Cycle 1
Health 2025-03-07 · Fire 2025-03-07
16 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Hillsborough, NJ
Foothill Acres Rehabilitation & Nursing Center
3-star overall rating with 2-star inspections with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
39 East Mountain Road, Hillsborough, NJ
(908) 369-8711
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
163
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-10-15
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
Hours and turnover
RN hours / resident day
0.78
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
2.57
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.32
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,090
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9994
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.23
Baseline 22.98% · Performance 21.96% · Measure score 1.23 · Achievement 0 · Improvement 1.23
Healthcare-associated infections
5.10
Baseline 8.48% · Performance 6.53% · Measure score 5.10 · Achievement 4.36 · Improvement 5.10
Total nurse turnover
8.22
Baseline 31.53% · Performance 30.08% · Measure score 8.22 · Achievement 8.22 · Improvement 1.68
Adjusted total nurse staffing
3.89
Baseline 4.17 hours · Performance 4.18 hours · Measure score 3.89 · Achievement 3.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 334 · Observed rate 9.28% · Lower 95% interval 7.92% |
| Discharge to community | 61.12% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 308 · Observed rate 53.9% · Lower 95% interval 55.11% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 212 · Denominator 212 |
| Falls with major injury | 0.94% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 212 |
| Discharge self-care score | 66.01% |
53.69%
12.3 pts better
|
Numerator 101 · Denominator 153 |
| Discharge mobility score | 54.9% |
50.94%
4 pts better
|
Numerator 84 · Denominator 153 |
| Pressure ulcers or injuries, new or worsened | 1.42% |
2.29%
0.9 pts better
|
Numerator 3 · Denominator 212 · Adjusted rate 1.24% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 216 · Observed rate 6.02% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 4.85% |
8.2%
3.3 pts worse
|
Numerator 8 · Denominator 165 |
| Staff flu vaccination coverage | 57.78% |
42%
15.8 pts better
|
Numerator 104 · Denominator 180 |
| Discharge function score | 60.78% |
56.45%
4.3 pts better
|
Numerator 93 · Denominator 153 |
| Transfer of health information to provider | 99.02% |
95.95%
3.1 pts better
|
Numerator 101 · Denominator 102 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 50 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 21.82% |
25.2%
3.4 pts worse
|
Numerator 24 · Denominator 110 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.5 · 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 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.0%
7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 0.9% |
2.4%
1.5 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
11.4%
4.2 pts better
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.6% · Q3 3.0% · Q4 5.1% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
4.6%
1.6 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.6% · Q3 3.9% · Q4 3.2% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
19.0%
2.5 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 21.5% · Q3 19.7% · Q4 23.4% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.7% |
13.5%
19.2 pts worse
|
16.7%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 30.3% · Q3 29.9% · Q4 38.9% · 4Q avg 32.7% · 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 | 7.8% |
9.8%
2 pts better
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 11.5% · Q3 5.6% · Q4 4.9% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
9.7%
0.5 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 11.4% · Q3 8.2% · Q4 8.2% · 4Q avg 9.2% · 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 | 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 | 6.7% |
15.9%
9.2 pts better
|
19.8%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 11.2% · Q3 4.9% · Q4 1.6% · 4Q avg 6.7% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.0%
0.6 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.9% · Q3 7.1% · Q4 6.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
78.7%
21.1 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
8.2%
0.9 pts worse
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.4% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.9% · Q3 0.8% · Q4 0.8% · 4Q avg 1.3% · 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 | 25.0% |
25.4%
0.4 pts better
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 23.8% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-23 · Fire 2023-02-23
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-07-15 · Fire 2021-07-15
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-03-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-16
F · Potential for more than minimal harm
2023-02-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-17
D · Potential for more than minimal harm
2021-07-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-08-05
D · Potential for more than minimal harm
2021-07-15
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 2021-07-23
D · Potential for more than minimal harm
2021-07-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-03-07
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 2025-05-15
E · Potential for more than minimal harm
2025-03-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-03-07
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 2025-05-15
E · Potential for more than minimal harm
2025-03-07
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 2025-05-15
E · Potential for more than minimal harm
2025-03-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-07
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 2025-05-15
D · Potential for more than minimal harm
2025-03-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-07
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 2025-05-15
D · Potential for more than minimal harm
2025-03-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-03-07
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 2025-05-15
D · Potential for more than minimal harm
2025-03-07
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 2025-05-15
D · Potential for more than minimal harm
2025-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
D · Potential for more than minimal harm
2023-02-23
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 2023-03-31
D · Potential for more than minimal harm
2023-02-23
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 2023-03-31
D · Potential for more than minimal harm
2023-02-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
Ownership
Schon, Mordechai
5% Or Greater Direct Ownership Interest · Individual
Schon, Mordechai
Corporate Director · Individual
Steinfeld, Yehuda
Corporate Officer · Individual
Steinfeld, Yehuda
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Bridgeway Care And Rehab Center At Hillsborough
Hillsborough, NJ
2-star overall rating with 2-star inspections with $17,192 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Bridgeway Care And Rehab Center At Bridgewater
Bridgewater, NJ
2-star overall rating with 2-star inspections with abuse icon flag with $7,901 in total fines with 3 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Waterfront Rehabilitation And Healthcare Center
Raritan, NJ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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