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Complete Care at Laurelton, LLC

475 Jack Martin Blvd, Brick, NJ 08724 · For profit - Limited Liability company · 180 certified beds · (732) 458-6600 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Feb 20241 immediate-jeopardy citation$163,101 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $163,101 in federal fines (most recent 2026-03-23)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (72%) runs well above the national median (45%)

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.

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

Worth a closer look. This home's quality-measure rating runs 2 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
495 Jack Martin Blvd Ste #1 Ste 1 · (732) 836-9800 · Call to confirm hours
Pharmacy
1659 State Highway 88 · (848) 241-3129 · Call to confirm hours
Grocery
ALDI0.7 mi
Jack Martin · (833) 460-7069 · Call to confirm hours
Park
1890 Route 88 · (732) 955-8288 · Typically dawn to dusk
Place of worship

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 5 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 held steady at 3 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 rating3★
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 increased1.4%8.7%15.4%better
Long-stay residents who lose too much weight3.1%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms76.4%12.1%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%2.3%3.3%better
Long-stay residents whose ability to walk worsened2.9%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.0%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine97.8%97.2%95.3%typical
Long-stay residents with pressure ulcers5.6%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control26.2%15.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.6%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine43.3%80.1%79.4%worse
Short-stay residents rehospitalized after admission26.0%24.9%22.6%worse
Short-stay residents with an outpatient ER visit5.8%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.942.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.921.111.80typical

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

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.

52.4% 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 228 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.4%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
79.5%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 79.5% 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 88 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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 SNF52.4%CMS range 45.1–57.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.8–12.810.7%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 discharge79.5%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 discharge81.8%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 discharge60.2%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 identified96.4%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 setting92.7%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 discharge97.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.8%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 worsened4.2%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 hospitalization6.6%CMS range 3.8–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.141.02Oct 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

0.40
RN hours/ resident / day
0.85
LPN hours/ resident / day
2.14
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.29
RN hoursweekends
72.4%
Total nursing turnover
61.5%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 119.8 residents a day — about 67% occupied, or roughly 60 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.06 hrs/resident/day on weekends vs 3.53 on weekdays — 13% thinner on weekends. RN hours go from 0.45 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above 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

6
deficiencies at the latest standard inspection (2025-06-13)
11
at the previous standard inspection (2024-02-09)

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.

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

  • Immediate jeopardy · Jdisputed · IIDR2026-04-24 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and review of the facility's policy titled Discharge Planning Process, on 04/21/2026 through 04/23/2026, it was determined that the facility failed to ensure that a resident was discharged to a safe home, including the repair of a water pipe prior to discharge, for 1 of 1 residents (Resident (R) 1) reviewed for appropriate discharge from the facility. As a result, R1 was discharged to an unsafe home without running water or heat. Ten days after discharge, the police were called to the home to find the resident with limited electricity, no running water or working heating system, and unable to walk or get down the stairs, other than sliding down on his/her buttocks. R1 was taken by the Police Department (PD) to the Emergency Department (ED) for care. The facility's failure to ensure a resident was discharged to a safe home posed a likelihood that serious injury, harm, impairment, or death could occur to all discharged residents. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 04/06/26 after R1 was discharged to an unsafe home…

    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
  • Actual harm · G2024-02-09 · 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 Based on interview, record review and document review it was determined that the facility failed to recognize a change in condition and ensure that no delay in treatment occurred, when on 09/23/23, a resident presented with pain accompanied by an externally rotated bruised left lower extremity and the resident was not immediately assessed by a Registered Nurse, and waited over 24 hours to receive an X-ray and was then transferred to the Emergency Room. This deficient practice occurred for 1 of 1 resident (Resident #257) reviewed for fracture of unknown origin. Resident #257 was diagnosed with an impacted comminuted fracture of the base of the left femoral neck (hip fracture) which required surgery on 09/25/23 for Open Reduction and Internal Fixation (ORIF) of the Left Hip. Refer to 610G The evidence was as follows: 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…

    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 · E2025-06-13 · 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

