Cedar Grove, NJ

Canterbury At Cedar Grove

1-star overall rating with 1-star inspections with $9,661 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

398 Pompton Avenue, Cedar Grove, NJ

(973) 239-7600

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

0 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

180

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Mb Healthcare

Operator or chain grouping

Approved since

1984-09-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

11 facilities

Chain averages 3 overall / 3 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

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

28%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,088

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

Performance score

13.95

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

How the VBP score is built

Readmission

3.58

Baseline 23.40% · Performance 20.80% · Measure score 3.58 · Achievement 1.36 · Improvement 3.58

Healthcare-associated infections

0.61

Baseline 7.70% · Performance 7.65% · Measure score 0.61 · Achievement 0.61 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

Baseline 3.17 hours · Performance 2.69 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.38%	10.72% 1.3 pts better	No Different than the National Rate · Eligible stays 116 · Observed rate 6.03% · Lower 95% interval 6.7%
Discharge to community	45.28%	50.57% 5.3 pts worse	No Different than the National Rate · Eligible stays 102 · Observed rate 33.33% · Lower 95% interval 34.46%
Medicare spending per beneficiary	0.91	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 74 · Denominator 74
Falls with major injury	6.76%	0.77% 6 pts worse	Numerator 5 · Denominator 74
Discharge self-care score	25.45%	53.69% 28.2 pts worse	Numerator 14 · Denominator 55
Discharge mobility score	23.64%	50.94% 27.3 pts worse	Numerator 13 · Denominator 55
Pressure ulcers or injuries, new or worsened	1.35%	2.29% 0.9 pts better	Numerator 1 · Denominator 74 · Adjusted rate 1.4%
Healthcare-associated infections requiring hospitalization	7.65%	7.12% 0.5 pts worse	No Different than the National Rate · Eligible stays 47 · Observed rate 8.51% · Lower 95% interval 4.68%
Staff COVID-19 vaccination coverage	0.56%	8.2% 7.6 pts worse	Numerator 1 · Denominator 180
Staff flu vaccination coverage	98.33%	42% 56.3 pts better	Numerator 177 · Denominator 180
Discharge function score	36.36%	56.45% 20.1 pts worse	Numerator 20 · Denominator 55
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 27 · Denominator 27
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	2.86%	25.2% 22.3 pts worse	Numerator 1 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.0	2.1 0.1 pts better	1.9 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.2 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.1 0.3 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.1%	93.0% 2.9 pts worse	93.4% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 64.5% · Q2 100.0% · Q3 98.5% · Q4 98.4% · 4Q avg 90.1%
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	3.1%	2.4% 0.7 pts worse	3.3% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.5% · Q3 3.7% · Q4 3.1% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.0%	11.4% 6.4 pts better	11.4% 6.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 3.3% · Q3 3.2% · Q4 4.5% · 4Q avg 5.0%
Percentage of long-stay residents who lose too much weight	6.2%	4.6% 1.6 pts worse	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 5.5% · Q3 2.4% · Q4 0.8% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	26.1%	19.0% 7.1 pts worse	19.6% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 26.4% · Q3 25.4% · Q4 25.8% · 4Q avg 26.1%
Percentage of long-stay residents who received an antipsychotic medication	26.1%	13.5% 12.6 pts worse	16.7% 9.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 24.1% · Q3 29.6% · Q4 29.8% · 4Q avg 26.1% · 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	4.5%	9.8% 5.3 pts better	16.3% 11.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 9.5% · Q3 1.4% · Q4 1.5% · 4Q avg 4.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.9%	9.7% 4.8 pts better	14.9% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.7% · Q3 7.6% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.7% 0.3 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · 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	4.1%	15.9% 11.8 pts better	19.8% 15.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.7% · Q3 4.0% · Q4 3.4% · 4Q avg 4.1%
Percentage of long-stay residents with pressure ulcers	6.7%	6.0% 0.7 pts worse	5.1% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 8.6% · Q3 6.4% · Q4 4.2% · 4Q avg 6.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	85.4%	78.7% 6.7 pts better	81.7% 3.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 70.0% · Q2 88.7% · Q3 97.6% · Q4 100.0% · 4Q avg 85.4%
Percentage of short-stay residents who had an outpatient emergency department visit	7.0%	8.2% 1.2 pts better	12.0% 5 pts better	Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 7.5% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	1.2% 0.2 pts worse	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	83.3%	80.1% 3.2 pts better	79.7% 3.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	38.2%	25.4% 12.8 pts worse	23.9% 14.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 38.2% · Observed 37.5% · Expected 23.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-07-03 · Fire 2024-07-03

12 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2023-07-26 · Fire 2023-07-26

28 health deficiencies

Top issue: Resident Rights (7 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2021-06-10 · Fire 2021-06-10

7 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-07-03

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-23

F · Potential for more than minimal harm 2024-07-03

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2024-07-23

F · Potential for more than minimal harm 2024-07-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-23

F · Potential for more than minimal harm 2024-07-03

K521 · Services Deficiencies

Fire Safety

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

Corrected 2024-07-23

F · Potential for more than minimal harm 2024-07-03

K531 · Services Deficiencies

Fire Safety

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

Corrected 2024-07-23

F · Potential for more than minimal harm 2024-07-03

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-07-23

F · Potential for more than minimal harm 2024-07-03

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2024-07-23

F · Potential for more than minimal harm 2024-07-03

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-07-03

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-07-03

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-07-03

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 2024-07-23

D · Potential for more than minimal harm 2024-07-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-23

F · Potential for more than minimal harm 2023-07-26

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2023-08-18

F · Potential for more than minimal harm 2023-07-26

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-08-18

F · Potential for more than minimal harm 2023-07-26

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-08-18

F · Potential for more than minimal harm 2023-07-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-08-18

D · Potential for more than minimal harm 2021-06-10

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2021-07-30

D · Potential for more than minimal harm 2021-06-10

K523 · Services Deficiencies

Fire Safety

Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly.

Corrected 2021-07-01

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-21

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-12-11

D · Potential for more than minimal harm 2025-05-08

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 2025-06-09

E · Potential for more than minimal harm 2024-12-16

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 2025-01-13

D · Potential for more than minimal harm 2024-09-17

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 2024-10-09

F · Potential for more than minimal harm 2024-07-03

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 2024-07-23

F · Potential for more than minimal harm 2024-07-03

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 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F657 · Resident Assessment and Care Planning Deficiencies

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 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F710 · Nursing and Physician Services Deficiencies

Health

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-07-23

D · Potential for more than minimal harm 2024-07-03

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-07-23

F · Potential for more than minimal harm 2023-07-26

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2023-08-18

F · Potential for more than minimal harm 2023-07-26

F727 · Nursing and Physician Services Deficiencies

Health

Have 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.

Corrected 2023-08-18

F · Potential for more than minimal harm 2023-07-26

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2023-09-25

E · Potential for more than minimal harm 2023-07-26

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2023-08-18

E · Potential for more than minimal harm 2023-07-26

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 2023-08-18

E · Potential for more than minimal harm 2023-07-26

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 2023-08-18

E · Potential for more than minimal harm 2023-07-26

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-08-18

E · Potential for more than minimal harm 2023-07-26

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2023-08-18

E · Potential for more than minimal harm 2023-07-26

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 2023-08-18

E · Potential for more than minimal harm 2023-07-26

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-08-18

E · Potential for more than minimal harm 2023-07-26

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-08-18

E · Potential for more than minimal harm 2023-07-26

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-08-18

E · Potential for more than minimal harm 2023-07-26

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2023-08-18