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Elmwood Hills Healthcare Center LLC

425 Woodbury-Turnersville Road, Blackwood, NJ 08012 · For profit - Limited Liability company · 300 certified beds · (856) 374-6600 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Apr 20231 immediate-jeopardy citation$9,113 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $9,113 in federal fines (most recent 2025-10-16)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • about 31% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
527 S Black Horse Pike · (856) 228-1061 · Call to confirm hours
Pharmacy
425 Woodbury Turnersville Rd · (856) 374-6430 · Call to confirm hours
Grocery
500 Woodbury Turnersville Rd · (856) 227-9696 · Call to confirm hours
Park
Brown and East Atlantic Avenues · Typically dawn to dusk
Place of worship
508 Woodbury Turnersville Rd

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.4%8.7%15.4%better
Long-stay residents who lose too much weight3.9%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.6%0.9%better
Long-stay residents with a urinary tract infection0.8%0.8%2.0%typical for the state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.8%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.3%2.3%3.3%better
Long-stay residents whose ability to walk worsened3.3%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication31.2%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine96.1%97.2%95.3%typical
Long-stay residents with pressure ulcers2.5%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control8.7%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.9%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.3%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine69.3%80.1%79.4%worse
Short-stay residents rehospitalized after admission24.4%24.9%22.6%typical
Short-stay residents with an outpatient ER visit8.1%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.092.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.301.111.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 224 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.1%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
68.6%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 68.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 156 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.1%CMS range 49.1–64.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.8–13.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge68.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge59.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting83.9%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 4.2–9.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.191.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.35
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.24
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.20
RN hoursweekends
46.4%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 300 beds and averages 290.1 residents a day — about 97% occupied, or roughly 10 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.478 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.10 hrs/resident/day on weekends vs 3.63 on weekdays — 15% thinner on weekends. RN hours go from 0.42 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2025-05-09)
13
at the previous standard inspection (2023-04-19)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · J2025-10-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #: 2629258Based on interviews, review of medical records, and other pertinent facility documentation on 10/9/2025 and 10/10/25, it was determined that the facility failed to provide adequate supervision for a resident (Resident #2) who was cognitively impaired with documented history of exit seeking behaviors; and who eloped out of the facility building on 9/28/2025. The deficient practice was identified for 1 of 3 residents reviewed (Resident #2). A review of Facility Reportable Event (FRE) revealed that on 9/28/2025, a Licensed Practical Nurse (LPN #1) asked a Certified Nursing Assistant (CNA #1) to use her employee identification (ID) badge to swipe open the locked door on the second floor secured unit for Resident #2, which CNA #1 did provide. This allowed Resident #2 to exit the unit because both CNA #1 and LPN #1 thought the resident was a visitor. The FRE indicated that pictures of residents at risk for elopement, including Resident #2, were located by the same entrance door on the second-floor nursing unit to help staff identify at-risk residents and stop them from…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-04-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ Complaint #159807 Based on interviews, review of closed medical records, and review of pertinent facility documents, it was determined that the facility failed to ensure appropriate care was provided with no delay in treatment for a resident with an indwelling pleural chest catheter/tube who had a change in condition with respiratory distress on [DATE] received a chest x-ray on [DATE], and was hospitalized via emergency services prior to chest x-ray results. This deficient practice was identified for 1 of 45 residents (Resident #439) reviewed for quality of care, and was evidenced by the following: On [DATE] at 8:52 AM, the surveyor reviewed the closed medical records for Resident #439. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in November of 2022 with diagnoses which included chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes difficulty breathing), chronic respiratory failure with hypoxia…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-09 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ176228 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) follow a physician's order to apply a urinary catheter stabilization device, b.) accurately identify a resident's urinary stabilization device was applied in the electronic medical record (EMR), c.) properly identify a resident's incontinence status in the EMR, and d.) monitor urinary output according to the physician's orders in the EMR. This deficient practice was identified for 2 of 2 Residents (Resident #104 and #196) reviewed for urinary catheters and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to complete a discharge Minimum Data Set (MDS), an assessment tool, as required for 1 of 1 resident (Resident #275) system selected for MDS over 120 days. This deficient practice was evidenced by the following: The MDS is a comprehensive federally mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must complete the assessment at discharge and electronically transmit the MDS no later than 14 days after completing the assessment. The surveyor reviewed the electronic medical record (EMR) for Resident #275. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but was not limited to, spinal stenosis (a condition where the spaces within the spine narrow, putting pressure on the spinal cord and nerve roots), difficulty walking, and muscle weakness. Further review of Resident #275's EMR revealed that the resident was discharged…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #: NJ165862, NJ184181 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to a dependent resident in a timely manner. This deficient practice was identified for 1 of 4 residents (Resident #247) reviewed for Activities of Daily Living (ADL) care and was evidenced by the following: On 4/30/25 at 10:16 AM, during the initial tour of the 2 East Unit, the surveyor observed Resident #247 awake and alert lying in bed, the bed sheets were wet and there was a strong odor of urine in the room. At that time, the surveyor requested Licensed Practical Nurse/Unit Manager (LPN/UM #3) to check the resident for incontinence care. The resident stated, I am sure I am wet. LPN/UM #3 checked the resident's incontinence brief which was saturated with urine and the bed sheet underneath was wet. LPN/UM #3 then stated, I will get the aide, and that the resident should have been changed in the morning during the Certified Nursing Assistant (CNA) morning rounds. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to ensure that treatment to prevent or reduce range of motion limitations were provided for 1 of 1 resident (Resident #11) reviewed for limited range of motion. This deficient practice was evidenced by the following: On 5/6/25 at 10:30 AM, the surveyor observed Resident #11 lying in bed in watching television. The resident's left hand was resting on the bed without a hand roll in place (which is used to prevent the fingers from contracting tightly into the palm). On 5/7/25 at 11:22 AM, the surveyor observed Resident #11 lying in bed watching television. The resident's left hand was resting on the bed without a hand roll in place. The surveyor reviewed the electronic medical record (EMR) for Resident #11. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: osteoarthritis. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that oxygen was administered in accordance with a physician's order for 1 of 1 resident (Resident #146) reviewed for respiratory care. This deficient practice was evidenced by the following: On 4/30/25 at 10:23 AM, the surveyor observed Resident #146 who was seated in a wheelchair at the bedside. The resident was receiving 3.5 liters of oxygen from an oxygen concentrator (a medical device) via a nasal cannula (two prongs inserted into the nostrils with a tube that connects to an oxygen source). When interviewed, the resident stated that he/she was ordered two liters of oxygen but the oxygen concentrator was weak and they needed to turn it up. On 5/1/25 at 11:59 AM, the surveyor observed Resident #146 seated on the side of the bed with noted shortness of breath. The resident stated that he/she had been exercising and was trying to catch their breath. The resident's oxygen concentrator was set at 3.5 liters via nasal cannula. On 5/2/25 at 10:48 AM, the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to administer pain medication according to the physician's order for 1 of 5 residents (Resident #155) reviewed for unnecessary medications. This deficient practice was evidenced by: On 5/7/25 at 9:21 AM, the surveyor observed Resident #155 sitting in their room. When asked about pain, the resident stated he/she had chronic pain in his/her lower back from an old injury. The resident further stated that their pain was typically a level 7 out of 10, but that they received as needed pain medication that brought the pain level down to a level three (3) which was effective for the resident. The surveyor reviewed the medical record for Resident #155. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, lumbar spondylopathies (arthritis of the spine), spinal stenosis, chronic pain, and low back pain. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint # NJ00176228 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain complete and accurate medical records in accordance with acceptable standards of practice. The facility failed to ensure a.) weekly skin assessments were accurately documented in the Treatment Administration Record (TAR) and b.) the physician's orders were followed and accurately documented the medication administration on the Medication Administration Record (MAR). This deficient practice was identified in 1of 2 residents (Resident #82) reviewed for pressure ulcer and 1of 1 resident (Resident #60) reviewed for communication and sensory problems and was evidenced by the following: 1.) On 4/30/25 at 10:34 AM, the surveyor observed Resident #82 awake and alert, lying in bed with a pressure relieving mattress on the bed. The surveyor reviewed the medical record for Resident #82. