Daughters Of Israel Pleasant Valley Home
1155 Pleasant Valley Way, West Orange, NJ 07052 · Non profit - Corporation · 279 certified beds · (973) 731-5100 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- 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
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 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 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.9% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.6% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.3% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 12.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.3% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.8% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.4% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.6% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.4% | 12.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.2% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.1% | 24.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.0% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.73 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.78 | 1.11 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.7% 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 182 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 81 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 32% 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 | 55.7%CMS range 48.9–62.5 | 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 | 8.4%CMS range 5.6–11.4 | 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 | 42.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 32.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 45.7% | 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 | 6.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.7–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.72 | 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 279 beds and averages 98.2 residents a day — about 35% occupied, or roughly 181 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 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 3.64 hrs/resident/day on weekends vs 3.95 on weekdays — 8% thinner on weekends. RN hours go from 0.87 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
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 · Fcited before2026-03-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 3/9/26 at 11:07 AM, in the presence of the General Manager (GM) and the Executive Chef (EC), the surveyor observed the following:On the dairy side of the kitchen, on a shelf in the food preparation area, the surveyor also observed 6 spice containers with their tops opened. The GM stated these lids should be closed. On the dairy side of the dish washing area, the surveyor observed 2 large shallow steam table pans, stacked and wet nested with water between them, the surveyor also observed 3- 2/3rd sized steam table pans, stacked and wet nested with water between them. The GM stated that the steam table pans should not be stacked when wet and should have been air dried first.A review of the Labeling and Dating policy, dated 5/2023, revealed…
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 before2026-03-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) that the physician's orders were followed according to the standard of clinical practice for 4 of 4 residents, (Resident #8, 72, 108 and 114), reviewed for respiratory care, and b.) failed to provide a humidifier according to the facility's policy and procedure for one (1) of 4 residents, (Resident #108) reviewed for respiratory care.This deficient practice was evidenced by the following:1.On 3/6/26 at 10:35 AM, the surveyor observed Resident #8 in bed in their room, receiving oxygen via a nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which O2 flows) from a concentrator and the surveyor observed the oxygen flow meter was set at 3.5 liters per minute (lpm). A review of Resident #8's electronic health record (EHR) reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but were not…
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 before2026-03-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices to prevent and control the spread of infection. Specifically the facility failed to: a) post required signage at the rooms for 9 of 9 residents reviewed for Enhanced Barrier Precautions (Resident #'s 1, 2, 4, 8, 12, 67, 108, 113, 114), b) failed to handle medications in a sanitary manner during medication administration observation and medication storage review by 1 of 3 nurses observed during medication administration and 1 of three nurses observed during medication storage review, and c) a failure to cleanse blood glucometer between uses by 1 of 3 nurses observed during medication administration. This deficient practice was evidenced by the following:1.On 3/6/25 at 10:35, the surveyor conducted initial tour of the HP nursing care unit and observed no enhanced barrier precaution (EBP) signage on door, doorway or entrance to room #HP-334, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · 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
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 resident's call device was readily accessible. The deficient practice was identified for 4 of the 22 residents (Resident #19, 61, 108, and #114) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 3/6/26 at 10:33 AM, the surveyor observed Resident #19 in bed awake, alert, and able to make needs known. The surveyor observed that the resident's call device was hanging on the bed, and the resident was leaning to the opposite side of the bed, where the call bell was out of reach. Resident #19 was asking where the call device was, and they stated they cannot reach it. On the same day at 12:09 PM, the surveyor observed that the resident's call device was out of the resident's reach. On 3/6/26 at 12:54 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #19, which revealed the following: A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for one resident's room (Resident # 3's room [ROOM NUMBER]) and in the hallway of the HP unit. This deficient practice was evidenced by the following: 1. On 3/6/26 at 12:32 PM, in Resident # 3's room (room [ROOM NUMBER]), the surveyor observed that approximately 10 inches of the wall paper was peeling off the wall near the bottom of the window sill. The surveyor also observed an approximately 2 inch break in the plastic corner protector on the wall in the resident's room. 2. On 03/6/26 at 11:00 AM, during the initial tour of the facility the surveyor observed the following in the hallway and common area of the HP nursing care unit: In the hallway, near the smoke doors in the area of room [ROOM NUMBER], there was an approximately 24 inch wide by 4-foot-tall area of missing wallpaper with hanging ragged edges. In the same area of the hall as the 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.
