Greenwood House Home For The Jewish Aged
53 Walter Street, Trenton, NJ 08628 · Non profit - Church related · 137 certified beds · (609) 883-5391 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- it has abuse, neglect, or exploitation citations (F0600, F0610) — most recent Aug 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $323,570 in federal fines (most recent 2024-08-21)
- 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) | 5 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 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 fell from 2 to 1 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 | 14.0% | 8.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 10.8% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.2% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.2% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.9% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.5% | 8.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 15.5% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.4% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.8% | 15.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.3% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 92.8% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.2% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.1% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.21 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.65 | 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.
59.8% 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 282 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.1% 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 109 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 0.37 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | 59.8%CMS range 55.1–65.4 | 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 | 7.9%CMS range 5.6–10.2 | 10.7% | Oct 2022–Sep 2024 | better than 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 | 54.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 61.5% | 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 | 56.9% | 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 | 95.0% | 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 | 96.5% | 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 | 0.6% | 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 | 0.6% | 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 4.6–8.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.81 | 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 137 beds and averages 107.1 residents a day — about 78% occupied, or roughly 30 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 4.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 is at or above 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 4.28 hrs/resident/day on weekends vs 5.04 on weekdays — 15% thinner on weekends. RN hours go from 0.78 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · L2024-08-21 · tag F0600 — failed to protect residents from abuse and neglect — widespreadProtect 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
PART A NJ Complaint #: 174306 Based on interview and review of pertinent facility documents, it was determined that the facility failed to follow their abuse policies and procedures by ensuring a resident (Resident #171) was free from verbal abuse and an involuntary restraint by: a.) immediately suspending the Registered Nurse (RN #1) and Certified Nursing Aide (CNA #1) who the allegation was made against pending a thorough investigation; and b.) thoroughly investigating an allegation of verbal abuse and involuntary restraint. This deficient practice was identified for 1 of 5 residents (Resident # 171); and two staff members (RN #1 and CNA #1) who had access to all the residents in the facility on 3 of 3 nursing units, reviewed for abuse. Resident #171, who had diagnoses which included arthritis, anxiety, and depression reported to the Social Worker (SW) on 6/3/24, that two nurses were extremely rude to the resident on the 11:00 PM to 7:00 AM (11-7) shift; the nurses yelled at the resident and demanded that the resident turn the light off. The resident reported that the nurses said…
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.
- Immediate jeopardy · L2024-08-21 · tag F0610 — failed to investigate and act on abuse reports — widespreadRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NJ Complaint #: 174306 Based on interview and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an allegation of verbal abuse and involuntary restraint for a resident (Resident #171) who informed the facility that the Registered Nurse (RN #1) and Certified Nursing Aide (CNA #1) verbally abused them and placed a chair on the side of their bed preventing the resident from using the restroom. This deficient practice was identified for 1 of 5 residents (Resident # 171); and two staff members (RN #1 and CNA #1) who had access to all the residents in the facility on 3 of 3 nursing units, reviewed for abuse. Resident #171, who had diagnoses which included arthritis, anxiety, and depression reported to the Social Worker (SW) on 6/3/24, that two nurses were extremely rude to the resident on the 11:00 PM to 7:00 AM (11-7) shift; yelled at the resident and demanded the resident turn the light off. The resident reported that the nurses said the resident was embarrassing the nurses, and the nurse blocked the bedside with a chair so 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 before2026-03-26 · 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 policy review, the facility failed to ensure kitchen utensils were stored in a clean and sanitary manner. These failures had the potential to cause food-borne