Bridgewater, NJ

N J Eastern Star Home

5-star overall rating with 4-star inspections with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

111 Finderne Avenue, Bridgewater, NJ

(908) 722-4140

Compare this facility

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

82

Certified beds

Average residents

73

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1997-12-01

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

0.79

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

1.11

Licensed practical nurse staffing · state 0.94 · national 0.87

Aide hours / resident day

2.37

Nurse aide staffing · state 2.23 · national 2.35

Total nurse hours

4.27

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.90

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

3.88

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.46

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.81

CMS adjusted RN staffing hours

Adjusted total hours

4.39

CMS adjusted total nurse staffing hours

Case-mix index

1.33

Higher values indicate more complex resident acuity

RN turnover

13%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

31%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,029

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.26

Composite VBP score used to determine payment impact.

Payment multiplier

0.9883

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.47

Baseline 21.97% · Performance 21.49% · Measure score 0.47 · Achievement 0 · Improvement 0.47

Healthcare-associated infections

0

Baseline 4.91% · Performance 7.76% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

6.97

Baseline 38.03% · Performance 35.21% · Measure score 6.97 · Achievement 6.97 · Improvement 1.64

Adjusted total nurse staffing

6.27

Baseline 5.17 hours · Performance 4.86 hours · Measure score 6.27 · Achievement 6.27 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.65%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 178 · Observed rate 7.87% · Lower 95% interval 7.61%
Discharge to community	62.71%	50.57% 12.1 pts better	Better than the National Rate · Eligible stays 180 · Observed rate 65.56% · Lower 95% interval 55.62%
Medicare spending per beneficiary	1	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 122 · Denominator 122
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 122
Discharge self-care score	73.74%	53.69% 20 pts better	Numerator 73 · Denominator 99
Discharge mobility score	77.78%	50.94% 26.8 pts better	Numerator 77 · Denominator 99
Pressure ulcers or injuries, new or worsened	0.82%	2.29% 1.5 pts better	Numerator 1 · Denominator 122 · Adjusted rate 0.73%
Healthcare-associated infections requiring hospitalization	7.76%	7.12% 0.6 pts worse	No Different than the National Rate · Eligible stays 108 · Observed rate 6.48% · Lower 95% interval 4.63%
Staff COVID-19 vaccination coverage	1.6%	8.2% 6.6 pts worse	Numerator 2 · Denominator 125
Staff flu vaccination coverage	97.97%	42% 56 pts better	Numerator 145 · Denominator 148
Discharge function score	75.76%	56.45% 19.3 pts better	Numerator 75 · Denominator 99
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 74 · Denominator 74
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 34 · Denominator 34
Resident COVID-19 vaccinations up to date	31.67%	25.2% 6.5 pts better	Numerator 19 · Denominator 60

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.1	2.1 1 pts worse	1.9 1.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.2 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.1 0.1 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	93.0% 6.5 pts better	93.4% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5%
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	1.5%	2.4% 0.9 pts better	3.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	11.4% 11.4 pts better	11.4% 11.4 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 who lose too much weight	7.5%	4.6% 2.9 pts worse	5.4% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.3% · Q3 8.9% · Q4 6.5% · 4Q avg 7.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.2%	19.0% 3.8 pts better	19.6% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.5% · Q3 16.7% · Q4 14.9% · 4Q avg 15.2%
Percentage of long-stay residents who received an antipsychotic medication	6.0%	13.5% 7.5 pts better	16.7% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.0% · Q3 7.0% · Q4 7.1% · 4Q avg 6.0% · 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	15.1%	9.8% 5.3 pts worse	16.3% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 15.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.8%	9.7% 1.9 pts better	14.9% 7.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 8.7% · Q3 8.9% · Q4 11.6% · 4Q avg 7.8% · 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 4.2% · Q2 2.1% · Q3 2.0% · Q4 1.8% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	0.8% 0.3 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	7.4%	15.9% 8.5 pts better	19.8% 12.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.0% · Q3 13.7% · Q4 10.2% · 4Q avg 7.4%
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 3.0% · Q2 4.6% · Q3 3.3% · Q4 8.5% · 4Q avg 4.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	78.7% 21.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	6.5%	8.2% 1.7 pts better	12.0% 5.5 pts better	Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 5.5% · Expected 9.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	80.1% 19.9 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.0%	25.4% 3.4 pts better	23.9% 1.9 pts better	Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 18.3% · Expected 19.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-27 · Fire 2024-09-27

3 health deficiencies

Top issue: Infection Control (1 deficiency)

11 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2023-05-17 · Fire 2023-05-17

6 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2021-04-23 · Fire 2021-04-23

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-27

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2024-10-08

F · Potential for more than minimal harm 2024-09-27

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-09-27

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 2024-11-05

F · Potential for more than minimal harm 2024-09-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-09-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-25

F · Potential for more than minimal harm 2024-09-27

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-09-27

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-09-27

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-09-27

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-11-05

F · Potential for more than minimal harm 2024-09-27

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-11-25

F · Potential for more than minimal harm 2024-09-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-11-25

F · Potential for more than minimal harm 2023-05-17

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2023-06-15

F · Potential for more than minimal harm 2023-05-17

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2023-06-15

F · Potential for more than minimal harm 2023-05-17

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-06-15

F · Potential for more than minimal harm 2023-05-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-06-15

D · Potential for more than minimal harm 2021-04-23

K252 · Egress Deficiencies

Fire Safety

Provide at least two remote exits on each floor or fire section of the building.

Corrected 2021-06-04

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-09-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-05

D · Potential for more than minimal harm 2024-09-27

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 2024-11-05

D · Potential for more than minimal harm 2024-09-27

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-11-05

E · Potential for more than minimal harm 2023-05-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-06-15

D · Potential for more than minimal harm 2023-05-17

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-06-15

D · Potential for more than minimal harm 2023-05-17

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2023-06-15

D · Potential for more than minimal harm 2023-05-17

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 2023-06-15

D · Potential for more than minimal harm 2023-05-17

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 2023-06-15

D · Potential for more than minimal harm 2023-05-17

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 2023-06-15

Penalties and ownership