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, Parkinson's Disease (a progressive…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the pneumococcal vaccination was administered to a resident upon admission to the facility. This deficient practice was identified for 1 of 5 residents (Resident #72) reviewed for immunizations and was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Pneumococcal Vaccine for Adults Aged >19 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP), United States, 2023 Recommendations and Reports / September 8, 2023 / 72(3);1-39 Adults aged >19 years who have received PCV13 only are recommended to receive a single dose of PCV20 at an interval >1 year after receipt of the PCV13 dose or to receive >1 dose of PPSV23 to complete their pneumococcal vaccine series. -When PPSV23 is used instead of PCV20, the minimum recommended interval between PCV13 and PPSV23 administration is >8…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-04-19 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure appetizing and palatable temperature of food for 1 of 1 lunch meals observed on 1 of 6 nursing units (1 East). This deficient practice was evidenced by the following: On 4/10/23 at 10:14 AM, the surveyor conducted a Resident Council meeting which included six residents (Residents #87, #118, #135, #208, #212, and #260). All six residents informed the surveyor that the food was served cold on all shifts to which they attributed to short staffing. On 4/14/23 at 8:35 AM, the surveyors informed the Assistant Food Service Director (AFSD) that they wanted to observe the lunch meal service for that day including food temperatures. The AFSD acknowledged the request and stated that lunch service began at 11:15 AM. On 4/14/23 at 11:20 AM, the surveyor observed the Chef Manager (CM) who had already began to serve food on the tray line. When interviewed, the CM stated that the food temperatures were already completed by the AM Cook. The CM stated that she obtained…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-04-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) store, label, date and properly document and cool potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; c.) ensure that dented cans were removed from storage; d.) ensure that serving trays were dried in a safe and sanitary manner prior to meal service; e.) ensure that food was served in a safe and sanitary manner to prevent contamination; f.) ensure that the dish machine in use maintained the appropriate temperature and sanitizer levels according to the manufacturer's specifications; and g.) maintain multiuse food-contact surface cutting board and can opener in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 4/3/23 at 9:33 AM, the surveyors entered the kitchen and asked to tour with the Food Service Director (FSD). The surveyors met with the FSD who stated that both the hot water booster and chemical sanitizer were down on the dish…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Fcited before2023-04-19 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring a.) appropriate personal protection equipment was worn for residents on transmission-based precautions; b.) appropriate hand hygiene including donning (put on) and doffing (removing) of gloves and hand washing; c.) appropriate disposal of resident's garbage in the room; d.) appropriate storage of respiratory equipment; and e.) sanitizing of reusable equipment in accordance with nationally accepted guidance and facility policy. This deficient practice was identified in 4 of 6 nursing units (S1, S2, 1 West, and 1 East) with multi-disciplinary staff and was evidenced by the following: 1. On 4/5/23 at 10:30 AM, the surveyor observed outside Resident room [ROOM NUMBER] a sign that indicated the resident was on transmission-based precautions (TBP) and prior to entering and exiting room you must perform hand hygiene; wear gloves…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-19 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ Complaint #157789 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey State Department of Health (NJDOH) a.) an injury of unknown origin for an incident on 10/8/22; b.) an allegation of staff to resident abuse for an incident on 1/30/23; and c.) and allegation of staff to resident mistreatment on 9/24/22. This deficient practice was identified for 3 of 3 residents (Resident #15, #152, and #440) reviewed for abuse, and the evidence was as follows: 1. On 4/6/23 at 9:37 AM, the surveyor observed Resident #15 sitting in their wheelchair in their room asleep. The surveyor reviewed the medical record for Resident #15. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in August of 2020 with diagnoses which included dementia, major depressive disorder, persistent mood disorder, unspecified psychosis not known to a substance or known physiological…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-19 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the appropriate management of enteral feeding formula and piston syringes. This deficient practice was identified for 2 of 3 residents (Resident #77 and #88) reviewed for tubing feeding, and was evidenced by the following: 1. On 4/3/23 at 10:50 AM, the surveyor observed Resident #88 in bed asleep with an enteral feeding tube pump (FT; a tube surgically inserted to the stomach to provide food and nutrients) administering Jevity 1.5 (nutritional formula) at a rate of 85 milliliters (mL) per hour. The surveyor observed the 1000 mL bottle of Jevity 1.5 had approximately 300 mL of formula remaining, and the label was not filled out with the resident's name, date, or rate of infusion (mL per hour). The surveyor also observed a piston syringe irrigation kit (used to flush the FT) dated 3/31/23. There was also no name labeled on the bag that contained the irrigation piston syringe kit. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-19 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to a.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 6 of 6 forms provided; and b.) to accurately document the administration of controlled medication for 2 sampled residents (Resident #19 and Resident #216) identified upon inspection of 1 of 6 medication carts (1 [NAME] right hall cart). The evidence was as follows: 1. On 4/17/23 at 1:37 PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on six of the six provided forms Part 5, had not been completed upon receipt of the medications from the Provider Pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form number: 221704808; 221704809; 221704810; 221704811; 221704812; and 221704816. On 4/17/23 at 2:13 PM, the surveyor and Director of Nursing (DON) reviewed the provided DEA 222 forms. The DON…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed a.) to ensure residents on transmission-based precautions (TBP) were treated in a dignified and respectful manner for their toileting needs and b.) ensuring the privacy curtain was closed during personal care. This deficient practice was identified for 2 of 35 residents (Residents #19 and #213) reviewed for dignity, and was evidenced by the following: 1. On 4/14/23 at 9:30 AM, during the initial tour of the facility, the surveyor observed cautionary signage and a personal protective equipment (PPE; clothing or equipment worn to protect the body from harm or infection) bin outside of Resident #19's room. A Stop Sign cautioned that TBP (precautions intended to prevent transmission of infectious agents) were in effect and directed to perform hand hygiene and don (put on) gloves and gown before entering the room. The surveyor observed Resident #19 who self-propelled themselves in a wheelchair…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (Resident #152) reviewed for abuse. This deficient practice was evidenced by the following: On 4/3/23 at 11:18 AM, the surveyor observed Resident #152 laying on the bed requesting assistance from the nursing staff. On 4/12/23 at 10:20 AM, the surveyor was informed by Resident#152 of a situation involving a Certified Nursing Assistant (CNA). With Resident #152's permission, this conversation was held in the presence of their roommate (Resident #113). Resident #152 advised that the CNA grabbed my arm [ .] shook me [ .] I was crying. Resident #152 further stated that the CNA pulled on my arm [to cover me up] because I had a rash from dialysis. I told her i got a rash and she said you don't have [breasts] hanging out like that. Resident #113 confirmed the entire event and stated that Resident #152 was crying after the event.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ Complaint #157789 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) implement care plan interventions of a silent bed alarm for a resident with a history of falls; and b.) develop and implement a care plan for a resident with limited range of motion which included daily right hand splints and a bilateral knee pillow. This deficient practice was identified for 2 of 35 residents (Resident #15 and #152) reviewed for comprehensive care plans and the evidence was as follows: 1. On 4/6/23 at 9:37 AM, the surveyor observed Resident #15 sitting in their wheelchair in their room asleep. The resident was wearing non-skid socks. The surveyor reviewed the medical record for Resident #15. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in August of 2020 with diagnoses which included dementia, major depressive disorder, persistent mood disorder, unspecified psychosis not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of pertinent facility documents, it was determined that the facility failed to ensure that residents who required extensive assistance from staff with activities of daily living (ADL) were provided care consistent with their needs and preferences. This deficient practice was identified for 2 of 4 residents (Resident #223 and Resident #285) reviewed for activities of daily living, and was evidenced by the following: 1. On 4/4/23 at 10:10 AM, during the initial tour of the facility, the surveyor observed Resident #223 lying in bed awake. The resident stated that they had left sided weakness related to a cerebrovascular accident (CVA; a loss of blood flow to part of the brain, which damages brain tissue). Resident #223 held up his/her left hand and demonstrated an impaired ability to fully open and close their left hand. The surveyor observed that the resident's fingernails were long. The resident stated the staff did not offer to cut or trim his/her fingernails and the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure resident's weights obtained were accurate after significant weight changes. This deficient practice was identified for 1 of 4 residents (Resident #47) reviewed for nutrition and the evidence was as follows: On 4/3/23 at 11:20 AM, the surveyor observed Resident #47 sitting in wheelchair in the unit's dayroom. Resident #47 was petite and dressed in well-fitted clothes. On 4/6/23 9:45 AM, the surveyor observed Resident #47 sitting at table in dayroom eating their breakfast independently. The resident consumed approximately 75% of their meal. The surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included cerebral infarction, vascular dementia, type 2 diabetes, and hypothyroidism. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/26/23, reflected that the resident had a brief…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly label and date medication in accordance with manufacturer recommendations. This deficient practice was observed in 1 of 3 medication storage rooms (1 West) inspected and was evidenced by the following: On 4/17/23 at 12:07 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the 1 [NAME] medication room refrigerator. The surveyor observed an opened and undated bottle of lorazepam 2 milligrams per 1 milliliter (mg/ml) concentrated oral solution in active inventory. The prescription label as well as the product label instructed Discard opened bottle after 90 days. The LPN acknowledged that neither the medication bottle nor the medication box had been dated when opened or when to discard and should have been. On 4/17/23 at 12:24 PM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) for the 1 [NAME] nursing unit. The surveyor and the UM/LPN reviewed the lorazepam in the 1 [NAME] medication room refrigerator, and the UM/LPN…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-04-22 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to a.) supervise the administration of one medication and b.) follow their policy for self-medication administration for 1 of 3 residents (Resident # 77) reviewed for oxygen, c.) follow fluid restriction instructions in accordance with the physician's order, professional standards of care and the care plan for 1 of 5 residents (Resident #242) reviewed for unnecessary medications, and d.) verify and accurately document the presence of a physician ordered pressure relieving device to the bed for 1 of 3 residents (Resident #242) reviewed for pressure ulcer/injury. This deficient practice evidenced by the following:. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of facility documentation, it was determined that the facility failed to a.) ensure that staff wore Personal Protective Equipment (PPE) properly when caring for long term care residents, this was noted for 1 staff member on 1 of 6 units (2 West); and b.) ensure the urinary catheter drainage bag (drainage bag) was stored in an appropriate manner to prevent the spread of infection for Resident #20, 1 of 3 resident's reviewed for the use of an indwelling urinary catheter. This deficient practice was evidenced by the following: 1. During the Entrance Conference with the facility on 04/13/21 at 9:50 AM, the Director of Nursing (DON) stated that the required PPE used on all units was an N95 face mask and face shield or goggles. The DON stated that S1 and S2 units house the new admission and readmission residents and 1 East, 1 West, 2 East and 2 [NAME] Units house the long term care residents. On 04/15/21 at 11:37 AM, the surveyor observed a Registered Nurse (RN) at the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2021-04-22 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) Quarterly assessment was completed accurately. This was observed for 1 of 38 residents observed for MDS accuracy. This deficient practice was evidenced by the following: According to the admission Record, Resident #20 was admitted to the facility with medical diagnoses that included left sided Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness of one side of the body) following a stroke. Review of the Quarterly MDS, an assessment tool, dated 04/14/21, revealed Resident #20 was cognitively intact, needed extensive assistance from staff for Activities of Daily Living (ADLs) (transfers, dressing, toileting, personal hygiene and bathing). The 04/14/21 Quarterly MDS did not reflect an impairment to the upper or lower extremities. On 04/19/21 at 10:26 AM, the surveyor observed Resident #20 in bed eating breakfast. Resident #20 stated that he/she was unable to use his/her left side and his/her left hand was observed to be contracted,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$9,113 in federal fines across 1 penalty.

  • $9,113 — penalty dated 2025-10-16

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to OCEAN HEALTHCARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.8-0.8 vs chain
Health inspection 1 of 52.3-1.3 vs chain
Staffing 3 of 52.9+0.1 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 10 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
MDF FAMILY 2015 TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 12/28/2016
DREW, ZALMANIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/25/2013
FEIGENBAUM, AVRAHAMIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/25/2013
FEIGENBAUM, DEBORAHIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/25/2013
MAIEROVITS, AVROHOMIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/25/2013
MANUFACTURERS & TRADERS TRUST COMPANYOrganization5% OR GREATER MORTGAGE INTERESTsince 11/25/2013
DYNAMIC HEALTHCARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/29/2025
WEISSMAN, MOSHEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/30/2023

CMS files one row per role, so the 16 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$80.8M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$25.4M
Related-party expense31% of expenses
Who pays — share of resident-days
Medicaid 49%Medicare 5%Other / private 46%

This home reported $25.4M paid to related parties — landlords or management companies under common ownership — equal to about 31% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$521per resident / day
operating cost
$15,838per month
≈ monthly operating cost
$518per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315159. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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