Cycle 1
Health 2024-12-31 · Fire 2024-12-31
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Pleasantville, NJ
Our Ladys Center For Rehabilitation & Healthcare
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1100 Clematis Ave, Pleasantville, NJ
(609) 646-2450
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
214
Certified beds
Average residents
171
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Center Management Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 2 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
0.63
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,795
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.63
Baseline 19.80% · Performance 20.67% · Measure score 1.63 · Achievement 1.63 · Improvement 0
Healthcare-associated infections
0
Baseline 7.76% · Performance 8.10% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.50
Baseline 43.07% · Performance 37.10% · Measure score 6.50 · Achievement 6.50 · Improvement 2.78
Adjusted total nurse staffing
0.87
Baseline 4.05 hours · Performance 3.33 hours · Measure score 0.87 · Achievement 0.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.6% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 159 · Observed rate 12.58% · Lower 95% interval 8.79% |
| Discharge to community | 57.04% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 49.68% · Lower 95% interval 48.87% |
| Medicare spending per beneficiary | 1.45 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 201 · Denominator 201 |
| Falls with major injury | 1% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 201 |
| Discharge self-care score | 39.13% |
53.69%
14.6 pts worse
|
Numerator 45 · Denominator 115 |
| Discharge mobility score | 48.7% |
50.94%
2.2 pts worse
|
Numerator 56 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 201 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.1% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 9.92% · Lower 95% interval 5.1% |
| Staff COVID-19 vaccination coverage | 95.15% |
8.2%
87 pts better
|
Numerator 196 · Denominator 206 |
| Staff flu vaccination coverage | 49.36% |
42%
7.4 pts better
|
Numerator 115 · Denominator 233 |
| Discharge function score | 54.78% |
56.45%
1.7 pts worse
|
Numerator 63 · Denominator 115 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 71 · Denominator 71 |
| Transfer of health information to patient | 95.89% |
96.28%
0.4 pts worse
|
Numerator 70 · Denominator 73 |
| Resident COVID-19 vaccinations up to date | 0.93% |
25.2%
24.3 pts worse
|
Numerator 1 · Denominator 107 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.1
0.7 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.7% |
93.0%
18.3 pts worse
|
93.4%
18.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 80.0% · Q3 70.3% · Q4 65.4% · 4Q avg 74.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.2% |
97.2%
9 pts worse
|
95.5%
7.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.4%
0.8 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.4% · Q3 1.4% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 68.4% |
11.4%
57 pts worse
|
11.4%
57 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 56.9% · Q2 67.7% · Q3 73.7% · Q4 76.2% · 4Q avg 68.4% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
4.6%
4.7 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 11.2% · Q3 13.0% · Q4 6.9% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.2% |
19.0%
4.2 pts worse
|
19.6%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 23.8% · Q3 21.3% · Q4 25.0% · 4Q avg 23.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
13.5%
3.8 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 10.8% · Q3 5.7% · Q4 5.3% · 4Q avg 9.7% · 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 ability to walk independently worsened | 3.9% |
9.8%
5.9 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 10.7% · Q3 0.0% · Q4 1.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
9.7%
5.4 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 7.4% · Q3 3.8% · Q4 3.3% · 4Q avg 4.3% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.7% |
15.9%
6.2 pts better
|
19.8%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 12.9% · Q3 12.2% · Q4 4.3% · 4Q avg 9.7% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
6.0%
3.3 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.3% · Q3 2.7% · Q4 1.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 23.4% |
78.7%
55.3 pts worse
|
81.7%
58.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 25.3% · Q3 23.3% · Q4 20.1% · 4Q avg 23.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.8% |
8.2%
6.6 pts worse
|
12.0%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 14.3% · Expected 10.8% · 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 | 32.3% |
80.1%
47.8 pts worse
|
79.7%
47.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
25.4%
5.4 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 21.8% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-22 · Fire 2023-11-22
9 health deficiencies
Top issue: Environmental (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-02-09 · Fire 2022-02-09
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-11
F · Potential for more than minimal harm
2024-12-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-11
F · Potential for more than minimal harm
2024-12-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-11
E · Potential for more than minimal harm
2024-12-31
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-02-11
E · Potential for more than minimal harm
2024-12-31
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 2025-02-11
E · Potential for more than minimal harm
2024-12-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-11
F · Potential for more than minimal harm
2023-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-11-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-11-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-11-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-11-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-22
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-01-12
E · Potential for more than minimal harm
2022-02-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-04-08
E · Potential for more than minimal harm
2022-02-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-02-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-02-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-02-09
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-02-09
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-04-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-31
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 2025-02-11
E · Potential for more than minimal harm
2024-12-31
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 2025-02-11
D · Potential for more than minimal harm
2024-12-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-12-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-12-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-12-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-12-31
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-12-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-11
F · Potential for more than minimal harm
2023-11-22
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 2024-01-15
E · Potential for more than minimal harm
2023-11-22
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 2024-01-15
E · Potential for more than minimal harm
2023-11-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-22
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-22
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-15
E · Potential for more than minimal harm
2022-02-09
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 2022-02-25
E · Potential for more than minimal harm
2022-02-09
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 2022-02-25
D · Potential for more than minimal harm
2022-02-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-02-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-02-09
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 2022-02-25
D · Potential for more than minimal harm
2022-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-02-09
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-02-25
Penalties and ownership
What sits behind the stars
Ownership
Pleasantville Ventures LLC
5% Or Greater Direct Ownership Interest · Organization
Gros, Charles-Edouard
5% Or Greater Indirect Ownership Interest · Individual
Boehm, Caroline
5% Or Greater Indirect Ownership Interest · Individual
Babroff, Sherri
Operational/Managerial Control · Individual
Delaney, Diane
Operational/Managerial Control · Individual
Flancia, Maria
Operational/Managerial Control · Individual
Greystone Funding Company LLC
5% Or Greater Mortgage Interest · Organization
Klein, Baruch
Operational/Managerial Control · Individual
Levi, Shlomo
Operational/Managerial Control · Individual
Thadhani, Ramchand
Operational/Managerial Control · Individual
Vinitsky, Avrohom
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Meadowview Nursing And Rehabilitation Center
Northfield, NJ
2-star overall rating with 2-star inspections with $49,754 in total fines with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Excel Care At Egg Harbor
Egg Harbor Township, NJ
3-star overall rating with 2-star inspections with $18,119 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Complete Care At Linwood, LLC
Linwood, NJ
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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