Cornell Hall Care & Rehabilitation Center
234 Chestnut Street, Union, NJ 07083 · For profit - Limited Liability company · 177 certified beds · (908) 687-7800 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $175,196 in federal fines (most recent 2024-01-24)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 1 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 | 12.5% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.9% | 4.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 29.1% | 12.1% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.3% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.2% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.3% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.6% | 15.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.1% | 12.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.2% | 80.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.2% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.5% | 8.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.95 | 2.07 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.21 | 1.11 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ 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.
58.5% 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 193 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.0% 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 76 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | 58.5%CMS range 51.9–65.1 | 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 | 9.6%CMS range 7.5–12.8 | 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 | 71.0% | 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 | 64.5% | 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 | 52.6% | 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 | 0.8% | 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 | 2.5% | 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 | 8.7%CMS range 5.6–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 177 beds and averages 133.3 residents a day — about 75% occupied, or roughly 44 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.20 hrs/resident/day on weekends vs 3.54 on weekdays — 10% thinner on weekends. RN hours go from 0.69 to 0.59 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
34 citations, most serious first. The 11 most serious are shown; the remaining 23 are one tap away and print in full.
- Actual harm · Gcited before2024-01-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY C # NJ166425 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to prevent, identify and address an unintended insidious (gradual but with harmful effects) weight loss of 9.4 pounds in less than a two-month period (4/10/23 to 6/5/23) in a timely manner for a resident who was identified as underweight, with inadequate intake and at nutritional risk on admission. The facility failed to: a.) obtain, record and monitor weekly weights for 4 weeks after admission, and b.) implement a nutritional care plan in a timely manner. This deficient practice was identified for 1 of 2 resident's reviewed for nutrition (Resident #358). The evidence was as follows: The surveyor reviewed the medical record for Resident # 358. Review of the resident's admission Record (an admission summary) reflected the resident was admitted with diagnoses that included but were not limited to; type two diabetes, hypertension, chronic lymphocytic leukemia, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-16 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of medical records, it was determined that the facility failed to ensure medication administration without significant error for a resident who received insulin on a sliding scale received their insulin as ordered on multiple dates and times. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #40), and was evidenced by the following: On 4/9/25 at 10:00 AM, the surveyor observed Resident #40 lying in bed. The resident appeared clean and dry, and the resident's head of bed was up. The surveyor was unable to interview the resident due to cognitive impairment. The surveyor reviewed the medical record for Resident #40. A review of the admission Record face sheet (an admission summary) indicated that Resident #40 was admitted to the facility with the diagnoses which included but were not limited to; diabetes mellitus (DM), metabolic encephalopathy (a change in how your brain works due to an underlying condition which can cause confusion, memory loss and loss of consciousness.), unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint: #NJ183048 Based on interview, review of medical record, and other pertinent facility documentation, it was determined that the facility failed to thoroughly and accurately investigate an injury of unknown origin on 10/16/2024 and 10/22/2024. This deficient practice was identified for 1 of 4 residents reviewed for accidents (Resident #260), and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #260. A review of the admission Record face sheet (an admission summary) indicated that Resident #260 had the diagnoses which included but were not limited to; schizophrenia, depression, and mood disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 8/24/24, reflected that Resident #260 had severe cognitive impairment, required supervision with activities of daily living (ADLs), and had no falls since admission to the facility. A review of the Incident Accident Report (IAR) dated 10/16/24 at 1:37 PM, indicated that while the nurse was performing rounds, Resident #260 was noted to have a scratch on their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · 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
