Aristacare At Cedar Oaks
1311 Durham Avenue, South Plainfield, NJ 07080 · For profit - Limited Liability company · 230 certified beds · (732) 287-9555 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.7% | 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 | 0.6% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 7.3% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.2% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.7% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.4% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.5% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.1% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.0% | 80.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.5% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.2% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.72 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.69 | 1.11 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 258 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.6% 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 141 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.5%CMS range 53.1–66.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.7–14.2 | 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 | 81.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 80.8% | 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 | 78.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 4.8–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.20 | 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 230 beds and averages 203.1 residents a day — about 88% occupied, or roughly 27 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 2.90 hrs/resident/day on weekends vs 3.33 on weekdays — 13% thinner on weekends. RN hours go from 0.64 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% 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 more than at the previous inspection — worsening. 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 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · J2025-08-25 · 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
COMPLAINT #: NJ00183422, NJ00186468 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on 08/22/25, it was determined that the facility failed to immediately implement their abuse policy to ensure residents were protected from abuse by not removing the accused staff from resident care pending full investigation of an abuse allegation. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #1) and had the potential to affect all residents. According to Facility Reportable Event (FRE), at approximately 6:00 AM on 05/03/2025 Resident #6 (the roommate of Resident #1) reported to Registered Nurse #1 (RN #1) that Resident #1 moaned in pain while a Certified Nursing Assistant (CNA) was providing morning care (turning and repositioning) for the resident. The FRE included that RN #1 assessed the resident and reported the incident to the Nursing Supervisor. No further action was taken to investigate Resident #6's report as an abuse allegation. On 05/05/2025, the Unit Manager (UM) #1 and the Director…
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 before2026-04-15 · 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 observations, interviews, and review of facility provided documents, it was determined that the facility failed to store and prepare food in a manner which followed kitchen sanitation practices to prevent the potential development of food borne illness. This deficient practice was identified in 2 of 2 kitchens (main kitchen and ethnic specialty kitchen) reviewed, and was evidenced by the following: A.On 4/9/26 at 9:37 AM, during the initial tour of the main kitchen with the Food Service Director (FSD) and the Regional FSD (RFSD), the surveyor observed the following: 1. A stacked refrigerator against the back wall. On the top shelf inside the refrigerator, the surveyor observed a dark cloth bag with a paper attached. The paper had a name and Do not touch 4/10 written on it. The FSD stated the refrigerator was used to store margarine, juice, and other small items for residents that could be grabbed by kitchen staff quickly and easily if needed. The FSD removed the cloth bag from the refrigerator and acknowledged the bag contained a staff member's food which should not have…
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 before2026-04-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and review of pertinent facility provided documents, it was determined that the facility failed to; a.) ensure kitchen staff followed hand hygiene practices to prevent the spread of infection or food borne illness; b.) wear appropriate Personal Protective Equipment (PPE) and use appropriate hand hygiene during tracheostomy care and c.) follow appropriate hand hygiene during meal service to prevent the potential spread of infection. This deficient practice was identified in 2 of 2 kitchens observed for hand hygiene, 1 of 1 resident (#16) reviewed for tracheostomy care, and 1 of 4 dining areas reviewed for infection prevention, and was evidenced by the following: 1. On 4/9/26 at 8:52 AM, during an initial tour of the main kitchen, the surveyor observed [NAME] #1 wipe her bare hands on the sides of her pantlegs then don (put on) gloves and transport a plastic bin of food, which she identified as seasoned raw chicken, to the refrigerator. She returned, removed and disposed of her gloves, and donned new gloves. The surveyor did not observe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility documents it was determined that the facility failed to maintain the dignity of an unsampled resident who required assistance to eat during lunch. This deficient practice was identified on 1 of 4 units (Cedar Unit) observed during lunch. This deficient practice was evidenced by the following:On 4/13/26 at 12:58 PM, the surveyor observed Certified Nursing Aide (CNA) #1 feeding an unsampled resident while standing up. At 1:01 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) instructed CNA #1 to sit down. CNA #1 left the dining room and returned with a folding chair. CNA #1 sat behind to the right side of the resident and proceeded to feed them. On 4/13/26 at 1:15 PM, the surveyor interviewed CNA #1, who stated staff were supposed to be sitting on the side of the resident or next to the resident when assisting with feeding. CNA #1 further stated you should be facing the resident so you can control and see the resident chewing their food. He further stated, if you are standing while feeding them, you cannot see their face.