Whiting Gardens Rehabilitation And Nursing Center
3000 Hilltop Road, Whiting, NJ 08759 · For profit - Limited Liability company · 200 certified beds · (732) 849-4400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
- it has abuse, neglect, or exploitation citations (F0600, F0603, F0610) — most recent Apr 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 4 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (40) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $306,201 in federal fines (most recent 2026-07-09)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- about 28% of its spending goes to commonly-owned related companies
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — 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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 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 | 26.7% | 8.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.4% | 4.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.2% | 0.8% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 14.4% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.7% | 2.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.2% | 8.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 39.0% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.4% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.2% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.5% | 12.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.8% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.1% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.8% | 8.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.84 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.06 | 1.11 | 1.80 | worse |
‡ 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.
51.6% 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 213 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.4% 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 151 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 41% 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 | 51.6%CMS range 45.1–59.5 | 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 | 11.4%CMS range 8.4–14.1 | 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 | 42.4% | 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 | 43.7% | 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 | 39.1% | 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 | 98.6% | 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 | 0.5% | 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 | 0.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 5.0–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 200 beds and averages 151.4 residents a day — about 76% occupied, or roughly 49 beds typically open. It usually has some room. 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 3.09 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 2.74 hrs/resident/day on weekends vs 3.23 on weekdays — 15% thinner on weekends. RN hours go from 0.41 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
40 citations, most serious first. The 20 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-02-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # 2731929 Based on observation, interviews, review of medical records, and review of other pertinent facility documents, it was determined that the facility failed to provide adequate supervision to a moderately cognitively impaired resident (Resident #1) with a known history of wandering and wore a wanderguard (security bracelet), who eloped from the facility on 2/1/26. The deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #1). Interviews on 2/4/26, revealed on 2/1/26 between 4:20 and 5:00 PM, the Licensed Practical Nurse (LPN #1) observed Resident #1 dressed in a winter coat and hat on [a unit the resident did not reside on] pushing a wheelchair that was holding a bag of personal belongings. Resident #1 informed LPN #1 that they were visiting their sister and were bringing home their sister's laundry to wash and could not find the front door exit. LPN #1 stated that they brought Resident #1 to the front lobby and entered the code into the keypad, and Resident #1…
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.
- Immediate jeopardy · Jcited before2025-04-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 #: NJ00184635 Based on observations, interviews, review of medical records, and pertinent facility documentation on 03/26/25, the facility failed to: a.) ensure the safety of a moderately cognitively impaired resident with aggressive behaviors from a staff member who pepper sprayed the Resident in the face and b.) follow their, Abuse, Neglect, and Exploitation of Residents and Unmanageable Residents policies. The deficient practice resulted in Resident #6 being treated for chemical conjunctivitis and pain to the left eye. This deficient practice was identified for 1 out 2 residents (Resident #6) who were reviewed for abuse and was evidenced by the following: A review of the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by facilities to report incidents, revealed that on 3/19/25, Resident #6 was standing at the nurse's station grabbing at electronics/equipment, smashing it, and attempting to hit staff. The FRE further revealed that the Licensed Practical 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.
- Immediate jeopardy · Jcited before2025-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #NJ00183371 Based on observations, interviews, review of the medical record and other pertinent facility records on 3/6/25 and 3/7/25, it was determined on 3/7/25 that the facility failed to provide adequate supervision of a severely cognitively impaired resident with a known history of exit seeking which resulted in the resident eloping from the facility on 2/10/25 for 1 of 4 residents (Resident #1). The resident was located at an off-site location by an unidentified caller and returned to the facility on 2/10/25 at approximately 5:58 P.M. by the local police department. The facility's failure to provide adequate supervision to a cognitively impaired resident who was at risk for elopement posed a likelihood of serious harm, injury, impairment or death. This deficient practice placed Resident #1 and all other residents who were at risk or who had a known history of wandering or elopement in an Immediate Jeopardy (IJ) situation. The deficient practice was evidenced by the following: A Facility Reportable Event (FRE) sent to the New Jersey Department of Health dated 2/10/25,…
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.
