Cycle 1
Health 2025-09-02 · Fire 2025-09-02
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fairlawn, NJ
Maple Glen Center
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
12-15 Saddle River Road, Fairlawn, NJ
(201) 797-9522
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
159
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1993-11-01
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
0.79
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.11
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.88
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
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,848
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9914
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.17
Baseline 19.58% · Performance 20.89% · Measure score 1.17 · Achievement 1.17 · Improvement 0
Healthcare-associated infections
5.02
Baseline 5.81% · Performance 6.34% · Measure score 5.02 · Achievement 5.02 · Improvement 0
Total nurse turnover
8.55
Baseline 40.66% · Performance 28.72% · Measure score 8.55 · Achievement 8.55 · Improvement 7.05
Adjusted total nurse staffing
0.61
Baseline 3.38 hours · Performance 3.25 hours · Measure score 0.61 · Achievement 0.61 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.22% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 11.76% · Lower 95% interval 7.85% |
| Discharge to community | 50.01% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 41.91% · Lower 95% interval 41.98% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.48% |
95.27%
2.8 pts worse
|
Numerator 123 · Denominator 133 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 133 |
| Discharge self-care score | 60.27% |
53.69%
6.6 pts better
|
Numerator 44 · Denominator 73 |
| Discharge mobility score | 60.27% |
50.94%
9.3 pts better
|
Numerator 44 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 1.5% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 133 · Adjusted rate 1.18% |
| Healthcare-associated infections requiring hospitalization | 6.34% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 5.43% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 5.3% |
8.2%
2.9 pts worse
|
Numerator 7 · Denominator 132 |
| Staff flu vaccination coverage | 56.16% |
42%
14.2 pts better
|
Numerator 196 · Denominator 349 |
| Discharge function score | 69.86% |
56.45%
13.4 pts better
|
Numerator 51 · Denominator 73 |
| Transfer of health information to provider | 91.84% |
95.95%
4.1 pts worse
|
Numerator 45 · Denominator 49 |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 36 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 18.18% |
25.2%
7 pts worse
|
Numerator 12 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · 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 | 98.9% |
93.0%
5.9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 98.2% · Q4 98.2% · 4Q avg 98.9% |
| 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 | 2.4% |
2.4%
About the same
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.4% · Q3 1.8% · Q4 1.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.5% |
11.4%
9.1 pts worse
|
11.4%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 28.2% · Q3 14.2% · Q4 10.4% · 4Q avg 20.5% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
4.6%
2.8 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 10.4% · Q3 6.6% · Q4 5.9% · 4Q avg 7.4% |
| 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 6.6% · Q2 7.3% · Q3 11.2% · Q4 6.7% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.9% |
13.5%
11.6 pts better
|
16.7%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.9% · Q3 1.3% · Q4 0.0% · 4Q avg 1.9% · 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 | 21.2% |
9.8%
11.4 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 28.5% · Q3 8.3% · Q4 9.4% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.9% |
9.7%
9.2 pts worse
|
14.9%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 22.3% · Q3 12.8% · Q4 10.9% · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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 | 19.8% |
15.9%
3.9 pts worse
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 26.7% · Q3 13.8% · Q4 11.2% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
6.0%
2.3 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.2% · Q3 4.2% · Q4 3.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
78.7%
15.7 pts better
|
81.7%
12.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 94.1% · Q3 95.9% · Q4 93.1% · 4Q avg 94.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
8.2%
1.9 pts worse
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 9.5% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.7% |
80.1%
12.6 pts better
|
79.7%
13 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
25.4%
0.6 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 26.2% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-03 · Fire 2024-04-03
3 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-11-09 · Fire 2021-11-09
4 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-02
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-09-16
F · Potential for more than minimal harm
2025-09-02
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-09-02
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 2025-09-22
F · Potential for more than minimal harm
2025-09-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-09-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-09-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-09-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-09-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-09-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-09-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-09-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-29
F · Potential for more than minimal harm
2024-04-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-03
K222 · Egress Deficiencies
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 2024-05-03
E · Potential for more than minimal harm
2024-04-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-03
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-15
E · Potential for more than minimal harm
2021-11-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-12-02
D · Potential for more than minimal harm
2021-11-09
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 2021-11-22
D · Potential for more than minimal harm
2021-11-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-01-19
D · Potential for more than minimal harm
2021-11-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-09
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-01-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-02
F838 · Administration Deficiencies
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 2025-09-29
F · Potential for more than minimal harm
2025-09-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-09-02
F584 · Resident Rights Deficiencies
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 2025-09-29
D · Potential for more than minimal harm
2025-09-02
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-02
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-02
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 2025-09-17
C · Minimal harm
2025-09-02
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-09-22
C · Minimal harm
2025-09-02
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-03-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-11
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-04-30
D · Potential for more than minimal harm
2024-04-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-31
C · Minimal harm
2024-04-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-31
B · Minimal harm
2024-04-03
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-05-31
E · Potential for more than minimal harm
2021-11-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-03
D · Potential for more than minimal harm
2021-11-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-09
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 2021-12-17
D · Potential for more than minimal harm
2021-11-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-12-17
Penalties and ownership
What sits behind the stars
Ownership
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Dublin, Trevor
W-2 Managing Employee · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Direct 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 Nj Holdings LLC
5% Or Greater Direct 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
Mendelson, Avi
Corporate Officer · Individual
Rutkowska, Ewa
W-2 Managing Employee · 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 Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Careone At Ridgewood Avenue
Paramus, NJ
2-star overall rating with 2-star inspections with $16,149 in total fines with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Family of Caring Healthcare at Ridgewood
Ridgewood, NJ
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Bergen New Bridge Medical Center
Paramus, NJ
3-star overall rating with 3-star inspections with $47,430 in total fines with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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