Cycle 1
Health 2024-11-07 · Fire 2024-11-07
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Jersey City, NJ
Peace Care St Joseph's
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
537 Pavonia Avenue, Jersey City, NJ
(201) 653-8300
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
139
Certified beds
Average residents
125
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
1.06
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.52
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.81
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,479
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9928
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.39
Baseline 22.18% · Performance 20.18% · Measure score 3.39 · Achievement 2.71 · Improvement 3.39
Healthcare-associated infections
2.39
Baseline 8.52% · Performance 7.51% · Measure score 2.39 · Achievement 1.10 · Improvement 2.39
Total nurse turnover
6.99
Baseline 95.00% · Performance 42.48% · Measure score 6.99 · Achievement 5.19 · Improvement 6.99
Adjusted total nurse staffing
3.17
Baseline 4.40 hours · Performance 3.98 hours · Measure score 3.17 · Achievement 3.17 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.13% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 261 · Observed rate 11.49% · Lower 95% interval 8.37% |
| Discharge to community | 57.89% |
50.57%
7.3 pts better
|
Better than the National Rate · Eligible stays 287 · Observed rate 51.57% · Lower 95% interval 51.06% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.04% |
95.27%
3.8 pts better
|
Numerator 207 · Denominator 209 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 209 |
| Discharge self-care score | 52.23% |
53.69%
1.5 pts worse
|
Numerator 82 · Denominator 157 |
| Discharge mobility score | 66.24% |
50.94%
15.3 pts better
|
Numerator 104 · Denominator 157 |
| Pressure ulcers or injuries, new or worsened | 1.91% |
2.29%
0.4 pts better
|
Numerator 4 · Denominator 209 · Adjusted rate 1.86% |
| Healthcare-associated infections requiring hospitalization | 7.51% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 183 · Observed rate 7.1% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 160 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 158 · Denominator 158 |
| Discharge function score | 61.15% |
56.45%
4.7 pts better
|
Numerator 96 · Denominator 157 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 54 · Denominator 54 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 128 · Denominator 128 |
| Resident COVID-19 vaccinations up to date | 68.18% |
25.2%
43 pts better
|
Numerator 75 · Denominator 110 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.1
0.1 pts worse
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.6 · 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 | 95.1% |
97.2%
2.1 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
2.4%
0.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 3.2% · Q4 1.1% · 4Q avg 2.2% · 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 | 3.0% |
4.6%
1.6 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.8% · Q3 3.4% · Q4 2.5% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.6% |
19.0%
2.4 pts better
|
19.6%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 18.5% · Q3 17.2% · Q4 16.9% · 4Q avg 16.6% |
| 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 · Q1 6.5% · Q2 5.1% · Q3 4.3% · Q4 4.3% · 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 ability to walk independently worsened | 26.4% |
9.8%
16.6 pts worse
|
16.3%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 45.5% · Q3 10.0% · Q4 14.6% · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
9.7%
15.3 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 37.0% · Q3 15.8% · Q4 12.8% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.7%
0.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
15.9%
3.1 pts worse
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 21.6% · Q3 19.2% · Q4 20.4% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.0%
2 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 7.7% · Q3 8.4% · Q4 6.2% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
78.7%
19.2 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 99.6% · Q3 99.6% · Q4 97.2% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
8.2%
2.4 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 5.2% · Expected 9.9% · 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 0.6% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
80.1%
10.5 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.9% |
25.4%
4.5 pts worse
|
23.9%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 28.5% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-22 · Fire 2023-08-22
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-05-28 · Fire 2021-05-28
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2024-11-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-04
F · Potential for more than minimal harm
2024-11-07
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 2024-11-26
F · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-11-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-13
F · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-04
F · Potential for more than minimal harm
2024-11-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-04
F · Potential for more than minimal harm
2024-11-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-02-04
F · Potential for more than minimal harm
2024-11-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-04
F · Potential for more than minimal harm
2024-11-07
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 2024-11-26
F · Potential for more than minimal harm
2024-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-04
F · Potential for more than minimal harm
2024-11-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-04
D · Potential for more than minimal harm
2024-11-07
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 2025-02-04
D · Potential for more than minimal harm
2024-11-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-24
F · Potential for more than minimal harm
2023-08-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-29
F · Potential for more than minimal harm
2023-08-22
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-08-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-07
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 2024-11-25
E · Potential for more than minimal harm
2024-11-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-11-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-07
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 2024-11-22
D · Potential for more than minimal harm
2024-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-09-20
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 2024-09-23
D · Potential for more than minimal harm
2024-09-20
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 2024-09-23
G · Actual harm
2023-08-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-29
E · Potential for more than minimal harm
2023-08-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-29
E · Potential for more than minimal harm
2023-08-22
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-22
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 2023-08-29
D · Potential for more than minimal harm
2023-08-22
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 2023-08-29
D · Potential for more than minimal harm
2023-08-22
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 2023-09-08
D · Potential for more than minimal harm
2023-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-29
Penalties and ownership
What sits behind the stars
$0
2024-11-07
Payment Denial
Payment Denial · denial start 2025-02-07 · 6 days
6 day denial
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,893
2024-02-12
Fine
Fine · fine $4,893
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$13,762
2023-12-11
Fine
Fine · fine $13,762
Fine
$4,587
2023-11-20
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-13
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-06
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-30
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-23
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-17
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-10
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-02
Fine
Fine · fine $4,587
Fine
$4,587
2023-09-25
Fine
Fine · fine $4,587
Fine
$4,587
2023-09-18
Fine
Fine · fine $4,587
Fine
$4,587
2023-09-11
Fine
Fine · fine $4,587
Fine
$4,545
2023-09-05
Fine
Fine · fine $4,545
Fine
$4,587
2023-08-28
Fine
Fine · fine $4,587
Fine
$57,944
2023-08-22
Fine
Fine · fine $57,944
Fine
$4,587
2023-08-21
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-14
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-07
Fine
Fine · fine $4,587
Fine
$13,409
2023-07-17
Fine
Fine · fine $13,409
Fine
$3,875
2023-03-20
Fine
Fine · fine $3,875
Fine
Ownership
Peace Care Inc
5% Or Greater Direct Ownership Interest · Organization
Peace Ministries Inc
5% Or Greater Indirect Ownership Interest · Organization
Buccianti, Silvana
Corporate Officer · Individual
Donohue, Teresa
Corporate Officer · Individual
Doren, Elizabeth
Corporate Officer · Individual
Hreben, Kyle
Operational/Managerial Control · Individual
Hreben, Kyle
Corporate Officer · Individual
Lynch, Donald
Operational/Managerial Control · Individual
Lynch, Donald
Corporate Officer · Individual
Peace Ministries Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Alaris Health At Hamilton Park
Jersey City, NJ
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Optima Care Harborview
Jersey City, NJ
3-star overall rating with 4-star inspections with $13,674 in total fines with 6 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Hoboken University Medical Center Tcu
Hoboken, NJ
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out