2 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Somerset, NJ
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
15 Dellwood Lane, Somerset, NJ
(732) 545-4200
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-01-15
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
RN hours / resident day
1.60
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
3.87
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
6.23
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.36
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
5.83
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
1.29
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.65
CMS adjusted RN staffing hours
Adjusted total hours
6.44
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
131
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
82.71
Composite VBP score used to determine payment impact.
Payment multiplier
1.0264
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.79
Baseline 22.41% · Performance 19.57% · Measure score 4.79 · Achievement 4.03 · Improvement 4.79
Healthcare-associated infections
9.34
Baseline 5.50% · Performance 5.04% · Measure score 9.34 · Achievement 9.34 · Improvement 8.52
Total nurse turnover
10
Baseline 14.56% · Performance 15.27% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
8.96
Baseline 5.18 hours · Performance 5.63 hours · Measure score 8.96 · Achievement 8.96 · Improvement 6.94
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 457 · Observed rate 8.1% · Lower 95% interval 7.6% |
| Discharge to community | 60.83% |
50.57%
10.3 pts better
|
Better than the National Rate · Eligible stays 451 · Observed rate 56.1% · Lower 95% interval 56.48% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 81.56% |
95.27%
13.7 pts worse
|
Numerator 283 · Denominator 347 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 347 |
| Discharge self-care score | 41.98% |
53.69%
11.7 pts worse
|
Numerator 102 · Denominator 243 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 108 · Denominator 243 |
| Pressure ulcers or injuries, new or worsened | 0.86% |
2.29%
1.4 pts better
|
Numerator 3 · Denominator 347 · Adjusted rate 0.72% |
| Healthcare-associated infections requiring hospitalization | 5.04% |
7.12%
2.1 pts better
|
Better than the National Rate · Eligible stays 303 · Observed rate 3.63% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 9.09% |
8.2%
0.9 pts better
|
Numerator 29 · Denominator 319 |
| Staff flu vaccination coverage | 97.49% |
42%
55.5 pts better
|
Numerator 311 · Denominator 319 |
| Discharge function score | 50.62% |
56.45%
5.8 pts worse
|
Numerator 123 · Denominator 243 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 77 · Denominator 77 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 217 · Denominator 217 |
| Resident COVID-19 vaccinations up to date | 5.11% |
25.2%
20.1 pts worse
|
Numerator 9 · Denominator 176 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.1
0.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · 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 | 98.9% |
97.2%
1.7 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
2.4%
0.5 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.4% · Q3 3.4% · Q4 2.4% · 4Q avg 2.9% · 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 | 2.8% |
4.6%
1.8 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.3% · Q3 2.6% · Q4 1.4% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.6% |
19.0%
12.4 pts better
|
19.6%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 4.2% · Q3 7.9% · Q4 6.8% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
13.5%
0.5 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 14.8% · Q3 14.5% · Q4 16.7% · 4Q avg 13.0% · 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 | 3.0% |
9.8%
6.8 pts better
|
16.3%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 0.0% · Q3 4.0% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
9.7%
4.1 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.3% · Q3 9.1% · Q4 3.2% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.7%
1.2 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.6% · Q3 1.8% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
0.8%
0.7 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 3.4% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.0% |
15.9%
9.9 pts better
|
19.8%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.2% · Q3 8.2% · Q4 2.6% · 4Q avg 6.0% |
| 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 2.8% · Q2 1.9% · Q3 2.5% · Q4 3.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
78.7%
19.8 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 98.4% · Q3 99.2% · Q4 98.6% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
8.2%
1 pts worse
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.5% · Q3 0.5% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
80.1%
17.6 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
25.4%
3 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 29.0% · Expected 24.3% · Used in QM five-star |
Survey summary
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-30
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-18
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-06-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-18
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-31
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-31
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-31
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-18
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2025-03-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-12-04
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-12-04
Health
Provide and implement an infection prevention and control program.
Corrected 2020-12-08
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
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