Complete Care At Burlington Woods, LLC
115 Sunset Road, Burlington, NJ 08016 · For profit - Limited Liability company · 215 certified beds · (609) 387-3620 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $63,469 in federal fines (most recent 2023-12-13)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 18% 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) | 2 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
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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 | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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.
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 | 3.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.6% | 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 | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 21.2% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.2% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.7% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.5% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.4% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 5.4% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 23.3% | 15.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.0% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 96.6% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.8% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.2% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.49 | 2.07 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.75 | 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.
52.2% 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 143 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.4% 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 81 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 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 52.2%CMS range 45.8–61.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.3–12.9 | 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 | 70.4% | 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 | 64.2% | 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 | 54.3% | 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 | 100.0% | 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 | 100.0% | 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 | 1.3% | 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 | 3.1% | 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 | 6.5%CMS range 3.5–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 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 215 beds and averages 180.9 residents a day — about 84% occupied, or roughly 34 beds typically open. It usually has some room. 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.27 hrs/resident/day on weekends vs 3.68 on weekdays — 11% thinner on weekends. RN hours go from 0.43 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2023-12-13 · 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 Based on observation, interview, and record review, it was determined that the facility failed to: a) ensure adequate supervision was provided to a resident to prevent falls, b) follow the facility accident policy to investigate falls, and consistently initiate new fall prevention interventions in response to falls, c) ensure current care plan interventions to prevent accidents were implemented. This deficient practice occurred for 1 of 1 resident reviewed (Resident #116) for fall with major injury who was identified as being at high risk for falls, sustained multiple falls including a fall on 02/14/22 that required transfer to the emergency room which resulted in a fracture of the left proximal humerus (arm bone) and the left olecranon (bony part of elbow), and required a surgical Open Reduction and Internal Fixation (ORIF). The deficient practice was evidenced by the following: On 11/28/23 at 11:44 AM, the surveyor toured the D Unit and observed Resident #116 seated in a wheelchair in the hallway and appeared…
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 before2026-01-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Complaint #2698562Based on interviews, record review of the medical records, and other pertinent facility documents on 1/27/26, it was determined that the facility failed to provide adequate assessment and to provide needed care or services to manage resident's symptoms in accordance with professional standards of practice; after they received report from the resident's family member that the resident had decline in condition. This deficient practice was identified for 1 of 4 residents, (Resident #2) reviewed 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 casefinding; 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…
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 · D2025-06-04 · 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 172662 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to administer medications within scheduled parameters on various shifts in accordance with professional standards of practice. This deficient practice was identified for 1 of 34 residents reviewed for professional standards of practice (Resident #269). 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 Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of 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 · D2025-06-04 · 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, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to 1.) contain nebulizer (a machine used to administer medication in the form of a mist inhaled into the lungs) delivery systems in protective coverings and 2.) ensure a nebulizer was stored appropriately to prevent the potential spread of infection in accordance with the Center for Disease Control (CDC) guidelines for 2 of 4 residents (Resident #99 and Resident #151) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/28/25 at 9:08 AM, Resident #99 was observed lying in bed and the nurse was present for morning medication administration. An oxygen (O2) concentrator (a medical device that separates nitrogen and oxygen from the air around you so you can breathe up to 95% pure oxygen) with oxygen tubing attached was observed at the side of the bed. The O2 concentrator was off on this observation. Resident #99 was not wearing oxygen via nasal cannula (n/c) (a medical device that provides…