Complaint # NJ175980 Based on observation, interview, and review of medical records, it was determined that the facility failed to provide necessary treatment services consistent with professional standards of clinical practice by not ensuring that a resident diagnosed with the shingles virus received care and services in a timely manner. This deficient practice was identified for 1 of 26 residents reviewed for quality of care (Resident #262), and was evidenced by the following: On 4/10/25 at 11:08 AM, the surveyor reviewed the closed medical record for Resident #262. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (ESRD), spinal stenosis (condition where the spaces within the spine narrow, compressing the spinal cord and nerve roots), and dependence on renal dialysis (filtering waste and excess fluid from the blood when the kidneys are failing). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection by ensuring proper use of personal protective equipment (PPE) for a resident on contact precautions. This deficient practice was identified for 1 of 1 resident reviewed for transmission-based precautions (TBP) (Resident #90), and was evidenced by the following: On 4/9/25 at 10:45 AM, during initial tour, the surveyor observed signage on Resident #90's door which indicated that the resident was on TBP, specifically, contact precautions. The signage specified that gloves and an isolation gown were to be applied prior to entering the resident's room. The surveyor observed two bins inside of the resident's door; one used for trash and the other used for laundry. The resident was lying in bed and was unable to be interviewed secondary to cognitive deficits. The surveyor reviewed the medical record for Resident #90. A review of the admission…
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 · D2024-10-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ177876, NJ178837 Based on interviews, review of the medical records, and pertinent facility documents on 10/24/24 and 10/25/24, it was determined that the facility failed to follow professional standards of clinical practice with respect to nursing staff provided a service when the accepted standards of quality dictate that the service or care should not have been provided for 1 of 3 Residents (Resident #2). This deficient practice is evidence by the following: According to the admission Record Resident #2 was admitted to the facility on [DATE], with diagnosis that included but was not limited to: Polyneuropathy and Chronic Pain. The Minimum Data Set (MDS), an assessment tool dated 9/13/24, revealed that Resident #2's cognitive function was 15/15 indicating resident is cognitively intact. The Care Plan (CP) initiated on 9/26/24 indicated that Resident #2 had chronic pain related to polyneuropathy. Interventions included but were not limited to administer analgesia (medication, that prevents pain)…
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 · F2024-01-24 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 # NJ169272 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey and b) provide sufficient nursing staff for three (3) of three (3) units of the facility according to facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio (s) were effective on 02/01/2021: One (1) Certified Nurse Aide (CNA) to every eight (8) residents for the day shift. One (1) direct care staff member to every 10 residents for the evening…
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 · F2024-01-24 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of three PBJ Report submissions reviewed, (Fiscal Year Quarter 4 2023, July 1 - September 30) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the fourth fiscal year quarter to CMS. The dates of the fourth quarter included July 1, 2023, through September 30, 2023. On 1/12/24 at 12:01 PM, during an interview with the surveyor, the Infection Preventionist/ Regional, stated that the Regional Clinical Manager (RCM) submitted staffing to CMS on a quarterly basis. At that time, the IP/R informed the surveyor that the RCM was no logger employed with the facility. At that time, the IP/R stated that on 11/14/23, the same date as the due date for submission of the fourth quarter PBJ report to CMS, the RCM attempted to log…
