Cycle 1
Health 2024-09-26 · Fire 2024-09-26
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Bridgewater, NJ
Complete Care At Green Knoll
4-star overall rating with 3-star inspections with $23,430 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
875 Route 202-206 North, Bridgewater, NJ
(908) 526-8600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
176
Certified beds
Average residents
148
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1972-02-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 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
0.39
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.20
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,277
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.46
Baseline 24.19% · Performance 21.35% · Measure score 3.46 · Achievement 0 · Improvement 3.46
Healthcare-associated infections
3.78
Baseline 9.21% · Performance 7.40% · Measure score 3.78 · Achievement 1.44 · Improvement 3.78
Total nurse turnover
4.44
Baseline 60.53% · Performance 45.53% · Measure score 4.44 · Achievement 4.44 · Improvement 3.70
Adjusted total nurse staffing
1.68
Baseline 3.45 hours · Performance 3.56 hours · Measure score 1.68 · Achievement 1.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.12% |
10.72%
2.6 pts better
|
No Different than the National Rate · Eligible stays 193 · Observed rate 5.18% · Lower 95% interval 5.47% |
| Discharge to community | 47.68% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 39.26% · Lower 95% interval 39.95% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 145 · Denominator 145 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 145 |
| Discharge self-care score | 59.57% |
53.69%
5.9 pts better
|
Numerator 56 · Denominator 94 |
| Discharge mobility score | 65.96% |
50.94%
15 pts better
|
Numerator 62 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 2.07% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 145 · Adjusted rate 1.51% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 8.26% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 8.87% |
8.2%
0.7 pts better
|
Numerator 11 · Denominator 124 |
| Staff flu vaccination coverage | 99.58% |
42%
57.6 pts better
|
Numerator 236 · Denominator 237 |
| Discharge function score | 74.47% |
56.45%
18 pts better
|
Numerator 70 · Denominator 94 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 29.58% |
25.2%
4.4 pts better
|
Numerator 21 · Denominator 71 |
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 1.6 · Expected 1.9 · 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 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
93.0%
5.6 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.2% · Q3 100.0% · Q4 96.0% · 4Q avg 98.6% |
| 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 | 2.9% |
2.4%
0.5 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.1% · Q3 3.2% · Q4 2.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 42.8% |
11.4%
31.4 pts worse
|
11.4%
31.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.6% · Q2 41.9% · Q3 42.1% · Q4 46.7% · 4Q avg 42.8% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
4.6%
3.7 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.9% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
19.0%
0.6 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 17.9% · Q3 18.6% · Q4 16.8% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
13.5%
2.1 pts worse
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 15.9% · Q3 17.4% · Q4 15.2% · 4Q avg 15.6% · 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 | 2.9% |
9.8%
6.9 pts better
|
16.3%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.2% · Q3 3.3% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.1% |
9.7%
6.6 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.0% · Q3 3.9% · Q4 5.6% · 4Q avg 3.1% · 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 | 0.0% |
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 | 20.0% |
15.9%
4.1 pts worse
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 20.7% · Q3 13.7% · Q4 21.3% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.0%
0.2 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.0% · Q3 8.9% · Q4 7.2% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
78.7%
19.7 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 94.1% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.1% |
8.2%
4.1 pts better
|
12.0%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.1% · Observed 3.8% · Expected 10.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
80.1%
17.6 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
25.4%
5.5 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 20.2% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-29 · Fire 2022-09-29
4 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-02-13 · Fire 2020-02-13
11 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
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
2024-09-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-26
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 2024-10-04
F · Potential for more than minimal harm
2024-09-26
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-09-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-26
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-26
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-26
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-15
F · Potential for more than minimal harm
2022-09-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-07
F · Potential for more than minimal harm
2022-09-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-07
F · Potential for more than minimal harm
2022-09-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-17
E · Potential for more than minimal harm
2022-09-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-26
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-26
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 2024-10-11
E · Potential for more than minimal harm
2024-09-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-26
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 2024-10-11
D · Potential for more than minimal harm
2024-09-26
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 2024-10-11
D · Potential for more than minimal harm
2024-09-26
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 2024-10-11
J · Immediate jeopardy
2023-04-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-04-24
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 2023-06-12
D · Potential for more than minimal harm
2023-04-24
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 2023-06-12
D · Potential for more than minimal harm
2022-09-29
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-29
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-09-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-29
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 2022-11-07
F · Potential for more than minimal harm
2020-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-22
D · Potential for more than minimal harm
2020-02-13
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 2020-04-22
D · Potential for more than minimal harm
2020-02-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-04-22
D · Potential for more than minimal harm
2020-02-13
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 2020-04-22
D · Potential for more than minimal harm
2020-02-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-04-22
D · Potential for more than minimal harm
2020-02-13
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 2020-04-22
B · Minimal harm
2020-02-13
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 2020-04-22
B · Minimal harm
2020-02-13
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 2020-04-22
Penalties and ownership
What sits behind the stars
$23,430
2023-04-24
Fine
Fine · fine $23,430
Fine
Ownership
Stein, Shalom
5% Or Greater Indirect Ownership Interest · Individual
Eef Capital LLC
5% Or Greater Direct Ownership Interest · Organization
Schlaff, Benny
5% Or Greater Indirect Ownership Interest · Individual
Schlaff, Nachum
5% Or Greater Indirect Ownership Interest · Individual
Grewal, Baljinder
Operational/Managerial Control · Individual
Levovitz, Yitz
Operational/Managerial Control · Individual
Libatique, Rikka
Operational/Managerial Control · Individual
Mercado, Wanda
Operational/Managerial Control · Individual
Mur, Ahmad
Operational/Managerial Control · Individual
Stein, Shalom
Corporate Director · Individual
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#3
The Arbor at Laurel Circle
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