Avalon Rehab and Care Center
2020 Route 23 North, Wayne, NJ 07470 · For profit - Limited Liability company · 170 certified beds · (973) 305-8400 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (59%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 4 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 | 6.3% | 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 | 1.1% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.9% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.8% | 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 | 3.0% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.8% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.7% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.2% | 15.6% | 21.2% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 55.9% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.8% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.0% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.31 | 2.07 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.20 | 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.
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.
53.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 86 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 95 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 73% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | 53.1%CMS range 42.5–65.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 6.3–14.7 | 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 | 72.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 62.1% | 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 | 60.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.9% | 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 | 98.4% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.4% | 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 | 8.3%CMS range 4.7–14.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 170 beds and averages 168.4 residents a day — about 99% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.98 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.57 hrs/resident/day on weekends vs 3.15 on weekdays — 18% thinner on weekends. RN hours go from 0.44 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 1 administrator has left in the past year.
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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · E2026-06-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to date, label, and/or cover food products stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 154 of 159 residents who consume food prepared from the facility's kitchen.Findings include:An observation on 06/02/26 from 10:25 AM to 11:15 AM, with the Dietary Manager (DM), revealed the following: The main refrigerator contained 56 carrots in an open plastic bag with no date label.Two halves of lettuce heads in plastic wrap with no date label. An open cardboard box with ten limes with no date label. Two of the limes had visible white spots. Four opened pie shells with no date label. During an interview on 06/02/26 at 11:20 AM, the DM confirmed the above observations and stated that staff should date all refrigerated products once the food items are opened. The DM also stated that there was no schedule for checking all food for date labels or expired food. Review of the facility's policy titled, Pinnacle Dietary Global, which indicated…
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 · D2026-06-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure one of 42 sampled residents (Resident (R) 2) were treated with dignity and respect in a manner and environment that maintained their quality of life. This failure had the potential to negatively impact the quality of life and self-esteem for the affected residents. Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses of dementia with agitation, left femur fracture, and peripheral vascular disease. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/26, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated that R2's cognitive function was moderately impaired. Review of R2's care plan focus initiated on 06/01/26, R2 had a functional ability performance deficit related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-05 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to inform and provide written information for 13 out of 19 residents (Residents (R ) 9 R10, R11, R15, R17, R19, R36, R92, R99, R117, R121, R140 and R142 concerning the right to accept or refuse medical or surgical treatment and, at the resident's or family's or legal representative's option, to formulate and advance directive. This failure had the potential to affect the residents' and their legal representatives' right to participate in and be informed of his or her treatment. Findings include:1.Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed Resident (R) 10 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), type II diabetes, and schizoaffective disorder. Review of R10's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/21, located in the EMR under the MDS tab, revealed a Brief Interview…
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 · D2026-06-05 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 and interviews the facility failed to ensure Pre-admission Screen and Resident Review (PASARR), an evaluation for serious mental illness and/or intellectual disability, Level I (preliminary assessment) was accurately completed to identify the resident's psychiatric diagnoses for two out of seven residents, (Resident (R) 5 and R19). The failure to accurately complete the assessment created the potential for R5 and R19 not to be assessed to receive specialized services as needed. Findings Include:1. Review of R5's admission Record, found in the electronic medical record (EMR) under the Profile tab, revealed R5 was initially admitted to the facility on [DATE] with diagnoses that included bipolar disorder. Review of R5's annual Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/06/26, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 was cognitively intact. The MDS revealed R5 had a diagnosis…
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 · D2026-06-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to provide assistance with activities of daily living (ADLs) for five residents (Resident (R) 6, 16, 9, 140, and R36) reviewed for activities of daily living (ADLs) out of a total sample of 33. This failure increased the potential for residents to have unmet hygiene needs. Findings include:1. Review of R140's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R140 was admitted to the facility on [DATE] with diagnoses that included sepsis, unspecified chronic obstructive disease (COPD), and methicillin resistant Staphylococcus aureus (MRSA). Review of R140's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/20/26 and located under the MDS tab of the EMR, revealed R140 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R140 was cognitively intact. It was recorded that R140 was dependent on staff for assistance with ADL's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to ensure proper personal protective equipment (PPE), was donned (put on) by Licensed Practical Nurse (LPN) 1 prior to entering into one of six sample residents (Resident (R) 92's) room who was under enhanced barrier precaution. This increased the likelihood that infectious organisms could be transmitted from residents to staff, other residents, or the environment.Findings include: Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R92 was admitted to the facility on [DATE] with diagnoses of osteomyelitis on ankle and foot, non-pressure chronic ulcer of left heel and midfoot with unspecified severity, and type II diabetes. Review of R92's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/26, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R92's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-22 · tag F0576 — isolatedEnsure residents have reasonable access to and privacy in their use of communication methods.