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the resident's call bell (CB; a bell used to summon staff for assistance) was readily accessible and within reach of the resident. The deficient practice was identified for one (1) of one (1) resident, Resident #184, reviewed for accommodation of needs. This deficient practice was evidenced by the following:On 4/9/26 at 11:41 AM, the surveyor observed Resident #184 resting in their bed. The surveyor greeted the resident and the resident sat up to speak with the surveyor. The surveyor observed Resident #184's CB was out of reach on the floor, which was on the left side of the nightstand. The surveyor asked the resident how they would call the staff for help, the resident stated that they would call out (shout out) for help when needed. On 4/10/26 at 12:54 PM, the surveyor observed Resident #184 sitting in their wheelchair. The surveyor observed the CB on the floor, in the same position as it was observed on the previous day. 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 · D2026-04-15 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete timely background checks for 4 out of 155 employees (Employee #1, #4, #12, and #14) and b.) complete timely reference checks for 3 out of 155 employees (Employee #3, #7, and #8). This deficient practice was identified for newly hired, since last survey of 11/21/2024, employee files reviewed.This deficient practice was evidenced by the following:On 4/9/26 at approximately 10:22 AM, during the entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), all newly hired employee files for active and inactive employees from 11/21/24 to the current date.a. A review of the employee personnel files revealed the following:Employee #1, a Speech Therapist with a date of hire (DOH) 7/7/25, the background check was completed 6/5/24. Employee #4, a Registered Nurse (RN) with a DOH 7/18/25, the background check was completed 7/23/25. Employee #12, a RN with a DOH 3/27/26, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · 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 observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop an individual comprehensive care plan (ICCP) to address the needs of a resident with Asthma (a condition that causes your airways to swell, narrow and fill with mucus), and nebulizer treatments (a way to deliver liquid medicine directly into the lungs by turning it into a fine breathable mist). This was identified for 1 of 3 residents (Resident #69) reviewed for Respiratory Care. This deficient practice was evidenced by the following:On 04/09/2026 at 10:21 AM, the surveyor observed Resident #69's nebulizer tubing and mouthpiece (a device used to deliver medication directly into the lungs) on the table in a clear plastic bag, dated 4/8/2026.The surveyor reviewed the electronic medical records for Resident #69 which revealed the following:The admission Record (AR; an admission summary) reflected that the resident was admitted to the facility, with diagnoses that included but were not limited to; Cerebral Infarction (disrupted blood flow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · 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 a low air loss (pressure reducing) mattress was functioning properly and accurately setup according to resident weight for a resident who was previously identified to have had an alteration in skin integrity.This deficient practice was identified for 1 of 4 residents (Resident #16) reviewed for pressure ulcers and was evidenced by the following:On 4/10/26 at 10:06 AM, the surveyor observed Resident #16 lying in bed, awake, on an air mattress. The air mattress pump was observed to be set to a weight of 380 pounds. Resident #16 was wearing a hospital gown and noted to have a tracheostomy site (a surgical hole in the neck to assist breathing). The resident was able to communicate with the surveyor using short one- or two-word answers. Resident Representative #1 was at the bedside and able to provide resident history and information to the surveyor with the resident's consent and input. Resident Representative #1 stated that they came to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow a physician's order for oxygen therapy. This deficient practice was identified for 1 of 3 residents (Resident #101) reviewed for respiratory care.This deficient practice was evidenced by the following: On 4/9/26 at 11:25 AM, during the initial tour of the facility, the surveyor observed Resident #101 lying in their bed watching television. The surveyor observed an oxygen concentrator (device that delivers oxygen) with a nasal cannula tubing (NC - device that delivers additional oxygen through the nose) administering oxygen at 3 liters per minute (lpm). The resident stated that they always wear the nasal cannula and receive oxygen continuously. On 4/10/26 at 9:49 AM, the surveyor observed the resident in their room lying in bed awake watching television. The surveyor observed the resident receiving oxygen via nasal cannula at 3 lpm. On 4/10/26 at 12:25 PM, the surveyor observed the resident in the dining room area in their wheelchair eating lunch. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure professional standards of nursing practice were followed by performing accurate verification of a resident's name on the label of a medication (Eliquis) (a medication used to thin the blood) prior to administration. The deficient practice was identified for one (1) of three (3) nurses administering medications to one (1) of five (5) residents, (Resident #3) observed during the medication administration observation. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-15 · 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 observations, interviews, review of the medical record, and review of other facility documentation, it was determined that the facility failed to respond timely to the monthly Consultant Pharmacist (CP) recommendations. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications (Resident #46 and #194). The deficient practice was evidenced by the following:1.On 4/9/2026 at 11:45 AM, during initial tour, the surveyor observed Resident #194 sitting in a wheelchair, in their room. The surveyor reviewed the electronic medical record (EMR) for Resident #194 A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions 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.
