Cycle 1
Health 2024-06-18 · Fire 2024-06-18
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hoboken, NJ
Hoboken University Medical Center Tcu
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
308 Willow Avenue, Hoboken, NJ
(201) 418-1000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
15
Certified beds
Average residents
10
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-10-23
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
4.79
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
3.08
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
7.86
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
4.79
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
6.59
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
4.05
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.80
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
4.51
CMS adjusted RN staffing hours
Adjusted total hours
7.41
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
11%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
769
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0186
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.75
Baseline 20.75% · Performance 21.08% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Healthcare-associated infections
8.46
Baseline 5.05% · Performance 5.31% · Measure score 8.46 · Achievement 8.46 · Improvement 0
Total nurse turnover
10
Baseline 18.75% · Performance 18.18% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.91% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 210 · Observed rate 11.9% · Lower 95% interval 8.83% |
| Discharge to community | 76.32% |
50.57%
25.7 pts better
|
Better than the National Rate · Eligible stays 189 · Observed rate 76.72% · Lower 95% interval 70.09% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 131 · Denominator 131 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 131 |
| Discharge self-care score | 35.19% |
53.69%
18.5 pts worse
|
Numerator 38 · Denominator 108 |
| Discharge mobility score | 38.89% |
50.94%
12 pts worse
|
Numerator 42 · Denominator 108 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 131 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.31% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 1.09% · Lower 95% interval 2.88% |
| Staff COVID-19 vaccination coverage | 30% |
8.2%
21.8 pts better
|
Numerator 6 · Denominator 20 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 21 · Denominator 21 |
| Discharge function score | 41.67% |
56.45%
14.8 pts worse
|
Numerator 45 · Denominator 108 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 107 · Denominator 107 |
| Resident COVID-19 vaccinations up to date | 1.64% |
25.2%
23.6 pts worse
|
Numerator 1 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
78.7%
19.8 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 97.8% · Q4 98.3% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
8.2%
1.3 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 6.5% · Expected 10.4% · 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 4.1% · Q2 0.0% · Q3 1.8% · Q4 3.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.5% |
80.1%
11.4 pts better
|
79.7%
11.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
25.4%
6 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 25.0% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-05 · Fire 2023-01-05
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-09-29 · Fire 2020-09-29
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2024-06-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-06-18
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 2024-07-31
D · Potential for more than minimal harm
2024-06-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-31
F · Potential for more than minimal harm
2023-01-05
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 2023-01-25
D · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-25
Penalties and ownership
What sits behind the stars
Ownership
Carepoint Health System, Inc
5% Or Greater Direct Ownership Interest · Organization
Dalton, Christopher
Operational/Managerial Control · Individual
Dalton, Christopher
Corporate Director · Individual
Rodriguez, Frank
Operational/Managerial Control · Individual
Rodriguez, Frank
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Optima Care Harborview
Jersey City, NJ
3-star overall rating with 4-star inspections with $13,674 in total fines with 6 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Alaris Health At Hamilton Park
Jersey City, NJ
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Peace Care St Joseph's
Jersey City, NJ
3-star overall rating with 3-star inspections with $196,510 in total fines with 7 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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