- Potential for harm · D2026-03-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines, for 1 (one) of 22 residents (Resident #108), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 3/6/26 at 10:52 AM and on 3/9/26 at 10:12 AM, the surveyor observed Resident #108 awake, lying on the bed, with an indwelling catheter with a privacy bag attached to the lower side of the bed. On 3/6/26 at 1:21 PM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #108, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #108 was admitted with diagnoses that included, but were not limited to, a pressure ulcer of the sacral region, unstageable. A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) dated 2/12/26, indicated that the facility assessed 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 · D2026-03-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure care and services were provided in accordance with professional standards of practice for 2 of 22 residents reviewed (Residents #1 and #11). Specifically, the facility failed to clarify a physician order resulting in duplicative treatment orders, accurately document completion of a treatment order for Resident # 1, and provide comprehensive insulin management for Resident # 11.The findings are as follows: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 casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing 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.
- Potential for harm · D2026-03-12 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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, record review, and review of pertinent facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) which was identified for 1 of 5 residents (Resident #113) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 3/9/2026 at 10:20 AM, the surveyor observed Resident #113 lying in their bed, alert, and verbally responsive. Resident #113 was receiving an enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) via a feeding pump. The resident had a urinary drainage bag covered with a urinary privacy bag, hanging from the bottom of the bed frame.On 3/9/2026 at 10:45 AM, the surveyor reviewed the facility provided admission Medication Review (aMRR) for Resident #113 dated 2/13/26 completed by the Consultant Pharmacist (CP). The aMRR included a recommendation to clarify the resident's Flomax capsule order with the physician as the medication should be swallowed whole, not opened, crushed, or chewed; and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
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) properly store, and date medications in 1 of 4 medication carts and 1 of 2 medication storage rooms inspected; and (b) ensure controlled medications were stored in a separately locked, permanently affixed compartment in 1 of 3 medication carts inspected for medication storage. This deficient practice was evidenced by the following: 1. On [DATE] at 11:08 AM, the surveyor inspected the medication storage room on the HP unit in the presence of Licensed Practical Nurse (LPN) # 1 assigned to the unit. There were 2- 0.45% Normal Saline, one Liter intravenous bags which both had a manufacturer's expiration date of [DATE] stored in a cabinet. LPN #1 confirmed the IV bags were expired and removed them to be disposed. The LPN stated she was unsure of when the eye drops were opened or if it was used. The pharmacy label read refrigerate before opening. There was a Novolin R flexpen for a resident observed with a written…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: 392826 (187404)Based on observations, interviews, record review, and review of other pertinent facility provided documentation, the facility failed to ensure a.) the residents' current active care plan (CP) contained the interventions that were implemented after each resident's fall and were followed in order to prevent any additional falls for 3 of 3 residents (Residents #1, #2, and #3) reviewed for accidents and falls and b) fall investigations were thoroughly investigated and completed in accordance with the facility's practice and policy for 2 of 3 residents reviewed for falls (Residents #1 and #2). The deficient practice was evidenced by the following: 1.On 11/10/25 at 9:20 AM, Surveyor #1 (S #1) toured the Memory Unit and interviewed the Registered Nurse Supervisor (RNS), who informed S #1 that Resident #1 was at risk for falls due to cognitive impairment and had recent falls. On that same date at 9:25 AM, S #1 observed Resident #1 in the dining area, seated in a wheelchair (w/c) with other…
