Cycle 1
Health 2024-09-13 · Fire 2024-09-13
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Pompton Plains, NJ
Cedar Crest/Mountainview Gardens
2-star overall rating with 1-star inspections with abuse icon flag with $58,262 in total fines with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
4 Cedar Crest Village Drive, Pompton Plains, NJ
(973) 831-3504
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Erickson Senior Living
Operator or chain grouping
Approved since
2005-04-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 3 health / 5 staffing / 4 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
0.79
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
13%
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
336
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
72.78
Composite VBP score used to determine payment impact.
Payment multiplier
1.0236
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 18.58% · Performance 16.27% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
7.69
Baseline 5.61% · Performance 5.54% · Measure score 7.69 · Achievement 7.69 · Improvement 0.76
Total nurse turnover
5.25
Baseline 28.70% · Performance 42.22% · Measure score 5.25 · Achievement 5.25 · Improvement 0
Adjusted total nurse staffing
6.17
Baseline 4.39 hours · Performance 4.83 hours · Measure score 6.17 · Achievement 6.17 · Improvement 2.69
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.04% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 223 · Observed rate 9.42% · Lower 95% interval 8.17% |
| Discharge to community | 71.78% |
50.57%
21.2 pts better
|
Better than the National Rate · Eligible stays 195 · Observed rate 70.77% · Lower 95% interval 65.62% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 112 · Denominator 112 |
| Falls with major injury | 0.89% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 112 |
| Discharge self-care score | 44.55% |
53.69%
9.1 pts worse
|
Numerator 45 · Denominator 101 |
| Discharge mobility score | 39.6% |
50.94%
11.3 pts worse
|
Numerator 40 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 0.89% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 112 · Adjusted rate 1.13% |
| Healthcare-associated infections requiring hospitalization | 5.54% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 2.31% · Lower 95% interval 3.22% |
| Staff COVID-19 vaccination coverage | 23.73% |
8.2%
15.5 pts better
|
Numerator 28 · Denominator 118 |
| Staff flu vaccination coverage | 88.42% |
42%
46.4 pts better
|
Numerator 229 · Denominator 259 |
| Discharge function score | 50.5% |
56.45%
6 pts worse
|
Numerator 51 · Denominator 101 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.06% |
96.28%
1.2 pts worse
|
Numerator 77 · Denominator 81 |
| Resident COVID-19 vaccinations up to date | 35.85% |
25.2%
10.7 pts better
|
Numerator 19 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.4 · 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 0.3 · Expected 1.4 · 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 99.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
97.2%
1.8 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
2.4%
1.5 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.1% · Q3 3.2% · Q4 1.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
11.4%
10.6 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 2.3% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
4.6%
1.3 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.7% · Q3 10.3% · Q4 3.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
19.0%
8.4 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 28.9% · Q3 28.2% · Q4 22.1% · 4Q avg 27.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
13.5%
5.7 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.6% · Q3 18.5% · Q4 19.7% · 4Q avg 19.2% · 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 | 13.0% |
9.8%
3.2 pts worse
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 6.7% · Q3 12.6% · Q4 17.1% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.2% |
9.7%
7.5 pts worse
|
14.9%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 13.7% · Q3 10.6% · Q4 16.4% · 4Q avg 17.2% · 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 | 2.6% |
0.8%
1.8 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.1% · Q3 1.1% · Q4 3.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
15.9%
2.2 pts better
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 15.2% · Q3 14.5% · Q4 12.3% · 4Q avg 13.7% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
6.0%
1.9 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.6% · Q3 8.2% · Q4 10.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
78.7%
13.5 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 95.3% · Q3 91.7% · Q4 90.8% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
8.2%
1.9 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.2%
1.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.0% · Q3 2.7% · Q4 1.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
80.1%
16.2 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
25.4%
6.6 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 15.3% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-25 · Fire 2023-05-25
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-05-11 · Fire 2021-05-11
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-13
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 2024-10-15
F · Potential for more than minimal harm
2024-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-09-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-13
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-09-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-09-13
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-13
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-28
C · Minimal harm
2021-05-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-05-27
Inspection history
Recent health citations
G · Actual harm
2026-01-07
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.
Not marked corrected
J · Immediate jeopardy
2025-09-23
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 2025-10-21
D · Potential for more than minimal harm
2025-03-12
F578 · Resident Rights Deficiencies
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 2025-04-14
D · Potential for more than minimal harm
2025-03-12
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 2025-04-14
F · Potential for more than minimal harm
2024-09-13
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 2024-10-15
E · Potential for more than minimal harm
2024-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-09-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-15
G · Actual harm
2024-07-25
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-26
D · Potential for more than minimal harm
2023-05-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-25
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-15
E · Potential for more than minimal harm
2021-05-11
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-05-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-05-27
Penalties and ownership
What sits behind the stars
$49,750
2025-09-23
Fine
Fine · fine $49,750
Fine
$8,512
2024-07-25
Fine
Fine · fine $8,512
Fine
Ownership
National Senior Communities, Inc
5% Or Greater Direct Ownership Interest · Organization
Brown, Ian
Corporate Director · Individual
Brown, Patricia
Corporate Director · Individual
Butler, Richard
Operational/Managerial Control · Individual
Clupper, Katherine
Corporate Director · Individual
Colins, Mary
Corporate Director · Individual
Colins, Mary
Corporate Officer · Individual
Embley, Mark
Operational/Managerial Control · Individual
Embley, Mark
Corporate Officer · Individual
Erickson Senior Living LLC
Operational/Managerial Control · Organization
Erstad, Eileen
Corporate Director · Individual
Erstad, Eileen
Corporate Officer · Individual
Gantert, Neal
Operational/Managerial Control · Individual
Gantert, Neal
Corporate Officer · Individual
Hall, John
Operational/Managerial Control · Individual
Hall, John
Corporate Officer · Individual
Jacque, Zina
Corporate Director · Individual
Leonard, Monty
Corporate Director · Individual
Leonard, Monty
Corporate Officer · Individual
Moscato, Mary
Corporate Director · Individual
National Senior Communities, Inc
Operational/Managerial Control · Organization
Orlic, Peter
Operational/Managerial Control · Individual
Paulk, Pamela
Corporate Director · Individual
Pomeranz, William
Corporate Director · Individual
Randazzo, Renee
Operational/Managerial Control · Individual
Reel, Stephanie
Corporate Director · Individual
Roskiewicz, Michael
Corporate Director · Individual
Sawicki, Scott
Corporate Officer · Individual
Sharp, Russel
Corporate Director · Individual
Sharp, Russel
Corporate Officer · Individual
Stiner, Pamela
Operational/Managerial Control · Individual
Stiner, Pamela
Corporate Officer · Individual
Sweetser, Christian
Operational/Managerial Control · Individual
Tausner, Miriam
Corporate Director · Individual
Tyler, Daniel
Corporate Officer · Individual
Wallick, Daniel
Corporate Director · Individual
Nearby options
Other facilities in reach
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Health Center At Bloomingdale
Bloomingdale, NJ
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Phoenix Center for Rehabilitation and Pediatrics
Haskell, NJ
3-star overall rating with 3-star inspections with $7,900 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Complete Care At Wayne Hills Rehab & Resp Center
Wayne, NJ
2-star overall rating with 3-star inspections with $54,406 in total fines with 15 recent health deficiencies
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