Show the remaining 17 citations
- Potential for harm · Ddisputed · IDR2026-04-15 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to obtain consent to ensure that the residents did not receive an unnecessary medication for 1 of 5 residents reviewed for unnecessary medications, (Resident #46). This deficient practice was evidenced by the following:On 04/10/2026 at 10:17 AM, Resident # 46 was observed sitting in a wheelchair in the activities, in the Day Room. The resident was quiet, calm, and not interactive.On 04/13/2026 10:40 AM, the resident was observed in the Day Room during religious activities, the resident was sitting in a wheelchair, not engaging in activities.The surveyor reviewed the electronic medical record (EMR) for Resident #46:A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; other specified mental disorders due to known physiological condition, and other specified depressive episodes (mood disorders characterized by significant depressive symptoms that do not fulfill the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 11/07/24 at 9:39 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and a second surveyor. The following was observed: 1. Two top reach in refrigerators that held milk. The refrigerator on the right stored four- and eight-ounce milks and the refrigerator on the left stored gallon milk. Both had gray gaskets on the doors which had a heavy buildup of a black substance on the underside of the top gaskets. The FSD stated it was mold and needed to be cleaned. 2. In the room outside the main kitchen, the surveyor observed a windowsill next to a metal rack which stored boxes of salt and pepper packets. The sill had large amount 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 · D2024-11-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 37 residents reviewed (Resident #16, Resident #34, and Resident #429). This deficient practice was evidenced by the following: 1. On 11/7/24 at 11:08 AM, the surveyor observed Resident #16 to be out of bed, in a wheelchair, and in the dayroom participating in activities. On 11/8/24 at 1:10 PM, the surveyor observed Resident #16 in a wheelchair, outside smoking with staff supervision. A smoking apron was visible on Resident #16's lap. A review of the admission Record face sheet (an admission summary) reflected Resident #16 had diagnoses which included but not limited to: Alzheimer's disease. A review of the admission MDS, an assessment tool dated 4/23/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 9…
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 before2024-11-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to ensure the necessary respiratory care and services were provided in a manner to prevent the spread of infection for 1 of 4 residents (Resident #4) reviewed for respiratory care. This deficient practice was evidenced by the following: On 11/7/24 at 10:57 AM, the surveyor observed Resident #4's nebulizer machine (an electric machine that converts liquid medication to a fine mist) on the dresser in their room, surrounded by personal items. The tubing attached to the nebulizer was not labeled or dated. Additionally, the nebulizer mask was not covered and was left exposed to the air. The exterior of the nebulizer machine showed yellowish stains and a brown fuzzy debris accumulation on the surface. On 11/12/24 at 12:09 PM, the surveyor observed the same nebulizer machine. The stains on the exterior of the machine and the brown fuzzy debris covering the surface remained present. The nebulizer mask was uncovered and exposed to the air. On 11/13/24 at 9:51 AM, the surveyor interviewed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · 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
Compliant #: NJ169617 Based on observation, interviews, review of the medical record and other pertinent facility documents, it was determined that the facility failed to ensure that a resident received preferred and accurate meal items at lunch service and in accordance to what was indicated on the meal ticket. This deficient practice occurred for 1 of 8 residents observed during dining service (Resident #147), and was evidenced by the following: On 11/08/24 at 12:29 PM, during the lunch meal service, the surveyor observed Resident #147 sitting in a wheelchair in their room. The resident was accompanied by a family member who stated that the resident consistently received incorrect meals. The resident stated that he had ordered pork chops but was served fish instead. The resident confirmed he has previously informed the staff that he did not like fish. A review of the admission Record (an admission summary) included that the resident was admitted with diagnoses that included but were not limited to; cerebral infarction (stroke), essential hypertension, Alzheimer's disease,…
