Cycle 1
Health 2024-09-27 · Fire 2024-09-27
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Pitman, NJ
United Methodist Communities At Pitman
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
535 N Oak Ave, Pitman, NJ
(856) 589-7800
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
63
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
1.19
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.57
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
0.80
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,578
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.65
Baseline 20.32% · Performance 20.67% · Measure score 1.65 · Achievement 1.65 · Improvement 0
Healthcare-associated infections
3.59
Baseline 4.90% · Performance 6.76% · Measure score 3.59 · Achievement 3.59 · Improvement 0
Total nurse turnover
7.18
Baseline 92.68% · Performance 40.58% · Measure score 7.18 · Achievement 5.65 · Improvement 7.18
Adjusted total nurse staffing
3.33
Baseline 4.92 hours · Performance 4.03 hours · Measure score 3.33 · Achievement 3.33 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 219 · Observed rate 9.59% · Lower 95% interval 7.42% |
| Discharge to community | 67.75% |
50.57%
17.2 pts better
|
Better than the National Rate · Eligible stays 211 · Observed rate 62.56% · Lower 95% interval 60.61% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 149 · Denominator 149 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 149 |
| Discharge self-care score | 63.41% |
53.69%
9.7 pts better
|
Numerator 78 · Denominator 123 |
| Discharge mobility score | 51.22% |
50.94%
0.3 pts better
|
Numerator 63 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 2.68% |
2.29%
0.4 pts worse
|
Numerator 4 · Denominator 149 · Adjusted rate 2.82% |
| Healthcare-associated infections requiring hospitalization | 6.76% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 5.67% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 16.48% |
8.2%
8.3 pts better
|
Numerator 15 · Denominator 91 |
| Staff flu vaccination coverage | 97.85% |
42%
55.8 pts better
|
Numerator 91 · Denominator 93 |
| Discharge function score | 58.54% |
56.45%
2.1 pts better
|
Numerator 72 · Denominator 123 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | 98.91% |
96.28%
2.6 pts better
|
Numerator 91 · Denominator 92 |
| Resident COVID-19 vaccinations up to date | 41.67% |
25.2%
16.5 pts better
|
Numerator 25 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.1
0.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
93.0%
5 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 95.9% · Q3 97.9% · Q4 100.0% · 4Q avg 98.0% |
| 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 | 4.1% |
2.4%
1.7 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.1% · Q3 4.2% · Q4 5.9% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
11.4%
5.3 pts better
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 2.5% · Q3 5.0% · Q4 9.1% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
4.6%
0.1 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.6% · Q3 5.1% · Q4 5.1% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
19.0%
3.8 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 23.1% · Q3 12.8% · Q4 7.5% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.5% |
13.5%
6 pts worse
|
16.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 18.2% · Q3 21.9% · Q4 19.4% · 4Q avg 19.5% · 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 | 14.0% |
9.8%
4.2 pts worse
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
9.7%
6.5 pts worse
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 16.7% · Q3 10.8% · Q4 18.4% · 4Q avg 16.2% · 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 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
0.8%
0.8 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 4.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.7% |
15.9%
14.8 pts worse
|
19.8%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 37.0% · Q3 31.5% · Q4 32.4% · 4Q avg 30.7% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
6.0%
4.1 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 1.4% · Q4 1.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
78.7%
9.9 pts better
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 90.8% · Q3 86.8% · Q4 88.4% · 4Q avg 88.6% |
| 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 4.8% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 2.4% · Q4 3.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.3% |
80.1%
11.2 pts better
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
25.4%
7.4 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 15.1% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-14 · Fire 2023-07-14
5 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2021-05-24 · Fire 2021-05-24
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-27
F · Potential for more than minimal harm
2024-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-27
F · Potential for more than minimal harm
2024-09-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-27
F · Potential for more than minimal harm
2024-09-27
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-10-27
F · Potential for more than minimal harm
2024-09-27
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 2024-10-27
F · Potential for more than minimal harm
2024-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-27
F · Potential for more than minimal harm
2024-09-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-27
E · Potential for more than minimal harm
2023-07-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-07-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-07-14
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-07-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-08-03
F · Potential for more than minimal harm
2021-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-05-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-06-01
Inspection history
Recent health citations
G · Actual harm
2025-08-13
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 2025-10-03
E · Potential for more than minimal harm
2023-07-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-03
E · 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 2023-08-03
D · Potential for more than minimal harm
2023-07-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-08-03
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 2023-08-03
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 2023-08-03
E · Potential for more than minimal harm
2021-05-24
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 2021-06-14
Penalties and ownership
What sits behind the stars
Ownership
Ellis, Julie
Operational/Managerial Control · Individual
Matthews, Michele
Operational/Managerial Control · Individual
Peterson, Robert
Operational/Managerial Control · Individual
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#3
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