illness for 101 out of 106 residents who received meals prepared in the facility (five residents received nutrition via feeding tubes). Findings include:1. During the initial kitchen inspection, completed with the Dietary Manager (DM) and Executive Chef (EC) on 03/23/26 at 10:18 AM, the following concerns were noted: a. In a bin of serving utensils (spoons and scoops), the handle of one serving spoon was covered with a white substance on the handle. The DM stated the white substance was mayonnaise. b. On the three-compartment sink's metal counter were four out of 13 full sheet trays stacked wet. Also on the counter was a mixture of two-inch, four-inch, and six-inch hotel pans. Six of the pans were stacked wet and greasy to touch. The DM stated, They (pans) were washed last night, and the drying rack was full, so they put them over here. c. On one of four drying rack carts were five…
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 before2026-03-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure staff performed appropriate hand hygiene when moving between rooms, including one with enhanced barrier precautions (EBP), creating a risk for cross-contamination. Additionally, the facility failed to process laundry in a clean and sanitary manner and did not ensure laundry staff consistently washed their hands. This failure has the potential to spread infection among the facility's 106 residents. Findings include:1. On 03/23/26 at 3:13 PM, Licensed Practical Nurse (LPN) 3 was observed entering and exiting multiple resident rooms and touching surfaces in the rooms without washing or sanitizing his/her hands between residents' rooms. LPN3 left room [ROOM NUMBER], entered room [ROOM NUMBER], left room [ROOM NUMBER], entered room [ROOM NUMBER], left room [ROOM NUMBER] and entered room [ROOM NUMBER]. The resident in room [ROOM NUMBER] was on EBP secondary to having an indwelling catheter. LPN3 was immediately interviewed…
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 · E2026-03-26 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure that food was served at the correct temperature for two residents who received hamburgers (Residents (R) 19 and 90) and food served was palatable in taste for two residents (R 70 and R135). Specifically, the facility did not ensure that dietary staff followed appropriate processes to prepare and serve food palatable for 101 out of census of 106 residents during meal service. This failure had the potential to place residents at increased risk for meal dissatisfaction and the service of potentially unsafe food. Findings include: 1. Review of R70's undated Face Sheet provided by the facility indicated R70 was admitted to the facility on [DATE]. Review of R70's quarterly Minimum Data Set (MDS), located under the MDS tab in the electronic medical record (EMR), with an Assessment Reference Date (ARD) of 01/24/26 indicated R70 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R70 had moderate…
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 · D2026-03-26 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and document review, the facility failed to provide residents and their resident representatives (RR) with the required written transfer notice following emergent hospital transfers for two of three residents (Resident (R) 129, and R138) reviewed for hospitalization out of 27 sampled residents. This failure created a risk that residents and their RRs would be uninformed about the reason and location of the transfer and their right to appeal it, if desired. Findings include:1. Review of R129's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R129 was admitted to the facility on [DATE]. Review of R129's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/26 revealed a Brief Interview for Mental Status (BIMS) was unable to be completed due to R129 rarely being understood. Review of R129's Progress Notes, dated 12/16/25 and located under the Progress Notes tab of the EMR, revealed R129 was, extremely…
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 · D2026-03-26 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that one resident of 60 residents (Resident (R) 18) reviewed for missing Minimum Data Set (MDS) assessments over 120 days old had a tracking discharge assessment completed and transmitted in a timely manner. Failure to complete and transmit MDS data timely can lead to inaccurate federal reimbursement and quality measures. Findings include: Review of R18's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R18 was admitted to the facility on [DATE] and discharged on 08/24/25. Review of R18's discharge return anticipated MDS with an Assessment Reference Date (ARD) of 08/24/25, located under the MDS tab in the EMR, indicated that the assessment was batched and accepted on 02/04/26. During an interview on 03/26/26 at 5:00 PM, the MDS Coordinator confirmed that the tracking assessment was late, but he/she was unsure why it was late. The MDS…
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 · D2026-03-26 · 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 record review, interview, and policy review, the facility failed to ensure that a comprehensive Minimum Data Set (MDS) assessment was submitted accurately for one resident (Resident (R) 83) reviewed for MDS assessments out of a total sample of 27 residents. This had the potential to affect quality measures and the resident's care planning process. Findings include:Review of R83's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE]. Review of R83's Physician Orders located under the Orders, tab in the EMR revealed hospice services were ordered on 07/16/24. Review of R83's quarterly MDS under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 10/21/25, revealed the Brief Interview for Mental Status (BIMS), was unable to be completed due to R83 rarely being understood. Further review revealed the resident was documented not to be receiving hospice care. Review of R83's Physician Orders located under the Orders tab…