    Based on observation, interview, and record review, it was determined that the facility failed to consistently document enteral tube feeding flush administration to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 residents (Residents #5), reviewed for enteral tube feeding and was evidenced by the following: Review of the admission Record (admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses that included but was not limited to; acute respiratory failure, aphasia (difficulty expressing self or difficulty in processing language), dysphasia (swallowing problems) and epilepsy (seizures). Review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/23/25, indicated that Resident #5 had short and long-term memory deficits. The resident was severely impaired for decision making and required maximum assistance with activities of daily living (ADLs). The MDS also indicated that the resident received nutritional, and hydration…

    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 · E2025-06-13 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NJ Complaint: #NJ186246 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 3 of 3 (Resident #77, 110, ) residents reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #77's quarterly Minimum Data Set (an assessment tool) dated 12/25/2024, revealed that Resident #77 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. A review Resident # 77's diagnoses located in the Electronic Medical Record (EMR) include but are not limited to Diabetes Mellitus (the body's inability to use insulin properly, leading to high blood sugar levels). A review of Resident #77 physician's orders revealed the following orders but not limited to Insulin Regular Human Injection Solution 100 UNIT/Milliliter (a hormone produced in 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 other facility documentation it was determined that the facility failed to to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 of 3 nursing units observed for environment and evidenced by the following: Upon initial tour of Unit 2 on 06/04/2025 at 10:24 AM, the surveyor observed a nurse's call bell wall unit depressed through the drywall with medical tape securing it to the wall. On 06/06/2025 at 11:11 AM, the surveyor observed the same nurse's call bell unit depressed through the drywall with medical tape securing it to the wall. During an interview with the surveyor on 06/06/2025 at 11:17 AM Certified Nursing Assistant (CNA#1) indicated that their responsibilities included daily check of the resident's room to make sure everything was in a safe working order. On 06/11/2025 at 10:32 AM, the surveyor requested that Licensed Practical Nurse Unit Manager (LPN/UM#1)…

    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 · D2025-06-13 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 34 residents reviewed, Resident #18 as evidenced by the following: Upon initial tour of the Unit 2 on 06/04/2025 at 9:52 AM, the surveyor observed an individual outside room [ROOM NUMBER] putting on personal protective equipment. The surveyor observed the individual's uniform displaying a hospice name and she identified herself as a hospice aide caring for Resident #18. On 06/06/2025 at 10:23 AM, the surveyor observed Resident #18 in resting in bed with family in room holding their hand. Resident #18 was admitted to the facility on [DATE] with diagnosis that included Multiple Sclerosis. A review of the Physician's Orders identified an order for Hospice Evaluation and Treatment on 2/3/2025. The surveyor reviewed the MDS assessments for Resident #18. A SCSA MDS was not completed for the change in status for Resident #18.…

    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 before2025-06-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that a resident's Interdisciplinary Care Plan (ICP) was resident specific and reflected accurate resident care. The deficient practice was identified for 1 of 23 residents (Resident #5) reviewed and was evidenced by the following: A review of the admission Record (admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses that included but was not limited to; acute respiratory failure, aphasia (difficulty expressing self or difficulty in processing language), dysphasia (swallowing problems) and epilepsy (seizures). A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/23/25, indicated that Resident #5 had short and long-term memory deficits. The resident was severely impaired for decision making and required maximum assistance with activities of daily living (ADLs). The MDS…

    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 before2025-06-13 · 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 and record review it was determined that the facility failed to maintain the necessary respiratory care and services for 1 of 2 residents (Resident #74) reviewed. This deficient practice was evidenced by: A review of the admission Record (admission summary) indicated that Resident #74 was admitted to the facility with the diagnoses which included but was not limited to respiratory conditions due to other external agents, chronic respiratory failure with hypoxia (a condition that occurs when the body tissues do not get sufficient oxygen supply) and chronic obstructive pulmonary disease (COPD) (an ongoing lung condition caused by damage to the lungs). A review of the quarterly Minimum Data Set (MDS) an assessment that facilitates a resident's care dated 4/11/25, indicated that Resident #74 scored a 14 on the basic interview for mental status (BIMS) which indicated that the resident was cognitively intact. The MDS also indicated that the resident required supervision with activities of daily living (ADL's) and was on oxygen (O2). On 6/5/25 at 10:39 AM,…

