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Stratford Manor Rehabilitation and Care Center

787 Northfield Ave, West Orange, NJ 07052 · For profit - Limited Liability company · 131 certified beds · (973) 731-4500 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Sep 20251 immediate-jeopardy citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — 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.

4/5
CMS overall
4 of 5
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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
375 Mount Pleasant Ave Ste 202 · (973) 731-7707 · Call to confirm hours
Pharmacy
Asp Cares0.1 mi
365 E Northfield Rd · (973) 535-0900 · Call to confirm hours
Grocery
581 Northfield Ave #C · (973) 243-1000 · Call to confirm hours
Park
Dogwood Dr · (973) 325-4150 · Typically dawn to dusk
Place of worship
747 Northfield Ave · (973) 731-7744

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 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.7%8.7%15.4%better
Long-stay residents who lose too much weight1.3%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.6%0.9%better
Long-stay residents with a urinary tract infection0.3%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms7.0%12.1%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.7%2.3%3.3%better
Long-stay residents whose ability to walk worsened2.8%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.2%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine98.2%97.2%95.3%typical
Long-stay residents with pressure ulcers4.6%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control10.7%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.0%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.2%1.4%typical
Short-stay residents given the seasonal flu vaccine94.5%80.1%79.4%better
Short-stay residents rehospitalized after admission23.2%24.9%22.6%typical
Short-stay residents with an outpatient ER visit3.6%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.872.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.561.111.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

54.9% 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 127 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.9%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
61.2%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 61.2% 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 85 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.9%CMS range 42.7–62.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.2–15.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge48.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.0–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.541.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.63
RN hours/ resident / day
0.67
LPN hours/ resident / day
2.04
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
0.40
RN hoursweekends
22.8%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 131 beds and averages 124.5 residents a day — about 95% 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.96 hrs/resident/day on weekends vs 3.48 on weekdays — 15% thinner on weekends. RN hours go from 0.72 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% is below the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2025-09-22)
12
at the previous standard inspection (2024-04-24)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · K2022-03-08 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    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 other pertinent facility documentation, it was determined that the facility failed to ensure: a.) 2 of 3 anti-seizure medications (Vimpat and Keppra) ordered upon discharge from the hospital were appropriately discussed with the Physician for re-order, reconciled, received from the Provider Pharmacy, and administered in accordance with hospital discharge instructions for a resident with recent seizure activity (Resident #163), and b.) an anti-seizure medication (Vimpat) was available and administered as ordered for a second resident with a history of seizure disorders (Resident #27). This deficient practice was identified for 2 of 3 residents reviewed for anti-seizure medication management (Resident #27 and #163). Resident #163, who had a severe cognitive impairment, was admitted to the facility on [DATE] with active diagnoses which included traumatic subdural hemorrhage (a bleed in the area between the brain and skull) without loss of consciousness, syncope…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-22 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure a.) the bed hold-policy that was provided to the Resident or Resident's Representative (RR) included information about the reserve bed payment policy plan, the explanation of the right to appeal the transfer, and the Resident and/or RR's information for 2 of 2 residents (Residents #2 and #16) reviewed for hospital transfer and b.) the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution, including the discharge summary for 1 of 1 resident (Resident #15) reviewed for transfer.The deficient practice was evidenced by the following: 1.On 9/15/25 at 1:24 PM, Surveyor #1 (S#1) reviewed the electronic medical records (eMR) of Resident #2, and revealed: A review of the admission Record (AR; an admission summary) or face sheet, revealed Resident #2 had been admitted with diagnoses which included but were not limited to; heart failure unspecified, other sequelae…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-22 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire for 3 of 7 licensed staff of the total 10 newly hired staff reviewed, Staff Member (SM) #6, #7 and #8. The deficient practice was evidenced by the following:On 9/18/25 at 12:40 PM, the surveyor reviewed the facility provided employee files of 10 randomly selected newly hired employees of which 7 were licensed staff which included the following: 1. A review of Staff Member #6 (SM#6), a Certified Nursing Assistant (CNA), hired on 6/12/24, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which was