Willow Springs Rehabilitation and Healthcare Cente
1049 Burnt Tavern Road, Brick, NJ 08724 · For profit - Corporation · 164 certified beds · (732) 840-3700 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,512 in federal fines (most recent 2024-07-05)
- its facility-reported quality-measure score sits well above its independent inspection score
- about 20% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 3 to 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.8% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 0.8% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.3% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 2.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.5% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.1% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 85.2% | 97.2% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.3% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.5% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.4% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 42.0% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 28.9% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.3% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.14 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.11 | 1.11 | 1.80 | better |
‡ 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.
58.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 378 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.5% 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 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 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.0%CMS range 53.5–63.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 7.9–12.8 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 63.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 53.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 66.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 99.5% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.6%CMS range 6.6–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 164 beds and averages 151.2 residents a day — about 92% occupied, or roughly 13 beds typically open. It runs fairly full. 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.75 hrs/resident/day on weekends vs 3.32 on weekdays — 17% thinner on weekends. RN hours go from 0.68 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%. 1 administrator has left in the past year.
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
Deficiencies are more than at the previous inspection — worsening. 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.
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2024-07-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C/O # NJ163363 Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to: a) assess a resident (Resident #534) in a timely manner by a Registered Nurse (RN) who had an unwitnessed fall which resulted in the resident experiencing pain and a right hip fracture. Resident #534 fell on 4/16/23 at approximately 6:00 PM, and was not assessed until the next day at approximately 10:15 AM (over 12 hours) by the Medical Doctor. This deficient practice was identified for 1 of 4 residents reviewed for falls; and b) failed to ensure that there was a physician order for the use and monitoring of a safety device (Wander Bracelet) used to prevent residents from elopement (leaving a specified area without permission or supervision) in place. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #107). This deficient practice was evidenced by the following: A review of an undated facility provided policy titled,…
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.
- Potential for harm · Fcited before2026-01-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 policy review, the facility failed to ensure the kitchen was clean, staff washed hands and wore gloves appropriately between task changes, and dishes were stacked dry. These failures had the potential to affect 153 residents who consumed food prepared by the kitchen.Findings include:Observations of the kitchen on 01/05/26 at 10:16 AM, revealed dust and debris were visible on the top of the dishwasher that included a rusted spring and dirty knife. The tile wall next to the grill had dust and stains scattered throughout the surface. The floor behind the oven and stove had a layer of black substance against the floorboard and under the three-compartment sink. The oven and stove top had built up grease and black debris. Also, the plate warmers had debris and dust on top of them and there were plates in the warmer that had water on them stacked on top of each other. During an interview on 01/05/26 at 10:45 AM, the Regional Dietary Director (RDD) confirmed the areas during the initial tour of the kitchen, stating they were not clean. The RDD also…
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.
- Potential for harm · Ecited before2026-01-08 · tag F0880 — failed to prevent and control infections — patternProvide 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 facility policy review, the facility failed to ensure staff donned personal protective equipment (PPE) when entering a room with a resident on transmission-based precautions, droplet precautions, and while providing direct care to a resident on enhanced barrier precautions (EBP) for two of five residents (Resident (R)40 and R89) reviewed for infection prevention and control out of a total sample of 49 residents. This failure placed staff and residents at risk of infection from cross-contamination.Findings include:.1. Review of R89's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R89 was admitted to the facility on [DATE], with diagnoses that included stroke, non-Alzheimer's dementia, aphasia (difficulty speaking), and a feeding tube.Review of R89's undated Physician Orders, located under the Orders tab of the EMR, reflected the following orders: Enteral Feed Order four times a day. Give Jevity 1.5 Bolus Feeding…
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.