    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 · Dcited before2025-04-24 · tag F0658 — failed to meet professional standards of care — isolated
    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

    Complaint #: NJ183557 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 04/24/2025 and 04/29/2025, it was determined that the facility failed to follow standards of clinical practice for Physician Orders (POs) for medication administration and follow the Care Plan (CP) interventions for a resident (Resident #5). The facility also failed to follow its policy titled Medication Administration. This deficient practice was identified for 1of 6 residents reviewed for medication administration 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally…

    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 · D2025-04-24 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #: NJ183557 Based on interview and review of facility documents on 5/22/25, it was determined that the facility failed to ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day for 1 of 21 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Reports completed by the facility for the weeks of 02/09/25 through 02/15/25, 04/06/2025 through 04/12/2025, and 04/13/2025 through 04/119/25, revealed that the facility had no RN coverage for all shifts on 02/09/25 The surveyor reviewed the facility's policy titled Nursing Services and Sufficient Staff updated 03/05/25 which indicated, It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment.…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    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

    Complaint # NJ00181615, NJ00177959 Based on observations, interviews, and record review, as well as a review of pertinent facility documents on 12/23/24, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice by not ensuring that a medication [Sucralfate], an anti-ulcer medication, was administered to a resident (Resident #1) in a timely manner as ordered by a physician. Sucralfate was a medication to be administered before meals. This deficient practice was observed in 1 of 4 residents reviewed for medication administration 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 and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and…

    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 · F2024-02-09 · 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 document review it was determined that the facility failed to ensure meals were served at a palatable temperature for 6 of 6 residents who attended a resident council meeting, and on 2 of 3 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 01/30/24 at 11:04 AM, the surveyor conducted a resident council meeting with six residents. The surveyor inquired about the meals served and 6/6 residents interviewed stated the [hot food] was always served cold and especially the coffee. On 01/31/24 at 7:30 AM, surveyor #1 observed the meal truck enter Unit 3. The first meal tray was passed at 7:31 AM, and the last meal tray was passed at 7:49 AM. At that time, the surveyor removed the last meal tray and completed a test meal observation, in the presence of the Unit Manager Nurse, with the following recorded temperatures: Oatmeal: 136 degrees Farenheight (F) Sausage: *112 F 2 Pancakes: *120 F 4-ounce Orange Juice: *51 F 8-ounce Low Fat Milk: *56 F Coffee: *112 F On 01/31/24 at 8:40 AM, surveyor #2 observed the meal…

    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 12 citations
  • Potential for harm · Fcited before2024-02-09 · 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 document review it was determined that the facility failed to ensure a) the kitchen environment and equipment was maintained in a clean and sanitary manner, b) all food items were labeled with a use by date, and c) staff practiced appropriate hand hygiene during meal service to prevent the potential spread of food borne illness. The deficient practice was evidenced by the following: On 01/29/24 at 9:24 AM, the surveyor completed an initial tour of the kitchen with the Food Service Director (FSD) and the Regional Director of Food Service (RDFS) and observed the following: 1. The walk-in refrigerator unit identified as the cold cut box had debris and crumbs on the floor underneath the racks. The surveyor asked when the box was cleaned and the FSD stated, not as often as it should. The door gasket was visibly soiled and ripped. 2. The walk-in freezer unit had ice buildup by the door and the gasket was ripped. 3. The bread rack contained a package of rye bread that was dated with an expiration date of 01/22/24, and there was an unsealed package 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-09 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility self-identified areas for improvement and followed the facility policy to ensure the Quality Assurance and Performance Improvement (QAPI) Program reviewed adverse events. This deficient practice occurred for 1 of 1 fractures of unknown origin and was evidenced by the following: Refer to 610G, 761E, 880E On 02/02/24 at 8:55 AM, the surveyor interviewed the LNHA, in the presence of the survey team, regarding what the process was to determine what became a QAPI. The LNHA stated I haven't done anything because I have only been here one month. The LNHA stated he had a meeting with his staff and the surveyor inquired as to what QAPIs were in place already. The LNHA stated that he started looking through the old LNHA's QAPI documents, but he did not get through all of it. The surveyor asked the LNHA how he established what is a high-risk concern and reviewed at QAPI, including adverse events like a reportable event (RE). The LNHA stated he was…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-09 · tag F0761 — failed to label and store drugs safely — pattern
    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, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure resident specific prescription medications were stored securely. This deficient practice was identified for 1 of 2 units (Unit 2) observed and was evidenced by the following: On 01/31/24 at 6:13 AM, the surveyor observed two nurses on Unit 2 working at their medication carts. One nurse was at the high end of the hall, and the second nurse was at the low end of the hall. Both nurses were observed actively working at their nursing carts. The surveyor walked down toward the low end of the hall, toward the middle of the unit and observed a third nursing medication cart. The third nursing medication cart was placed up against a wall across from the nursing desk. The surveyor observed six bingo cards (a pop out pill dispensing system) with resident names printed on them, with prescription medication inside the bingo cards, a container with a resident name printed on it that contained prescription eye drops, and a prescription inhaler system…