- Immediate jeopardy · Jcited before2024-10-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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#: NJ#162903, NJ#173303, NJ#175318, NJ#177086 Based on interviews, Medical Records (MRs) review, and review of other pertinent facility documents on 09/30/24, 10/01/24, 10/02/24, 10/3/24, and 10/04/24, it was determined that the facility failed to protect two residents (Resident #16 and Resident #7) from physical abuse from Resident #14, who was non-compliant with his/her Psychotropic medication, required close supervision and has a known history of aggressive behavior and diagnoses of Dementia with Anxiety Disorder, Schizophrenia and Other Specified Mental Disorders due to known psychological conditions. According to the MRs, on 04/24/24, Resident #14 physically attacked Resident #16 by punching Resident #16 in the face with a closed fist and became verbally aggressive. The residents were separated, the Physician was notified and ordered Resident #14 to be sent to the local hospital for evaluation and treatment. Further review of the MRs revealed on 07/01/24, Resident #14 was observed hitting Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-11-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who was dependent on staff for transfers was safely and properly transferred with two staff members via mechanical lift. Instead, the resident was transferred by one staff member from their bed to a shower stretcher on 9/30/25, which resulted in the resident falling and sustaining a left upper extremity humeral fracture. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for accidents and was evidenced by the following:On 11/6/25 at 9:40 AM, the surveyor requested from the Licensed Nursing Home Administrator (LHNA), a copy of the Facility Reportable Event (FRE) that was reported to the New Jersey Department of Health (NJDOH) for Resident #2. On 11/6/25 at 9: 55 AM, the surveyor reviewed the FRE provided by the LHNA that indicated that on 9/30/25 at 9:10 AM, the Certified Nursing Assistant (CNA#1) was transferring the resident from the bed to a shower…
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.
- Actual harm · H2024-10-11 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaints #: NJ162903, NJ166982, NJ168479 NJ172819, NJ172820, NJ173142 NJ173303, NJ175318, NJ175692 NJ177086 610 S/S H Based on interviews, review of medical records (MR), and other facility documentation on 9/30/24, 9/30/24, 10/01/24, 10/02/24, 10/03/24, and 10/04/24, it was determined that the facility failed to ensure residents' safety by not initiating a thorough and complete investigation was completed for employee-to-resident and resident-to-resident abuse allegation. Specifically, the facility failed to conduct a thorough investigation when Resident #10 was placed in involuntary seclusion, and Resident #14 threw a knife into the hallway and continued to display verbal and physical threats toward staff and other residents. The facility also failed to implement its policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice was identified for 2 of 29 residents (Resident #10 and Resident #14) and was evidenced by the following 1. According to the admission RECORD (AR), Resident #10 was admitted with diagnoses which…
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.
- Actual harm · Hcited before2024-10-11 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 #: NJ#162903, NJ#166982, NJ#168479, NJ#172819, NJ#172820, NJ#173142, NJ#173303, NJ#175318, NJ#175692, NJ#177086 Based on interviews, record review, and review of other pertinent facility documentation, it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure 1) residents' safety and well-being were maintained for physical and verbal abuse. The LNHA also failed to ensure the facility's policies titled Physical Restraints, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, and the Administrator job description were followed. This deficient practice was identified for 5 of 29 residents (Resident #7, Resident #10, Resident #13, Resident 16, and Resident #19) and was evidenced by the following: A review of Resident #14's Progress Note (PN) revealed the following: 1. According to the Electronic Medical Records (EMR), Resident #14 was admitted with a diagnosis of Schizophrenia. The Minimum Data Set (MDS), an assessment tool with an Assessment Reference Date…
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.
- Actual harm · G2024-10-11 · tag F0603 — failed to not confine residents against their will — isolatedProtect each resident from separation (from other residents, his/her room, or confinement to his/her room).
What the surveyor found here — an excerpt from the official record, may be distressing
Complaints #: NJ162903, NJ166982, NJ168479 NJ172819, NJ172820, NJ173142 NJ173303, NJ175318, NJ175692 NJ177086 Based on interviews, review of the Medical Records (MR), and other pertinent facility documentation on 9/30/24, 10/01/24, 10/02/24, 10/03/24, and 10/04/24, it was determined that the facility failed to ensure that Resident #10 was free from involuntary seclusion. On 4/19/24, a Certified Nursing Aide (CNA #1) placed Resident #10 in the dayroom of the [NAME] Unit. CNA #1 shut and blocked the door, sat outside the dayroom to prevent Resident #10 from exiting. According to Resident #10, she/he begged and was terrified when the CNA would not let her/him leave the day room. In addition, the facility failed to follow its policies titled PHYSICAL RESTRAINTS and Abuse, Neglect, Exploitation, and Misappropriation Prevention Program for 1 of 29 residents (Resident #10) reviewed for incident and accident. This deficient practice was evidenced by the following: A review of the REPORTABLE EVENT RECORD (RER), a New Jersey Department of Health (NJDOH) document used by the healthcare…
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.
