Complete Care At Summit Ridge
20 Summit Street, West Orange, NJ 07052 · For profit - Limited Liability company · 152 certified beds · (973) 736-2000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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 | 1.3% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.7% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.0% | 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 | 0.4% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.3% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.6% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 5.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 10.4% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.0% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 34.4% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.7% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.06 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.91 | 1.11 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.0% 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 92 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.9% 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 56 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 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.0%CMS range 44.7–63.5 | 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 | 13.1%CMS range 9.3–17.3 | 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 | 67.9% | 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 | 75.0% | 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 | 51.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 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 | 3.7% | 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 | 7.6%CMS range 4.2–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 152 beds and averages 145.6 residents a day — about 96% occupied, or roughly 6 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.23 hrs/resident/day on weekends vs 3.69 on weekdays — 12% thinner on weekends. RN hours go from 0.57 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2025-11-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: 2661084Based on interviews, medical record review, and review of other pertinent facility documentation on 11/17/2025 and 11/20/2025, it was determined that the facility failed to report a verbal abuse allegation that a resident's representative (RR) reported to the facility's staff and to the Department of Health (DOH) for 1 of 3 residents reviewed for abuse. The deficient practice was identified for 1 of 3 residents reviewed (Resident #3) and was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. According to the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/24/2025, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.A review of the facility's document titled Summary of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-20 · 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
Complaint: 2661084Based on interviews, medical record review, and review of other pertinent facility documents on 11/17/2025 and 11/20/2025, it was determined that the facility failed to provide documented evidence that care was provided to a resident who required maximal assistance for toileting hygiene. This deficient practice occurred for 1 of 3 residents (Resident #3) reviewed.The deficient practice was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. According to the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/24/2025, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident needed substantial and maximal assistance with toileting hygiene…
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 · D2025-11-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: 2661084Based on interviews, medical record review, and review of other pertinent facility documents on 11/17/2025 and 11/20/2025, it was determined that the facility failed provide evidence that a physician's order for wound care was carried out and documented for two days to treat a facility acquired pressure injury in accordance with professional standards. This deficient practice occurred for 1 of 3 residents reviewed for wound. The deficient practice was evidenced by the following:According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: paraplegia (type of paralysis that affects the lower half of the body), spinal stenosis (when the space inside the backbone is too small and puts pressure on the spinal cord), and diabetes. According to the Comprehensive Minimum Data Set (MDS), an assessment tool dated 10/24/2025, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact.A review of the facility's document titled…
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 · D2025-05-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility failed to maintain the dignity of 2 unsampled residents during the lunchtime meal in the main dining room and 1 sampled resident (#53) during a wound treatment observation. The deficient practice was evidenced by the following. 1. The surveyor observed the lunchtime meal in the main dining room on 05/22/25 at 12:23 PM. The surveyor observed as a Certified Nursing Assistant (CNA) placed a disposable clothing protector on a cognitively impaired resident. The CNA did not explain the procedure of placing the clothing protector prior to attempting to fit it over the resident's head. The clothing protector had a opening where it would be fitted over the resident's head. The opening was too small for the resident's head and got stuck with the clothing protector covering the resident's head and face. The resident became startled and tried to push the protector away from their head. The CNA was able to rip the clothing protector's opening so that it eventually fit over the resident's head. The CNA…