    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 · E2024-02-09 · tag F0880 — failed to prevent and control infections — pattern
    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, record review, and review of facility documentation, it was determined that the facility failed to a.) properly don (put on) a Personal Protective Equipment (PPE) gown used to mitigate the spread of infection for Resident #306, 1 of 4 residents reviewed for Transmission Based Precautions (TBP) , b.) maintain appropriate infection control practices for 2 residents (Resident #106 and #306) with an indwelling urinary catheter, and c.) to perform appropriate hand hygiene during meal service on 1 of 3 units (Unit 3) for two meals. This deficient practice was evidenced by the following: a.) On 01/30/24 at 8:21 AM, Surveyor #1 observed a staff member outside of Resident #306's room. The surveyor observed signage posted at the door for enhanced barrier precautions which included but was not limited to; providers and staff must also: wear gloves and gown for the following high-contact resident care activities which included dressing and transferring. The surveyor observed a bin full 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-09 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to ensure all residents had a call bell available and within reach to alert staff for assistance. This deficient practice was identified for 2 of 25 residents reviewed for call bells (Resident 100 and Resident #6) on 2 of 3 resident units (Unit #1 and #2) and was evidenced by the following: On 01/29/24 at 11:40 AM, while in the hallway on the Unit #1, Surveyor #1 heard a staff member calling on the nurse to assist with Resident #106. The surveyor followed the nurse and observed Resident #106 sitting on a low bed and had attempted to get out of the bed unassisted. The resident stated that he/she needed to go the bathroom. The surveyor did not observe a call bell located near the resident. On 01/29/24 at 12:11 PM, Surveyor #1 observed the resident in a recliner chair at the nurse's station. The surveyor attempted to interview the resident. The resident stated,I need to go to sleep and you should go to sleep. The surveyor returned to the room and observed the call…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · 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 interview, record review and document review it was determined that the facility failed to ensure that a complete and thorough investigation was conducted for Resident # 257 who sustained a fracture of unknown origin of the left hip. Resident # 257 required an Open Reduction and Internal Fixation (ORIF) of the left hip on 09/25/23 . This deficient practice was identified for 1 of 1 Resident (Resident #257) reviewed for fracture of unknown origin and was evidenced by the following: Refer to 684G On 02/02/24 at 9:58 AM the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) regarding reportable events and the Quality Assurance and Performance Improvement process. The surveyor inquired about any recent significant events and the DON informed the surveyor about Resident #257 who sustained a fracture of unknown origin. The surveyor inquired further about what was completed regarding the incident, and the DON stated the resident fell at home and I just did an investigation…