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 · D2025-06-04 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the updated nurse staffing report daily. This deficient practice was identified on 5/27/25, and was evidenced by the following: On 5/27/25 at 9:15 AM, upon initial entrance to the facility, the surveyor observed the posted daily staffing in the lobby was dated 5/23/25. While the survey team was in the lobby awaiting the facility administration, the staffing coordinator (SC) entered the lobby and replaced the posted staffing sheet for the current day 5/27/25. At that time, the surveyor interviewed the SC who stated staffing should be posted and updated daily and should have been changed by the weekend nursing supervisors in her absence. She further acknowledged that the posting was four days old for the 5/23/25 staffing. On 6/2/25 at 11:37 AM, the surveyor re-interviewed the SC who stated that staffing should be updated and posted daily in the facility lobby to be visible by everyone. She stated that nursing supervisors should make updates if there are any…
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 before2023-12-13 · 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 document review it was determined that the facility failed to ensure: a) potentially hazardous and perishable food items located in the refrigerator were labeled with a use by date and covered. b) staff restrained hair c) resident food storage areas were maintained in a clean and sanitary manner and food was appropriately labeled and dated with a use by date to prevent the potential for food borne illness. This deficient practice occurred in the main kitchen and 2 of 2 remote resident food pantries and was evidenced by the following: On 11/28/23 at 8:54 AM, the surveyor conducted a tour of the kitchen with Food Service Manager FSM and observed the following: 1) The walk-in refrigerator was observed with opened potentially hazardous food items that were not labeled with a used by date and expired dairy products. This included half a case of bacon stored in a box that was uncovered, exposed to air and was not labeled with a use by date, ham that was opened and exposed to the environment, located on a tray without use by date, and a bag of shredded…
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 · F2023-12-13 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 quality assessment and assurance committee (QAPI) facility failed to ensure: a) written policies and procedures were followed to ensure all adverse events were identified and investigated, b) written procedures were followed to ensure the QAPI was consistently data driven and measurable to ensure the effectiveness of the performance improvement initiative, and c) a mechanism was in place and consistently followed to obtain input from staff, residents/ resident representatives. The deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F584E, F585D, F677E, F686E, F689G, F924E On 11/28/23, during the initial tour of the facility, multiple surveyors observed the following: -9:40 AM: the D Unit had a strong odor of urine throughout the Unit. -11:35 AM, two surveyors observed the condition of room on the D Unit which included: D1- room and bathroom floor visibly soiled. D9- the air conditioner unit and door appeared to be torn…
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 before2023-12-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 #NJ 152052, NJ 152420, NJ 153704 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced on 2 of 3 resident Wings (Wing A & D) and was evidenced by the following: Interviews and observations of Surveyor #2 were as follows: On 11/28/23 at 09:23 AM, upon entrance to the facility, the Director of Nursing (DON) stated that the facility had 3 wings which consisted of Wing A which was the Subacute Unit and had 50 beds, D Wing had 59 beds and E Wing had 50 beds. On 11/28/23 at 9:45 AM, an unsampled resident on D wing informed the surveyor the heat in his/her room had been broken for 4 days. The resident stated that they had been unable to sleep because of the cold. At that time, the Registered Nurse Unit Manager (RN UM) confirmed the head had not been working and that maintenance was made aware. On 11/28/23 at 10:00 AM, a maintenance worker confirmed that the heat had not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-13 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ# 151052, NJ #152112 Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents who were dependent on staff assistance for care, by failing to provide: a) nail care, and b) incontinence care. This deficient practice was identified for 5 of 5 dependent residents (Resident # 20, 76, #101, #106 and Resident #116) reviewed for assistance with activities of daily living. Findings included: On 11/28/23 at 9:40 AM, during the initial tour of the D Unit, a strong urine odor was noted in the hallway. 1. On 11/28/23 at 10:03 AM, the surveyor observed Resident #20 lying in bed in their room. The resident was alert and informed the surveyor that he/she was soiled. He/she could not find the call light to alert the staff, and stated, Please help. The surveyor left the room and informed the nurse of the resident's request. The resident informed 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.