- Potential for harm · D2026-01-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, record review, and interviews, the facility failed to promote a dignified dining experience by standing to feed two of 15 residents (Resident (R)42 and R101) reviewed for dignity while dining on the Memory Care Unit. This failure had the potential to negatively impact the quality of life for the affected residents.Findings include:1.Review of the admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R42 was admitted on [DATE], with diagnoses including dementia with anxiety, aphasia, and dysphagia.Review of the modified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/25, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R42 was severely cognitively impaired.2.Review of the admission Record, located in the EMR under the Profile tab revealed R101 was admitted on [DATE], with diagnoses that included Alzheimer's disease and aphasia. Review of the quarterly MDS with an ARD of 09/18/25,…
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.
- Potential for harm · D2026-01-08 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed within 14 calendar days after one of one resident (Resident (R) 36 elected hospice benefits out of a sample of 33 residents. This failure could potentially place the resident(s) at risk for unmet care needs being addressed, coordination of hospice care, and care planning of the resident.Findings include:Review of the RAI Manual, dated 10/01/2019, indicated under Section A0310A=04 Significant Change in Status Assessment (SCSA) The SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change in guidelines for either major improvement or decline.An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program.and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date 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.
- Potential for harm · Dcited before2026-01-08 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two of 33 sampled residents (Residents (R) 9 and R36) receiving hospice services. Failure to ensure the accuracy of the MDS for residents receiving hospice services could lead to inaccurate assessment, place the residents at risk for unmet care needs being addressed, and care planning of the residents.Findings include: Review of the RAI Manual, dated 10/01/2019, indicated under Section J1400 Prognosis: indicated Definition: Condition or chronic disease that may result in a life expectancy of less than 6 months; In the physician's judgement, the resident has a diagnoses or combination of clinical conditions that have advanced or will continue to advance to a point that the average resident with that level of illness would not be expected to survive more than 6 months. This judgement should be sustained by a physician note.Steps for Assessment: 1. Review the medical record for documentation…
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.
- Potential for harm · D2026-01-08 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 facility policy review, the facility failed to ensure two of 33 sampled residents (Resident(R)7 and R174) received a baseline care plan within 48 hours of admission into the facility. This deficient practice had the potential to allow residents not to receive the instructions for a person-centered care plan after admission. Findings include:1.Review of R7's admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R7 was admitted to the facility on [DATE], with diagnoses of muscle wasting, heart failure, and falls.Review of the Progress Notes, located in the EMR under Progress Notes revealed an Initial Navigation Guide Meeting note dated 10/15/25, revealed the review of the baseline care plan was completed13 days after R7's admission.2.Review of R174's admission Record, located in the EMR under the Profile tab revealed R174 was admitted to the facility on [DATE], with diagnoses of trauma ischemic muscle, type two diabetes, 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.
- Potential for harm · D2026-01-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure a person-centered comprehensive care plan was developed for one of one resident (R36) receiving hospice services out of a total of 33 sampled residents. This deficient practice placed the resident at risk for unmet resident care needs.Findings include:During an observation and interview on 01/05/26 at 10:00 AM, R36 was observed in his/her room and confirmed that he/she was receiving hospice services.Review of R36's facility Physician orders, dated 08/25/25, and located under the Orders tab in the electronic medical record (EMR) indicated, Admit to [name of hospice agency].Review of R36's [name of hospice agency] documentation located in a white hospice binder at the nurse's station indicated R36 was admitted to hospice services on 08/22/25 with a terminal diagnosis to include malignant neoplasm of overlap sites of bronchus and lungs.Review of R36's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/25, and located in the residents EMR…
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.
- Potential for harm · D2026-01-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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, record review, and facility policy review, the facility failed to ensure feeding tube placement was verified prior to administering a nutrition supplement for one of two residents (Resident (R) 89) reviewed with feeding tubes out of a total sample of 33. This failure had the potential to place residents at risk of aspiration and hospitalization.Findings include:Review of R89's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R89 was admitted to the facility on [DATE], with diagnoses that included stroke, non-Alzheimer's dementia, aphasia (difficulty speaking), and a feeding tube.Review of R89's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/13/25, and located under the MDS tab of the EMR, revealed R89 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R89 was cognitively intact.Review of R89's undated Physician Orders, located under the Orders tab of the EMR,…
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.