    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 · Dcited before2024-02-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to revise a resident-centered on-going Care Plan (CP) for a resident who received oxygen therapy. This deficient practice was identified for 1 of 25 residents (Resident #47) reviewed for CP and was evidenced by the following: On 01/29/24 at 11:05 AM, the surveyor observed Resident #47 lying in bed. The resident was observed to be wearing a nasal cannula (nc) with oxygen tubing attached to an oxygen concentrator that was situated on the floor next to the bed. On 01/29/24 at 2:21 PM, the surveyor observed Resident #47 in his/her room lying in bed with a nc on, the oxygen tubing attached to an oxygen concentrator which was situated on the floor next to the bed. Resident #47 stated he/she was not aware of the amount of oxygen that he/she was receiving. A review of the admission Record revealed that Resident #47 had diagnoses which included but were not limited to; chronic respiratory failure with hypoxia (lack of oxygen), paraplegia (a type 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-09 · tag F0658 — failed to meet professional standards of care — isolated
    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

    Complaint #169841 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain professional standards of nursing practice by failing to: a.) follow a physician order for weights for 1 of 4 residents (Resident #95) reviewed for nutrition, and b.) administer physician prescribed medications and document physician notification for 1 of 4 closed records (Resident # 256) reviewed. The deficient practice 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 counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference:…

    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 before2024-02-09 · 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

    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 follow physician orders for the oxygen settings at liters per minute (lpm). This deficient practice was identified for 2 of 2 residents (Resident #34 and #47) reviewed for oxygen and was evidenced by the following: a.) On 01/29/24 at 9:39 AM, the surveyor toured the Unit 2 and observed Resident #34 lying in bed awake and alert. The surveyor observed that Resident #34 had a nasal cannula (nc) on, and the tubing was attached to an oxygen concentrator which was situated on the floor next to the bed. The oxygen setting was 3.5 lpm. Resident #34 stated that staff had told him/her their oxygen level was low and he/she needed to use oxygen and he/she had never used oxygen before. Resident #34 stated the oxygen dries out my nose. A review of the admission Record revealed that Resident #34 had diagnoses which included but were not limited to; multiple sclerosis, Chronic Obstructive Pulmonary Disease (COPD) chronic respiratory…

    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 · Fcited before2021-10-19 · tag F0761 — failed to label and store drugs safely — widespread
    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 documentation, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This deficient practice was observed in 3 of 3 medication carts on 3 of 3 nursing units and 1 of 2 medication storage rooms reviewed for medication storage and was evidenced by the following: On 10/14/21 at 9:51 AM, the surveyor in the presence of Licensed Practical Nurse (LPN #1) observed nursing Unit 3's medication cart which contained a total of 16 loose medication pills of various colors and sizes in the bottom of the drawers. LPN #1 collected these pills as they were discovered, counted, and were disposed of using the medication cart drug buster bottle. At this time, LPN #1 informed the surveyor that medication carts were cleaned monthly by housekeeping and that the nurses assigned to each cart ensured medication pills were not loose in the drawers. LPN #1 further stated that she checked for loose pills a couple…

    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 before2021-10-19 · 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 record review, it was determined that the facility failed to: a.) ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on five of five medication carts and 2 of 3 medication carts reviewed for medication storage (Unit 1 and 2 high sides). This deficient practice was evidenced by the following: 1. On 10/14/21 at 10:19 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the nursing Unit 3's October 2021 Narcotic Shift Count log which revealed the following: 10/1/21 11 PM - 7 AM shift; 10/3/21 3 PM - 11 PM shift; and 10/6/21 3 PM - 11 PM shift Is the count correct column was blank. 10/13/21 7 AM - 3 PM shift, the column for correct count and the nurse's signature for going off duty was blank. 10/14/21 11 PM - 7 AM, going off duty nurse signature was blank At this time, the surveyor interviewed LPN #1 who stated that both the incoming and…

    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 · Dcited before2021-10-19 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 10/12/21 at 9:42 AM, the surveyor toured the kitchen with the Food Service Manager (FSM) and observed the following: In the milk walk-in refrigerator 1. One opened nine-pound container of feta cheese labeled received 9/27/21. There was no date when the feta cheese was opened or when to use by. The FSM stated that the cheese should be used within seven days of opening and discarded. 2. One chocolate cake labeled and dated 10/6/21 and 10/8/21. The FSM stated that the chocolate cake should have been discarded on 10/8/21. 3. One five-pound opened cottage cheese container. The container had a printed use by date of 9/4/21. 4. Four five-pound unopened cottage cheese containers with a use by date of 9/4/21. 5. One opened container of blueberry muffin batter. The container had no…

    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

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

$163,101 in federal fines across 2 penalties.