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 before2026-03-26 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure residents did not have side rails on beds when they had not been assessed for their use for one of four residents (Resident (R) 139) reviewed for side rails out of a total of 27 sampled residents. The lack of appropriate assessment placed residents at risk for unintended restraint and potential side rail entrapment. Findings include:Review of R139's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R139 admitted to the facility on [DATE] with a diagnosis of weakness. Review of R139's Admission/readmission Evaluation Section-Siderail, completed by Licensed Practical Nurse (LPN) 2, dated 03/05/26 and located under the Assessments tab in the EMR, revealed side rails were not being considered at the time. Further review revealed no discussion of risks versus benefits and informed consent. Review of R139's admission Minimum Data Set (MDS), with an Assessment Reference Date…
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 · D2026-03-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to maintain accurate resident medical records, including physician orders and medication administration records (MARs), for one (Resident (R) 132) of five residents reviewed for medication administration and accuracy of medical records. R132 had a duplicate physician order for the same medication, which was transcribed as two separate entries on the resident's MAR. This documentation error created the potential for the medication to be administered more than once as prescribed, placing the resident at risk for medication errors and possible adverse health effects. Findings include:A review of R132's admission Record found under the Profile tab in the electronic medical record (EMR) revealed R132 was admitted to the facility on [DATE] with diagnoses of heart failure, chronic obstructive pulmonary disease, hypertension, type 2 diabetes mellitus, and atrial fibrillation. The resident was discharged from the facility on 07/23/25 to an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-21 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to serve all residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for 3 of 3 residents sampled for bedtime snacks (Resident #29, Resident #46, and Resident #65), and was evidenced by the following: A review of the facility's Nourishment Between Meals policy dated reviewed/revised August 2024, included nursing staff are responsible for offering each resident and afternoon and evening snack to the extent medically possible . During initial tour of the kitchen on 8/5/24 at 9:31 AM, the surveyor accompanied by the Dietary General Manager (DGM) observed half sandwiches on a tray in the walk-in refrigerator. The DGM stated the sandwiches were for hour of sleep (HS) snacks. The surveyor asked if all residents received HS snacks, and the DGM stated no, that some residents had physician ordered snacks. On 8/5/24 at 9:50 AM, the surveyor interviewed the Unit…
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 · D2024-08-21 · 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 pertinent facility documents, it was determined that the facility failed to store the resident's urinary drainage bag in a dignified manner. This deficient practice was identified for 1 of 2 residents reviewed for urinary catheter (Resident #15), and was evidenced by the following: A review of the facility's Catheter Care - Foley policy, dated revised August 2024, did not include covering the foley catheter bag with a privacy cover. On 8/5/24 at 10:45 AM, during initial tour of the facility, the surveyor observed Resident #15 in their bedroom sitting in a wheelchair. Resident #15 stated that they had a suprapubic (SP) catheter (flexible tube that is inserted into the bladder through the abdominal wall to drain urine) and wore a leg bag during the day. The resident further stated that at night, the urinary bag was switched to a foley catheter bag (drainage collection bag). On 8/6/24 at 10:13 AM, the surveyor reviewed the medical record for Resident #15. A review of the admission Record face sheet (an admission summary) reflected that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · D2024-08-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint NJ #: 166488 Based on interview, review of the closed medical record, and pertinent facility documents, it was determined that the facility failed to notify a resident's family after a change of condition. This deficient practice was identified for 1 of 31 sampled residents (Resident #170), and was evidenced by the following: A review of the facility's Notification of Changes policy, dated revised July 2021, included it is the policy of [the facility] to notify the resident, resident representative(s) and resident's physician (when applicable) of any changes in a manner to acknowledge and respect the resident's rights .[the facility] will immediately inform the resident, consult the resident's physician, and notify, consistent with his/her authority, the resident representative(s) when there is: A significant change in the resident's physical, mental or psychological status (i.e. a deterioration in health, mental or psychological status, skin integrity, life threatening conditions or clinical complications, etc.) . On 8/7/24 at 9:31 AM, the surveyor reviewed the closed…