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 · F2024-10-18 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of facility provided documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received a performance review for five (5) of five (5) CNA files reviewed. This deficient practice was evidenced by the following: A review of the facility provided, Licensed annual education, competencies, and performance reviews, dated January 2023 to October 2024, did not reveal performance reviews for the five (5) randomly selected CNAs. On 10/16/24 at 11:24 AM, during an interview with the surveyor, the Human Resources Director (HRD) stated that the Director of Nursing (DON) was in-charge of education, competencies (lecture, training, pre and posttests) and performance reviews for the nursing staff. On 10/17/24 at 11:57 AM, during an interview with the surveyor, the DON stated that the performance reviews were conducted based on the results of the competencies. When a nursing staff's competencies resulted with a concern, then a performance review was conducted. The DON stated that the 5 randomly selected CNAs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-18 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 3 of 3 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: The surveyor requested to review the QA meeting sign in sheets for the last 3 quarters dated September 5, 2024, July 16, 2024 and May 23, 2024, upon entrance. A review of the QA meetings sign in sheets revealed that the Infection Control Preventionist (IP) had not been in attendance for the three meetings. On 10/15/24 at 11:40 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the IP was not able to attend the QAPI meetings since that staff member works the evening shift (3-11) and is also the nursing supervisor. The DON stated that they do received reports from the IP, who meets with the DON often. A review of the Quality Assurance Performance Improvement (QAPI) Program, dated July 2024, revealed that the members of the QAPI shall include but not be limited to: Medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · 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 maintain the prior year's State of New Jersey (State) inspection results and post the location of those 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 10/16/24 at 11:00 AM with 6 alert and oriented residents chosen by the facility. Six of 6 residents stated they did not know where to find the State inspection results. The surveyor looked for the most recent State inspection results (8/10/23) on each of the 3 nursing units (LP, SP, HP) on 10/17/24 at 9:00 AM. The LP Nursing Station had a plastic binder holder affixed to the front wall of the station. The binder contained 2017 and 2018 State inspection results. The HP Nursing Station had no visible binder available at the station. The surveyor asked the nurse supervisor for the binder. The nurse looked for the binder and was unable to locate it. A few minutes later she located the binder in a closed closet behind the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · 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, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure staff follow the physician's order for the use of side rails for 1 of 21 residents, (Resident #56) and b.) ensure staff follow the physician's order according to the facility's policies and standards of clinical practice for 1 of 3 nurses, Licensed Practical Nurse (LPN)), for 1 of 9 Residents (Resident #252) observed during medication administration. 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-18 · 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
Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents dependent on staff for Activities of Daily Living (ADL) received personal hygiene care in accordance with the facility policy. This deficient practice was identified for 1 of 1 resident (Resident #22,) reviewed for ADL care and was evidenced by the following: On 10/10/24 at 10:49 AM, the surveyor observed Resident #22 in bed with the Certified Nursing Assistant (CNA) assigned to their care in their room. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance underneath. Resident #22 stated that he/she would like to go to the salon to have their nails cleaned and manicured. The CNA told the resident she would see if the resident was on the list to go to the salon. On 10/16/24 at 12:00 PM, the surveyor observed Resident #22 in the HP front dining room seated in a wheel chair. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-18 · 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 and failed to ensure respiratory nasal cannula tubing was stored in accordance with infection control measures for 1 of 1 resident reviewed for Respiratory therapy, Resident #22. 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to consistently provide pharmaceutical services in accordance with professional standards to ensure a.) reconciliation and accountability of dispensed and administered controlled dangerous substance (narcotic medications, with high potential for abuse and are tracked with detail) to Resident #19, and discrepancies were identified, for the narcotic stored in the medication cart located on the high side of the LP unit, and b.) reconciliation of Controlled Drug Inventory Record (CDIR; shift to shift log, a count/signature of two (2) nurses for narcotic accountability) were consistently signed/completed for the medication cart located on the B-side of the HP unit. The deficient practice was identified for one (1) of two (2) medication carts reviewed during the medication storage and labeling task and was evidence by