  • $148,970 — penalty dated 2026-03-23
  • $14,131 — penalty dated 2024-02-09

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 COMPLETE CARE — 85 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 3 of 53.1-0.1 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 84 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Complete Care At Chestnut Hill LLCPassaic, NJ 1 of 5Complete Care At HagerstownHagerstown, MD 1 of 5Complete Care At Harston Hall LLCFlourtown, PA 1 of 5Complete Care At Kimberly Hall NorthWindsor, CT 1 of 5Complete Care At Laplata LLCLaplata, MD 1 of 5Complete Care At Milford Manor LLCWest Milford, NJ 1 of 5Complete Care At Wayne Hills Rehab & Resp CenterWayne, NJ 1 of 5Complete Care at Care AgeBrookfield, WI 1 of 5Complete Care at KensingtonWaukesha, WI 1 of 5Complete Care at Maple Grove LLCMadison, WI 1 of 5Complete Care at Margate ParkChicago, IL 1 of 5Complete Care at the BoulevardChicago, IL 2 of 5Complete Care At Brakeley ParkPhillipsburg, NJ 2 of 5Complete Care At Fox HillVernon, CT 2 of 5Complete Care At Harborage LLCNorth Bergen, NJ 2 of 5Complete Care At Harrington CourtColchester, CT 2 of 5Complete Care At HyattsvilleHyattsville, MD 2 of 5Complete Care At Inglemoor, LLCEnglewood, NJ 2 of 5Complete Care At Monmouth, LLCLong Branch, NJ 2 of 5Complete Care At Ocean Grove LLCOcean Grove, NJ 2 of 5Complete Care At Prospect Heights LLCHackensack, NJ 2 of 5Complete Care At Regent LLCHackensack, NJ 2 of 5Complete Care at Christian Home LLCWaupun, WI 2 of 5Complete Care at Grande PrairiePleasant Prairie, WI 2 of 5Complete Care at Heritage LLCDundalk, MD 2 of 5Complete Care at Linwood, LLCLinwood, NJ 2 of 5Complete Care at Nazareth LLCStoughton, WI 2 of 5Complete Care at Voorhees, LLCVoorhees, NJ 2 of 5Complete Care at Wall LLCWall, NJ 3 of 5Complete Care At Fair Lawn EdgePaterson, NJ 3 of 5Complete Care At Holiday CityToms River, NJ 3 of 5Complete Care At Lehigh LLCMacungie, PA 3 of 5Complete Care At Oak Ridge LLCCharleston, WV 3 of 5Complete Care At Orange ParkEast Orange, NJ 3 of 5Complete Care At Phillipsburg, LLCPhillipsburg, NJ 3 of 5Complete Care At Severna Park LLCSeverna Park, MD 3 of 5Complete Care At Shrewsbury LLCShrewsbury, NJ 3 of 5Complete Care At Silver Lake LLCDover, DE 3 of 5Complete Care At SpringbrookSilver Spring, MD 3 of 5Complete Care at Brick LLCBrick, NJ

Showing 40 of 84; lowest-rated first.

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
EEF CAPITAL LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST40%since 06/13/2018
PEACE CAPITAL LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST59%since 06/13/2018
SCHLAFF, BENNYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST20%since 06/13/2018
SCHLAFF, NACHUMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST20%since 06/13/2018
STEIN, SHALOMIndividualW-2 MANAGING EMPLOYEEsince 06/13/2018

2 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.

$12.9M
Net patient revenuemost recent cost report
-15.8%
Operating marginrevenue minus expenses
$2.5M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 12%Other / private 17%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$408per resident / day
operating cost
$12,414per month
≈ monthly operating cost
$353per 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 315274. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, 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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