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 · D2024-11-21 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to a.) ensure a resident received liquids in the appropriate consistency at bedside in accordance with physician orders and b.) follow the guidance on the resident's individualized comprehensive care plan. This deficient practice was identified for 1 of 3 residents reviewed for nutrition (Resident #60). This deficient practice was evidenced by the following: On 11/13/24 at 10:40 AM, two surveyors observed Resident # 60 in bed awake and alert. The surveyors observed a 16-ounce (oz.) water cup with a straw on the bedside table which was not in the resident's reach. The resident was unable to state whether he/she had a thickened liquid diet order. A review of the admission Record (an admission summary) reflected the resident had diagnoses that included but were not limited to: cerebral infarction (stroke), asthma and dementia. A review of a Quarterly Minimum Data Set, a tool used to facilitate the management of care, dated 10/18/24, reflected 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 · Fcited before2023-08-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain, store, and hold potentially hazardous foods in acceptable temperatures to prevent food-borne illness; b.) maintain multi-use food-contact surfaces in a manner to prevent bacterial growth; c.) maintain kitchen equipment in a sanitary manner; d.) store potentially hazardous foods to prevent food-borne illness; and e.) maintain handwashing sinks to ensure appropriate infection control practices. This deficient practice was evidenced by the following: On 8/3/23 at 9:12 AM, the surveyor entered the kitchen and requested to wash their hands in the kitchen's handwashing sink. The Food Service Director (FSD) showed the surveyor the handwashing sink, and the surveyor proceeded to turn on the hot water handle, but the water came out in drops only. The surveyor then proceeded to turn on the cold water handle, and the water came out in a steady flow. The surveyor asked the FSD if there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ#: 151826 Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to provide the residents with a safe, comfortable, clean, homelike environment. This deficient practice was identified on 4 of 4 nursing units, (Oak, Willow, Cedar, and Maple) and in 2 of 36 resident rooms, (Resident #112 & Resident #190) reviewed for residing in a clean, comfortable, homelike environment. This deficient practice was evidenced by the following: On 08/03/23 at 10:46 AM, the surveyor started the environmental tour on the [NAME] unit. Between rooms [ROOM NUMBERS], the surveyor observed a long, black in color indentation and scratch mark along the wall. There was an area to the left of the television screen on the wall where the peach-colored paint was peeling. Exposing green colored paint underneath. [NAME] colored paint was further observed above the television. At 10:48 AM, the surveyor observed to the right of room [ROOM NUMBER] above the floorboard 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 · Ecited before2023-08-11 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ#: 154501 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This deficient practice was identified for 5 of 39 residents, (Resident #45, #57, #58, #81, and #418) reviewed for the development and implementation of a comprehensive person-centered care plan and was evidenced by the following: 1.) On 8/2/23 at 11:08 AM, the surveyor observed Resident # 58 in bed. Resident #58 stated that they have been on peritoneal dialysis (PD) for four years and performed their PD daily. The PD supplies were observed in boxes in the resident's room. The surveyor reviewed the medical records for Resident #58. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in May of 2022 with diagnoses which included diabetes (too much sugar in the blood), end-stage renal disease (loss of kidney function),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-11 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to: a.) obtain a physician's order to perform Range of Motion (ROM) exercises and b.) document the performance of ROM exercises in the resident's medical record for 1 of 3 residents, (Resident #45) reviewed for position and mobility. This deficient practice was evidence by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-11 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) appropriately discard unused medication and b.) properly label and date medication in accordance with manufacturer recommendations for medications being stored in 1 of 2 medication storage rooms inspected (Cedar unit medication room). This deficient practice was evidenced by the following: 1.) On 8/3/23 at 9:15 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) in the room of Resident #145. The surveyor observed the LPN informing Resident #145 that she would be administering the resident's medications. The surveyor observed that the resident was in their bed and just finished eating breakfast. On 07/12/23 at 9:20 AM, the surveyor observed the LPN preparing to administer seven medications to Resident #145 which included: Losartan/Hydrochlorothiazide (medication for lowering blood pressure), Potassium Chloride 20 MEQ ER tablet (potassium supplement), Furosemide 20 mg tablet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) On 8/2/23 at 11:29 AM, the surveyor observed Resident #117 in bed with his/her eyes open. The resident did not respond to the surveyor. The surveyor reviewed the medical record for Resident #117. A review of the resident's admission Record face sheet (admission summary) reflected that the resident was admitted to the facility in January 2019 and readmitted in June 2023 with diagnoses that included but were not limited to stage 3 sacral ulcer, tracheostomy, diabetes mellitus, dementia, aphasia (inability to speak), and cerebral infarction (stroke). A review of the quarterly MDS dated [DATE], reflected the resident had severely impaired cognition. The MDS further indicated that Resident #117 was dependent on staff for activities of daily living, and had a range of motion impairment on both sides of the upper and lower extremities. A further review of the resident's MDS, Section M - Skin Conditions indicated the resident had one Stage 3 pressure ulcer (a bed sore with full thickness breakdown of tissue down 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 · D2023-08-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility documents, it was determined that the facility failed to: a.) notify the physician or Nurse Practitioner (NP) of an abnormal urine lab result and b.) administer antibiotic treatment in a timely manner for 1 of 3 residents, (Resident #133) reviewed for antibiotic use. This deficient practice was evidenced by the following: On 08/02/23 at 10:42 AM, the surveyor observed Resident #133 sitting in a chair in his/her room. The resident stated that he/she had an infection but was unsure where. According to the admission Record, Resident #133 had diagnoses which included, but were not limited to, chronic kidney disease, end stage renal disease, and retention of urine. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/12/23, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further 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 before2023-08-11 · 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, and record review, 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 1 of 5 residents, (Resident #129) reviewed for pressure ulcers and was evidenced by the following: The surveyor observed Resident #129 lying in bed with his/her air mattress set to 360 to 400 pounds (lbs) on the following dates and times: -08/02/23 at 10:22 AM -08/03/23 at 9:24 AM -08/04/23 at 9:48 AM According to the admission Record, Resident #129 had diagnoses which included, but were not limited to, paraplegia and unspecified protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/13/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS included the resident had one unstageable pressure ulcer that was not present on admission. 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 · Dcited before2023-08-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to maintain proper infection control practices during tracheostomy care. This deficient practice was identified for one of two residents reviewed for tracheostomy care, (Resident #117) and was evidenced by the following: On 8/2/23 at 11:29 AM, the surveyor observed Resident #117 in their room in bed. The resident had a tracheostomy (a hole made surgically through the front of the neck into the trachea (windpipe) with a tube placed through the hole to help the person breath) which was attached to an oxygen concentrator (machine that provides oxygen). The surveyor reviewed the medical record for Resident #117. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in January of 2019 and readmitted in June of 2023 and had diagnoses which included tracheostomy, respiratory failure and dementia. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-11 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to: a.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 5 of 6 forms provided; and b.) accurately document the administration of controlled medication for 2 sampled residents, (Resident #27 and Resident #44) identified upon inspection of 1 of 5 medication carts (Willow unit, high-side cart). This deficient practice was evidenced by the following: 1.) On 8/9/23 at 12:52 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the [NAME] unit, high-side cart. The surveyor and the LPN reviewed the narcotic medication located in a secured and locked narcotic box. When the narcotic inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns. Resident #27's methadone 8 milligram (mg)/1 milliliter (ml) oral solution, a medication used 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 · D2023-08-11 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 3 of 4 meal entrees observed during 1 of 1 meal observations (lunch) for 1 of 2 residents reviewed for food (Resident #122). This deficient practice was evidenced by the following: On 8/2/23 at 12:57 PM, the surveyor observed Resident #122 in their room. The resident stated that they did not receive their lunch tray today; that it was not on the meal cart, and they were waiting for staff to bring their lunch tray to them. On 8/3/23 at 12:00 PM, the surveyor observed the lunch meal trays arrive to the Oak nursing unit day room. The surveyor made the following observations: At 12:03 PM, Certified Nursing Aide (CNA#1) placed milk on all the trays. At 12:10 PM, Licensed Practical Nurse (LPN #1) passed out the first meal tray to an unsampled resident. At 12:13 PM, Resident #122 received their meal tray and asked CNA #1 to heat up their water for their hot chocolate; that it was cold. The surveyor observed on 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.
“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.
- 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 ARISTACARE — 9 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 | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 1 of 5 | 1.9 | -0.9 vs chain |
| Staffing | 3 of 5 | 2.1 | +0.9 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 8 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GREENBERGER, SIDNEY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/19/2007 |
| KLEIN, ZVI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/19/2007 |
| ISAAC, STEVEN | Individual | W-2 MANAGING EMPLOYEE | — | since 08/01/2010 |
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 78% 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 $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
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 315214. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, 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.