Cycle 1
Health 2025-08-12 · Fire 2025-08-12
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
12 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Watchung, NJ
Mcauley Hall Health Care Cente
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1633 Highway 22, Watchung, NJ
(908) 754-3663
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
66
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-10-04
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
44%
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
1,869
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.42
Composite VBP score used to determine payment impact.
Payment multiplier
1.0081
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.84
Performance 19.65% · Measure score 3.84 · Achievement 3.84 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0.59
Performance 7.66% · Measure score 0.59 · Achievement 0.59 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
10
Baseline 14.54% · Performance 15.52% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
6.93
Baseline 5.04 hours · Performance 5.05 hours · Measure score 6.93 · Achievement 6.93 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 8% · Lower 95% interval 6.83% |
| Discharge to community | 51.53% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 47.44% · Lower 95% interval 44.65% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 82.61% |
53.69%
28.9 pts better
|
Numerator 38 · Denominator 46 |
| Discharge mobility score | 67.39% |
50.94%
16.5 pts better
|
Numerator 31 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 2 · Denominator 48 · Adjusted rate 6.46% |
| Healthcare-associated infections requiring hospitalization | 7.66% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 8.16% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 92.79% |
42%
50.8 pts better
|
Numerator 103 · Denominator 111 |
| Discharge function score | 76.09% |
56.45%
19.6 pts better
|
Numerator 35 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.1
0.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 76.7% |
93.0%
16.3 pts worse
|
93.4%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 73.8% · Q3 65.2% · Q4 84.7% · 4Q avg 76.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
97.2%
0.1 pts worse
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
2.4%
2.7 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.6% · Q3 6.1% · Q4 8.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
11.4%
10.5 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
4.6%
3.1 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 6.8% · Q3 4.9% · Q4 7.3% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
19.0%
0.5 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 18.6% · Q3 19.4% · Q4 21.4% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
13.5%
6.6 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 9.6% · Q3 6.0% · Q4 5.8% · 4Q avg 6.9% · 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 | 16.5% |
9.8%
6.7 pts worse
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 16.4% · Q3 19.3% · Q4 22.2% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
9.7%
3.9 pts worse
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 14.8% · Q3 17.2% · Q4 17.0% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
0.7%
1.8 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 2.5% · Q4 3.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.1% |
15.9%
0.2 pts worse
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 18.9% · Q3 15.9% · Q4 20.4% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
6.0%
2.5 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.8% · Q3 0.0% · Q4 2.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.7% |
78.7%
33 pts worse
|
81.7%
36 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 27.0% · Q3 51.4% · Q4 75.0% · 4Q avg 45.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
8.2%
0.7 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 6.7% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.1% |
80.1%
16 pts worse
|
79.7%
15.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
25.4%
6.8 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 15.6% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-13 · Fire 2024-03-13
18 health deficiencies
Top issue: Administration (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-02-08 · Fire 2022-02-08
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-11-25
F · Potential for more than minimal harm
2025-08-12
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 2025-12-29
F · Potential for more than minimal harm
2025-08-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-11-25
F · Potential for more than minimal harm
2025-08-12
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-11-25
F · Potential for more than minimal harm
2025-08-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-11-26
F · Potential for more than minimal harm
2025-08-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-11-26
F · Potential for more than minimal harm
2025-08-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-12
F · Potential for more than minimal harm
2025-08-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-11-25
F · Potential for more than minimal harm
2025-08-12
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-11-25
F · Potential for more than minimal harm
2025-08-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-07
F · Potential for more than minimal harm
2025-08-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-08-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-11-25
E · Potential for more than minimal harm
2024-03-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-22
F · Potential for more than minimal harm
2022-02-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-03-09
E · Potential for more than minimal harm
2022-02-08
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-04-05
E · Potential for more than minimal harm
2022-02-08
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 2022-02-26
E · Potential for more than minimal harm
2022-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-25
E · Potential for more than minimal harm
2022-02-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-02-14
E · Potential for more than minimal harm
2022-02-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-22
D · Potential for more than minimal harm
2022-02-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-02-17
D · Potential for more than minimal harm
2022-02-08
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-02-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-02-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-12
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 2025-09-10
D · Potential for more than minimal harm
2025-08-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-10
F · Potential for more than minimal harm
2024-03-13
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-13
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 2024-04-22
E · Potential for more than minimal harm
2024-03-13
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 2024-05-10
E · Potential for more than minimal harm
2024-03-13
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-13
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-13
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 2024-04-22
D · Potential for more than minimal harm
2024-03-13
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-04-22
C · Minimal harm
2024-03-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-22
C · Minimal harm
2024-03-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-22
C · Minimal harm
2024-03-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-04-22
C · Minimal harm
2024-03-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-22
Penalties and ownership
What sits behind the stars
Ownership
Davis, Margaret
Corporate Director · Individual
Davis, Margaret
Corporate Officer · Individual
Davis, Margaret
W-2 Managing Employee · Individual
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