the following: 1.) On 10/17/24 at 9:16 AM, the two (2) surveyors and the Registered Nurse (RN) began the inspection of the narcotic medication cart inspection, which was stored in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-18 · 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 pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring proper hand hygiene was performed prior to dining services and hand wipes were used and discarded appropriately . This deficient practice was identified on 1 of 3 nursing units (HP) and evidenced by the following: On 10/10/24 at 12:00 PM, the surveyor observed twenty residents seated in the HP front dining room preparing for their lunch meal. On 10/10/24 at 12:20 PM, the surveyor observed the Certified Nursing Assistant (CNA) assisted the residents with their hand hygiene. The surveyor observed the CNA cleaned a resident's hands with hand wipes, applied a clothing protector and without performing hand hygiene, cleaned another resident's hands with a hand wipe, applied a clothing protector and without performing hand hygiene reached back into the container of hand wipes, removed 4 wipes and handed them to four different residents. The four unsampled residents cleaned their hands and handed 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 · E2023-08-10 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to promote the dignity and independence for three of three residents (Resident (R)88, R47 and R9) reviewed for dining in a total sample of 24 residents. Specifically, R88 and R47 were observed being assisted with feeding by staff standing throughout the meal service. Additionally, R9 was observed to sit and wait for lunch to be served while other residents were already served. Findings include: 1. Review of R88's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed R10 was admitted to the facility on [DATE] with diagnoses that included Nontraumatic intracerebral hemorrhage (bleeding in the brain) and Unspecified dementia. Review of R88's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/23, located in the resident's EMR under the MDS tab indicated the facility assessed R88 to have a Brief Interview for Mental Status (BIMS) score was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-10 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and facility policy review, the facility failed to provide meals at regular times. Specifically, the facility failed to deliver resident meals in a timely manner, for three of three (Residents (R)24, R42, and R62) reviewed for meal service. This had the potential to affect residents receiving room trays, and residents eating in the LP unit's back dining room. Findings include: In an interview with the Dietary Manager (DM) on 08/07/23 at 9:30 AM, he stated the mealtimes for all dining rooms were as follows: 8:30 AM breakfast; 12:30 PM lunch; and 5:15 PM dinner. The food was prepared in the main kitchen and transported, via a heated cart, to each of the pantry kitchenettes to be served to the residents. The food arrived 45 minutes prior to each meal service and was placed on the pantry steam tables to be kept hot. 1. The following observations of the lunch meal service occurred on 08/09/23: The meal was identified to be BBQ chicken or grilled hotdog on a bun, coleslaw, corn on the cob and fresh watermelon slice. Observation of the back dining room at…
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 before2023-08-10 · 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 observations, interviews, and facility policy review, the facility failed to keep the food storage bins clean and failed to ensure opened food was dated, labeled, and sealed. This had the potential to affect 91 of 93 residents who resided in the facility and consumed food prepared from the facility's kitchen. Findings include: During an initial tour of the kitchen on 08/07/23 at 9:30 AM, with the interim Dietary Manager (DM) present, the following observations were made: Dry Storage and Freezer: a. Four large bins, containing flour, sugar, breadcrumbs, and rice respectively, were observed to have dirt and grime on the top and sides of each container. b. An open container of peanut butter was observed on a shelf. There was no date identifying when the peanut butter was opened. c. A box of baking powder, open to air, was observed on the shelf. The baking powder had no date to identify when it had been opened, nor was the box sealed in a plastic bag or container. d. A bag of pancake mix, open to air, was observed on a shelf. The pancake mix had no date identifying when it was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-10 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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 policy, the facility failed to ensure four residents (Residents (R)24, R37, R42 and R56) of 24 sample residents had their call lights within reach when in their rooms, specifically when they were in their beds. This failure created the potential for the residents not to have a means of directly contacting caregivers. Findings include: 1. Review of R24's admission Record, located under the ADT [Admission, Discharge, Transfer] tab of the electronic medical record (EMR) revealed R24 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Palliative Care, Chronic Respiratory Failure, and Chronic Congestive Heart Failure. Review of R24's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/29/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. Per the MDS, R24…
