17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Dover, NJ
1-star overall rating with 1-star inspections with $139,113 in total fines with 11 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
65 North Sussex Street, Dover, NJ
(973) 361-5200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
155
Certified beds
Average residents
134
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelcare
Operator or chain grouping
Approved since
1996-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 2 overall / 2 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
RN hours / resident day
0.58
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.43
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
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
4,685
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.67
Baseline 20.89% · Performance 18.80% · Measure score 5.67 · Achievement 5.67 · Improvement 4.91
Healthcare-associated infections
4.55
Baseline 11.65% · Performance 8.29% · Measure score 4.55 · Achievement 0 · Improvement 4.55
Total nurse turnover
3.66
Baseline 49.09% · Performance 48.74% · Measure score 3.66 · Achievement 3.66 · Improvement 0
Adjusted total nurse staffing
1.70
Baseline 3.72 hours · Performance 3.56 hours · Measure score 1.70 · Achievement 1.70 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.63% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 258 · Observed rate 14.34% · Lower 95% interval 9.54% |
| Discharge to community | 48.94% |
50.57%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 287 · Observed rate 41.46% · Lower 95% interval 42.97% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.18% |
95.27%
1.9 pts better
|
Numerator 241 · Denominator 248 |
| Falls with major injury | 0.4% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 248 |
| Discharge self-care score | 63.86% |
53.69%
10.2 pts better
|
Numerator 106 · Denominator 166 |
| Discharge mobility score | 52.41% |
50.94%
1.5 pts better
|
Numerator 87 · Denominator 166 |
| Pressure ulcers or injuries, new or worsened | 1.21% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 248 · Adjusted rate 1.02% |
| Healthcare-associated infections requiring hospitalization | 8.29% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 9.38% · Lower 95% interval 5.79% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 164 |
| Staff flu vaccination coverage | 95.4% |
42%
53.4 pts better
|
Numerator 166 · Denominator 174 |
| Discharge function score | 53.61% |
56.45%
2.8 pts worse
|
Numerator 89 · Denominator 166 |
| Transfer of health information to provider | 97.26% |
95.95%
1.3 pts better
|
Numerator 71 · Denominator 73 |
| Transfer of health information to patient | 94.95% |
96.28%
1.3 pts worse
|
Numerator 94 · Denominator 99 |
| Resident COVID-19 vaccinations up to date | 6.98% |
25.2%
18.2 pts worse
|
Numerator 9 · Denominator 129 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · 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 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
93.0%
6.6 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 99.1% · 4Q avg 99.6% |
| 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 | 2.1% |
2.4%
0.3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.8% · Q3 0.9% · Q4 4.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
11.4%
5.6 pts better
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 7.1% · Q3 0.0% · Q4 0.0% · 4Q avg 5.8% |
| 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 10.4% · Q2 7.6% · Q3 2.7% · Q4 3.7% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
19.0%
11 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.9% · Q3 7.2% · Q4 8.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
13.5%
1.4 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 9.5% · Q3 14.0% · Q4 12.0% · 4Q avg 12.1% · 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 | 13.6% |
9.8%
3.8 pts worse
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 21.8% · Q3 10.5% · Q4 5.8% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
9.7%
0.4 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 16.4% · Q3 8.3% · Q4 0.9% · 4Q avg 9.3% · 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 | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.7% |
15.9%
1.2 pts better
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 19.7% · Q3 12.7% · Q4 9.3% · 4Q avg 14.7% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
6.0%
1.2 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.7% · Q3 4.5% · Q4 2.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
78.7%
15.4 pts better
|
81.7%
12.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 94.3% · Q3 96.2% · Q4 96.5% · 4Q avg 94.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
8.2%
1.8 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 6.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
80.1%
14.9 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
25.4%
4 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 29.8% · Expected 24.2% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
15 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-15
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-14
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2024-08-16
Fire Safety
Install proper backup exit lighting.
Corrected 2024-07-15
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-15
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 2024-07-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-15
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-06-14
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-15
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-15
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-07-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-15
Fire Safety
Use approved construction type or materials.
Corrected 2022-07-13
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 2022-06-27
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-06-27
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2022-07-27
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-07-01
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-27
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-27
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-06-27
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-06-27
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-06-27
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-06-27
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 2022-06-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-27
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2021-10-04
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-15
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-15
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 2024-07-15
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-15
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-15
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-07-15
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-15
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 2024-07-15
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 2024-07-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-15
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-07-15
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-30
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 2024-04-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-07-08
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 2022-07-08
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-07-01
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2022-07-08
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-08
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-07-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-07-08
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 2022-06-13
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-07-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-08
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2021-05-24
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-05-24
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-20
Penalties and ownership
Fine · fine $139,113
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
Dover, NJ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Morristown, NJ
2-star overall rating with 1-star inspections with $165,519 in total fines with 17 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
Denville, NJ
4-star overall rating with 3-star inspections with $4,580 in total fines with 6 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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