not dated. There was no documented evidence that SM#6's license was verified prior to the date of hire (doh).2. A review of Staff Member #7 (SM#7), a CNA, hired on 10/2/24, had a NJDOH online Public Registry license verification printout which was not dated. There was no…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-22 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the admission Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 1 resident (Residents #4) reviewed for timing of assessments.This deficient practice was evidenced by the following:Reference: According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2024, page 2-17, the Comprehensive admission assessment must be completed no later than the admission date + 13 calendar days.On 9/22/25 at 9:09 AM, the surveyor reviewed the electronic medical record (eMR) of Resident #4, reflected that the resident was admitted to the facility on [DATE]. The Comprehensive (and modified) admission MDS with an assessment reference date (ARD) of 8/12/25, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-22 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to ensure that the residents Attending Physician visited and documented monthly visits, every other month when the Advanced Nurse Practitioner (ANP) visited on the subsequent month for 1 of 28 residents reviewed (Resident #11). This deficient practice was evidenced by the following:On 9/17/25 9:31 AM, the surveyor reviewed Resident #11's hybrid (paper and electronic) medical record which revealed that the resident's attending physician had no documented visit from 5/1/24 through 12/31/24. The remaining documented visits in the resident's electronic medical record were done by the ANP for the same time frame.A review of Resident #11's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; cerebral infarction (a stroke, where blood flow to part of the brain is blocked), atherosclerotic heart disease (a condition of progressive narrowing and hardening of coronary arteries), and essential…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-22 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 3 medication carts observed on 1 of 2 nursing units of the facility. 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 9/16/25 at 1:55 PM, the surveyor began to inspect selected medication (med) storage areas in the facility and observed the following:The surveyor in the presence of Licensed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-22 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, accurately documented, readily accessible, and systematically organized medical records. This deficient practice was identified for 2 of the 28 residents reviewed (Residents #2 and #15). This deficient practice was evidenced by the following:1.On 9/15/25 at 1:24 PM, The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #2, and revealed:A review of the admission Record (AR; an admission summary) or face sheet, revealed Resident #2 had been admitted with diagnoses which included but were not limited to; heart failure unspecified, other sequelae following unspecified cerebrovascular disease (stroke), hemiplegia (a neurological condition characterized by paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction affecting right dominant side, and chronic obstructive…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, 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 maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/18/24 at 9:52 AM, in the presence of the Dietary Director (DD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed seven of seven oven knobs and the oven handle soiled with a brown colored substance, which was able to be lifted with the tip of a pen. In the food preparation area, the surveyor also observed 1 of 2 handles of the convection oven soiled with a brown colored substance, which was also able to be lifted with the tip of a pen. The DD stated that these areas should be cleaned. 2. In the dry storage room, the surveyor observed the following cans with dents, which were in rotation for use: - 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-24 · tag F0711 — pattern
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 6 of 24 residents (Resident #12, #16, #22, #111, #13, and #62) reviewed and occurred over several months. This deficient practice was evidenced by the following: 1. A review of the hybrid medical record for Resident #12 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2024, February 2024, and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature. 2. A review of the hybrid medical record for Resident #16 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2024, February 2024, and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature. 3. A review of the hybrid 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-24 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    REPEAT DEFICIENCY Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that manufacturer's specifications were followed for the administration time and sequence of a medication Alendronate Sodium (Fosamax)(a medication used to treat and prevent osteoporosis/low bone mass) from October 2023 until surveyor inquiry. This occurred for one (1) of 11 residents, (Resident #25), reviewed for medication management. 