Cycle 1
Health 2025-03-14 · Fire 2025-03-14
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
West Caldwell, NJ
Lutheran Social Ministries Cranes Mill
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
459 Passaic Avenue, West Caldwell, NJ
(973) 276-3018
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
56
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-06-30
CMS approved date
Coverage
Medicare
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
1.06
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.99
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
1.10
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,122
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.63
Composite VBP score used to determine payment impact.
Payment multiplier
1.0060
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.27
Baseline 19.72% · Performance 19.92% · Measure score 3.27 · Achievement 3.27 · Improvement 0
Healthcare-associated infections
5.15
Baseline 5.60% · Performance 6.30% · Measure score 5.15 · Achievement 5.15 · Improvement 0
Total nurse turnover
10
Baseline 43.24% · Performance 16.67% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
2.24
Baseline 4.04 hours · Performance 3.71 hours · Measure score 2.24 · Achievement 2.24 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.14% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 219 · Observed rate 12.33% · Lower 95% interval 9.06% |
| Discharge to community | 66.06% |
50.57%
15.5 pts better
|
Better than the National Rate · Eligible stays 218 · Observed rate 60.55% · Lower 95% interval 60% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 110 · Denominator 110 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 110 |
| Discharge self-care score | 54.67% |
53.69%
1 pts better
|
Numerator 41 · Denominator 75 |
| Discharge mobility score | 61.33% |
50.94%
10.4 pts better
|
Numerator 46 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 4 · Denominator 110 · Adjusted rate 4.95% |
| Healthcare-associated infections requiring hospitalization | 6.3% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 4.55% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 3.85% |
8.2%
4.3 pts worse
|
Numerator 4 · Denominator 104 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 129 · Denominator 129 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 45 · Denominator 75 |
| Transfer of health information to provider | 96.3% |
95.95%
0.3 pts better
|
Numerator 26 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 19.05% |
25.2%
6.1 pts worse
|
Numerator 12 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.1
1.1 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
93.0%
0.1 pts worse
|
93.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.4% · Q3 85.0% · Q4 86.4% · 4Q avg 92.9% |
| 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 | 6.1% |
2.4%
3.7 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 7.1% · Q3 10.0% · Q4 0.0% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.6% |
11.4%
2.8 pts better
|
11.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · 4Q avg 8.6% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
4.6%
2.9 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
19.0%
9.5 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
13.5%
6.8 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% · 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 need for help with daily activities has increased | 16.7% |
9.7%
7 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · 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% · 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% · 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 | 10.6% |
15.9%
5.3 pts better
|
19.8%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 22.8% · Q4 4.4% · 4Q avg 10.6% |
| 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 10.5% · Q2 6.1% · Q4 0.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
78.7%
15.9 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 92.5% · Q3 95.4% · Q4 97.2% · 4Q avg 94.6% |
| 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 3.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
80.1%
7.1 pts better
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
25.4%
4.7 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 25.0% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-27 · Fire 2023-01-27
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-02-25 · Fire 2021-02-25
5 health deficiencies
Top issue: Quality of Life and Care (2 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
2025-03-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-03-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-03-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-14
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 2025-04-05
D · Potential for more than minimal harm
2025-03-14
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-01
E · Potential for more than minimal harm
2023-08-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-01-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-03
D · Potential for more than minimal harm
2023-01-27
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 2023-02-10
D · Potential for more than minimal harm
2023-01-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-10
D · 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 2023-02-10
D · Potential for more than minimal harm
2023-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-10
G · Actual harm
2021-02-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-03-31
E · Potential for more than minimal harm
2021-02-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-03-19
D · Potential for more than minimal harm
2021-02-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-03-19
D · Potential for more than minimal harm
2021-02-25
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 2021-03-19
Penalties and ownership
What sits behind the stars
Ownership
Bartholomew, Tracie
Corporate Director · Individual
Frankenfield, Colleen
Corporate Director · Individual
Frankenfield, Colleen
Corporate Officer · Individual
Gewecke, Stephen
Corporate Director · Individual
Haciski, Rafael
Corporate Director · Individual
Hildebrandt, Bardford
Corporate Director · Individual
Hildebrandt, Bardford
Corporate Officer · Individual
Lutheran Social Ministries Of New Jersey, Inc.
5% Or Greater Direct Ownership Interest · Organization
Noble, Edward
Corporate Director · Individual
Noble, Edward
Corporate Officer · Individual
Richman, Jeannine
Corporate Officer · Individual
Runne, Juhan
Corporate Director · Individual
Runne, Juhan
Corporate Officer · Individual
Shaker, David
Operational/Managerial Control · Individual
Singer, Ronald
Corporate Director · Individual
Steinbronn, Anthony
Corporate Director · Individual
Vandongen, Kenneth
Corporate Director · Individual
Vandongen, Kenneth
Corporate Officer · Individual
Williams, Christopher
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Complete Care At West Caldwell LLC
West Caldwell, NJ
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
St Catherine Of Siena
Caldwell, NJ
2-star overall rating with 3-star inspections with $16,171 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Green Hill
West Orange, NJ
3-star overall rating with 2-star inspections with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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