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Llanfair House Care & Rehabilitation Center

1140 Black Oak Ridge Road, Wayne, NJ 07470 · For profit - Limited Liability company · 180 certified beds · (973) 835-7443 Medicare & Medicaid certified

Call the home — (973) 835-7443 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609) — most recent Jun 20261 actual-harm citation$47,304 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — 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 (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $47,304 in federal fines (most recent 2024-12-16)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 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

Urgent care / clinic
2035 Hamburg Tpke · (973) 831-5651 · Call to confirm hours
Pharmacy
2075 Hamburg Tpke · (973) 513-9940 · Call to confirm hours
Grocery
500 State RT 23 · (973) 839-5510 · Call to confirm hours
Park
Pompton Aquatic Park · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 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 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.7%8.7%15.4%better
Long-stay residents who lose too much weight6.3%4.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.6%0.9%better
Long-stay residents with a urinary tract infection0.6%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.8%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.5%2.3%3.3%better
Long-stay residents whose ability to walk worsened4.5%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.1%18.8%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%97.2%95.3%typical
Long-stay residents with pressure ulcers3.6%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control7.2%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table37.1%12.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication5.4%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine85.3%80.1%79.4%typical
Short-stay residents rehospitalized after admission28.7%24.9%22.6%worse
Short-stay residents with an outpatient ER visit2.8%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.642.071.67worse
Long-stay outpatient ER visits per 1,000 resident days0.971.111.80better

‡ 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.

45.5% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.5%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
56.7%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.30
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 56.7% 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 30 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 0.22 therapist hours per resident per day in 2025Q4 — more than 27% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 14% — 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.5%CMS range 33.7–61.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.6–15.010.7%Oct 2022–Sep 2024no 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 discharge56.7%56.6%Oct 2024–Sep 2025CMS 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 discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.3%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.2–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 2022–Sep 2024CMS 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

0.63
RN hours/ resident / day
0.72
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.44
RN hoursweekends
50.0%
Total nursing turnover
61.5%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 104.3 residents a day — about 58% occupied, or roughly 76 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.26 hrs/resident/day on weekends vs 3.93 on weekdays — 17% thinner on weekends. RN hours go from 0.56 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10 →
deficiencies at the latest standard inspection (2026-06-04)
10
at the previous standard inspection (2024-12-16)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