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 · D2023-08-10 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policy, the facility failed to provide a baseline care plan within 48 hours of admission for one resident (Resident (R)98) of one resident reviewed for base line care plans out of 24 sampled residents. Findings include: Review of R96's Face Sheet located in the resident's electronic medical records (EMR) section titled Print Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the digestive system, colostomy, diverticulitis of large intestine with perforation and abscess, acute respiratory failure with hypoxia, and pleural effusion. Review of R96's Baseline Care Plan located in the resident's EMR section titled Care Plans revealed the resident had a baseline care plan dated 07/21/23. The care plan identified the resident had the following problems identified: self-care deficit; at risk for falls; and at risk for alteration in skin integrity. The care plan was unsigned…
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 before2023-08-10 · 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
Based on observations, interviews, record review, and facility policy review, the facility failed to provide timely morning (AM) care for one of one resident (Resident (R)40) reviewed for Activities of Daily Living (ADLs) out of a total sample of 24 residents. Findings include: Review of the resident's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. R40's functional status was extensive assistance with toileting and personal hygiene. R40 was documented as a one-person physical assist for bathing. Review of R40's care plan dated 01/19/23 in section under Focus: revealed that the resident has been care planned for the following interventions by the staff: To be assisted out of bed by 7:30 AM. To call for assistance prior to transferring. To offer to assist to bathroom every two hours. To offer and assist with AM care by 8AM. To provide incontinent care as needed for urinary incontinence. 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 · D2023-08-10 · 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 facility policy review, the facility failed to ensure a medication error rate of less than 5%. Medication errors were noted for two out of 25 medications observed, affecting two residents (Resident (R)70 and R12) for a medication error rate of 8%. Findings Include: 1. Review of R70's annual MDS with an ARD of 06/12/23, found in the EMR under the MDS tab, revealed R70 was admitted to the facility on [DATE] and had a BIMS score of 13 out of 15, which indicated R70 was not cognitively impaired. The MDS also indicated R70 had a diagnosis of but not limited to hypertension, diabetes mellitus, stroke, and depression. Review of R70's Physician Orders, dated 08/04/23, found in the EMR under the Orders tab, revealed Carbamide Peroxide 0.65% ear drops Instill 5 drops in each ear TID (9:00 AM, 1:00 PM, and 5:00 PM) for 5 days. During an observation on 08/08/23 at 4:20 PM, Licensed Practical Nurse (LPN)6 stated, I won't administer these until around 7:00 PM because the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and facility policy review, the facility failed to ensure two of two medication carts on the secured unit were locked while unattended. This had the potential to affect two (Resident (R)3 and R37) of 16 residents who were in the dining room on the secured unit while the med carts were observed unlocked. R3 and R37 could ambulate/self-propel themselves while in the dining room. Findings include: Review of R3's quarterly Minimum Data Set (MDS), located under the MDS tab of the electronic medical record (EMR) and with an Assessment Reference Date (ARD) of 06/03/23, revealed R3 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R3 was severely cognitively impaired. The MDS recorded R3 had diagnoses which included dementia, stroke, hypertension, and coronary artery disease. R3 was coded as only requiring supervision with moving around on unit. Review of R3's Care Plan located in the EMR under the Care Plan tab, dated 06/03/2023, revealed the resident could ambulate independently with supervision as needed. 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DAUGHTERS OF ISRAEL INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/1966 |
| THOMPSON, COLLEEN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | since 03/15/2024 |
| GUITTARI, NICHOLAS | Individual | ADP OF THE SNF | since 09/01/2025 |
CMS files one row per role, so the 7 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315029. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, 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 →
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