- Actual harm · G2024-10-11 · 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
Complaints #: NJ173888 Based on interviews, record reviews, and review of other pertinent facility documents on 9/30, 10/1, 10/2, 10/3, and 10/4/2024, it was determined that the facility failed to assess and monitor for delayed complications after a resident fell from a geriatric chair in the day room and sustained a hematoma. The facility also failed to follow its policy titled Assessing Falls and their Causes. This deficient practice was identified for 1 of 3 residents (Resident #11) reviewed for falls and was evidenced by the following: A review of the facility's undated policy titled Assessing Falls and their Causes revealed, . Steps in the Procedure After a fall . 6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record. 7. Document any observed signs of symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings . 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.
- Actual harm · Gcited before2024-10-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C#: NJ173888 Based on interviews, record review, and review of other pertinent facility documents on [DATE], [DATE], [DATE], 10/3, and [DATE], it was determined that the facility failed to provide adequate supervision to prevent falls, determine the root cause of the falls, and implement effective interventions to prevent further falls. The facility also failed to follow its policy titled Falls and Fall Risk, Managing. This deficient practice was identified for 1 of 3 residents (Resident #11) reviewed for falls and was evidenced by the following: Review of the facility's policy titled, Falls and Fall Risk, Managing, dated [DATE] provided by the facility, revealed, . Based on previous evaluations and current data, the staff will identify interventions related to the Resident's specific risks and causes to try to prevent the Resident from falling and to try to minimize complications from falling . Policy Interpretation and Implementation Prioritizing Approaches to Managing falls and Fall Risk . 4. If falling…
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 · D2026-02-10 · 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 and interviews, it was determined that the facility failed to ensure controlled medications were stored within a double lock system. This deficient practice was identified on 1 of 3 units inspected (East Wing), and was evidenced by the following:On 2/10/26 at 10:30 AM, during a tour of the East Wing, the surveyor, accompanied by the Licensed Nursing Home Administrator (LNHA), observed the door to the medication room was propped open with an industrial floor fan. The LNHA stated that a small pipe broke yesterday in the medication room which flooded the area, and the area was being dried. Upon further observation, with the Licensed Practical Nurse (LPN), the surveyor observed that the medication refrigerator was not locked. The LPN opened the refrigerator, and a locked box was noted. The LPN opened the locked box to reveal two boxes each containing a 30 milliliter (mL) bottle of liquid Lorazepam (a Schedule 4 controlled substance used to treat anxiety). Upon further investigation, one bottle was sealed, and the other one had one dose of 0.5 mL removed. The LPN 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 · Fcited before2026-02-05 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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's Licensed Nursing Home Administrator (LNHA) failed to ensure himself as well as staff a.) implemented the facility's emergency preparedness plan including but not limit to; fire watch, availability of keys to first responders, notifying the New Jersey Department of Health (NJDOH) of the sprinkler system not operating or the relocation of residents, and properly tagging residents with identification during relocation; and b.) maintained the facility's fire sprinkler system to ensure all their residents attain their highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to affect all residents and was evidenced by the following. Refer F 836A review of the undated Administrator Job Description included; the primary purpose of your position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure…
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 · F2026-02-05 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed operate in accordance with all state regulations to implement their emergency preparedness plan. This deficient practice has the potential to affect all residents, and was evidenced by the following:Reference: N.J.A.C. 8:39-31.6 Mandatory fire and emergency preparedness .(j) Any staff member who is designated as the acting administrator shall be knowledgeable about and authorized to implement the facility's plans in the event of an emergency. On 2/3/26 at 9:00 AM, the surveyor arrived to the facility and observed the Emergency Management Services (EMS) at the facility. At that time, the surveyor interviewed the Director of EMS, who stated last night, 2/2/26 at 10:30 PM, the [NAME] Wing nursing unit lost fire protection. The Director of EMS stated that the fire sprinkler system was not operating on that unit. The Director of EMS continued that at 2:45 AM, the South Wing nursing unit had a pipe burst, and the unit was flooded with contaminated water. The Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-23 · 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 Based observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently perform quarterly smoking assessments according to facility policy for residents designated as active smokers. This deficient practice occurred for 3 