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.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2024-12-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 #'s: NJ175457, NJ175482 Based on observation, interview, and record review, it was determined that the facility failed to report a newly developed pressure ulcer (PU) and implement a physician's order (PO) for wound care to treat a facility acquired PU for 1 of 3 residents reviewed for PU's, (Resident #110). The PU worsened from an excoriation (wearing off the skin) that was identified on 6/20/24 to an unstageable PU ( covered with slough (a soft, yellow or white, often stringy material that accumulates on the surface of a wound) or eschar (a layer of dry, dead tissue that forms over a deep wound) and cannot be staged which are caused by prolonged pressure, shear and friction and can lead to infection and complications). This deficient practice was evidenced by the following: On 12/5/24 at 10:30 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #110, which revealed the following: A review of the admission Record (an admission summary) reflected that Resident #110…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-06-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food was served under sanitary conditions which included proper glove use for one of one kitchen. This failure placed 113 census residents at risk for food borne illnesses. Findings include:During an observation and interview on 06/03/26 at 11:42 AM, a [NAME] was observed with gloves on preparing the plates for each food tray. As the [NAME] was preparing specialized plates, the [NAME] was touching other items in the kitchen (opening and closing the warmer, touching other surfaces away from the tray line) with the same gloved hands. The [NAME] then went back to tray line and started preparing plates for residents and touched the food on the plate with the same gloved hands used when starting to prepare resident food plates. The [NAME] stated gloves needed to be changed when they touched other things before they went back to touching food on tray line. During an observation on 06/03/26 at 12:45 PM, the Dietary Manager (DM) was assisting with tray line preparing plates for the residents. A meal slip showed a resident…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-04 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure female residents had facial hair removed for two of four residents (Resident (R) 43 and R70) and fingernails were kept clean and trimmed for two of four residents (R65 and R92) reviewed for activities of daily living (ADL) of 35 sample residents. This failure had the potential to affect resident care including personal hygiene in the facility. Findings include: Findings include: 1. Review of R43's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses of Parkinson's disease, dementia, and lack of coordination. Review of R43's Care Plan located under the Care Plan tab of the EMR, dated 02/15/24, revealed R43 had ADL self-care performance deficiencies related to dementia, disease process related to Parkinson's disease and limited mobility. R43 required total staff assistance of one staff with personal hygiene. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure medications were evaluated with clinical indications for use documented for as needed (PRN) psychotropic medication (lorazepam) beyond 14 days for one of five residents (Resident (R) 10) and ensure target psychotropic behavior monitoring was conducted for one of five residents (R4) reviewed for unnecessary medications of 35 sample residents. This failure had the potential to place the residents at risk of adverse consequences. (Cross Reference F756)Findings include:1. Review of R10's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 10/20/25, with a diagnosis of unspecified dementia, unspecified severity, with agitation. Review of R10's EMR Care Plan located under the Care Plan tab, dated 12/09/25, indicated that the resident was placed on hospice care and the goal was to provide the resident with comfort care. Review of R10's EMR Treatment…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and policy review, the facility failed to ensure allegations of abuse were reported timely to the State Survey Agency (SSA) for one of one resident (Resident (R) 66) reviewed for abuse out of 35 sampled residents. This failure increased the risk of other vulnerable residents being abused. Findings include:Review of R66's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 06/06/26. Review of R66's EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) located under the MDS tab, dated 05/13/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which revealed that the resident was cognitively intact. During an interview on 06/01/26 at 10:36 AM, R66 stated he felt like he/she was being mentally abused since the facility held his/her mental health medications. There was no documentation related to this allegation. During an interview on 06/03/26 at 1:35 PM, the Administrator and Director of Nursing (DON) 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure residents were appropriately screened and had documentation to support the use of wander guards for one of two residents (Residents (R) 4) reviewed for wander guards