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 · E2024-01-24 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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 interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure a) licensed staff credentials were verified upon hire (Staff #7 and #8) and b) reference checks were completed (Staff #2, #3, #4, #8 and #9). This deficient practice was identified for seven (7) of nine (9) newly hired staff reviewed, and was evidenced by the following: 1.) The surveyors randomly selected nine new employee files for license verification which revealed the following: Staff #7, a Registered Nurse (RN), was transferred to the facility on 7/30/23, had a New Jersey Division Consumer Affairs (NJCA) license verification printout for license verification (used to verify the status of a RN's license status) which was dated 12/22/23, after the employee's transfer date of 7/30/23. Staff #8, a Licensed Nursing Home Administrator (LNHA), with a date of hire of 7/11/23, did not have a license verification print out. There was no documented evidence that Staff #8's license was verified. 2.) Further 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 · E2024-01-24 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ#163297, NJ#164216, and NJ#169168 Based on interviews, review of medical records (MR) and other facility documentation, it was determined that the facility failed to report an allegation of Abuse / Neglect to the New Jersey Department of Health (NJ DOH) in the required timeframe for 5 of 10 sampled residents, (Residents #35, #63, #90, #361, #362). This deficient practice was evidenced by the following: 1.) A review of the reportable event record report (FRE; Facility Reported Event) which was called in on 4/6/23 at 10:00 AM, with an event date of 4/5/23 at 7:00 PM. The FRE was reported as an allegation of resident-to-resident abuse and was described as follows: On 4/5/23 at 2:00 PM, Resident #362 was admitted to the facility screaming /yelling and cursing at the staff asking for pain medications. The resident was made aware that the orders had to be verified with the primary Medical Doctor and that the hospital report reflected the resident received the pain medication at 11:30 AM, before admission.…
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 · E2024-01-24 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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 interviews, record review, and a review of pertinent facility documents, it was determined that the facility failed to a.) provide oversight by a licensed Consultant Pharmacist (CP) in the entire month of August 2023, for 4 of 5 residents reviewed for unnecessary medications (Resident #46, #68, #80, and #87) and b.) act upon a recommendation made by a CP in a timely manner for 1 of 28 residents (Resident #92) reviewed for medication management . This deficient practice was evidenced by the following: 1. On 01/11/24 11:45 AM, the surveyor observed Resident #46 in bed. The resident was wearing a CPAP (a continuous positive airway pressure ventilation system in which the mild pressure from the system prevents the airway from collapsing or becoming blocked) mask. The resident's eyes were closed. The surveyor reviewed Resident #46's electronic medical record (eMR). According to the admission Record (AR), (an admission summary) Resident #46's was admitted to the facility with diagnoses that included but were…
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 23 citations
- Potential for harm · Ecited before2024-01-24 · 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 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a) follow isolation precautions for a resident who was on Transmission Based Precautions (TBP) by two (2) of two (2) medical staff (one Physician and one Registered Nurse) for Residents #210, #9, and #45, b) follow appropriate hand hygiene practices during an incontinence rounds observation by two (2) of three (3) staff observed (one Licensed Practical Nurse and one Certified Nursing Aide) according to the facility's policy and Centers for Disease Control and Prevention (CDC) guidelines, and c) follow facility policy and standard of practice regarding not wearing personal protective equipment (PPE) in the hallway by one (1) of three (3) staff (one Certified Nursing Aide). This deficient practice was evidenced by the following: According to the CDC Hand Hygiene in Healthcare…
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 · D2024-01-24 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) - Discharge Assessment in accordance with federal guidelines. This deficient practice was identified for two (2) of 28 residents, (Residents #21 and #94), reviewed for resident assessments. This deficient practice was evidenced by: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. After the transition of the MDS, a quality measure will be transmitted to enable a facility to monitor the residents decline or progress. page 2-11 Discharge refers to the date a resident leaves the facility . There are two types of OBRA (Omnibus Budget Reconciliation Act)…