of 3 residents (Resident #30, #58, and #127) reviewed for smoking. This deficient practice was evidenced by the following: 1. On 01/15/2025 at 10:21 AM, Surveyor #1 observed Resident #30 in his/her room getting a haircut. Resident #30 stated that he/she was a smoker, and that the facility staff held their smoking materials. Resident told Surveyor #1 that he/she had designated smoke times, and they could not smoke whenever they wanted to. On 01/16/25 at 12:44 PM, Surveyor #1 reviewed the electronic medical record (EMR) as follows; A review of the admission Record revealed Resident #30 was admitted to the facility with the following but not limited to diagnoses: Parkinson's disease, dementia, anxiety disorder, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-23 · tag F0712 — patternEnsure 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 observation, interview, and review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This deficient practice continued over several months for 8 of 35 sampled residents (Resident #1, Resident #31, Resident #53, Resident #59, Resident #78, Resident # 79, Resident #120, and Resident#139) and was evidenced by the following: 1.) On 01/21/2025 at 09:01 AM, a review of the EMR for Resident # 139 revealed the following: According to the admission Record, Resident #139 was admitted to the facility with diagnoses including but not limited to: Dementia with other behavioral disturbance, anxiety disorder. A review of the EMR revealed that there was no documentation to indicate Resident #139 was seen by attending physician at any time from 06/10/2024 thru 01/08/2025.…
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 before2025-01-23 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. This deficient practice was evidenced by the following: On 01/15/2025 at 09:16 AM, the surveyor, accompanied by the Food Service Director (FSD) observed the following in the kitchen: 1. A meat slicer was observed on a metal table in the cook's area. The meat slicer was not covered and was exposed to the air. The surveyor asked the facility cook if she had used the meat slicer at any point this AM for food production. The cook stated that she had not utilized the meat slicer for food production this AM. The surveyor asked the FSD if the meat slicer was cleaned and sanitized and he said yes that it was cleaned and sanitized. The table behind the blade guard/slicer wheel had unidentified food debris and a white slimy substance present when observed. The meat slicer was not covered while not in use and was exposed to contamination. The cook then further clarified to the surveyor that she had 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 · D2025-01-23 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure residents were treated with dignity whole being assisted with a meal. This deficient practice was identified for 1 of 3 units, [NAME] wing and was evidenced by the following: On 01/15/2025 at 12:38 PM, the surveyor observed the Infection Preventionist (IP) assisting a resident with their meal who was seated in his/her Geri chair. The IP was standing over the resident while feeding her/him. During an interview at that time, the IP said yes I attempting to feed resident. When asked how should you be positioned when feeding a resident and he replied I would like to be head level with resident but I don't have a chair. On 01/16/2025 at 08:25 AM, Certified Nursing Assistant (CNA #1) was observed to be standing while assisting a resident to eat who was seated in a Geri chair in the west unit dining room. After CNA #1 completed assisting the 1st resident, CNA #1 proceeded to move to a 2nd resident and stood while feeding him/her. There was a chair observed to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure residents were treated with dignity while being assisted with a meal and creating a homelike environment during dining by removing the food from the tray. This deficient practice was identified for 2 of 3 units, [NAME] wing and South wing and was evidenced by the following: 1. On 01/15/2025 at 12:38 PM, Surveyor #1 observed the Infection Preventionist (IP) assisting a resident with their meal who was seated in his/her Geri chair. The IP was standing over the resident while feeding her/him. During an interview at that time, the IP said yes I attempting to feed resident. When asked how should you be positioned when feeding a resident and he replied I would like to be head level with resident but I don't have a chair. 2. On 01/16/2025 at 08:25 AM, Certified Nursing Assistant (CNA #1) was observed to be standing while assisting a resident to eat who was seated in a Geri chair in the west unit dining room. After CNA #1 completed assisting the 1st resident, CNA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to follow hold parameters for the administration of a blood pressure medication in accordance with professional standards of practice. This deficient practice was identified for 1 of 28 residents (Resident #46) reviewed for standards of practice and 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 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 the State of New Jersey…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical record, and other facility documentation, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased Range of Motion (ROM). This deficient practice was identified for 1 of 1 resident reviewed for limited ROM, (Resident #78) and was evidenced by the following: On 01/15/2025 at 10:04 AM during the initial tour of the facility, Resident #78 was observed by the surveyor sleeping with right arm bent at the elbow close to their body. Their right hand was clenched in a fist. There was no observed splint, handroll, rolled towel or napkin on the right hand. During an interview with the surveyor on 01/15/2025 at 12:36 PM, the resident family stated that no splint or hand roll was being applied to resident's right hand. The family said that…
