty dated 2023-10-30
• $4,587 — penalty dated 2023-10-23
• $4,587 — penalty dated 2023-10-17
• $4,587 — penalty dated 2023-10-10
• $4,587 — penalty dated 2023-10-02
• $4,587 — penalty dated 2023-09-25
• $4,235 — penalty dated 2023-09-18
• $3,812 — penalty dated 2023-09-11
• $3,529 — penalty dated 2023-09-05
• $3,176 — penalty dated 2023-08-28
• $2,823 — penalty dated 2023-08-21

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to AUTUMN LAKE HEALTHCARE — 59 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 →

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

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.

This home reported $1.2M 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