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 · D2024-08-21 · 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 facility policy, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy by completing a criminal background check prior to the start of employment. This deficient practice was identified for 1 of 10 employee files reviewed (Employee #4) and was evidenced by the following: A review of the facility's Abuse Policy dated January 2024, included . A. Screening Components Abuse Policy Requirements: It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check . On 8/8/24 at 12:00 PM, the surveyor reviewed Employee #4's employment file which revealed the following: Employee #4, a physical therapist (PT), was hired on 9/6/23. There was no criminal background check. On 8/8/24 at 12:52 PM, the surveyor reviewed Employee #4's personnel file with the Medical Secretary (MS), who confirmed the criminal background check was not done for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 a.) ensure the plan of care was updated and interventions were implemented to reduce hazards and risks for a resident with a high risk of injury during dining who burned themself with soup (Resident #37); and b.) implement the facility's smoking policy and procedure for a resident who smoked (Resident #84). This deficient practice was identified for 2 of 5 residents reviewed for accidents and hazards (Resident #37 and Resident #84), and was evidenced by the following: 1. A review of the facility's Incident/Accident Report Investigation (Resident) policy, dated revised January 2024, included when an accident or incident occurs to a resident, an investigation is conducted followed by documentation of the incident, cause and effect and the recommendation and intervention that were implemented to prevent or minimize future incidents .initiate interventions/recommendations to minimize or prevent future occurrences . A review of the facility's Care Plan policy, dated…
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 · D2024-08-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure respiratory equipment was stored and dated in accordance with professional standards when not in use, and b.) ensure an individualized comprehensive care plan included oxygen therapy. This deficient practice was identified for 2 of 2 residents reviewed for respiratory care (Resident #101 and #319), and the evidence was as follows: A review of the facility's Oxygen Administration policy dated revised January 2024, included date the humidifier when put into use .a plastic zip-lock bag is to be attached to the side of the concentrator so the nasal cannula or oxygen mask can be stored there when not in use . A review of the facility's Care Plan Policy dated revised August 2024, included the Multidisciplinary Care team shall review the comprehensive care plan no less than every three months (more often if there is a significant change); the assessments will be updated and revised as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-21 · 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 that the facility failed to maintain a system of record keeping that ensures an accurate inventory of controlled medications. This deficient practice was identified on 3 of 7 medication carts reviewed and was evidenced by the following: A review of facility's Controlled Substances policy dated January 2024, included all scheduled II, II, IV and V controlled substances are to be stored under double locks, separate from all other medications. Schedule II through V are counted by incoming and outgoing nurses each shift and signatures documented . On 8/7/24 at 10:28 AM, during medication storage observation, the surveyor, in the of the Licensed Practical Nurse (LPN #1), observed the controlled substances inventory and count logs for the B Wing North nursing unit's medication. A review of the Record of Narcotic Count log (a log used track the count of controlled medications) for August 2024, revealed the following nurses' signatures were missing: On 8/1/24, the 7:00 AM to 3:00 PM (7-1) shift,…
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 before2024-08-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility records, it was determined that the facility failed to implement infection control protocols for residents on enhanced barrier precautions to prevent the spread of infection. This practice was identified for 1 of 3 residents observed on enhanced barrier precautions (Resident# 87), and was evidenced by the following: A review of the facility's Enhanced Barrier Precautions (EBP) policy dated revised August 2024, included enhanced barrier precautions (EBP) will be used in conjunction with standard precautions by implementing the expanded use of personal protective equipment [PPE] to the donning of gowns and gloves during high contact resident care activities for residents who have an indwelling medical device (urinary catheter, feeding tube etc.) wound or known to be colonized (no active infection) with an organism. EBP is a transmission-based precaution measure focusing on the use of gown and gloves during high contact resident care activities that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