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 20 citations
- Potential for harm · D2025-01-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain an indwelling urinary catheter tubing off the floor to prevent the spread of infection. This deficient practice was identified for 1 of 2 residents (Resident #261) reviewed for catheter care and was evidenced by the following: On 1/15/25 at 11:14 AM, during initial tour the surveyor observed Resident #261 seated in a wheelchair self ambulating using his/her feet down the hallway. The resident was wearing shorts and the tubing of the urinary collection bag was visible hanging out of their shorts and the tubing was dragging on the ground below the chair. The surveyor reviewed the medical record for Resident #261 as follows: A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses which included urinary tract infection, dementia, and neuromuscular dysfunction of the bladder. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/21/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · 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, review of the medical record and review of other facility documentation, it was determined that the facility failed implement infection control measures for the handling and storage of respiratory equipment for 1 of 3 residents reviewed for respiratory care reviewed (Resident #53). This deficient practice was evidenced by the following: During the initial tour on 01/05/2025 at 09:26 AM, the surveyor interviewed Resident #53 who stated that they had COPD (Chronic Obstructive Pulmonary Disease), (a lung disease causing restricted airflow when breathing). During the interview, the surveyor observed a nebulizer mask ( a machine and tubing used to deliver an inhaled solution into the lungs) was face down inside the bedside on top of the resident's belongings including a book, mirror, napkins, and bracelet. The mask was exposed and was undated. On 01/16/2025 at 08:09 AM, the surveyor observed Resident #53 eating breakfast in bed. A nebulizer mask connected to the machine was observed inside the side table drawer exposed and undated on top of the side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the electronic medical record (EMR) and review of other facility documentation, it was determined that the facility failed to consistently ensure communication with a contracted dialysis facility according to facility policy and procedure. This deficient practice was evidenced for 1 of 2 residents (Resident #88) reviewed for dialysis. This deficient practice was evidenced by the following: 1. On 01/15/2025 at 10:31 AM, during the initial tour of the facility, the surveyor interviewed Resident #88 room and asked if he/she had any concerns with their dialysis treatment. Resident #88 stated that he/she attends dialysis 4 days per week. Resident #88 stated that they had been receiving dialysis treatment for approximately 5 years. A review of Resident #88's admission Record revealed that he/she had been admitted to the facility with the following but not limited to diagnoses: Type 2 diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, and dependence on renal dialysis (a treatment to remove extra fluid and waste when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-23 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to maintain a Hospice Communication Record for 1 of 1 resident (Resident #85) reviewed for Hospice Services. This deficient practice was evidenced by the following: During the initial tour of the North Unit on 01/15/2025 at 10:19 AM, the surveyor observed Resident #85 in his/her room with no concerns. At that time, Resident #85 was identified as having Hospice Services. A review of the admission record, revealed Resident # 85 was admitted with diagnoses including but not limited to; Encounter for Palliative Care, Depression, and Sacral Wounds. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 12/14/24 indicated that Resident #85 was on Hospice Care. A review of Resident #85's individual comprehensive care plan (ICCP) on 01/16/2025 at 11:39 AM, included a focus area, dated 12/6/24, that indicated resident #85 was on Hospice. Interventions included to coordinate Care Plan with…
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 · F2024-10-11 · 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 interview and review of facility's documents on 9/30/24, 10/1/24, 10/2/24, 10/3/24, and 10/4/24, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistant (CNAs) on an annual basis. This deficient practice was identified for 5 of 5 CNAs (CNAs #3, #13, #14, #15, and #16) reviewed for personnel records. This deficient practice was evidenced by the following: The Surveyor reviewed the employee file (Efile) presented by the facility. 1. According to CNA #3's Efile, revealed date of hire (DOH) was 10/19/19 and the Performance Evaluation for Non-Exempt Employees (PENEE) was signed and dated 2/13/23 to indicated that the CNA #3's PENEE was completed. The facility was unable to provide documented evidence that the PENEE was completed for CNA #3 for the year of 2/2024. 