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 · D2025-05-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 29 residents reviewed for accommodation of needs (Resident #57), and was evidenced by the following: On 5/22/25 at 12:37 PM, the surveyor observed Resident # 57 seated in a wheelchair with his/her overbed table and lunch tray positioned in front of them. The surveyor observed that the resident's call bell (a bell used to summon staff for assistance) was in the middle of the bed not within the resident's reach. The surveyor reviewed the medical record for Resident #57. A review of the admission Record reflected that Resident #57 was admitted to the facility with diagnoses that included but were not limited to; Diabetes Mellitus, Schizophrenia and Leukocytosis. A review of Resident #57's Annual Minimum Data Set (MDS), an assessment tool dated 3/18/25 revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated moderate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-27 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined that the facility failed to post the prior year's State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following. The surveyor conducted a group meeting on 5/22/25 at 10:30 AM, with 5 alert and oriented residents chosen by the facility. Five of 5 residents stated they did not know where to find the State inspection results. On 5/23/25 at 12:20 PM, the surveyor looked for the most recent State inspection results on the A and B Nursing Units and was unable to locate them. On 5/23/25 at 12:30PM, during an interview with the surveyor, the Director of Nursing (DON) stated that the results of the last survey were in a binder on the shelf by the receptionist. The surveyor observed the binder on the shelf behind the kiosk, not at wheelchair level and not easily accessible to residents. On 5/23/25 at 12:35 PM, the regional Registered Nurse (RRN) acknowledged that the binder should be kept in an area that is accessible 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 · D2025-05-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
Based on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 4 of 29 residents; (2 unsampled residents) and (Resident #60 and #38) reviewed. The deficient practice was evidenced by the following: 1. On 5/20/25 at 1:05 PM, the surveyor observed in an Unsampled Resident's room (Room A21), the privacy curtain was soiled with a white substance on several areas of the curtain. On 5/20/25 at 1:15 PM, the surveyor observed in an Unsampled Resident's room (Room A28), the privacy curtain was soiled with a white substance on several areas of the curtain. The surveyor observed on the wall by the headboards brown material splattered across the entire wall, ceiling tiles buckled and displaced, chipped paint on the wall by the window, and the radiator in the bathroom was rusted and soiled. On 5/23/25 at 12:15 PM, the surveyor interviewed the Regional Housekeeper (RHK), who confirmed that the privacy curtains were soiled and that the HK on the unit should be monitoring the curtains for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 4 Residents (Resident # 20), reviewed for respiratory therapy. 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) accurate administration of medications for Resident #70, b.) documentation of the removal of controlled dangerous substance (narcotic; with high potential for drug diversion) medication from inventory, maintained accountability, for accurate reconciliation of Resident #343, #132, #131, and #129's narcotic medications, identified during the medication storage inspection of 1 of 3 medication carts, c.) maintenance of the record keeping of the DEA Form-222 that ensured accurate ordering and receiving, narcotic inventory and reconciliation of controlled dangerous substance (narcotics medications, with high potential for abuse and are tracked with detail) identified in 1 of 14 forms reviewed and, d.) accurate receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 form) were completed with sufficient detail to enable accurate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-27 · 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, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary environment that helped prevent the development and transmission of communicable diseases and infections. This was identified for 3 of 29 residents (Resident #20, #53 and #57) reviewed for infection control. The deficient practice was evidenced by the following: 1. a. On 5/20/2025 at 11:10 AM, the surveyor observed Resident #53 in their bed. The surveyor observed an oxygen concentrator (a device that enriches air with oxygen by removing nitrogen) in the room with a humidifier bottle (a plastic bottle that infuses the normal flow of oxygen with water droplets) dated 10/25/24. The oxygen concentrator was not in use. The surveyor reviewed the medical record for Resident #53. A review of the admission record reflected Resident #53 was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's Disease, Diabetes Mellitus and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2025-05-27 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working 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, interview and record review it was determined that the facility failed to a.) maintain a Packaged Terminal Air Conditioner and Heating Unit (PTAC) in safe and optimal condition in an unsampled resident's room (Room A 21-2), b.) failed to ensure that the grab bar was securely affixed to the bathroom wall next to the toilet in Resident #20's room (Room A28-2) and, c.) failed to maintain the heat register unit in Resident #57's room (Room A20-1). This deficient practice was evidenced by the following: On 5/20/25 from 1:05 PM-1:30 PM, the surveyor toured the A Nursing Unit and observed the following: -The PTAC unit in room [ROOM NUMBER]-2 had broken and missing vents. -The grab bar in the bathroom in room [ROOM NUMBER] was loose and affixed to a broken tile and there were also several missing tiles. -The base board heat register in room [ROOM NUMBER] was pulled out of the wall and was on the floor in the bathroom with exposed pipes, which were not in working order. On 5/23/25 at 12:20 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-04-04 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide 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, record review, and review of facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a) dispensed and administered controlled substance (narcotic) medication was accurately accounted for (Resident #2, #12, #31, #78, and #120), b) discontinued medications