of 35 sample residents. This failure had the potential to affect all residents with wandering behaviors. Findings include:Review of R4's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R4 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, muscle weakness, and cognitive communication deficit. Review of R4's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/07/25, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. Further review of MDS along with previous MDS assessments completed on 01/13/26 and 10/14/25 revealed no wandering behavior was exhibited. Review of R4'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails for two of three residents (Resident (R) 12 and R54) reviewed for side rails out of 35 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include:1. Review of R12's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia and lack of coordination. Review of R12's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/26 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R12 was severely cognitively impaired. Review of R12's Care Plan located under the Care Plan tab of the EMR, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and policy review, the facility failed to ensure medication irregularities were responded to after the Consultant Pharmacist identified that there was a required stop date for one of six residents (Resident (R) 10) reviewed for medication regimens of 35 sampled residents. The Consultant Pharmacist identified that there was a required end date for an as needed (PRN) psychotropic medication (lorazepam) and the facility failed to respond and correct the order. This placed the residents at risk for unnecessary prolonged use of psychotropic medication. Findings include:Review of R10's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 10/20/25, with a diagnosis of unspecified dementia, unspecified severity, with agitation. Review of R10's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference date of 03/17/26, located under the MDS tab indicated that the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to ensure three of three medication storage rooms and one of four medication carts were free of expired medications, syringes, collections tubes for specimens, and COVID-19 test for 113 census residents. This practice had the potential to affect medications and biologicals efficacy.Findings include:During an observation on 06/02/26 at 10:28 AM, alongside the Licensed Practical Nurse (LPN) 2, revealed all three medication storage rooms had Medline industries, sterile foam tipped applicators, expired on 05/26 and Medline industries, safety syringe 25Gx1.0 (139 syringes), expired 11/26/25. Observation of the first and second floor medication storage rooms revealed Osang Heatlhcare, (OHC), covid-19 antigen self-test expired 05/05; One a day vitamin, two bottles expired 04/26; and Cyclosporine ophthalmic emulsion 0.05%, two bottles expired 05/26. Observation of the first-floor medication cart revealed morphine oral 5mg (milligram) (25 syringes Predose) expired on 03/24. LPN2 confirmed at this time 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy reviews, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in rooms with enhanced barrier precautions (EBP) for one of one resident (Resident (R) 83) reviewed for infection control of 35 sample residents. These deficient practices had the potential to affect all residents and increase the risk for cross contamination and the spread of infections throughout the facility. Findings include: Observation on 06/02/26 at 9:13 AM of room [ROOM NUMBER]-D revealed signage on the outside of door which indicated EBP. Registered Nurse (RN) 2 was administering medications to R83 in bed A by the door and checking the resident's percutaneous endoscopic gastrostomy (peg) tube. RN2 was observed wearing gloves but no gown and was observed pulling back the residents' blankets. RN2 was observed leaning across R83 contacting the residents' stomach area while he/she touched the residents' peg tube with his/her hand. RN2 removed gloves and disposed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0940 — failed to train staff — isolated
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility assessment review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for two of two staff (Registered Nurse (RN) 2 and Certified Nurse Aide (CNA) 1) reviewed for training with the potential to affect 113 census residents. This failure had the potential to lead to increased spread of infection. Findings include: Review of the Facility Assessment, updated 01/02/26 and provided by the facility, revealed the facility provided staff training/education and competencies that were necessary to provide care and support for their resident population. The training/education and competencies/skill checks were generally provided upon hire, during monthly in-service/training, whenever an area of concern was identified, or new areas were identified based on resident diagnosis and/or clinical condition. Review of RN2's employee Personnel Training File, provided by the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Fcited before2024-12-16 · tag F0658 — failed to meet professional standards of care — widespread
    Ensure 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

    REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to: a.) follow a physician's order (PO) for a bolus feeding (method of giving tube feeding where large doses of formula are administered several times a day) in one (1) of two (2) residents (Resident #51) reviewed for tube feeding (TF) and b.) failed to document for accountability of medications and treatments administered for 4 of 5 residents (Resident #28, #83, #88 and #110) reviewed for unnecessary medication. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing a medical regimens as prescribed by a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-12-16 · tag F0711 — widespread
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's primary physician (MD #1, MD #4) accurately dated their physician progress notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 8 of 16 residents, (Resident #41, # 51, #110, #45, #66, #84, and #71). This deficient practice was evidenced by the following: 1. On 12/4/24 at 11:07 AM, the surveyor interviewed Resident #41 in their room. The resident further stated to the surveyor they could not recall the last time they were assessed by their physician. A review of Resident #41's Face Sheet (an admission summary) reflected that Resident #41 was admitted to the facility with diagnoses that included but not limited to Schizophrenia, Chronic Kidney disease, and End Stage Renal Disease. A review of the 5-Day Minimum Data Set (MDS), an assessment tool used to facilitate care management dated 11/23/2024, indicated a Brief Interview for Mental Status (BIMS) scored of 14 out…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-16 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 3 of 3 residents (Resident #30, Resident #83, and Resident #13) reviewed. This deficient practice was evidenced by: The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related standard claim appeal rights. On 12/9/24 at 9:45 AM, the facility provided the surveyor with a list of residents who were discharged from the facility within the last 6 months and should have received the SNF ABN form. The surveyor reviewed Resident #30, Resident #83 and Resident #27 who were listed discharged from Medicare Part A coverage stay 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    REPEAT DEFICIENCY Complaints # NJ175457, NJ175482 Based on observations, interviews, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 2 of 28 residents reviewed (Resident #51 and #110). This deficient practice was identified by the following: 1. On 12/4/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid (paper and electronic) medical records. A review of the admission Record (an admission summary) (AR) for Resident #51 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), nontraumatic subdural hemorrhage (a rare condition that occurs without a head trauma) and gastrostomy (presence…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to maintain respiratory equipment in a sanitary manner for a resident who was receiving continuous oxygen (O2). The deficient practice was identified for 1 of 1 resident (Resident #95) reviewed for respiratory care. The deficient practice was evidenced by the following: On 12/4/24 at 11:46 AM, the surveyor observed Resident # 95 in bed with eyes closed with O2 in use via nasal cannula (a medical device used for delivering O2) at 4 Liters Per Minute (LPM.). The surveyor further observed the O2 tubing was dated 11/5/24. A review of the Face Sheet (an admission record) revealed that the resident was admitted to the facility with diagnosis that included but not were not limited to Pneumonia, Chronic Respiratory Failure, and Pulmonary Fibrosis. A review of the quarterly Minimum Data Set Assessment (Q/MDS), an assessment tool, used to facilitate the management of care, dated 9/2/24, reflected that the resident had a Brief Interview for Mental Status score of 14 out of 15 indicating 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0712 — isolated
    Ensure 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 observation, interview, and record review, it was determined that the facility failed to ensure the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every 30 days for Medicaid recipient residents and once every 60 days for Medicare recipient residents. This deficient practice was identified for 2 of 22 residents (Resident #95 and Resident 103), reviewed for physician visits and was evidenced by the following: 1. On 12/04/24 at 11:46 AM, the surveyor observed Resident # 95 with eyes closed. The surveyor reviewed the hybrid medical records (paper and electronic) (HMR) for the Resident #95 which revealed that the resident's primary physician (PP) (MD#2) no Physician Progress Notes (PPN) since Resident #95 was admitted to the facility on [DATE]. The surveyor reviewed Resident 95's Face Sheet (an admission record) which revealed that the resident was admitted to the facility with diagnosis that included but not limited 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-16 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to respond to the Consultant Pharmacist's (CP) monthly recommendations in a timely manner for 1 of 22 residents (Resident #51) reviewed. The deficient practice was evidenced by the following: On 12/04/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid medical records. A review of the admission Record (an admission summary) (AR) for Resident #51 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), nontraumatic subdural hemorrhage (a rare condition that occurs without a head trauma) and gastrostomy (presence of a surgical opening into the stomach,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-16 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to properly label, dispose and secure medications in one (1) of five (5) medication carts and one (1) of five (5) treatment carts inspected. This deficient practice was evidenced by the following: On 12/9/24 at 9:15 AM, the surveyor during observation of medication administration observed the 1st floor long-side treatment cart that was unlocked and unattended. The treatment cart contained ointments and creams. The surveyor did observe any residents near the treatment cart. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who acknowledged that the treatment cart was unlocked and further stated that the treatment cart must always be locked when unattended. On 12/12/24 at 11:35 AM, the surveyor inspected the 1st floor short-side medication cart in the presence of LPN#2. The surveyor observed an opened bottle of blood glucose test strips that was not dated. The surveyor also observed an unopened and undated Humalog insulin pen. At that time, the surveyor interviewed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, readily accessible medical records, and legible physician's progress notes (PPN). This deficient practice was identified for 2 of 22 residents reviewed, Resident #5 and #51, and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 12/4/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid (paper and electronic) medical records (HMR). A review of the admission Record (an admission summary) (AR) for Resident #51 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Anemia (a condition in which blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), type 2 Diabetes Mellitus (a long-term condition in which the body has…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-09 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure required monthly visits by the Consultant Pharmacist (CP) for the months of August, September, and October 2023. This irregularity was identified for 17 of 17 residents reviewed by the survey team for CP review, Resident #78, #8, #89, #71, #85, #40, #86, #90, #52, #91, #68, #75, #24, #46, #63, #59, #22, #70, #88 and #36. The deficient practice was evidenced by the following: On 10/30/23 at 12:30 PM, after completing the facility unit inspection, the surveyor asked the Director of Nursing (DON) for the Consultant Pharmacist (CP) 2023 previous unit inspections. The DON informed the surveyor that the facility had unit inspections performed by the CP until July 2023. The DON also informed the surveyor that the facility did not have a CP perform monthly medication reviews as they received notification in July 2023 that the CP company would no longer service the facility. On 11/2/23 at 10:00 AM, the DON informed the surveyor that the previous Consulting Pharmacist company could no…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, it was determined that the facility failed to maintain dignity during mealtime for a resident. This deficient practice was observed for 1 of 18 residents reviewed for dining observation, Resident #64 and was evidenced by the following: On 10/30/23 at 12:19 PM, the surveyor observed Resident #64 in the first floor dining room seated in a wheelchair. Resident #64 was observed eating their lunch. The surveyor observed that the Licensed Practical Nurse #2 (LPN #2) feeding Resident #64 while standing over them. The surveyor further observed that LPN #2 was wandering around the dining room assisting other residents with their meal. On 10/30/23 at 12:25 PM, the surveyor interviewed LPN #2 who stated that staff should be seated next to the resident while assisting them during feeding time. LPN #2 further stated that she wasn't really feeding Resident #64 but was just wandering around. A review of the admission Record for Resident #64 revealed that the resident was admitted to the facility with diagnoses which included but were not limited 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility failed to provide a homelike environment during meal service in both dining rooms located in the facility. The deficient practice was observed on 2 of 2 facility floors, dining room [ROOM NUMBER] (DR1) and dining room [ROOM NUMBER] (DR2) during lunch service observation. This deficient practice was evidenced by the following: On 10/30/2023 at 11:55 AM, during the lunch service located on 2nd floor dining room (DR2), the surveyor observed that all meals in DR2 were served and remained on meal trays throughout the meal. On 10/30/2023 at 12:02, during the lunch service located on 1st floor dining room (DR1), the surveyor observed that all meals in DR1 were served and remained on meal trays throughout the meal. On 10/31/2023 at 11:45 AM, during the lunch service located on 2nd floor dining room (DR2), the surveyor observed that all meals in DR2 were served and remained on meal trays throughout the meal. On 10/31/2023 at 12:11 PM, during the lunch…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation, interview, and record review, it was determined that the facility failed to revise the person centered comprehensive care plans (CCP) for 3 of 22 residents reviewed (Resident #63, #71, and #52). This deficient practice was identified by the following: 1. On 10/30/23 at 11:36 AM, the surveyor observed Resident #63 in bed, watching TV. The surveyor further observed a floor mat on both sides of the bed. The surveyor reviewed Resident #63's hybrid medical records. The admission Record (AR) reflected that Resident #63 was admitted to the facility with medical diagnoses that included but were not limited to, Fracture of neck of left Femur, Dementia and Cerebral Infarction. A review of the Significant Change Assessment Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/31/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating that the resident had moderately impaired cognition. A review of the November 2023 Order Summary Report (OSR) revealed a physician's order (PO)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 the facility failed to consistently follow standards of clinical practice with regards to: accurately documenting medication administration for 1 of 1 dialysis residents, Resident #40. 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…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to provide safety measures and follow interventions for a resident who has a history of being at high risk for falls. This deficient practice was identified for 1 of 3 residents reviewed for falls, Resident #52. The deficient practice was evidenced by the following: On 10/30/2023 at 11:28 AM, the surveyor observed Resident #52 in their room. The resident was in bed, the bed was in the lowest position. Resident # 52 had a mattress against the wall, no bed rails and/or floor mats were observed. The surveyor reviewed Resident #52's hybrid medical record. The Face Sheet (FS) (A one-page summary of important information about a patient) reflected that Resident #52 was admitted to the facility with medical diagnoses which included but were not limited to Epilepsy, Vascular Dementia, Functional Quadriplegia, Nontraumatic Subdural Hemorrhage and Other Specified Disorders of the Brain. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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, record review, and review of pertinent facility documents, it was determined that the facility failed to: a) ensure that a resident identified with a significant weight loss was comprehensively evaluated and assessed, and b) ensure accurate weights were obtained for a resident identified with significant weight loss. This deficient practice was identified for 2 of 6 residents, Resident #89 and #85 reviewed for nutrition and was evidenced by the following: 1. On 10/30/2023 at 12:00 PM, the surveyor observed Resident #89 walking in the hallways of the unit. The resident was alert, oriented to self and verbally responsive. On 11/3/23 at 9:45 AM, the surveyor reviewed the electronic health record (EHR) of Resident #89 which revealed the following: According to the admission Record (an admission summary), Resident #89 was admitted with diagnoses that included but were not limited to, unspecified Dementia, Hypertension, Anxiety Disorder, and Major Depressive Disorder. An Annual Minimum Data Set (MDS) assessment, a tool used to facilitate management 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to: a) ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule, b) monitor fluid intake for a dialysis resident on fluid restrictions, and c) ensure communication with a dialysis center regarding a resident's medication regimen. The deficient practice was evidenced for 1 out of 1 dialysis resident (Resident #40) reviewed, Resident #40. This deficient practice was evidenced by the following: a) On 10/30/23 at 12:40 PM, the surveyor observed Resident #40 sitting in the dayroom. The resident was alert, conversant and stated they were scheduled to go to dialysis later in the afternoon. Resident #40 was scheduled to go to dialysis every Monday, Wednesday, and Friday. The resident had no concerns with their care at the facility. A review of Resident #40's electronic health record (EHR) revealed the following: According to the admission Record (an admission summary),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 resident's primary physician accurately dated physician progress notes (PPN) during his visit to ensure that the resident's current medical regimen was up to date. This deficient practice was observed for 1 of 6 residents, Resident #91. This deficient practice was evidenced by the following: On 10/30/2023 at 11:51 AM, the surveyor observed Resident # 91 in their room eating. During the interview progress, the resident stated they could not recall the last time they saw their physician. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #91 which revealed that the resident's primary physician had inaccurately dated 10 physician progress notes written on 11/6/23 and 11/10/23. Per the guidelines, (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.30(b) Physician Visits The physician must- §483.30(b)(2) Write, sign, and date progress notes at each…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from a resident's active inventory after it had expired, and medications were administered according to manufacturer's recommendations. These deficient practices were identified for 1 of 2 units inspected during the facility unit inspection process and related to Resident #78. This deficient practice was evidenced by the following: On 10/30/23 at 10:00 AM, the surveyor inspected the 1st floor short hall medication cart. The surveyor noted a Novolog Insulin 100 units (u)/milliliter (ml) pen refill unit. The Novolog pen refill unit was stored in a plastic pharmacy provider bag labeled for Resident #78 and delivered to the facility on 8/25/23. Further review of the medication storage bag presented a label, Refrigerate Until Opened Date Opened:______ that was blank and another label, Store Using Directions Provided. Throw Away Any Medicine That Remains 28 Days After First…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-09 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility policies, it was determined that the facility failed to properly clean and sanitize kitchen equipment as well as store, label, and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/30/2023 at 09:19 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. On the Chef prep table, the surveyor observed on the inside of the microwave had caked on yellowish debris on microwave door and greyish debris observed on top and sides of microwave. The FSD stated the microwave should have been cleaned of debris after each use and at the end of the evening. 2. In the Standing freezer located next to the chef prep table, surveyor observed: a. Two frozen turkey burgers wrapped in plastic wrap, not labeled. b. One, 32oz bag of chopped spinach not labeled. c. One, 40oz bag Brussel sprouts not labeled. FSD stated, everything in the freezer should be labeled with the delivery date, open date and/or…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$47,304 in federal fines across 1 penalty.

  • $47,304 — penalty dated 2024-12-16

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 MB HEALTHCARE — 12 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 →

RatingThis homeChain avg
Overall 2 of 53.6-1.6 vs chain
Health inspection 2 of 53.1-1.1 vs chain
Staffing 3 of 52.9+0.1 vs chain
Quality measures 4 of 54.6-0.6 vs chain
The other 11 homes this chain runs (chain average 3.6★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
JACOBS, HYMANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST95%since 12/16/2009
JACOBS, LIVIAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 12/16/2009
STERNSCHEIN, RUDOLFIndividualW-2 MANAGING EMPLOYEE—since 12/04/2014
METTERNICH, CHRISTOPHERIndividualCORPORATE OFFICER—since 08/17/2017

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.

$9.6M
Net patient revenuemost recent cost report
-44.9%
Operating marginrevenue minus expenses
$1.5M
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 89%Medicare 4%Other / private 7%

About 89% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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

$442per resident / day
operating cost
$13,440per month
≈ monthly operating cost
$305per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

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 2026-09-01 — CMS provider number 315142. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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.

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