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 provide reasonable access to a telephone without being overheard. This deficient practice was identified for 1 of 3 residents reviewed, Resident#1, and as evidenced by the following:The surveyor reviewed the electronic medical record (EMR) for Resident #1. A review of the resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to, schizophrenia (a long-lasting brain disorder that affect how people think logically) and mild intellectual disabilities (below average cognitive functioning). A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 8/20/25, had a Brief Interview Mental Status (BIMS) score of 12 out of 15, which indicated the resident has moderate cognitive impairment. A review of the resident's Comprehensive Care Plan (CCP), a document that outlines a patient's healthcare needs and the nursing…
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 · E2024-12-19 · tag F0623 — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure residents were provided with written transfer/discharge notice that contained the option to appeal the transfer/discharge for four of four residents (Resident (R) 50, R110, R123, and R57) reviewed for facility initiated emergent hospital transfer of 33 sample residents. This failure had the potential to affect the residents and their Resident Representative by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: 1. Review of a Nursing Progress Note, located in the Progress Note tab of R123's electronic medical record (EMR), dated 10/14/24 and timed 6:40 PM, stated R123 was sent to the hospital emergency room for increased confusion, lethargy, stumbling and getting physically and verbally aggressive. Review a Nursing Progress Note, located in the EMR under the Progress Note tab, dated 10/15/24 and timed 3:03 AM, stated the hospital 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 · E2024-12-19 · tag F0625 — patternNotify 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure residents and/or resident representatives were provided with a written bed hold notice for facility initiated emergent hospital transfer for four of four residents (Resident (R) 50, R110, R123, R57) reviewed for facility initiated emergent hospital transfers of 33 sample residents. This failure had the potential for the residents to be denied return to their original room or denial of the resident returning to the facility. Findings include: 1.Review of Nursing Progress Note, located in the Progress Note tab of R123's electronic medical record (EMR) revealed she had a Nursing Note dated 10/15/24 and timed 6:40 PM stated she was sent to the hospital emergency room for increased confusion, lethargy, stumbling and getting physically and verbally aggressive. Review of the Nursing Progress Note, located in the Progress Note tab of R123's EMR, dated 10/15/24 and timed 3:03 AM, stated the hospital was called and the nurse was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · 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
Based on interviews, record review, and review of facility policy, the facility failed to ensure a care plan was revised quarterly for one of 36 residents (Resident (R) 103) reviewed for care plan revision. Specifically, the facility failed to schedule quarterly care conferences or invite R103 to the scheduled care conferences. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team, revealed, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. During an interview on 12/16/24 at 3:48 PM, R103 said she did not know about any care conferences and had never been invited. She said she would like to participate in the care conferences. Review of R103's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 10/05/23 with medical diagnoses that included type 2 diabetes, depression, and muscle weakness. Review of R103's annual Minimum Data Set (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.