- Potential for harm · Dcited before2026-01-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 facility policy review, the facility failed to ensure oxygen (O2) concentrators had filters or were free of dust for one of one sampled resident (Resident (R)66) out of a sample size of 33. This failure had the potential for residents to have an increased chance of unnecessary respiratory treatments and/or infection.Findings include:During an observation on 01/05/26 at 2:19 PM, R66 was wearing an oxygen canula connected to an O2 concentrator. The cabinet filter had a layer of dust and lint.During an observation on 01/07/26 at 9:12 AM, R66 was wearing an oxygen canula connected to an O2 concentrator. The cabinet filter had a layer of dust and lint.During an observation and interview on 01/08/26 at 9:41 AM, The Director of Nursing (DON) was shown the filter, and the DON confirmed the filter had lint that should not be there. The DON stated they were just out here servicing the concentrators. Review of R66's electronic medical record (EMR) located under the Profile tab was an undated admission Record, with an admission date 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.
- Potential for harm · D2026-01-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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, record review, and interviews, the facility failed to pharmacy implement processes for receiving controlled substances (CS) for two (Cedar Unit - High Side and Cedar Unit - Low Side Medication Carts) of three medication carts observed for medication storage and labeling. This failure had the potential to create a risk of drug diversion, theft, improper handling of returns, all impacting patient safety and compliance.Findings include:Observation of the medication cart on Cedar - High Side on 01/07/26 at 10:09 AM, with Licensed Practical Nurse (LPN)4 revealed the following controlled substance inventory log sheets of the logbook for controlled medications located on the medication cart, were missing all required components such as the Rx number (a unique identifier assigned to your specific prescription by the pharmacy), Rx date (date controlled substances were issued by pharmacy), and/or the controlled substance label directions:Page (pg) 147 - no Rx numberPg 148 - no Rx number, no Rx datePg 154 - no Rx number, no Rx datePg 155 - no label directionsPg 156 - 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.
Show the remaining 15 citations
- Potential for harm · Dcited before2026-01-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, policy review, and interviews, the facility failed to remove expired medications stored in two of three medication carts (Cedar Unit - High Side and Cedar Unit - Low Side Medication Carts) observed for medication storage and labeling. This failure had the potential for reduced effectiveness or ineffective treatment of medical issues and was at risk for bacterial growth.Findings include:Observation of the Cedar - High Side medication cart on 01/07/26 at 10:09 AM, with Licensed Practical Nurse (LPN)4 revealed the following expired (over the counter (OTC) medications:Zinc 50 mg (milligrams) tablets - expiration date 08/2025; opened 10/06/24Dairy Aid tablets - expiration date 08/2025; opened 11/20/24Folic Acid 800 mcg (micrograms) tablets - expiration date 09/2025; No open dateFish Oil 1000 mg softgels - expiration date 12/2025; No open dateFish Oil 1200 mg softgels - expiration date 11/2025; No open dateDuring a continued observation of the medication cart on Cedar - High Side on 01/07/26 at 10:14 AM, with LPN4 four Potassium chloride extended release (ER) 10…
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.
- Potential for harm · Dcited before2024-12-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 # 180991 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 12/09/2024, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 4 residents (Resident #1). The facility also failed to follow its policy titled Administering Medications. This 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 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 authorized physician or dentist. According to the admission Record (AR), Resident…
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.