were removed from active inventory (Resident #122 and #46), which was identified separately in two (2) of six (6) medication carts, c) medications were not pre-poured for more than one medication pass, medications were secured within the medication cart (Resident #78 and #12), d) medications were destroyed after resident refusal (Resident #12) e) accurate accounting of Resident #12's dispensed Tramadol (medication used for pain; a controlled substance tracked for substance abuse), which was identified in one (1) of four (4) nurses observed during medication administration f) expired narcotic medications were removed from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-04 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ00154046 Based on observation, interview, record review, and review of the facility provided pertinent documents, it was determined that the facility failed to: a) follow through with dental recommendation for a total of eleven (11) months for one (1) of four (4)residents, (Resident#80) reviewed for dental concerns; b) follow the physician's order with regard to blood pressure medications with parameters for one (1) of twenty nine (29) residents, (Resident#24) reviewed for medications; and, c) ensure that resident's weight was obtained and recorded according to the facility's procedure for one (1) of six (6), (Resident#295) reviewed for weights according to the standards of clinical practice. 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-04 · 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 review of pertinent facility documents, it was determined that the facility failed to: a) consistently monitor refrigerator and freezer temperatures and document them in the facility logs and b) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a foodborne illness. This deficient practice was evidenced by the following: On 3/10/22 at 9:59 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In walk-in refrigerator#1, the surveyor observed one of five pitchers of iced tea with a use-by date of 3/05. The pitcher was half full. The FSD stated that it should have been discarded on the use-by date. 2. In the food preparation (prep) area, near the oven, the surveyor observed five knives stocked in between the crease of the prep table and oven, two out of five knives with dried brown and white substances. The FSD asked the Dietary [NAME] (DC) why the five knives were not properly stored, then, the DC immediately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-04 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to conduct COVID-19 testing for two (2) of two (2) residents (Residents#132 and #39) and 16 of 16 staff identified as close contacts following a staff member testing positive for COVID-19 in accordance with the facility's policies and Centers for Disease Control and Prevention (CDC) guidelines for infection control and to mitigate the spread of COVID-19 (a deadly, highly transmissible infectious disease). The deficient practice was evidence by the following: Reference: According to the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic with an updated date of Sept. 23, 2022, included the following: Perform SARS-CoV-2 Viral Testing Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-04 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff for two (2) of two (2) facility areas observed for an environmental tour (laundry area and resident rooms) according to facility and standard of clinical practice. This deficient practice was evidenced by the following: On 3/16/23 at 11:49 AM, the surveyor toured the laundry area in the presence of the Laundry Service Director (LSD). The surveyor observed a commercial size trash can in the middle of the laundry room dryer area. The depth of water collection in the commercial trash can was approximately 5 (five) inches deep. The leak is in the folding and preparing laundered personal resident clothing area. There was a rack of clean clothes of residents that were not covered near the open ceiling tile with a leak. On that same date and time, the LSD stated that the leak in the laundry dryer area had been there since he was hired in mid-January. The LSD further stated, the trash…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to follow and maintain fall prevention interventions as ordered by the physician and as written on the resident's plan of care for one (1) of three (3) residents (Resident #94) reviewed for accidents. This deficient practice was evidenced by the following: On 3/10/23 at 10:36 AM, the surveyor observed Resident #94 lying in a low to the floor bed. The surveyor observed a blue floor mat that was upright on its side leaning against the right side of the bed. The surveyor did not observe a floor mat on the left side of the bed or anywhere else in the room. Resident #94 did not respond to the surveyor. On 3/16/23 at 10:50 AM, the surveyor observed Resident #94, with the bed sheet over the resident's head, lying in a low to the floor bed. The surveyor observed a blue floor mat that was upright on its side leaning against the right side of the bed. The surveyor did not observe a floor mat on the left side of the bed or anywhere else…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-04 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to: a) administer Tube Feeding (nutrition received through a flexible tube surgically inserted into the stomach) per the physician's order, b) document the total volume (TV) according to physician's order, and c) properly label the Tube Feeding (TF) bag according to the standard of clinical practice. This deficient practice was identified for one (1) of two (2) residents, (Resident #24) reviewed for receiving nutrition via TF and was evidenced by the following: On 3/10/23 at 11:52 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident #24 was on TF. On 3/10/23 at 12:01 PM, the surveyor observed the resident laying on the bed with the head of the bed elevated, and non-verbal. The surveyor observed that the resident had a TF formula hanging on a pole, attached to a TF pump, and infusing at a rate of 75 ml/hr (milliliters per hour). The resident's admission Record (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.
