Irvington, NJ

Alliance Care Rehabilitation And Nursing Center

3-star overall rating with 2-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

155 40th Street, Irvington, NJ

(973) 371-7878

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

212

Certified beds

Average residents

193

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Excelsior Care Group

Operator or chain grouping

Approved since

1996-09-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

33 facilities

Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.63

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.76

Licensed practical nurse staffing · state 0.94 · national 0.87

Aide hours / resident day

1.96

Nurse aide staffing · state 2.23 · national 2.35

Total nurse hours

3.35

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.39

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

2.91

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.39

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.56

CMS adjusted RN staffing hours

Adjusted total hours

2.95

CMS adjusted total nurse staffing hours

Case-mix index

1.56

Higher values indicate more complex resident acuity

RN turnover

23%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

30%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,480

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

39.82

Composite VBP score used to determine payment impact.

Payment multiplier

0.9928

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.61

Baseline 20.28% · Performance 19.76% · Measure score 3.61 · Achievement 3.61 · Improvement 1.12

Healthcare-associated infections

4.95

Baseline 6.70% · Performance 6.36% · Measure score 4.95 · Achievement 4.95 · Improvement 1.52

Total nurse turnover

7.37

Baseline 65.73% · Performance 33.57% · Measure score 7.37 · Achievement 7.37 · Improvement 7.37

Adjusted total nurse staffing

Baseline 3.26 hours · Performance 3.07 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.43%	10.72% 0.7 pts worse	No Different than the National Rate · Eligible stays 93 · Observed rate 17.2% · Lower 95% interval 7.76%
Discharge to community	50.13%	50.57% 0.4 pts worse	No Different than the National Rate · Eligible stays 116 · Observed rate 30.17% · Lower 95% interval 39.22%
Medicare spending per beneficiary	1.42	1.02 0.4 pts worse
Drug regimen review with follow-up	99.49%	95.27% 4.2 pts better	Numerator 195 · Denominator 196
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 196
Discharge self-care score	50%	53.69% 3.7 pts worse	Numerator 53 · Denominator 106
Discharge mobility score	57.55%	50.94% 6.6 pts better	Numerator 61 · Denominator 106
Pressure ulcers or injuries, new or worsened	4.08%	2.29% 1.8 pts worse	Numerator 8 · Denominator 196 · Adjusted rate 2.76%
Healthcare-associated infections requiring hospitalization	6.36%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 67 · Observed rate 7.46% · Lower 95% interval 4.04%
Staff COVID-19 vaccination coverage	2.88%	8.2% 5.3 pts worse	Numerator 4 · Denominator 139
Staff flu vaccination coverage	96.41%	42% 54.4 pts better	Numerator 215 · Denominator 223
Discharge function score	56.6%	56.45% 0.1 pts better	Numerator 60 · Denominator 106
Transfer of health information to provider	94.19%	95.95% 1.8 pts worse	Numerator 81 · Denominator 86
Transfer of health information to patient	98.36%	96.28% 2.1 pts better	Numerator 60 · Denominator 61
Resident COVID-19 vaccinations up to date	5.83%	25.2% 19.4 pts worse	Numerator 6 · Denominator 103

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	2.1 0.3 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.9 · Expected 3.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.4	1.1 0.7 pts better	1.8 1.4 pts better	Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.0 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	93.0% 6.5 pts better	93.4% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	97.2% 1.4 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	2.4% 2.4 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	91.7%	11.4% 80.3 pts worse	11.4% 80.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 92.4% · Q3 92.3% · Q4 94.3% · 4Q avg 91.7%
Percentage of long-stay residents who lose too much weight	5.3%	4.6% 0.7 pts worse	5.4% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.8% · Q3 7.0% · Q4 9.0% · 4Q avg 5.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	5.1%	19.0% 13.9 pts better	19.6% 14.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.1% · Q3 4.0% · Q4 6.8% · 4Q avg 5.1%
Percentage of long-stay residents who received an antipsychotic medication	11.9%	13.5% 1.6 pts better	16.7% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 12.4% · Q3 10.8% · Q4 13.3% · 4Q avg 11.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	10.2%	9.8% 0.4 pts worse	16.3% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 12.8% · Q3 6.4% · Q4 13.1% · 4Q avg 10.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.8%	9.7% 2.9 pts better	14.9% 8.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.5% · Q3 4.7% · Q4 7.5% · 4Q avg 6.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.7% 0.2 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 1.2% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.3%	15.9% 1.6 pts better	19.8% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 11.2% · Q3 20.0% · Q4 18.1% · 4Q avg 14.3%
Percentage of long-stay residents with pressure ulcers	10.9%	6.0% 4.9 pts worse	5.1% 5.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 10.3% · Q3 9.3% · Q4 11.1% · 4Q avg 10.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.7%	78.7% 15 pts better	81.7% 12 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.8% · Q2 91.8% · Q3 94.7% · Q4 95.7% · 4Q avg 93.7%
Percentage of short-stay residents who had an outpatient emergency department visit	8.1%	8.2% 0.1 pts better	12.0% 3.9 pts better	Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 9.6% · Expected 13.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.1%	1.2% 0.9 pts worse	1.6% 0.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.4% · Q3 2.2% · Q4 2.6% · 4Q avg 2.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.8%	80.1% 6.7 pts better	79.7% 7.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.9%	25.4% 4.5 pts better	23.9% 3 pts better	Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 30.9% · Expected 35.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-17 · Fire 2024-10-17