2. According to CNA #13's Efile revealed, DOH was 10/19/19 and the PENEE was signed and dated 3/14/22 to indicated that the CNA #13's PENEE was completed. The facility was unable to provide documented evidence that the PENEE was completed for CNA #13 for the year of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-11 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaints #: NJ162903, NJ166982, NJ168479 NJ172819, NJ172820, NJ173142 NJ173303, NJ175318, NJ175692 NJ177086 Based on interviews and record review, as well as a review of pertinent facility documents on 9/30/24, 10/01/24, 10/02/24, 10/03/24, and 10/04/24, it was determined that the facility failed to report an allegation of abuse in a timely manner to the New Jersey Department of Health (NJDOH). The facility also failed to implement its policy and procedure titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program. This deficient practice was identified for 3 of 29 residents(Residents #1, #2, and #14) reviewed for incident and accident and was evidenced by the following: A review of a policy provided by the facility titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated 05/2023, indicated, .9. Investigate and report any allegations within timeframes required by federal requirements . A review of the REPORTABLE EVENT RECORD/REPORT (RERR), completed by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-11 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, review of facility staffing records, and pertinent facility documents on 09/30/2024, 10/01/2024, 10/02/2024, 10/03/2024 and 10/4/2024, it was determined that the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week on 08/29/23. This deficient practice had the potential to affect all 157 residents residing in the facility. This deficient practice was evidenced by the following: Review of a document provided by the facility titled Facility Assessment, dated 01/25/24, indicated, .We provide adequate staffing to meet its resident's daily needs, preferences, and routines. This includes services of a registered nurse for at least eight (8) consecutive hours a day, 7 days a week . A review of a facility document titled Nurse Staffing Report, dated 08/29/23, indicated no RN coverage for at least eight consecutive hours. During an interview on 10/04/24 at 9:33 a.m., Unit Secretary/Staffing Coordinator (US/SC) stated she typically schedules RN coverage for eight hours per day, seven days a week.…
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 before2024-09-25 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ00172931 Based on interviews, medical record review, and review of other pertinent facility documents on 09/25/2024, it was determined that the facility failed to notify a resident's power of attorney (POA) of a room change and document notification in the progress notes. The facility also failed to follow Mandatory Resident Rights. This deficient practice was identified for 1 of 1 resident (Resident # 1) reviewed for room changes. This deficient practice was evidence by the following: According to the admission record (AR), Resident #1 was admitted to facility with diagnoses which included but were not limited to, Unspecified dementia (loss of thinking ability, memory, attention, logical reasoning, and other mental abilities), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Hypertension. A review of Resident #1's most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 09/12/2024 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Complaint #: NJ00172931 Based on interviews, medical record review, and review of other pertinent facility documents on 09/25/2024, it was determined that the facility failed to develop and implement Care Plan (CP) interventions for a resident after a fall. The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered. This deficient practice was identified for 1 of 3 residents (Resident # 3) reviewed for care plans. This deficient practice was evidence by the following: According to the admission Record (AR), Resident # 3 was admitted to facility with diagnoses which included but were not limited to, Dementia (loss of thinking ability, memory, attention, logical reasoning, and other mental abilities), Unspecified Depression, and Unspecified Anxiety Disorder. A review of Resident # 3's most recent 5-day admission Assessment Minimum Data Set (MDS), an assessment tool dated 08/26/2024 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident's cognition was moderately impaired. A review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-09 · 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 observations, interview, record review, and policy review, the facility failed to ensure that the kitchen was maintained in a sanitary manner for 104 out of 105 residents (one resident was receiving nutrition through tube feeding). Specifically, ice machines in the kitchen and unit pantries were not found to be kept in a sanitary manner, food items were found in dry and cold storage to be passed their use by dates, and refrigerators were found to contain unlabeled food items brought in by residents' family and were observed to have grime and food residue on the inside. Findings include: 1. During the initial kitchen tour on 03/06/23 at 9:20 AM with the Food Service Director (FSD) the following observations were recorded: In the second of two designated dry storage areas, a 10 pound, opened plastic bag of whole grain rotini pasta with a use by date of 01/22/23 was observed. The FSD stated it should have gone in the garbage and that he is the person in charge of discarding expired food items. The ice machine was observed with a black, spotty residue on the interior curtain…
