Cycle 1
Health 2024-08-09 · Fire 2024-08-09
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cedar Grove, NJ
Arbor Glen Center
1-star overall rating with 1-star inspections with $8,281 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
25 E Lindsley Road, Cedar Grove, NJ
(973) 256-7220
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
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
0.85
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.51
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
3.33
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
3.22
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
15%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,453
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.12
Baseline 17.98% · Performance 19.99% · Measure score 3.12 · Achievement 3.12 · Improvement 0
Healthcare-associated infections
0
Baseline 6.26% · Performance 9.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 19.48% · Performance 15.19% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0
Baseline 3.71 hours · Performance 3.2 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.47% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 10.74% · Lower 95% interval 7.34% |
| Discharge to community | 50.91% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 42.55% · Lower 95% interval 43.13% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.24% |
95.27%
1 pts better
|
Numerator 128 · Denominator 133 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 133 |
| Discharge self-care score | 53.61% |
53.69%
0.1 pts worse
|
Numerator 52 · Denominator 97 |
| Discharge mobility score | 50.52% |
50.94%
0.4 pts worse
|
Numerator 49 · Denominator 97 |
| Pressure ulcers or injuries, new or worsened | 2.26% |
2.29%
About the same
|
Numerator 3 · Denominator 133 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 9.79% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 13.73% · Lower 95% interval 6.82% |
| Staff COVID-19 vaccination coverage | 2.52% |
8.2%
5.7 pts worse
|
Numerator 3 · Denominator 119 |
| Staff flu vaccination coverage | 81.29% |
42%
39.3 pts better
|
Numerator 139 · Denominator 171 |
| Discharge function score | 56.7% |
56.45%
0.2 pts better
|
Numerator 55 · Denominator 97 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 73 · Denominator 73 |
| Resident COVID-19 vaccinations up to date | 7.58% |
25.2%
17.6 pts worse
|
Numerator 5 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.1
0.4 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
93.0%
6.2 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 98.9% · Q4 98.9% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
2.4%
2.1 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 24.1% |
11.4%
12.7 pts worse
|
11.4%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 22.4% · Q3 32.1% · Q4 15.9% · 4Q avg 24.1% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
4.6%
2 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 3.6% · Q3 8.9% · Q4 5.1% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
19.0%
4.1 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 15.5% · Q3 15.0% · Q4 13.8% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
13.5%
2.3 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 13.3% · Q3 15.5% · Q4 14.3% · 4Q avg 15.8% · 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 | 23.4% |
9.8%
13.6 pts worse
|
16.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 12.7% · Q3 23.2% · Q4 19.4% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
9.7%
6.5 pts worse
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 14.9% · Q3 11.4% · Q4 16.9% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.7%
About the same
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
15.9%
7.4 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 12.2% · Q3 23.7% · Q4 27.2% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 8.9% |
6.0%
2.9 pts worse
|
5.1%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 13.1% · Q3 8.2% · Q4 4.9% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
78.7%
21.1 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.1% |
8.2%
7.1 pts better
|
12.0%
10.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.1% · Observed 1.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.2%
1 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 2.8% · Q4 3.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
80.1%
15 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
25.4%
1.8 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 27.3% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-30 · Fire 2022-08-30
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2020-02-28 · Fire 2020-02-28
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-09
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-08-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-03
F · Potential for more than minimal harm
2022-08-30
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 2022-09-22
F · Potential for more than minimal harm
2022-08-30
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-09-22
F · Potential for more than minimal harm
2022-08-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-05
F · Potential for more than minimal harm
2022-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-22
F · Potential for more than minimal harm
2022-08-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-09-22
E · Potential for more than minimal harm
2022-08-30
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-09-22
E · Potential for more than minimal harm
2022-08-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-22
E · Potential for more than minimal harm
2022-08-30
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-09-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-23
J · Immediate jeopardy
2025-03-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-17
F · Potential for more than minimal harm
2024-08-09
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-09
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 2024-09-03
D · Potential for more than minimal harm
2024-08-09
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 2024-09-03
D · Potential for more than minimal harm
2024-08-09
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-03
D · Potential for more than minimal harm
2022-08-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-09-22
D · Potential for more than minimal harm
2022-08-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-09-22
D · Potential for more than minimal harm
2022-08-30
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-09-22
D · Potential for more than minimal harm
2022-08-30
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 2022-09-22
D · Potential for more than minimal harm
2022-08-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-22
D · Potential for more than minimal harm
2022-08-30
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 2022-09-22
D · Potential for more than minimal harm
2022-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-22
Penalties and ownership
What sits behind the stars
$8,281
2025-03-13
Fine
Fine · fine $8,281
Fine
Ownership
Genesis Nj Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Agresti, James
Operational/Managerial Control · Individual
Asefaha, Tsega
Operational/Managerial Control · Individual
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Fc Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Fishman, Steven
Corporate Director · Individual
Fishman, Steven
Corporate Officer · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Operations LLC
5% Or Greater Indirect Ownership Interest · Organization
Ghc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Morris, Diane
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Whitman, Arnold
Corporate Director · Individual
Whitman, Arnold
Corporate Officer · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Complete Care At St Vincents LLC
Cedar Grove, NJ
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#2
Alaris Health At Cedar Grove
Cedar Grove, NJ
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Complete Care At Cedar Grove
Cedar Grove, NJ
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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