- Potential for harm · Dcited before2024-07-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 other facility documentation, it was determined that the facility failed to provide the necessary care and maintenance of respiratory equipment for 1 of 2 residents reviewed for respiratory care (Resident #6). This deficient practice was evidenced by the following: During initial tour on 07/08/2024 at 8:08AM, the surveyor observed Resident # 6 oxygen tubing not labeled, and the bag that held the tubing when not in use was also not dated. On 07/09/2024 at 09:11 AM during an observation of Resident #6, the Oxygen tubing was not labeled or dated. On 07/10/24 at 10:12 AM during an observation of Resident #6, the oxygen tubing and bag were not labeled or dated. According to the admission Record, Resident #6 was admitted to the facility with diagnoses including but not limited to, Respiratory Failure with Hypoxia and Asthma. A review of the Order Summary Report revealed a physician order initiated date of 01/24/24 for oxygen at 2 liters/minute via nasal canula (a device that delivers extra oxygen through a tube into the nose)…
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.
- Potential for harm · D2024-07-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Resident #122 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure specific target behaviors were monitored prior to the administration of an anti-psychotic medication for a resident who received an anti-psychotic medication (Seroquel) since May of 2024. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #122), and was evidenced by the following: On 7/8/2024 at 9:45 AM, the surveyor observed Resident #122 in the dayroom seated in a wheelchair. The resident stated they had woken up early and had just come from therapy and stated his/her mood was fine. The surveyor reviewed the medical record for Resident #122. A review of the admission Record (an admission summary) reflected the resident was admitted to the facility with diagnoses which included heart failure, chronic kidney disease, restless and agitation, and dementia. A review of the admission Minimum Data Set (MDS), an…
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.
- Potential for harm · F2024-07-12 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ00168248, NJ00168274 Based on interviews, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: A review of the Facility Assessment revealed under the Staffing Guidelines that the facility created a staffing pattern to ensure their residents needs are met on a consistent basis. The assessment went on to indicate that Our facility staffing pattern provides a base to ensure that the facility has a sufficient number of qualified staff to meet the needs of the residents. We incorporate the State of New Jersey's regulatory requirements for ratios of direct care staff members to residents into our staffing baseline. A review of the Nurse Staffing Reports revealed the following: 1.For the 2 weeks of Complaint staffing from 01/08/2023 to 01/21/2023, the facility was deficient in Certified Nursing Assistant (CNA)…
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.
- Potential for harm · Dcited before2024-07-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 # NJ 160656 Based on interview, record review, and review of other facility documents, it was determined that the facility failed to ensure medications, treatments, and Enteral feedings were administered within the required time frame consistent with professional standards and facility policy. This deficient practice was identified for 1 of 7 residents (Resident # 234) reviewed for medication, treatment, and Enteral feedings administration. 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: New…
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.
- Potential for harm · D2024-07-05 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ156378, NJ157304, NJ157715, NJ158101, NJ159337, NJ159347, NJ159775, NJ160752 Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure the personal privacy of a resident's body during an incontinence care check. This deficient practice was identified for 1 of 1 residents reviewed for privacy (Resident #14) and was evidenced by the following. According to the admission Record (AR), Resident #14 was admitted to the facility with diagnoses which included but were not limited to, Diabetes (high blood sugar levels), Depression (a mood disorder that causes persistent sadness and loss of interest), and Unspecified Epilepsy (a neurological disorder that causes seizures). 1.) On 07/03/2024 at 9:59 A.M., the Surveyor observed Resident #14 in bed with head of bed elevated at 45 degrees. The Surveyor observed that the Licensed Practical Nurse/Unit Manager (LPN/UM) did not pull the privacy curtain during the incontinence care check. During an interview with the Surveyor on 07/03/2024 at 10:24 A.M., the LPN/UM stated…
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.