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 · F2023-03-09 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of facility documentation, the Quality Assurance (QA) committee failed to identify quality deficiencies related to the facility's Infection Control program and take corrective action to ensure that all pneumonia vaccinations were offered and provided in accordance with recognized national standards. This failure had the potential to affect all residents who were eligible for the Pneumococcal polysaccharide vaccine (PPSV23), Prevnar13 (PCV13), prior to 10/21. The facility failed to offer all residents, who qualified, Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Prevnar 20 (PCV20) in accordance with nationally recognized standards, which was updated 10/21. Findings include: Review of a document provided by the facility titled Quality Assurance and Performance Improvement (QAPI) Program, dated 11/22, indicated . This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven (QAPI) program that is focused on indicators of the outcomes of care and quality of-life for our residents.Provide a means to measure…
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 · F2023-03-09 · tag F0883 — failed to offer flu and pneumonia vaccines — widespreadDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer five of five residents (Resident (R) 60, R18, R33, R29, and R43) reviewed for flu/pneumonia vaccinations and/or their representatives out of a total sample of 34 residents, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R60, R18, R33, and R29 the opportunity to be vaccinated with Pneumococcal conjugate vaccine PCV13 (Prevnar13), prior to 10/21/21. The facility failed to offer R43 the opportunity to be vaccinated with Pneumococcal polysaccharide vaccine (PPSV23) prior to 10/21/21. The facility failed to offer all five residents with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Prevnar 20 (PCV20) in accordance with nationally recognized standards. This practice had the potential to increase the risk for these residents to contract pneumonia.…
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 · D2023-03-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to ensure the physician completed documentation on the Physician's Orders for Life-Sustaining Treatment (POLST-used as directions to emergency health personnel in the event of cardiac or respiratory failure) for one of four residents (Resident (R) 309) reviewed for advance directives in a total sample of 34 residents. This failure created the potential for residents to not have their wishes honored by emergency personnel should they suffer a health emergency. Findings include: Review of R309's profile, provided by the facility, revealed R309 was admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare, essential primary hypertension, displaced fracture of surgical neck of left humerus (upper arm), dementia, generalized muscle weakness, and difficulty in walking. Review of R309's POLST, located in R309's medical record provided by the facility, revealed under the signatures section for 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 before2023-03-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interviews, record review, and facility policy review, the facility failed to ensure Licensed Practical Nurse (LPN#3) notified one resident's (Resident (R) 2) legal guardian out of a total sample of 34 residents, immediately of a change in condition, which required physician ordered treatment. Findings include: Review of R2's electronic medical record (EMR) titled admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R2's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/22 indicated a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed R2 was severely cognitively impaired. The assessment indicated R2 required extensive assistance of two for bed mobility and transfers. The assessment indicated R2 was assessed for the development of pressure ulcers, was at risk for the development of pressure ulcers, and had no pressure ulcers. Review…
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 · D2023-03-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one of three residents (Resident (R) 108) reviewed for discharge out of a total sample of 34 residents. Findings include: Review of the facility provided Face Sheet revealed that R108 was admitted on [DATE] with a diagnosis of dementia, depression, and muscle weakness. Further review revealed that R108 was discharged on 02/06/23. Review of the facility provided, discharged Return Not Anticipated MDS tracking assessment dated [DATE] revealed that R108 had a planned discharge to the acute hospital. Review of the Clinical Physician Orders, facility provided and dated 02/06/23, revealed that R108 was discharged home with home care not to an acute hospital. Review of the Progress Note, facility provided and dated 02/03/23, revealed that The social worker made a call to R108's granddaughter to present R108's Notice of Medicare Coverage (NOMNC) with last covered date (LCD) of 02/05/23. She provided…
