35 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Trenton, NJ
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $27,571 in total fines with 35 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
439 Bellevue Avenue, Trenton, NJ
(609) 396-2646
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
106
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-03-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.29
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
2.93
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.42
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.05
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
12,112
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.76
Performance 52.38% · Measure score 2.76 · Achievement 2.76 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.20 hours · Performance 3.04 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 9.68% · Lower 95% interval 7.01% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 1 · Denominator 27 · Adjusted rate 4.02% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 99.22% |
42%
57.2 pts better
|
Numerator 128 · Denominator 129 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.1
0.4 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
93.0%
6.1 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 97.8% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.2%
1.6 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
2.4%
0.9 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.1% · Q4 2.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
11.4%
6.6 pts better
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.8% · Q3 3.4% · Q4 7.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
4.6%
2.2 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 3.3% · Q4 1.1% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
19.0%
4.9 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 11.5% · Q3 16.0% · Q4 16.1% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.2% |
13.5%
7.7 pts worse
|
16.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 17.1% · Q3 22.9% · Q4 26.5% · 4Q avg 21.2% · 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 | 6.7% |
9.8%
3.1 pts better
|
16.3%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.7% · Q3 12.1% · Q4 4.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
9.7%
1.2 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.9% · Q3 12.1% · Q4 7.8% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · 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 2.7% · Q2 0.0% · Q3 0.0% · 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 | 3.5% |
15.9%
12.4 pts better
|
19.8%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 2.9% · Q4 8.3% · 4Q avg 3.5% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.0%
1 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 2.4% · Q3 5.7% · Q4 6.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
78.7%
18 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.0% · Q3 94.3% · Q4 97.1% · 4Q avg 96.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.3% |
80.1%
12.2 pts better
|
79.7%
12.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
Survey summary
Top issue: Pharmacy Service (6 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Resident Assessment and Care Planning (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Install proper backup exit lighting.
Corrected 2024-08-25
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-25
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-08-25
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-25
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 2024-08-25
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-08-30
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-08-30
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-08-30
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-08-30
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-10
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-11-10
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-11-10
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-10
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 2022-11-10
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-18
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-09-18
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-09-18
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-09-18
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-09-18
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-09-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-30
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-30
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 2024-08-30
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-08-30
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-30
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-30
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-08-30
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-30
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-30
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-18
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-30
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 2024-08-30
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-30
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-30
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 2024-08-30
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-08-30
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-30
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-08-30
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-08-30
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-30
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 2024-08-30
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-30
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-30
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 2024-08-30
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-30
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-30
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-30
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-30
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-12-05
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-12-05
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-12-05
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-12-05
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-12-05
Health
Provide 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.
Corrected 2022-12-05
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-05
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-12-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-05
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 2022-12-05
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-12-05
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-05
Health
Honor 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.
Corrected 2022-12-05
Health
Assess the resident when there is a significant change in condition
Corrected 2022-12-05
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-05
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-05
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-05
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-05
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 2022-12-05
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-12-05
Health
Implement a program that monitors antibiotic use.
Corrected 2022-12-05
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-12-05
Health
Provide and implement an infection prevention and control program.
Corrected 2020-11-06
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-11-05
Penalties and ownership
Fine · fine $10,814
Fine
Fine · fine $16,757
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Nearby options
Trenton, NJ
1-star overall rating with 1-star inspections with Special Focus status with $499,537 in total fines with 21 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Trenton, NJ
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Trenton, NJ
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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