- Potential for harm · D2024-07-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
Complaint#: NJ159347 Based on observations and interviews, it was determined the facility failed to maintain a clean and homelike environment for 1 of 3 nursing units (Applewood Unit). The deficient practice was evidenced by the following: The surveyor toured the Applewood Unit on 07/03/2024 and observed the following: 1.) On 07/03/2024 at 9:05 A.M., upon entering the unit, the Surveyor noted a strong urine odor on the unit. The Surveyor observed the Housekeeper on the unit during the tour. 2.) On 07/03/2024 at 1:55 P.M., the Surveyor returned to the unit and as soon as the doors to the unit were opened, the Surveyor noted a strong pungent odor. The Surveyor noted a strong odor of feces while on unit. The Surveyor did not observe any dirty linens on the cart during the tour. Incontinence care was not being provided during that time. The surveyor toured the Applewood Unit on 07/05/2024 and observed the following: 1.) On 07/05/2024 at 9:40 A.M., upon entering the unit, the Surveyor noted a strong urine odor on the unit. The Surveyor observed 2 Housekeepers cleaning the unit. 2.) 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.
- Potential for harm · D2024-07-05 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ159337 Based on interviews and records review on 07/02/2024, 07/03/2024 and 07/05/2024, it was determined that the facility failed to ensure a resident (Resident #19) was free from a medication error for 1 resident of 3 residents (Resident #19) reviewed for medication administration and follow their policy titled Medication Administration. Resident #19 received medication in error that was not prescribed to be administered to the resident. This deficient practice was evidenced by the following. According to the admission Record (AR), Resident #19 was admitted to the facility with diagnoses which included but were not limited to Major Depressive Disorder (Mood disorder that causes a persistent feeling of sadness), Constipation (problem passing stool), Unspecified Dementia (impaired ability to remember, think or make decisions), Abnormal Gait and Dysphagia (difficulty swallowing). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 10/21/2023, Resident #19 had a Brief Interview of Mental Status (BIMS) score of 0/15, which indicated the Resident…
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.
- Potential for harm · Ecited before2022-12-20 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 4 of 4 medication carts on 2 of 2 (Cedar and Birch) nursing units reviewed for medication storage and was evidenced by the following: On 12/9/22 at 10:17 AM, while observing medication administration, the surveyor observed Licensed Practical Nurse (LPN #1) place a pre-filled insulin pen (injectable medication used to treat diabetes and lower blood sugar) with the needle still attached on Resident #70's tray table after administering the injection. LPN #1 then stated she needed to go to the medication storage room to obtain another medication to administer and left the resident's room, leaving the insulin pen with needle unsecured with the resident and their ambulatory roommate in the room. At 10:19 AM, LPN #1 returned with the newly obtained medication, administered it, 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.
- Potential for harm · Dcited before2022-12-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for two (2) of 29 residents reviewed Residents #114 and #112. This deficient practice was evidenced by the following: The surveyor reviewed the admission Record for Resident #114 which reflected that the resident was admitted with diagnoses that included schizoaffective disorder and essential hypertension. The surveyor reviewed the smoking safety evaluation dated 10/13/2022, which indicated that Resident #114 currently smokes. The surveyor reviewed Resident #114's admission MDS dated [DATE]. The section for current tobacco use was coded as zero (0) indicating that Resident #114 does not currently use tobacco. When interviewed on 12/19/2022 at 10:45 AM, the MDS Coordinator stated that she was unaware that Resident #114 was a smoker. She stated that Resident #114's admission MDS dated [DATE], should have been coded as Resident…
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.
- Potential for harm · Dcited before2022-12-20 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 12/6/22 from 10:15 AM -11:13 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The FSD wore a hair net on the top of his head with the sides and back of his hair exposed. The FSD acknowledged his hairnet and stated hairnets were required to be worn in the kitchen. The FSD further stated that it was important that hairnets covered all of the hair to prevent food contamination. 2. In the walk-in refrigerator, there was an open…
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.
- Potential for harm · Dcited before2022-12-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
b.) On 12/06/22 at 11:32 AM, the surveyor observed Resident #23 in their room resting with their eyes closed in bed on a pressure reducing, fully inflated air mattress (a mattress used to reduce the risk of pressure ulcers also known as bed sores). The resident had a sign on their room door indicating Enhanced Barrier Precautions and instructing the requirement to perform hand hygiene prior to entering and exiting the room and the use of PPE including gloves and gown when performing personal care for the resident or in contact with the resident. The surveyor reviewed the medical record for Resident #23. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in October 2022, with diagnosis which included Alzheimer's disease, diabetes, muscle wasting and atrophy (loss of body tissue or mass from wasting or lack of use), local infection of the skin and subcutaneous tissue (the innermost layer of skin in your body), and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or…
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.