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 · D2024-01-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, it was determined that the facility failed to revise comprehensive care plans for 2 of 28 residents reviewed (Resident #41 and #75). This deficient practice was identified by the following: 1. On 01/10/24 at 11:08 AM, the surveyor observed Resident #41 in bed watching television. The resident was alert and verbally responsive. The surveyor reviewed Resident #41's hybrid medical records. The admission Record (AR) (an admission summary), reflected that Resident #41 was admitted to the facility with medical diagnoses which included but was not limited to: atrial fibrillation (an irregular, often rapid heart rate), hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), type 2 diabetes mellitus (the body either doesn't produce enough insulin, or it resists insulin) and hyperlipidemia (elevated level of lipid, like cholesterol and triglycerides in-your blood). According to Resident #41's Comprehensive Minimum…
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 before2024-01-24 · 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
Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to follow the Physician's Order (PO) for a.) floor mats, b.) heel protection boots bilaterally (B/L) and c.) right arm and right leg splints. This deficient practice was identified for one (1) of twenty-eight (28) residents, (Resident #1) reviewed for quality of care. This deficient practice was evidenced by the following: On 01/12/24 at 11:12 AM, the surveyor observed resident #1 in their room, in bed, there were no floor mats on the floor. The resident presents with B/L hand contractures, right leg contracture and BL foot contractures. The resident did not have any hand gauze rolls or splints present. The resident was positioned on the right side hip with a pillow. The resident can move right lower extremity straight into the air. There was an air mattress on the bed and the resident head of bed (HOB) was at 30 degrees. The resident had tube feeding (TF) in use at 50 milliliter (ml) hour for 8 hours. Heel boots were observed on the chair in the corner. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 apply a left-hand roll (device that offers positioning of severely contracted hands) for the care and management of the left-hand contracture (a permanent shortening of muscle, tendon, or scar tissue, leading to deformity and rigidity of joints). This practice was observed for 1 of 5 (Resident #30) residents reviewed for limited range of motion. This deficient practice was evidenced by the following: On 01/10/24 at 11:25 AM, the surveyor observed Resident #30 in the great room sitting in the wheelchair and participating in a group activity. The surveyor observed the resident had on an elbow splint to the left upper extremity and a podus boot (a device used for the treatment and prevention of ankle/foot contractures and internal/external rotation of the lower extremity) to the left lower extremity. The left hand was observed to be in a closed fisted position and the thumb was tucked under the four (4) fingers. The surveyor reviewed the electronic health record (EHR) of Resident #30 which…
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 · D2024-01-24 · 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, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary respiratory care and services of residents in accordance with standard of practice for two (2) of four (4) residents, (Resident #42 and #85) reviewed for respiratory care. This deficient practice was evidenced by the following: According to the National Library of Medicine, Oxygen-induced hypercapnia: physiological mechanism and clinical implications Abstract Oxygen is probably the most commonly prescribed drug in the emergency setting and is a life-saving modality as well. However, like any other drug, oxygen therapy may also lead to various adverse effects. Patients with chronic obstructive pulmonary disease (COPD) may develop hypercapnia during supplemental oxygen therapy, particularly if uncontrolled. 1.) On 1/10/24 at 11:05 AM, the surveyor observed Resident #42 in bed with the Oxygen (O2) concentrator (a medical device used for delivering…
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 · D2024-01-24 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of Certified Nursing Aides (CNA) in order to provide specific education based on the outcomes of the reviews. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed, and was evidenced by the following: On 1/23/24 at 11:22 AM PM, the surveyor requested from the Infection Preventionist/Regional (IP/R) to provide the most recent performance evaluation for five randomly selected Certified Nursing Aides (CNA #1; #2; #3; #4; and #5). On 1/24/24 at 9:31 AM, in the presence of the survey team, the IP/R confirmed that there were no performance evaluations for the two (2) of the five (5) CNAs who had completed more than a year of service. CNA#1 with a date of hire on 11/9/22, had no performance evaluation. CNA #4 with a date of hire on 11/17/22, had no performance evaluations. On 1/24/24 at 11:23 AM, in the presence of the survey team, the Registered Nurse/Regional, the Director of Nursing, and the Licensed…
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 · D2024-01-24 · tag F0732 — isolatedPost nurse staffing information every day.
