Cycle 1
Health 2025-02-11 · Fire 2025-02-11
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Mendham, NJ
Holly Manor Center
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
84 Cold Hill Road, Mendham, NJ
(973) 543-2500
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1973-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.65
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
44%
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
1,184
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0143
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.27
Baseline 14.99% · Performance 18.99% · Measure score 5.27 · Achievement 5.27 · Improvement 0
Healthcare-associated infections
6.94
Baseline 6.32% · Performance 5.76% · Measure score 6.94 · Achievement 6.94 · Improvement 3.72
Total nurse turnover
10
Baseline 44.29% · Performance 22.22% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.44
Baseline 3.57 hours · Performance 3.49 hours · Measure score 1.44 · Achievement 1.44 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.14% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 173 · Observed rate 6.94% · Lower 95% interval 6.72% |
| Discharge to community | 56.25% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 177 · Observed rate 48.02% · Lower 95% interval 47.94% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.32% |
95.27%
4 pts better
|
Numerator 146 · Denominator 147 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 3 · Denominator 147 |
| Discharge self-care score | 70.19% |
53.69%
16.5 pts better
|
Numerator 73 · Denominator 104 |
| Discharge mobility score | 50.96% |
50.94%
About the same
|
Numerator 53 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 2.72% |
2.29%
0.4 pts worse
|
Numerator 4 · Denominator 147 · Adjusted rate 2.58% |
| Healthcare-associated infections requiring hospitalization | 5.76% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 3.85% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 4.9% |
8.2%
3.3 pts worse
|
Numerator 5 · Denominator 102 |
| Staff flu vaccination coverage | 97.84% |
42%
55.8 pts better
|
Numerator 136 · Denominator 139 |
| Discharge function score | 67.31% |
56.45%
10.9 pts better
|
Numerator 70 · Denominator 104 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 60 · Denominator 60 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 31.82% |
25.2%
6.6 pts better
|
Numerator 28 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| 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 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.1
0.6 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
93.0%
6.3 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.3% · 4Q avg 99.3% |
| 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 | 4.6% |
2.4%
2.2 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.0% · Q3 1.4% · Q4 4.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.9% |
11.4%
3.5 pts better
|
11.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 8.6% · Q3 14.9% · Q4 7.1% · 4Q avg 7.9% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
4.6%
0.6 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.3% · Q3 3.2% · Q4 4.8% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.1% |
19.0%
13.9 pts better
|
19.6%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.5% · Q3 3.2% · Q4 4.6% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
13.5%
11.8 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 29.8% · Q3 23.3% · Q4 26.7% · 4Q avg 25.3% · 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 | 11.6% |
9.8%
1.8 pts worse
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 13.4% · Q3 9.5% · Q4 18.9% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
9.7%
4.5 pts worse
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 10.0% · Q3 11.7% · Q4 30.0% · 4Q avg 14.2% · 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 | 1.4% |
0.8%
0.6 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.5% · Q3 1.5% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
15.9%
6.9 pts worse
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 21.8% · Q3 24.4% · Q4 25.9% · 4Q avg 22.8% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
6.0%
5.4 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 10.2% · Q3 13.9% · Q4 13.2% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
78.7%
16.6 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.6% · Q2 97.4% · Q3 97.1% · Q4 94.8% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.5% |
8.2%
3.7 pts better
|
12.0%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 4.4% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.2%
1.1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 1.0% · Q3 0.0% · Q4 3.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
80.1%
18.1 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
25.4%
5.7 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 20.2% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-27 · Fire 2023-01-27
9 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-02-05 · Fire 2021-02-05
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
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
2025-02-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-13
F · Potential for more than minimal harm
2025-02-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-11
F · Potential for more than minimal harm
2025-02-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-11
F · Potential for more than minimal harm
2025-02-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-11
F · Potential for more than minimal harm
2025-02-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-07
F · Potential for more than minimal harm
2025-02-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-02-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-02-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-07
F · Potential for more than minimal harm
2023-01-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-03
F · Potential for more than minimal harm
2023-01-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-01-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-01-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-11
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 2025-03-15
F · Potential for more than minimal harm
2025-02-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-02-11
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 2025-03-15
E · Potential for more than minimal harm
2025-02-11
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-03-15
E · Potential for more than minimal harm
2025-02-11
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 2025-03-15
E · Potential for more than minimal harm
2025-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-15
D · Potential for more than minimal harm
2025-02-11
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 2025-03-15
D · Potential for more than minimal harm
2025-02-11
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 2025-03-15
D · Potential for more than minimal harm
2025-02-11
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 2025-03-15
D · Potential for more than minimal harm
2023-06-02
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-02
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-06-02
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 2023-06-23
G · Actual harm
2023-01-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-03
F · Potential for more than minimal harm
2023-01-27
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 2023-03-13
E · Potential for more than minimal harm
2023-01-27
F725 · Nursing and Physician Services Deficiencies
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 2023-03-03
E · Potential for more than minimal harm
2023-01-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-27
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 2023-03-03
D · Potential for more than minimal harm
2021-02-05
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 2021-03-22
D · Potential for more than minimal harm
2021-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-03-23
Penalties and ownership
What sits behind the stars
Ownership
Genesis Nj Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Operations LLC
5% Or Greater Indirect Ownership Interest · Organization
Ghc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Martirano, Gloriana
Operational/Managerial Control · Individual
Mendelson, Avi
Corporate Officer · Individual
Shroff, Shilpa
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Morris View Healthcare Center
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
#2
Merry Heart Nursing Home
Succasunna, NJ
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
CareOne At Madison Avenue
Morristown, NJ
3-star overall rating with 2-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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