- Potential for harm · D2022-12-20 · tag F0888 — isolatedEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of COVID-19, a contagious respiratory infection. This deficient practice was identified for 1 of 2 unvaccinated staff on Cedar Unit and was evidenced by the following: On 12/6/22, during entrance conference, the facility was asked to provide a list of the COVID-19 staff vaccination status for all of their staff, which was provided by the Licensed Nursing Home Administrator (LNHA) on 12/7/22. On 12/12/22, the surveyor reviewed the list which revealed five staff members that were granted exemption from the COVID-19 vaccination. On 12/12/22 at 12:56 PM, on the Cedar Unit, the surveyor observed a COVID-19 exempted staff member exiting a resident's room wearing a surgical mask and a face shield. During an interview at that time, the temporary nurse aide (TNA) stated that he provided personal care (bathed, dressed, toileted) to the residents, assisted with meal tray pass, and fed 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.
- No harm found · B2023-11-03 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00166428 Based on interviews, medical record review, and review of other pertinent facility documents on 11/02/23 and 11/03/23, it was determined that the facility staff failed to consistently document on the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the resident. The deficient practice was identified for Resident #1, 1 of 4 residents reviewed for documentation and was evidenced by the following: The surveyor reviewed the closed record for Resident #1: According to the admission Record, Resident #1 was admitted on [DATE], with medical diagnoses that included but were not limited to fracture of unspecified part of neck of right femur (thigh bone), dementia, moderate with other behavioral disturbance, aphasia (language disorder of expression and comprehension), and muscle wasting and atrophy (decrease in size). The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/21/23, revealed 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.
“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.
- 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.
Fines & penalties
$8,512 in federal fines across 1 penalty.
- $8,512 — penalty dated 2024-07-05
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 MARQUIS HEALTH SERVICES — 87 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.0 | +1.0 vs chain |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; 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 / manager | Type | Role | Since |
|---|---|---|---|
| CIBC BANK USA | Organization | 5% OR GREATER SECURITY INTEREST | since 12/01/2014 |
| PRAMNAUTH, OMKAR | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/02/2025 |
| ROSENBLUM, ELIYAHU | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 08/01/2023 |
| POSEN, MINDEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 01/01/2022 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| RELIANT PRO REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/13/2025 |
| ROTHBERG, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2022 |
| KOHN FAM TR GST EXEMPT UAD 3-25-13 | Organization | ADP OF THE SNF | since 01/01/2022 |
| NFR 2020 IRRV TR | Organization | ADP OF THE SNF | since 01/01/2022 |
| QUINTO GUARDIAN LLC | Organization | ADP OF THE SNF | since 03/14/2019 |
| RSBRMK HOLDINGS LLC | Organization | ADP OF THE SNF | since 01/01/2022 |
| SK 2013 INVESTMENT TR UA 03252013 | Organization | ADP OF THE SNF | since 01/01/2022 |
| TRYKO GUARDIAN HOLDINGS LLC | Organization | ADP OF THE SNF | since 03/04/2019 |
| UAK 2020 IRRV TR | Organization | ADP OF THE SNF | since 01/01/2022 |
| UKR CONSULTING LLC | Organization | ADP OF THE SNF | since 03/14/2019 |
| WILLOW SPRINGS PROPERTY LLC | Organization | ADP OF THE SNF | since 12/01/2014 |
| YR 2013 INVESTMENT TRUST U/A/D 3/25/13 | Organization | ADP OF THE SNF | since 01/01/2022 |
CMS files one row per role, so the 25 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
13 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.
This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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
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
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.
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 315213. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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.