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 that the 24-hour staffing report that was posted was up to date for three (3) of nine (9) days. This deficient practice was evidenced by the following: On 01/22/24 at 7:18 AM, the surveyor in the presence of the Registered Nurse Supervisor (RNS) confirmed that the Nursing Home Resident Care Staffing Report (NHRCSR) that was posted in the reception area was dated 01/19/24 and not for 01/22/24. On that same date and time, the surveyor asked the RNS why the NHRCSR posted was from Friday (01/19/24) and there were no posted staffing report for Saturday (01/20/24), Sunday (01/21/24), and Monday (01/22/24). The RNS stated that because there were no admission people during weekends that was why the NHRCSR was not updated. She further stated that she was not responsible for posting the NHRCSR and she did not know about NHRCSR posting. The posted NHRCSR revealed the following information: 01/19/24-Day Shift Shift Hours: 7 AM-3 PM Census 103 Staff to Resident Ratio:…
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 · D2024-01-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to monitor target behaviors for the use of a psychotropic medication, Seroquel (used to treat certain mental/mood disorders such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder). This was identified for one of five residents, (Resident #87) reviewed for unnecessary medications. This deficient practice was identified by the following: On 01/10/24 at 11:30 AM, during the initial tour, Resident #87 was observed in bed, with eyes closed, and music on the television. The surveyor reviewed the electronic medical record (eMR) for resident #87. According to the admission Record, (an admission summary) Resident #87's was admitted to the facility with diagnoses that included but were not limited to: Dependence on Renal dialysis, Alzheimer's Disease and Unspecified Psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) not due…
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 · D2024-01-24 · 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
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 ensure the safe and appetizing temperatures of hot foods served to the residents. This deficient practice was identified for two (2) of three (3) residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 1/18/24 for 1 of 3 nursing units tested for food temperatures by two surveyors and was evidenced by the following: On 1/11/24 at 11:02 AM, the surveyor met with three residents for council meeting. Two out of three residents who resided on the [NAME] unit stated that hot food temperatures were unacceptable. On 1/18/24 at 11:48 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team. At 11:57 AM, the first food truck arrived at the [NAME] unit. A regular diet consistency tray was identified by the surveyor and Licensed Practical Nurse (LPN). This…
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 · D2024-01-24 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of pertinent facility documentation, the facility failed to have: a) the Licensed Nursing Home Administrator (LNHA) present for one (1) of three (3) Quality Assurance and Performance Improvement (QAPI) meetings and b) the Medical Director (MD) present for one (1) of three (3) quarterly QAPI meetings. The deficient practice was evidenced by the following: On 01/11/24 at 01:06 PM, the surveyor reviewed the provided last three quarters sign-in sheets for QAPI meetings that were provided by the LNHA. The QAPI committee was attended and included the required minimum members except the following who did not attend and were required to attend: 01/27/23=The MD was not in the meeting. 4/26/23=The LNHA was not in the meeting. On 01/18/24 at 10:57 AM, the survey team met with the Regional Nurse, Regional Infection Preventionist Nurse (RIPN), Director of Nursing (DON), and the LNHA. The surveyor notified the facility management of the above findings. On that same date and time, the LNHA provided a copy of the Medical Director Timeline for 2023 and showed 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.
- Potential for harm · D2024-01-24 · tag F0882 — isolatedDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP), and physically worked onsite in the facility for one (1) of two (2) staff. According to the NJ Executive Directive 21-012 (revised 12/22/22) included The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. According to the CMS QSO-22-19-NH Memo dated 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022 Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to have at least a part-time IP, the IP must meet…
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 · D2024-01-24 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of other facility documentation, it was determined that the facility failed to ensure 2 of 5 Certified Nursing Assistants (CNA #1 and CNA #4) received 12 hours of education annually. This deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files for the year 2023. A review of a facility form titled Individual Mandatory In-services revealed the following: CNA #1 with a date of hire on 11/9/22, had 8.5 education hours from the date of hire, to the anniversary date. CNA #4 with a date of hire on 11/17/22, had no education hours on file. On 1/23/24 at 12:04 PM, in the presence of the survey team, the Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA), the Infection Preventionist/Regional (IP/R) confirmed that CNA #4 and CNA #5 did not have their 12 hours of in-services training for 2023. On 1/24/24 at 11:23 AM, in the presence of the survey team, the Registered Nurse/Regional, IP/R and the DON, the LNHA stated we will be following-up to ensure the 12-hour mandatory in-services…