COMPLAINT#: NJ00171710 Based on observations, interviews, medical records review, and review of other pertinent facility documentation on 03/07/24 and 03/08/2024, it was determined that the facility failed to report within the required timeframe an incident involving an alleged abuse allegation to the New Jersey Department of Health (NJDOH) and b.) follow the facility's Abuse Policy. The alleged violation was reported to staff regarding an incident that involved a resident that was found to have a discoloration on the left arm. When the resident was asked how that happened, the resident said that a staff member had grabbed the arm. This deficient practice was identified for 1 of 4 sampled residents (Resident #1) and was evidenced by the following: During a tour of the unit on 03/07/24 at 10:36 a.m., the surveyor knocked on Resident #1's door and was granted entry by the resident. Resident #1 was observed wearing a long-sleeved shirt and pants, while seated in a wheelchair at the bedside, watching television. Resident #1 stated that the resident does not get along with some of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-12 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure informed consent was obtained, an assessment was completed, and inspections were completed for side rails. The deficient practice was identified for 1 of 2 residents (Resident #72) reviewed for side rails and was evidenced by the following: On 11/29/22 at 11:03 AM, the surveyor observed Resident #72 in bed with his/her eyes open. The surveyor observed the resident's bed had two half-length side rails in the up position on both upper sides of the bed. On 12/2/22 at 12:00 PM, the surveyor observed Resident#72 out of bed sitting in a geri chair (an adaptive chair) in the hallway just outside of his/her room. At that time, the surveyor observed two half side rails in the up position on both upper sides of the resident's bed. On 12/5/22 at 10:52 AM, the surveyor observed Resident #72 in bed with their eyes closed with two half side rails up on both upper sides of the bed. The surveyor reviewed the medical record for Resident #72. A review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to accurately document the administration of controlled medication for an unsampled resident. This deficient practice was identified on 1 of 5 medication carts (North A-Wing) reviewed and evidenced by the following: On 12/5/22 at 9:49 AM, the surveyor in the presence of the Registered Nurse (RN) inspected North A-Wing medication cart. The surveyor in the presence of the RN reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic medication inventory was compared to the declining inventory sheet, the surveyor identified an unsampled resident's pregabalin 150 milligram (mg) capsules, a medication used for anxiety, epilepsy and nerve pain, did not match. The blister pack contained 22 capsules and the declining inventory sheet indicated there should be 23 capsules remaining. The RN stated she had forgotten to sign the declining inventory sheet for the dose she had administered that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to a.) maintain a refrigerator temperature log to ensure medications were stored at appropriate temperature and b.) properly label and date medications in accordance with manufacturer recommendations. This deficient practice was observed in 1 of 2 medication (C-West) storage rooms and 1 of 5 medication carts (C-West) inspected and was evidenced by the following: 1. On 12/5/22 at 10:16 AM, the surveyor in the presence of the Registered Nurse/Unit Manager (RN/UM) inspected the C-West medication cart. The surveyor observed an opened and undated insulin lispro syringe in active inventory. The RN/UM stated the pen was supposed to be dated when it was opened. The RN/UM acknowledged the pen did not have an opened date or expiration date indicated on the pen. The RN/UM further acknowledged that the nurses needed to make sure they dated the medication once removed from the refrigerator because the medication had shortened dating once opened. A review of the manufacture's storage instructions 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 · Dcited before2022-12-12 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness and b.) maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 11/29/22 at 9:28 AM, the surveyor toured the kitchen with the Director of Dietary (DD) and observed the following: In the walk-in refrigerator: 1. One five-pound container of sour cream with an expiration date of 11/22/22. The DD confirmed it needed to be discarded. 2. One opened cottage cheese container with an expiration date of 1/2/23. The container was not labeled the date opened or when to discard. The DD stated that cottage cheese should be discarded three days after it was opened. In the meat preparation refrigerator, the bottom had a pinkish liquid and white debris. The DD stated the facility cleaned the refrigerator once a week and confirmed the refrigerator needed to be cleaned. On 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$323,570 in federal fines across 1 penalty.
- $323,570 — penalty dated 2024-08-21
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GOLDSTEIN, RICHARD | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | since 08/01/2019 |
| HUNTER, DEBORAH | Individual | W-2 MANAGING EMPLOYEE | since 04/26/2004 |
| MUNIZ, ROBERTO | Individual | W-2 MANAGING EMPLOYEE | since 07/22/2015 |
| SAINT-LOUIS, MILCHA | Individual | W-2 MANAGING EMPLOYEE | since 10/23/1989 |
| BARRACK, DONALD | Individual | CORPORATE DIRECTOR | since 01/01/1999 |
| GOODMAN, DAN | Individual | CORPORATE DIRECTOR | since 06/01/2019 |
| HOROWITZ, HERBERT | Individual | CORPORATE DIRECTOR | since 01/01/2000 |
| KAPLAN, LEON | Individual | CORPORATE DIRECTOR | since 06/01/2019 |
| NORMAN, ROBERT | Individual | CORPORATE DIRECTOR | since 01/01/1997 |
| PERLMAN, JEFFREY | Individual | CORPORATE DIRECTOR | since 01/01/1987 |
| SUSSMAN, JEFF | Individual | CORPORATE DIRECTOR | since 06/01/2019 |
| ZELTT, DOUGLAS | Individual | CORPORATE DIRECTOR | since 06/01/2019 |
CMS files one row per role, so the 13 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 315215. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.