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…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-24 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    REPEAT DEFICIENCY Based on observation, interviews, record review and a review of pertinent facility documents, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities to the physician and the facility regarding a.) a rationale for the length of therapy for a medication (Enoxaparin)(a medication used to reduce the risk of blood clots) from August 2023 until surveyor inquiry, b.) the appropriate documentation of vital sign parameters for a medication (Metoprolol)(a medication used to treat high blood pressure) as ordered by the physician according to standards of clinical practice and facility practice, c.) a rationale for the continued off-label use of a medication (Flomax) (a medication used to treat urinary retention usually in males) from January 2024 until surveyor inquiry and d.) following a cautionary warning for a medication (Alendronate)(Fosamax)(a medication used to treat and prevent osteoporosis/low bone mass) from October 2023 until surveyor inquiry. The deficient practices were identified for three…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2024-04-24 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by failing to document on the effectiveness, appropriate indication, or benefit vs risk statement for an unapproved use for one (1) of eleven (11) residents reviewed for medication management (Resident #103). The deficient practice was evidenced by the following: On 4/15/24 at 10:40 AM the surveyor attempted to interview Resident #103. The resident was in a wheelchair watching television. The resident was not able to answer basic questions posed by the surveyor. The surveyor was unable to conduct an interview due to the resident's cognitive status. The surveyor reviewed the electronic medical record (EMR) for Resident #103. A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 4/10/24, reflected the resident was unable to complete a brief interview for mental status (BIMS) test due to cognitive impairment. The MDS section…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 record review, it was determined that the facility failed to ensure the resident's call light was readily accessible. The deficient practice was identified for 1 resident (Resident #5) of 24 reviewed for the reasonable accommodations of needs/preferences as evidenced by the following. On 4/15/24 at 10:35 AM and 4/16/24 at 9:10 AM, the surveyor observed the resident in bed awake, able to answer the surveyor's inquiry. The surveyor asked the resident if she could reach her call light cord. The resident tried to reach for it three times and said they still could not get it. The call light cord was under the resident's right chest on both days. A review of the medical record revealed the following information. The admission record documented that Resident #5 was admitted to the facility with diagnoses that included but were not limited to cerebrovascular (conditions that affect the blood flow in the brain) disease and left-side hemiparesis (weakness or paralysis on one side of the body). The recent Quarterly Minimum Data Set, an assessment tool dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 4 of 24 residents (Resident #2, 5, 35, and #225). This deficient practice was evidenced by the following: 1. Resident #2 was observed to have a Quarterly MDS (QMDS) with an Assessment Reference Date (ARD) on 1/15/24, which was due to be transmitted to CMS no later than 1/29/24. However, the QMDS was not submitted to CMS until 2/9/24. 2. Resident #5 was observed to have a QMDS with an ARD on 12/12/23, which was due to be transmitted to CMS no later than 12/26/23. However, the QMDS was not submitted to CMS until 1/10/24. 3. Resident #35 was observed to have an Entry MDS (EMDS) with an ARD on 10/2/23. The EMDS was due to be transmitted to CMS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient practice was observed for 2 of 24 residents reviewed, Residents #13 and #25 as evidenced by the following: 1. The surveyor reviewed Resident #13's electronic medical records (EMR). Resident #13 was admitted to the facility with diagnoses which included Myocardial Infarction (heart attack). A review of the Physician's Orders (PO) for Resident #13 revealed that the resident had an order for Eliquis 5 mg 1 tablet by mouth twice daily for blood clot prevention. The surveyor reviewed the resident's current care plans. There was no care plan developed regarding the resident's PO for the anticoagulant medication. On 4/22/24 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to the resident. The LPN stated that a care plan for the anticoagulant medication should have been created 2. On 04/18/24 at 12:00 PM, the surveyor observed Resident #25 in bed. The…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-24 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following physician orders for 2 of the 24 residents reviewed (Residents #5 and #35). The deficient practice was evidenced by the following: 1. On 4/15/24 at 10:35 AM and 4/16/24 at 9:10 AM, the surveyor observed the resident in bed, awake, and able to respond to the surveyor's questions. The resident was not wearing a left-hand elbow resting splint on both days. A review of electronic medical record revealed the following information. The admission Record (AR or face sheet, an admission summary) documented that Resident #5 was admitted to the facility with diagnoses that included but were not limited to cerebrovascular (conditions that affect the blood flow in the brain) disease and left-side hemiparesis (weakness or paralysis on one side of the body). The recent Quarterly Minimum Data Set (QMDS), an assessment tool dated 3/12/24, reflected that Resident #5…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure that all nurses signed the electronic Medication Administration Record (eMAR) when oxygen was administered, and c.) ensure respiratory tubing and cannula was stored properly. This deficient practice was identified for one (1) of one (1) resident (Resident #425) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. 