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 before2022-11-10 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 of 21 residents reviewed, Resident #47 as evidenced by the following: According to the Resident Assessment Instrument Manual Version 3.0 of Centers for Medicaid and Medicare Services (CMS) guidelines, updated October 2019 a SCSA MDS is required if there is a Decline in two or more of the following: . Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); . Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/ injury, a new deep tissue injury or worsening in pressure ulcer status; . The ARD [Assessment Reference Date] must be less than or equal to 14 days after the IDT's [Interdisciplinary Team's] determination that the criteria for an SCSA are met (determination date + 14 calendar days). On 10/21/22 at 11:47 AM, two surveyors observed Resident #47 lying in bed. 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 before2022-11-10 · 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 5. On 10/25/22 at 12:10 PM, the surveyor observed Resident #47 being fed by the Certified Nursing Assistant (CNA). The surveyor reviewed the hybrid medical record for Resident #47: The admission Record revealed that Resident #47 was admitted to the facility with diagnoses that included but were not limited to Unspecified Dementia with Behavioral Disturbance, Major Depressive Disorder, and Primary Generalized Osteoarthritis (a joint disease in which the tissues in the joint break down). The 9/1/22 quarterly MDS, revealed a BIMS score of 0 out of 15, which indicated a severely impaired cognition. The MDS also indicated that Resident #47 required, supervision and setup help only with eating under Section G, which was inaccurate. The Dietary Alert Sheet dated 3/24/21 indicated, Resident needs to be fed as per ST [Speech Therapy]. The Activities of Daily Living (ADL) Tracker Form dated August 2022 for Resident #47 indicated that on 4 days of the MDS look-back period, 8/28-8/31/22, that the resident's eating was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan (CP) for residents at the facility. This deficient practice was identified for 3 of 24 residents reviewed for comprehensive care plans (Resident #69, #44, and #48), and was evidenced by the following: 1. On 10/27/22 at 12:01 PM, the surveyor observed Resident #69, awake and alert, seated in a wheelchair watching T.V. in their room. The surveyor reviewed the hybrid medical record belonging to Resident #69. Review of the admission Record (an admission summary) (AR) belonging to Resident #69 documented a diagnosis that included but was not limited to Depression, Unspecified. A Significant Change in Status in the Minimum Data Set (MDS), an assessment record used to facilitate the management of care, dated 9/21/22 indicated a Brief Interview of Mental Status (BIMS) score of 6, which indicated that the resident had severe cognitive impairment. The October…
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 before2022-11-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 a resident was weighed weekly and monthly in accordance with physician's orders and facility policy. This deficient practice was identified for 1 of 7 residents (Resident #47) reviewed for weight loss. The deficient practice was evidenced by the following: On 10/21/22 at 11:47 AM, two surveyors observed Resident #47 lying in bed. The resident did not respond to the surveyors' conversation. The surveyor reviewed the hybrid medical record for Resident #47. The admission Record revealed that Resident #47 was admitted to the facility with diagnoses that included but were not limited to Unspecified Dementia with Behavioral Disturbance, Major Depressive Disorder, and Primary Generalized Osteoarthritis (a joint disease in which the tissues in the joint break down). Review of the 9/1/22 quarterly MDS, an assessment tool used to facilitate the management of care, revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that Resident #47 had a severely…
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 · D2022-11-10 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes (PN) at least once every sixty days. This deficient practice was identified for 4 of 21 residents reviewed for physician visits, Resident #4, #26, #77, #79. This deficient practice was evidenced by the following: 1.) On 10/24/22 at 10:51 AM, the surveyor observed Resident #4 in bed with eyes closed. The resident was also observed lying on a pressure relieving air mattress and was wearing bilateral heel booties. The surveyor reviewed the admission Record (AR) which indicated that Resident #4 was admitted to the facility with diagnoses that included but were not limited to, Cerebral infarction; Hemiplegia and Hemiparesis; Peripheral Vascular Disease and Carcinoma of right breast. According to the Minimum Data Set (MDS), an assessment tool used to facilitate management of care which was dated 10/15/22,…
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 · D2022-11-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, it was determined that the facility failed to 1.) maintain food items in a manner to ensure they are not used past their use by date, 2.) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and the potential for developing food borne illness, and 3.) prevent staff from handling resident's food in a non-hygienic manner. This deficient practice was evidenced by the following: 1. On 10/21/22 at 10:15 AM, two surveyors in the presence of the Food Service noted a 2.05 once (oz) container of dried Bay leaves with an expiration date of 9/16/2022 and a 16 oz container of Cumin with an expiration date of 3/25/2021 were observed in the dry storage area. The FSD could not explain why both expired items had not been thrown away. 2. During the continued inspection of the kitchen, the two surveyors in the presence of the FSD observed a blackish/grey debris covering the fans and grey particles on the ceiling,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2025-04-16 · tag F0637 — patternAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that the completion of a significant change Minimum Data Set (MDS), an assessment tool, was completed in a timely manner. This deficient practice was identified for 1 of 23 residents reviewed for resident assessments (Resident # 40), and was evidenced by the following: On 4/9/25 at 10:00 AM, the surveyor observed Resident #40 lying in bed, clean, dry with the head of bed up. The surveyor was unable to interview the resident due to cognitive impairment. A review of the admission Record face sheet (an admission summary) indicated that Resident #40 was admitted to the facility with the diagnoses which included but were not limited to; diabetes mellitus (DM), metabolic encephalopathy (a change in how your brain works due to an underlying condition which can cause confusion, memory loss and loss of consciousness.), unspecified dementia, and chronic kidney disease. A review 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.