- Potential for harm · Dcited before2023-04-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to maintain the necessary respiratory care and services for a resident who was receiving oxygen (O2) treatment according to standards of practice. This deficient practice was identified for one (1) of one (1) resident (Resident #24) reviewed for respiratory care. This deficient practice was evidenced by the following: On 3/10/23 at 12:01 PM, the surveyor observed Resident#24 laying on the bed with the head of the bed elevated, and non-verbal. The surveyor observed that the resident had oxygen in use at 2LPM (two liters per minute) via a nasal cannula (consisting of two hollow prongs projecting from a hollow face piece) attached to a humidified oxygen concentrator (a medical device that gives extra oxygen). The resident's admission Record (or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Unspecified Dementia without behavioral disturbance, type two (2) diabetes mellitus…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-04 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 3/20/23, the surveyor observed four (4) nurses administer medications to four (4) residents. There were 29 opportunities, and two (2) errors were observed which resulted in a medication error rate of 6.9%. This deficient practice was identified for two (2) of four (4) nurses that administered medications to two (2) of four (4) residents (Resident #344 and Resident #31) and was evidenced by the following: 1) On 3/20/23 at 8:48 AM, the surveyor observed the Licensed Practical Nurse (LPN) take Resident #344's vitals, exited the room and cleaned the blood pressure cuff. On 3/20/23 at 8:53 AM, the surveyor observed the LPN prepare medications for Resident #344. The medications included the following: - Docusate 100 milligram (mg), 1 (one) tablet two times a day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-04 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ00152736 Complaint # NJ00154046 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot food, cold food and drinks served to the residents. This deficient practice was identified for 2 (two) of 2 (two) residents, (Residents #80 and #27) confirmed during the lunchtime meal service on 3/22/23 for 2 (two) of 2 (two) nursing units tested for food temperatures by two surveyors and was evidenced by the following: On 3/22/23 at 11:52 AM, the surveyors and the Food Service Director (FSD) were on the A-Wing unit observing lunch tray distribution. At 11:57 PM, surveyor #1 pulled a tray from the food truck (Cart 1) in the A-Wing unit. The surveyor observed that Certified Nursing Assistants (CNA) began to deliver meal trays to residents at 11:55 AM. After the last meal tray was delivered to a resident at 12:13 PM, the surveyors took the temperatures of the following items (regular consistency) in the presence of FSD with calibrated thermometers: Coffee 142.2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-04 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical record and review of pertinent facility documentation, it was determined that the facility failed to provide the correct consistency of diet according to physician's order. This deficient practice was identified for one (1) of twenty-nine (29) sampled residents (Resident #81) during dining observation. The deficient practice was evidenced by the following: On 3/16/23 at 12:37 PM, the surveyor observed Resident #81 seated in a wheelchair in the main dining room with their lunch meal on the table in front of him/her. The surveyor observed Resident #81's lunch plate had two whole chicken thighs on it. The surveyor then reviewed Resident #81's lunch meal ticket which included the following: CHOPPED MEATS ONLY. The meat served to Resident #81 was not chopped and was not the correct consistency of diet ordered. On 3/16/23 at 12:38 PM, the surveyor interviewed the Dietary Aide (DA) who had plated Resident #81's lunch from the steam table. The surveyor asked the DA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-04 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
