Cycle 1
Health 2025-01-31 · Fire 2025-01-31
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
14 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Denville, NJ
Oaks At Denville, The
4-star overall rating with 3-star inspections with $4,580 in total fines with 6 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
21 Pocono Road, Denville, NJ
(973) 586-5000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Springpoint Senior Living
Operator or chain grouping
Approved since
1994-02-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 3 health / 5 staffing / 4 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
1.64
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
5.35
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.58
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
4.82
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
1.18
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.37
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.63
CMS adjusted RN staffing hours
Adjusted total hours
5.30
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,682
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.90% · Performance 24.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 4.59% · Performance 8.15% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.79
Baseline 20.41% · Performance 44.12% · Measure score 4.79 · Achievement 4.79 · Improvement 0
Adjusted total nurse staffing
6.83
Baseline 4.61 hours · Performance 5.02 hours · Measure score 6.83 · Achievement 6.83 · Improvement 3
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 362 · Observed rate 9.67% · Lower 95% interval 8.36% |
| Discharge to community | 61.94% |
50.57%
11.4 pts better
|
Better than the National Rate · Eligible stays 415 · Observed rate 57.59% · Lower 95% interval 57.94% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.4% |
95.27%
4.1 pts better
|
Numerator 329 · Denominator 331 |
| Falls with major injury | 0.3% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 331 |
| Discharge self-care score | 46.73% |
53.69%
7 pts worse
|
Numerator 100 · Denominator 214 |
| Discharge mobility score | 50.93% |
50.94%
About the same
|
Numerator 109 · Denominator 214 |
| Pressure ulcers or injuries, new or worsened | 1.51% |
2.29%
0.8 pts better
|
Numerator 5 · Denominator 331 · Adjusted rate 1.63% |
| Healthcare-associated infections requiring hospitalization | 8.15% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 281 · Observed rate 7.83% · Lower 95% interval 5.52% |
| Staff COVID-19 vaccination coverage | 1.41% |
8.2%
6.8 pts worse
|
Numerator 2 · Denominator 142 |
| Staff flu vaccination coverage | 39.78% |
42%
2.2 pts worse
|
Numerator 72 · Denominator 181 |
| Discharge function score | 53.27% |
56.45%
3.2 pts worse
|
Numerator 114 · Denominator 214 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 84 · Denominator 84 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 204 · Denominator 204 |
| Resident COVID-19 vaccinations up to date | 49.13% |
25.2%
23.9 pts better
|
Numerator 85 · Denominator 173 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 6.6 |
2.1
4.5 pts worse
|
1.9
4.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 6.6 · Observed 4.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.1
0.9 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.0%
7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 6.0% |
2.4%
3.6 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.7% · Q3 6.1% · Q4 3.7% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
11.4%
6.4 pts better
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 7.1% · Q4 8.3% · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
4.6%
0.5 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 14.3% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
19.0%
1.6 pts better
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 22.7% · Q3 27.3% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.0% |
13.5%
8.5 pts better
|
16.7%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% · 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 need for help with daily activities has increased | 14.7% |
9.7%
5 pts worse
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.7%
0.2 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
0.8%
2 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 12.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
15.9%
11.3 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 32.6% · Q3 27.1% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
6.0%
2.1 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 2.3% · Q3 1.9% · Q4 2.6% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
78.7%
17.5 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 95.5% · Q3 97.0% · Q4 96.8% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
8.2%
1.8 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 5.8% · Expected 10.0% · 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 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.3% |
80.1%
2.2 pts better
|
79.7%
2.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
25.4%
7.3 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 28.5% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-31
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-31
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-02-06
F · Potential for more than minimal harm
2025-01-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-31
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 2025-02-28
F · Potential for more than minimal harm
2025-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-31
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-31
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-31
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-31
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-31
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-28
F · Potential for more than minimal harm
2023-11-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-31
F · Potential for more than minimal harm
2023-11-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-12
F · Potential for more than minimal harm
2023-11-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-11-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-11-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-01
D · Potential for more than minimal harm
2021-07-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-31
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 2025-02-28
E · Potential for more than minimal harm
2025-01-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-31
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 2025-02-28
D · Potential for more than minimal harm
2025-01-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-31
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 2025-02-28
B · Minimal harm
2025-01-31
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-28
F · Potential for more than minimal harm
2023-11-08
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 2023-12-01
E · Potential for more than minimal harm
2023-11-08
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 2023-12-01
E · Potential for more than minimal harm
2023-11-08
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 2023-12-01
E · Potential for more than minimal harm
2023-11-08
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-08
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-08
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 2023-12-01
D · Potential for more than minimal harm
2023-11-08
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-08
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 2023-12-01
D · Potential for more than minimal harm
2023-11-08
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-12-12
E · Potential for more than minimal harm
2021-07-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-09-03
E · Potential for more than minimal harm
2021-07-22
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 2021-09-03
E · Potential for more than minimal harm
2021-07-22
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-07-22
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 2021-09-03
D · Potential for more than minimal harm
2021-07-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-07-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-07-22
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2021-09-03
Penalties and ownership
What sits behind the stars
$4,580
2023-03-20
Fine
Fine · fine $4,580
Fine
Ownership
Argondizza, Anthony
Corporate Officer · Individual
Kopec, Marybeth
Operational/Managerial Control · Individual
Midgett, Garrett
Corporate Officer · Individual
Springpoint Senior Living Inc
Operational/Managerial Control · Organization
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