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…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-24 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and relevant document review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in one (1) of three (3) medication carts and one (1) one of two (2) medication storage rooms inspected on two (2) of two (2) units. This deficient practice was evidenced by the following: On 4/16/24 at 10:56 AM the surveyor in the presence of another surveyor and the Licensed Practical Nurse (LPN#1) assigned to the medication cart inspected the medication cart identified as the northwest cart. The surveyor observed one (1) brown package containing one (1) vial of latanoprost eye drops (a medication used to treat glaucoma). The brown packaging was labeled with a dispensing pharmacy label which reflected a dispensing date of 3/29/24. There was no date when the vial was opened observed on the packaging or on the vial. The surveyor observed one (1) package containing Fluticasone/salmeterol discus 500/50 (a medication used to treat asthma and chronic obstructive pulmonary…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to establish appropriate infection control practices for environmental cleaning for 1 of 24 residents (Resident #5). This deficient practice was evidenced by the following: On 04/15/24 at 10:40 AM, the first day during rounds in Resident #5 room, the surveyor noticed a splash of a creamy substance on the right-side wall near the metal pole, extending from the resident's bedside table to the electrical outlet. The Registered Nurse (RN) stated that it looked like a tube feeding milk on that wall and added that she would ask housekeeping to clean it. On 4/17/24 at 1:25 PM, the surveyor team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) about the concern regarding the splash of creamy milk-like substance on the wall. The LNHA stated it was already clean and did not provide further information. NJAC 8:39-19.1(a)

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-03-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 a.) administer oxygen therapy according to the physician's order and b.) ensure respiratory equipment was stored and dated properly. This deficient practice was identified for 5 of 7 residents (Resident #35, Resident #51, Resident #57, Resident #69, and Resident #363) reviewed for respiratory care and the evidence was as follows: 1. On 2/23/22 at 11:25 AM, the surveyor observed Resident #35 sitting in a wheelchair in their room watching television. The resident was being administered oxygen from a concentrator alongside their bed that was set to one liter per minute (1 lpm) via an undated nasal cannula (tubing used to deliver oxygen through the nose). The resident appeared to be in no distress. The surveyor reviewed the medical record for Resident #35. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility in January of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-08 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure that a Registered Nurse completed full body assessments after a fall prior to being moved in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 resident (Resident #50) reviewed for falls. 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 licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure medications were administered to a resident in accordance with professional standards of practice and b.) a controlled anti-seizure medication, Vimpat, was accurately accounted for in accordance with professional standards of practice. This deficient practice was identified for 2 of 24 residents (Resident #51 and Resident #163) reviewed for medication management and the evidence was as follows: 1. On 2/23/22 at 11:02 AM, the surveyor observed Resident #51 alone, lying in bed awake with their tray table directly over the bed. The surveyor observed on top of the tray table, a disposable medication cup that contained five medication pills and an additional medication cup that contained 30 milliliters (mL) of an orange/brownish colored liquid. The surveyor interviewed the resident who stated that he/she still had their morning medications in front of them because the nurse left their morning medications with them, but the nurse did not give them all their medications. The…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-08 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure the Consultant Pharmacist identified that a medication used to control seizures was administered in accordance with manufacturer's specifications. This deficient practice was identified for 1 of 3 resident (Resident #27) reviewed for anticonvulsant medications and was evidenced by the following: Reference: VIMPAT Highlights of Prescribing Information: VIMPAT tablets should be swallowed whole with liquid. Do not divide VIMPAT tablets. On 3/7/22 at 10:32 AM, the surveyor observed Resident #27 in bed with Jevity 1.5 (nutrition formula) being administered via a feeding tube (FT; tube surgically inserted through the abdomen to the stomach to provide nutrition). The resident was unable to be interviewed. The surveyor reviewed the medical record for Resident #27. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility in September of 2021 with diagnoses which included other sequale following unspecified cerebrovascular disease…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MB HEALTHCARE — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.7+0.3 vs chain
Health inspection 3 of 53.1-0.1 vs chain
Staffing 3 of 52.9+0.1 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 11 homes this chain runs (chain average 3.7★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
HEALTH CARE CENTERS OF NJ LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/24/2012
SMOLAROVA, ALEXANDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/05/2025
SOMMERS, DOVIDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/24/2012
MB HEALTHCARE SERVICES LLCOrganizationADP OF THE SNFsince 04/24/2012
BRODT, MOSHEIndividualADP OF THE SNFsince 04/24/2012
FRANKL, CINDIEIndividualADP OF THE SNFsince 04/24/2012
RAJIYAH, GITENDRAIndividualADP OF THE SNFsince 05/10/2024

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$17.7M
Net patient revenuemost recent cost report
+8.8%
Operating marginrevenue minus expenses
$1.9M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 18%Other / private 15%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$359per resident / day
operating cost
$10,911per month
≈ monthly operating cost
$393per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315066. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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