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 properly dispose of and maintain the waste in garbage dumpster areas. This deficient practice was identified for one (1) of two (2) garbage dumpsters in the garbage disposal area. This deficient practice was evidenced by the following: During an observation on 3/13/23 at 11:14 AM by two surveyors and the Food Service Director (FSD), the outside dumpster area revealed two dumpsters next to each other. Dumpster #1 had a lid open with garbage bags in it. Dumpster #1 with trash around the surrounding area on the floor that included plastics, papers, and other garbage. There was a puddle of water near Dumpster #1. In addition, there was garbage soaked in the puddle of water. The FSD stated that she was not able to determine how long the garbage was on the floor. She acknowledged that the puddle of water and garbage was there for more than a week because it was hard to identify what kind of garbage was on the floor. The FSD stated that Dumpster #1 lid should be closed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to: a) perform hand hygiene appropriately for two (2) (Certified Nursing Aide and Housekeeper) of eight (8) staff and b) properly use PPE (personal protective equipment) for two (2) (Certified Nursing Aide and Housekeeper) of four (4) observed in accordance with the Centers for Disease Control and Prevention (CDC) guidelines 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 (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. In addition, wear gloves, according to Standard…
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 before2021-03-29 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical records and other pertinent facility documents, it was determined that the facility failed to accurately follow the physician's orders for the administration of Oxygen. This deficient practice was observed for 1 of 2 residents reviewed for accuracy following the physician's oxygen orders, Resident #44. 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/22/21 at 11:01 AM, the surveyor observed Resident #44 lying in bed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2021-03-29 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview on 3/24/21, it was determined that the facility failed to provide a safe and sanitary physical environment. This deficient practice was evidenced by the following findings: During a tour of the facility's basement at 11:00 AM, with the facility's Administrator and Maintenance Director, the surveyor observed 5 of 5 rooms used for storage with stained or missing suspended ceiling tiles. Some of the stained ceiling tiles were water-logged and sagged, causing them to fall from the ceiling. Many ceiling tiles had varying degrees of an unidentified brown substance ranging from light brown to dark brown. Each storage room had two to four stained ceiling tiles with missing ceiling tiles scattered throughout. This finding was acknowledged and confirmed in interviews with the Administrator and Maintenance Director during the discovery. They indicated that they did not know the source of the problem. At 12:00 PM, the Administrator stated in an interview that he was aware of this issue. The Maintenance Director did not have a chance to address the problem 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.
“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.
Part of a chain
This home belongs to COMPLETE CARE — 85 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 84 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 84; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EEF CAPITAL LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 45% | since 02/01/2019 |
| SCHLAFF, BENNY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 23% | since 02/01/2019 |
| SCHLAFF, NACHUM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 23% | since 02/01/2019 |
| WEISSMAN, MALKA | Individual | INDIRECT OWNERSHIP INTEREST | — | since 02/01/2019 |
| STEIN, SHALOM | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 02/01/2019 |
| AGRESTI, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/05/2023 |
| GREWAL, BALJINDER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/06/2020 |
| LEVOVITZ, YITZCHOK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2019 |
| MERCADO, WANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/19/2022 |
| OLEKA, KANENE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/28/2022 |
| PEACE CAPITAL LLC | Organization | ADP OF THE SNF | — | since 02/01/2019 |
| SUMMIT CARE REALITY LLC | Organization | ADP OF THE SNF | — | since 02/01/2019 |
| ULYSSE, RONY | Individual | ADP OF THE SNF | — | since 04/29/2024 |
CMS files one row per role, so the 20 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners 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 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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.
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 315038. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-27, 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 →
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