7 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 2 Health 2022-11-23 · Fire 2022-11-23

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2021-09-23 · Fire 2021-09-23

4 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-17

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-11-04

F · Potential for more than minimal harm 2024-10-17

K227 · Egress Deficiencies

Fire Safety

Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

Corrected 2024-11-15

F · Potential for more than minimal harm 2024-10-17

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-11-15

F · Potential for more than minimal harm 2024-10-17

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-11-15

F · Potential for more than minimal harm 2022-11-23

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-12-23

F · Potential for more than minimal harm 2022-11-23

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-12-23

E · Potential for more than minimal harm 2022-11-23

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2022-12-23

E · Potential for more than minimal harm 2022-11-23

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-12-23

E · Potential for more than minimal harm 2022-11-23

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-12-23

E · Potential for more than minimal harm 2022-11-23

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-12-23

E · Potential for more than minimal harm 2022-11-23

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2022-12-23

D · Potential for more than minimal harm 2022-11-23

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-12-23

E · Potential for more than minimal harm 2021-09-23

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2021-10-27

E · Potential for more than minimal harm 2021-09-23

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2021-11-01

E · Potential for more than minimal harm 2021-09-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-10-22

E · Potential for more than minimal harm 2021-09-23

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2021-11-01

E · Potential for more than minimal harm 2021-09-23

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2021-10-06

D · Potential for more than minimal harm 2021-09-23

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2021-10-15

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-10-17

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-10-31

D · Potential for more than minimal harm 2024-10-17

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-11-21

D · Potential for more than minimal harm 2024-10-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-11-30

D · Potential for more than minimal harm 2024-10-17

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2024-11-21

D · Potential for more than minimal harm 2024-10-17

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-11-30

D · Potential for more than minimal harm 2024-10-17

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-11-21

D · Potential for more than minimal harm 2024-10-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-21

D · Potential for more than minimal harm 2023-08-04

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-08-28

G · Actual harm 2022-11-23

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-01-12

F · Potential for more than minimal harm 2022-11-23

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-01-19

F · Potential for more than minimal harm 2022-11-23

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2023-01-19

F · Potential for more than minimal harm 2022-11-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-01-12

F · Potential for more than minimal harm 2022-11-23

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2023-01-12

E · Potential for more than minimal harm 2022-11-23

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-01-19

E · Potential for more than minimal harm 2022-11-23

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-01-19

E · Potential for more than minimal harm 2022-11-23

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-01-19

E · Potential for more than minimal harm 2022-11-23

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-01-19

E · Potential for more than minimal harm 2022-11-23

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-01-19

E · Potential for more than minimal harm 2022-11-23

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2023-01-19

E · Potential for more than minimal harm 2022-11-23

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2023-01-19

E · Potential for more than minimal harm 2022-11-23

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2022-12-23

D · Potential for more than minimal harm 2022-11-23

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2023-01-19

C · Minimal harm 2022-11-23

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2023-01-19

E · Potential for more than minimal harm 2021-09-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-10-27

D · Potential for more than minimal harm 2021-09-23

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2021-10-08

D · Potential for more than minimal harm 2021-09-23

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2021-10-08

Penalties and ownership