- No harm found · C2024-01-24 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide written notification of the emergency transfer to the Office of the Long-Term Care Ombudsman (LTCO) for one (1) of two (2) residents (Resident #94), reviewed for hospitalizations. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #94. The admission Record (or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to diabetes insipidus (a disorder of salt and water metabolism marked by intense thirst and heavy urination), encephalopathy unspecified (means damage or disease that affects the brain), dysphagia (difficulty swallowing), and tracheostomy (help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) status. A review of the New Jersey Universal Transfer Form (UTF) showed 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.
- No harm found · C2024-01-24 · tag F0625 — widespreadNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide resident and/or their representatives with the facility's written notice of bed hold. This deficient practice was identified for one (1) of two (2) residents, (Resident #94), reviewed for hospitalization. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #94. The admission Record (or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to diabetes insipidus (a disorder of salt and water metabolism marked by intense thirst and heavy urination), encephalopathy unspecified (means damage or disease that affects the brain), dysphagia (difficulty swallowing), and tracheostomy (to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) status. A review of the New Jersey Universal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2024-01-24 · tag F0641 — widespreadEnsure 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 REPEAT DEFICIENCY Based on the interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of the 28 residents reviewed, Resident #105. This deficient practice was evidenced by the following: According to the admission Record (admission summary), Resident #105 was admitted to the facility with a diagnosis that included but was not limited to metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Alzheimer's disease unspecified (a progressive disease that destroys memory and other important mental functions), depression, and essential hypertension (abnormally high blood pressure that's not the result of a medical condition). A review of the resident's Progress Notes under Health Status Note (HSN) dated, 10/12/23 at 02:51 PM, revealed that the assisted living staff came, assessed the resident, will be discharged in the afternoon, and that the responsible party…
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
$175,196 in federal fines across 14 penalties.
- $123,014 — penalty dated 2024-01-24
- $4,587 — penalty dated 2023-11-13
- $4,587 — penalty dated 2023-11-06
- $4,587 — penalty dated 2023-10-30
- $4,587 — penalty dated 2023-10-23
- $4,587 — penalty dated 2023-10-17
- $4,545 — penalty dated 2023-10-10
- $4,587 — penalty dated 2023-10-02
- $4,235 — penalty dated 2023-09-25
- $3,882 — penalty dated 2023-09-18
- $3,529 — penalty dated 2023-09-11
- $3,176 — penalty dated 2023-09-05
- $2,823 — penalty dated 2023-08-28
- $2,470 — penalty dated 2023-08-21
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to AUTUMN LAKE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 58 homes this chain runs (chain average 2.8★, per CMS)
Showing 40 of 58; lowest-rated first.
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 |
|---|---|---|---|---|
| JACOBS, HYMAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 95% | since 04/30/2009 |
| JACOBS, LIVIA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 04/30/2009 |
| HAYES, VICKI | Individual | W-2 MANAGING EMPLOYEE | — | since 02/26/2015 |
| METTERNICH, CHRISTOPHER | Individual | CORPORATE OFFICER | — | since 08/17/2017 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315104. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-16, 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.