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 · D2023-03-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure one of three residents (Residents (R) 48) reviewed for care planning out of a total of 34 residents was invited to participate in their quarterly care plan meetings. Findings include: Review of R48's electronic medical record (EMR) admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R48's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 01/07/23 indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which revealed R48 was cognitively intact. During an interview with R48 on 03/06/23 at 10:38 AM, the resident stated he was not sure he was invited to his quarterly care plan meeting. During an interview on 03/07/23 at 4:16 AM, Social Services Assistant (SSA) stated R48 was not invited to his care conference. SSA stated she normally invites residents and/or the family members on a quarterly basis and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure the attending physician provided a clinical rationale for declining the pharmacist recommendation for one of five residents (Resident (R)309) reviewed for unnecessary medications out of a total sample of 34 residents. This failure increased the risk that residents will continue to receive unnecessary medications that potentially could cause serious adverse effects. Findings include: Review of R309's profile, provided by the facility, revealed R309 was admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare, essential primary hypertension, displaced fracture of surgical neck of left humerus (upper arm), dementia, generalized muscle weakness, and difficulty in walking. Review of Physician Orders, under the Orders tab in the electronic medical record (EMR), revealed R309's medication regimen included the following medication order, dated 02/24/23: Quetiapine Fumarate (used to treat bipolar…
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 · D2023-03-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, review of the Food and Drug Administration (FDA) warning (www.fda.gov), and policy review, the facility failed to ensure one (Resident (R) 73) of six residents reviewed for unnecessary medications out of a total of 34 residents, had adequate indications for use and behavior monitoring for an antipsychotic (Seroquel) medication. Findings include: Review of R73's electronic medical record (EMR) admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with schizoaffective disorder (mental disorder of psychosis (out of touch with reality) and unstable mood). Review of R73's EMR Care Plan, located under the Care Plan tab and dated 12/01/22, indicated the resident received a psychotropic medication due to his diagnosis of schizoaffective disorder. Review of R73's EMR Medication Administration Record (MAR), located under the Orders tab and dated 12/01/22 through 03/06/23, indicated R73 received Seroquel extended release 50…
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 before2023-03-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to perform hand hygiene and glove changes during treatment to pressure ulcers in one of four residents (Resident (R) 3) reviewed for pressure ulcers in a total sample of 34 residents. This failure increased the risk of contamination and infection of the pressure ulcers. Findings include: Review of facility provided Face Sheet revealed that R3 was admitted to the facility on [DATE] with a diagnosis that included osteoporosis, anxiety, dementia, and mild-calorie malnutrition. Further review revealed R3 was placed in hospice on 11/28/22. During wound observation with Licensed Practical Nurse (LPN) 2 on 03/08/23 at 10:15 AM, along with LPN 4 assisting, LPN2 started with the left lateral foot wound, where she removed R3's old dressing, cleaned the wound, and then re-dressed the wound per physician orders, all with the same gloves. LPN2 placed all unused items back into a zip loc baggie, then removed her gloves and washed her hands. LPN2 placed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-19 · 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, review of medical records, and other pertinent facility documentation, it was determined two facility staff members failed to don (put on) appropriate Personal Protective Equipment (PPE) while in the room of a resident on Transmission-based precautions (TBP - standard, contact, droplet) for Extended-Spectrum Beta-Lactamase (ESBL) of the urine (a condition wherein ESBL bodies are found in the urine which is normally not present in a healthy individual) who resided on the non-ill unit. This deficient practice was identified for 2 of 2 staff members on 1 of 3 units, during a focused infection control survey for COVID-19, as evidenced by the following: 1) On 3/17/21 at 8:23 AM, the surveyor observed Resident #43's room on the non-ill unit. Resident #43's room was observed to have a STOP see nurse standard and droplet precaution sign at the room entrance; a PPE bin in front of the door contained alcohol-based hand rub (ABHR), PPE gowns, gloves, and surgical masks. The surveyor observed Resident #43 sitting in a chair with an incontinent brief down around…
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
$306,201 in federal fines across 5 penalties.
- $70,637 — penalty dated 2026-07-09
- $16,575 — penalty dated 2026-02-05
- $61,770 — penalty dated 2025-11-06
- $91,176 — penalty dated 2025-04-02
- $66,043 — penalty dated 2024-10-11
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ABRAMCZYK, JACOB | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 52% | since 10/18/2023 |
| ABRAMCZYK, JOSEPH | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 14% | since 03/10/2023 |
| ABRAMCZYK, NAFTOLI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 17% | since 10/18/2023 |
| SHAPIRO, BRADLEY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 17% | since 03/10/2023 |
| NEWPOINT REAL ESTATE CAPITAL LLC | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 12/18/2024 |
| TTYY LLC | Organization | ADP OF THE SNF | — | since 03/10/2023 |
| WHITING GARDENS REHABILITATION AND NURSING CENTER LLC | Organization | ADP OF THE SNF | — | since 03/10/2023 |
| SHAPIRO, SIMA | Individual | ADP OF THE SNF | — | since 03/10/2023 |
CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.2M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315293. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-23, 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.