Cycle 1
Health 2024-05-22 · Fire 2024-05-22
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Newton, NJ
United Methodist Communities At Bristol Glen
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
200 Bristol Glen Drive, Newton, NJ
(973) 300-5788
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-02-19
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
1.05
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
3.97
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,037
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9908
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.95% · Performance 22.61% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.11
Baseline 6.09% · Performance 5.71% · Measure score 7.11 · Achievement 7.11 · Improvement 2.99
Total nurse turnover
3.97
Baseline 91.53% · Performance 61.73% · Measure score 3.97 · Achievement 0 · Improvement 3.97
Adjusted total nurse staffing
3.98
Baseline 5.33 hours · Performance 4.21 hours · Measure score 3.98 · Achievement 3.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.52% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 353 · Observed rate 11.9% · Lower 95% interval 8.77% |
| Discharge to community | 68.88% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 340 · Observed rate 62.94% · Lower 95% interval 61.82% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 229 · Denominator 231 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 231 |
| Discharge self-care score | 43.52% |
53.69%
10.2 pts worse
|
Numerator 94 · Denominator 216 |
| Discharge mobility score | 29.63% |
50.94%
21.3 pts worse
|
Numerator 64 · Denominator 216 |
| Pressure ulcers or injuries, new or worsened | 1.3% |
2.29%
1 pts better
|
Numerator 3 · Denominator 231 · Adjusted rate 1.54% |
| Healthcare-associated infections requiring hospitalization | 5.71% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 250 · Observed rate 4% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 5.41% |
8.2%
2.8 pts worse
|
Numerator 6 · Denominator 111 |
| Staff flu vaccination coverage | 94.23% |
42%
52.2 pts better
|
Numerator 147 · Denominator 156 |
| Discharge function score | 32.87% |
56.45%
23.6 pts worse
|
Numerator 71 · Denominator 216 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 180 · Denominator 180 |
| Resident COVID-19 vaccinations up to date | 31.13% |
25.2%
5.9 pts better
|
Numerator 33 · Denominator 106 |
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 2.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.1
About the same
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
93.0%
4.1 pts worse
|
93.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 94.7% · Q3 97.4% · Q4 97.4% · 4Q avg 88.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
2.4%
0.9 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.3% · Q3 2.6% · Q4 0.0% · 4Q avg 3.3% · 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 | 5.8% |
4.6%
1.2 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.9% · Q3 6.5% · Q4 3.1% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
19.0%
5.3 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 16.1% · Q3 16.1% · Q4 12.5% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
13.5%
1.5 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 9.5% · Q3 16.0% · Q4 12.9% · 4Q avg 12.0% · 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 need for help with daily activities has increased | 26.8% |
9.7%
17.1 pts worse
|
14.9%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.4% · Q2 28.6% · Q3 15.4% · Q4 16.7% · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
0.8%
2.5 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.9% · Q4 5.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.4% |
15.9%
20.5 pts worse
|
19.8%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.8% · Q2 44.5% · Q3 29.7% · Q4 24.0% · 4Q avg 36.4% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
6.0%
3.1 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 0.0% · Q3 0.0% · Q4 4.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.8% |
78.7%
6.9 pts worse
|
81.7%
9.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.8% · Q2 64.7% · Q3 85.9% · Q4 85.3% · 4Q avg 71.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
8.2%
1.7 pts worse
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 8.3% · Expected 9.4% · 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 0.0% · Q2 0.9% · Q3 0.9% · 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 | 78.6% |
80.1%
1.5 pts worse
|
79.7%
1.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.1% |
25.4%
7.7 pts worse
|
23.9%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.1% · Observed 27.7% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-17 · Fire 2022-03-17
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-12-06 · Fire 2019-12-06
1 health deficiencies
Top issue: Resident Assessment and Care Planning (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
2024-05-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-24
E · Potential for more than minimal harm
2024-05-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-22
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-22
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-22
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-06-24
F · Potential for more than minimal harm
2022-03-17
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 2022-05-19
E · Potential for more than minimal harm
2022-03-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-04-30
E · Potential for more than minimal harm
2022-03-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-19
E · Potential for more than minimal harm
2022-03-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-30
Inspection history
Recent health citations
G · Actual harm
2025-08-26
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 2025-09-29
D · Potential for more than minimal harm
2024-05-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-24
D · Potential for more than minimal harm
2022-03-17
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 2022-05-19
B · Minimal harm
2022-03-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-05-19
D · Potential for more than minimal harm
2019-12-06
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2020-01-07
Penalties and ownership
What sits behind the stars
Ownership
Ellis, Julie
Operational/Managerial Control · Individual
Lisk, Jeffrey
Operational/Managerial Control · Individual
Peterson, Robert
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Valley View Rehabilitation And Healthcare Ctr
Newton, NJ
2-star overall rating with 1-star inspections with 18 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Complete Care At Barn Hill
Newton, NJ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Mohawk Meadows
Lafayette, NJ
1-star overall rating with 1-star inspections with $738,307 in total fines with 10 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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