Cycle 1
Health 2024-09-13 · Fire 2024-09-13
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Bridgewater, NJ
The Arbor at Laurel Circle
3-star overall rating with 2-star inspections with $25,857 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
100 Monroe Street, Bridgewater, NJ
(908) 595-6500
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
64
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Services
Operator or chain grouping
Approved since
1998-06-16
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 4 health / 4 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
1.07
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.44
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,333
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9980
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.71% · Performance 21.23% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.36
Baseline 6.38% · Performance 6.23% · Measure score 5.36 · Achievement 5.36 · Improvement 0.60
Total nurse turnover
6.88
Baseline 88.46% · Performance 41.51% · Measure score 6.88 · Achievement 5.42 · Improvement 6.88
Adjusted total nurse staffing
5.70
Baseline 2.91 hours · Performance 4.69 hours · Measure score 5.70 · Achievement 5.66 · Improvement 5.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.7% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 327 · Observed rate 10.7% · Lower 95% interval 8.04% |
| Discharge to community | 61.58% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 354 · Observed rate 53.39% · Lower 95% interval 55.01% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 83.95% |
95.27%
11.3 pts worse
|
Numerator 136 · Denominator 162 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 162 |
| Discharge self-care score | 73.88% |
53.69%
20.2 pts better
|
Numerator 99 · Denominator 134 |
| Discharge mobility score | 59.7% |
50.94%
8.8 pts better
|
Numerator 80 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 0.62% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 162 · Adjusted rate 0.55% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 178 · Observed rate 5.62% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 12.12% |
8.2%
3.9 pts better
|
Numerator 20 · Denominator 165 |
| Staff flu vaccination coverage | 22.86% |
42%
19.1 pts worse
|
Numerator 40 · Denominator 175 |
| Discharge function score | 73.88% |
56.45%
17.4 pts better
|
Numerator 99 · Denominator 134 |
| Transfer of health information to provider | 96.97% |
95.95%
1 pts better
|
Numerator 32 · Denominator 33 |
| Transfer of health information to patient | 98.17% |
96.28%
1.9 pts better
|
Numerator 107 · Denominator 109 |
| Resident COVID-19 vaccinations up to date | 26.39% |
25.2%
1.2 pts better
|
Numerator 19 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.1
0.5 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
93.0%
3.4 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.7% · Q3 96.7% · Q4 93.1% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.9% |
97.2%
3.3 pts worse
|
95.5%
1.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
2.4%
3 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 6.7% · Q3 3.3% · Q4 3.4% · 4Q avg 5.4% · 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 | 5.1% |
4.6%
0.5 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.2% |
19.0%
3.2 pts worse
|
19.6%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 22.2% · Q3 24.0% · Q4 24.0% · 4Q avg 22.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
13.5%
10.5 pts worse
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 30.0% · 4Q avg 24.0% · 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 | 26.2% |
9.8%
16.4 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
9.7%
3.9 pts worse
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 20.0% · Q3 19.0% · Q4 4.5% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
0.7%
3.7 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.9% · Q3 3.3% · Q4 6.2% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
0.8%
1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 3.3% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
15.9%
2.6 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 10.3% · Q3 20.2% · Q4 13.8% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.0%
6 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
78.7%
12.9 pts better
|
81.7%
9.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.0% · Q2 91.5% · Q3 92.0% · Q4 87.8% · 4Q avg 91.6% |
| 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 5.0% · Expected 9.7% · 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 | 89.5% |
80.1%
9.4 pts better
|
79.7%
9.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
25.4%
2 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 19.2% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-14 · Fire 2023-07-14
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-05-20 · Fire 2021-05-20
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
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 2024-10-11
F · Potential for more than minimal harm
2024-09-13
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-09-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-09-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-09-13
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-10-11
F · Potential for more than minimal harm
2023-07-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-13
D · Potential for more than minimal harm
2021-05-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-05-30
Inspection history
Recent health citations
G · Actual harm
2024-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-13
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 2024-10-07
E · Potential for more than minimal harm
2024-09-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-13
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 2024-10-18
E · Potential for more than minimal harm
2024-09-13
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-09-13
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 2024-10-07
D · Potential for more than minimal harm
2024-09-13
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 2024-10-11
D · Potential for more than minimal harm
2024-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-13
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 2024-10-18
D · Potential for more than minimal harm
2024-09-13
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 2024-10-18
D · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
F · Potential for more than minimal harm
2023-07-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-07-14
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-14
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 2023-08-31
D · Potential for more than minimal harm
2023-07-14
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 2023-08-30
D · Potential for more than minimal harm
2023-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-14
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 2023-08-31
D · Potential for more than minimal harm
2023-04-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-04-10
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-05-24
E · Potential for more than minimal harm
2021-05-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-06-18
E · Potential for more than minimal harm
2021-05-20
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 2021-06-18
D · Potential for more than minimal harm
2021-05-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-06-18
B · Minimal harm
2021-05-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-05-30
Penalties and ownership
What sits behind the stars
$25,857
2024-09-13
Fine
Fine · fine $25,857
Fine
Ownership
Lcs Nj I LLC
5% Or Greater Direct Ownership Interest · Organization
Alexopoulos, Brian
Operational/Managerial Control · Individual
Anand, Alok
Operational/Managerial Control · Individual
Bird, John
Corporate Officer · Individual
Lahey, Daniel
Corporate Officer · Individual
Lcs Holding Company LLC
5% Or Greater Indirect Ownership Interest · Organization
Lcs Management Holding Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Life Care Companies LLC
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services Communities, LLC
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services LLC
Operational/Managerial Control · Organization
Mccarthy Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Mcmenamin, Roberta
Operational/Managerial Control · Individual
Mcmenamin, Roberta
Corporate Officer · Individual
Mpm Senior Living Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Nahass, Ronald
Operational/Managerial Control · Individual
Oak Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Oak Investment Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Rci Legacy Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Redwood Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Shaw, Gelynna
Corporate Officer · Individual
Uhlemann, Bridgette
Corporate Officer · Individual
Victor, Jason
Corporate Officer · Individual
Nearby options
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#3
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