Show the remaining 8 citations
- Potential for harm · E2024-05-17 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C#NJ 148344 C#NJ 148677 Based on observation, interview, and facility policy review, the facility failed to ensure window screens were in good repair, open windows had screens; and failed to ensure walls and floors in resident rooms were maintained in clean condition for 10 of 53 rooms. This failure created a non-homelike environment. Findings include: Observation on 05/14/24 at 3:38 PM of resident room [ROOM NUMBER] revealed the window screen in the window had a hole that extended the entire width of the window. Observation on 05/15/24 at 10:58 AM of resident room [ROOM NUMBER] revealed the window screen was torn all the way across the window. Observation on 05/15/25 at 2:41 PM of resident room [ROOM NUMBER] revealed the window screen was torn all the way across the window. Observation on 05/15/24 at 11:47 AM of resident rooms [ROOM NUMBER] revealed the window screens were torn and had several holes. Observation on 05/15/24 at 2:14 PM of resident room [ROOM NUMBER] revealed the window screen 232 was torn all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-17 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
C#NJ 148344 Based on observation interview, and facility policy review, the facility failed to ensure the meal menu was followed. This failure had the potential to result in weight loss and/or continued hunger for 40 of 119 residents. Findings include: Observation and interview on 05/14/24 at 11:45 AM in the kitchen revealed Dietary Employee (DE) 1 placed the scoops/serving utensils in the food items located on the steam table. He placed a #10 scoop (3.2-ounce scoop) in the sausage paella. He was observed to serve the residents on the first three carts the 3.2 ounce serving when the menu stated a 6-ounce portion should have been given. At 11:45 AM DE1 verified he used the #10 scoop to serve the sausage paella. At 11:54 AM the scoop size was again verified with DE1 and the Dietary Manager (DM). The DE used the 3.2-ounce scoop to serve the trays on the first and second carts to the first floor, and to the residents on the first cart to the second floor. During an interview on 05/16/24 at 9:12 AM the menu for the lunch meal on 05/14/24 meal was reviewed with the DM and the Regional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C#NJ 172626 Based on observation, record review, interview, and review of the facility's policy, the facility failed to ensure an Injury of Unknown origin was immediately reported to the State Survey Agency in accordance with the required timeframes for one of five residents (Resident (R) 20) reviewed for injuries of unknown origin out of a total sample of 24. R20 was found with redness and swelling to the right foot on 03/26/24 which resulted in a fracture of the fifth metatarsal bone. The facility did not report the injury of unknown origin until 03/29/24, which was four days later. This failure placed the resident at risk of possible abuse when. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised April 2021, indicated, All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies (as required by current regulations) .Reporting Allegations to the Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the facility's policy, the facility failed to ensure medications were locked in a secure storage area and only authorized personnel had access to the medications. Observation revealed medications delivered by the pharmacy was left at a nurses' station where residents, visitors, and unauthorized employees had access to the medications. This had the potential to cause injury to residents who would ingest them or to residents who need them in the event they are stolen due to not being supervised. This had the potential to affect the 93 residents residing on the second floor with a census of 119. Findings include: Observation on 05/16/23 at 6:05 AM of the second floor nurses' station revealed four brown paper bags of medications sitting on the nursing station within plain view and within reach of anyone standing at the nursing station. Continued observation revealed no staff around were in the line of sight of the bags of medications and Resident (R) 24 was sitting in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-13 · 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
Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for blood pressure (BP) parameters according to standards of clinical practice for one of 24 residents reviewed (Resident #18). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing…
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 · D2022-12-13 · 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 routinely and accurately post the nurse staffing information on four of 10 days during the survey period in a place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 11/28/22 at 8:48 AM, upon entry into the facility, the surveyor observed that the Nursing Home Staffing Report Form (NHSRF) that was posted in the reception area of the lobby showed a staffing report dated 11/28/22 with the census of 115 for Day Shift 7 AM - 3 PM. On that same date and time, the Licensed Nursing Home Administrator (LNHA) provided a copy of the facility's census in the presence of the Regional LNHA (RLNHA) and the Regional Director of Nursing (RDON). The provided copy of the facility's census showed 118 with one bed hold. The surveyor asked the facility management why the posted NHSRF in the reception area and the provided census copy did not match. The LNHA stated that she will get back to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-13 · 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 documents, it was determined that the facility failed to perform handwashing appropriately for two of five staff (agency Certified Nursing Aide (aCNA) and Supply Clerk/CNA) observed during incontinence care in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for infection control and facility policy. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines, Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 01/18/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub…
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 · C2022-12-13 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted 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 documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and apply for a change in ownership upon 30 days of their sale in April 2022 in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies the provider or supplier type will furnish and bill Medicare. (3)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KBWB OPERATIONS-ATRIUM | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/01/2016 |
| BURRIS, WILLIAM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 03/01/2016 |
| KHAWLY, MARY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 03/01/2016 |
| TUFARIELLO, VINCENT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 03/01/2016 |
| ZOIS, ELIA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 03/01/2016 |
| HOOK, GREGORY | Individual | CORPORATE OFFICER | — | since 03/01/2016 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. 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 315291. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-05, 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.