Cycle 1
Health 2024-10-17 · Fire 2024-10-17
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Jersey City, NJ
Peace Care St Ann's
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
198 Old Bergen Road, Jersey City, NJ
(201) 433-0950
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-10-15
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
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,262
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9936
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.71
Baseline 21.48% · Performance 21.10% · Measure score 0.71 · Achievement 0.71 · Improvement 0.35
Healthcare-associated infections
4.34
Baseline 12.14% · Performance 8.68% · Measure score 4.34 · Achievement 0 · Improvement 4.34
Total nurse turnover
8.81
Performance 27.66% · Measure score 8.81 · Achievement 8.81 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.40
Baseline 3.66 hours · Performance 3.76 hours · Measure score 2.40 · Achievement 2.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.19% |
10.72%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 303 · Observed rate 14.52% · Lower 95% interval 10.62% |
| Discharge to community | 57% |
50.57%
6.4 pts better
|
Better than the National Rate · Eligible stays 297 · Observed rate 53.54% · Lower 95% interval 51.46% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 80.72% |
95.27%
14.5 pts worse
|
Numerator 180 · Denominator 223 |
| Falls with major injury | 0.45% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 223 |
| Discharge self-care score | 32.91% |
53.69%
20.8 pts worse
|
Numerator 52 · Denominator 158 |
| Discharge mobility score | 56.33% |
50.94%
5.4 pts better
|
Numerator 89 · Denominator 158 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 3 · Denominator 223 · Adjusted rate 1.3% |
| Healthcare-associated infections requiring hospitalization | 8.68% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 195 · Observed rate 9.23% · Lower 95% interval 5.99% |
| Staff COVID-19 vaccination coverage | 3.13% |
8.2%
5.1 pts worse
|
Numerator 7 · Denominator 224 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 304 · Denominator 304 |
| Discharge function score | 33.54% |
56.45%
22.9 pts worse
|
Numerator 53 · Denominator 158 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 63 · Denominator 63 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 132 · Denominator 132 |
| Resident COVID-19 vaccinations up to date | 10.66% |
25.2%
14.5 pts worse
|
Numerator 13 · Denominator 122 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.1
0.2 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · 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 | 97.6% |
97.2%
0.4 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.4%
1.1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.6% · Q3 1.4% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
11.4%
8.3 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.7% · Q4 8.3% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
4.6%
1.6 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.1% · Q3 4.3% · Q4 4.5% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.9% |
19.0%
6.1 pts better
|
19.6%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 18.6% · Q3 10.0% · Q4 11.8% · 4Q avg 12.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.4% |
13.5%
5.1 pts better
|
16.7%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 13.8% · Q3 9.3% · Q4 3.5% · 4Q avg 8.4% · 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 10.2% · Q2 31.4% · Q3 5.7% · Q4 17.0% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
9.7%
6.8 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 27.4% · Q3 13.3% · Q4 17.5% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
0.7%
1.6 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.4% · Q3 1.0% · Q4 3.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 14.8% |
15.9%
1.1 pts better
|
19.8%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 18.4% · Q3 6.2% · Q4 10.5% · 4Q avg 14.8% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
6.0%
1 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.8% · Q3 5.6% · Q4 4.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
78.7%
20.6 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 100.0% · Q3 98.6% · Q4 99.1% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
8.2%
0.4 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.7% · Expected 11.0% · 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 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
80.1%
13.1 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
25.4%
0.5 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 26.3% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-22 · Fire 2022-11-22
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2020-09-24 · Fire 2020-09-24
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-10-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-19
F · Potential for more than minimal harm
2024-10-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-06
F · Potential for more than minimal harm
2022-11-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-24
F · Potential for more than minimal harm
2022-11-22
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-11-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-20
F · Potential for more than minimal harm
2022-11-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-20
F · Potential for more than minimal harm
2022-11-22
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-12-20
F · Potential for more than minimal harm
2022-11-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-11-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-01-27
E · Potential for more than minimal harm
2022-11-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-01
D · Potential for more than minimal harm
2024-10-17
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 2024-11-30
D · Potential for more than minimal harm
2024-10-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-30
F · Potential for more than minimal harm
2022-11-22
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 2022-12-30
D · Potential for more than minimal harm
2022-11-22
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 2022-12-30
D · Potential for more than minimal harm
2022-11-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-22
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 2022-12-30
D · Potential for more than minimal harm
2022-11-22
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2022-12-30
E · Potential for more than minimal harm
2020-09-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-10-06
D · Potential for more than minimal harm
2020-09-24
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-10-06
Penalties and ownership
What sits behind the stars
Ownership
Peace Care Inc
5% Or Greater Direct Ownership Interest · Organization
Peace Ministries Inc
5% Or Greater Indirect Ownership Interest · Organization
Backiel, Christine
Corporate Officer · Individual
Reyes, Robert
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Acclaim Rehabilitation And Nursing Center
Jersey City, NJ
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Bayonne University Hospital
Bayonne, NJ
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Peace Care St Joseph's
Jersey City, NJ
3-star overall rating with 3-star inspections with $196,510 in total fines with 7 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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