- Potential for harm · E2023-12-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 # NJ 151052 Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to follow the facility policy to ensure that residents who were admitted without a pressure ulcer (PU) and was identified at Mild risk for developing pressure ulcers, and a resident admitted without a PU and was identified as completely limited in ability to respond to pressure-related discomfort, were provided with care and services to prevent worsening, or development of a pressure ulcer by failing to ensure: a) comprehensive skin assessments were accurately documented for a pressure ulcer and interventions were implemented to prevent further skin breakdown and promote healing, b) a resident was kept clean and free of exposure to urine and fecal matter, and c) a resident was evaluated for nutritional status to determine if interventions to increase calories and protein were needed to assist with wound healing. This deficient practice occurred for 1 of 3…
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 · E2023-12-13 · tag F0725 — failed to have enough nursing staff — patternProvide 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 # NJ 149879, NJ 151052, NJ 151398, NJ 152112, Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure sufficient staff were available to: a) provide timely and appropriate incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs) care, b) provide nail care for a resident who was dependent on staff for ADLs, and c) provide colostomy (a surgically created opening in the colon or large intestine) for a resident dependent on staff for colostomy care. This deficient practice was identified for 7 of 9 residents reviewed for ADLs (Resident #20, #76, #101, #106, #116, #354, and closed record #159), and expressed by 5 of 5 residents who attended a resident council meeting and was evidenced by the following: Refer to 677E, 686E, 689G, and 691D. a) On 11/28/23 at 10:03 AM, Surveyor #1 observed Resident #20 lying in bed in his/her room. The resident was alert and informed the surveyor that he/she was soiled. He/she stated he/she could not find the call light to…
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 12 citations
- Potential for harm · E2023-12-13 · tag F0865 — failed to run a quality-improvement (QAPI) program — patternHave 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 observation, interview and document review, it was determined that the quality assessment and assurance committee (QAPI) facility failed to ensure that the facility self-identified areas for improvement including environmental concerns, resident care related concerns and significant incidents. This deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F584E, F585D, F677E, F686, F689G, F924E On 11/28/23, during the initial tour of the facility, multiple surveyors observed the following: -9:40 AM: the D Unit had a strong odor of urine throughout the Unit. -11:35 AM, two surveyors observed the condition of room on the D Unit which included: D1- room and bathroom floor visibly soiled. D9- the air conditioner unit and door appeared to be torn apart, the privacy curtain was stained and there was debris on the floor. On 11/28/23 at 12:40 PM, a surveyor interviewed two residents in their room on the A Unit (Sub-Acute). Lunch was delivered to the Room. The surveyor observed both Unsampled residents…
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 · E2023-12-13 · tag F0924 — patternPut firmly secured handrails on each side of hallways.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure handrails were secure and intact on 2 of 3 resident units. This deficient practice was evidenced by the following: On 11/29/23 at 11:52 AM, Surveyor #4 was on E unit and observed that outside of room [ROOM NUMBER], the handrail was not securely fastened to the wall and was slanting down on the left side. Surveyor #4 was able to physically move the handrail up and down. Surveyor #4 observed another handrail across from the E unit nurses station by the bathroom which had a broken jagged end cap. Surveyor #4 observed a handrail by the entrance door of the E unit day room which was visibly not secured to the wall. On 11/29/23 at 11:55 AM, the Registered Nurse Unit Manager (RN UM) on E wing was shown the handrails. The RN UM stated that handrails were for the safety of someone who ambulates. She stated when handrails were broken or loose, it would be very unsafe. On 12/05/23 at 8:30 AM, Surveyor…
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 · D2023-12-13 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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
Complaint # NJ 151052 Based on observation, interview, and review of pertinent facility provided documentation, it was determined that the facility failed to provide meals that were at acceptable temperatures for 5 of 5 residents interviewed and one test tray and ensure palatable food for 6 of 6 residents interviewed. a) On 11/28/23 at 10:27 AM, the surveyor observed Resident #355 sitting at the bedside eating breakfast. When interviewed, Resident # 355 stated the food tastes like prison food. It is bland and has no taste. On 11/29/23 at 12:39 PM, the surveyor observed Resident #355 eating his lunch. Resident # 355 stated the pork chop was a little tough. b) On 11/30/23 at 10:30 AM, Surveyor #4 conducted a resident council meeting with five residents. During the resident council meeting, five of the five residents expressed concerns with the palatability and temperature of the food served at the facility. Examples provided included but were not limited to; the liquid eggs were being baked in a square pan and had no flavor. The resident council participants prefer real eggs. A…
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 · D2023-12-13 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and document review, the facility failed to have the Director of Nursing (DON) present for one of four Quality Assurance and Performance Improvement (QAPI) meeting as evidenced by the following: On 12/12/23 at 12:20 PM, the surveyor reviewed the quarterly QAPI sign-in sheets for the last four quarterly QAPI meetings. The second quarter sign in sheet, dated 04/03/23, was missing the attendance signature of the Director of Nursing (DON). At that time, the DON stated she may have taken that day off but handed in her report for the meeting. A review of the Facility Assessment, dated 09/01/23, revealed that the QAPI committee included the Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing. Infection Control Preventionist, MDS ( Minimum Data Set), dietary representatives, pharmacy, social service, activities, environmental services, rehab/restorative, human resources, safety and records. NJAC 8:39-23.1(3)
- Potential for harm · D2023-12-13 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ 151052 Based on closed record review and review of facility documentation, it was determined that the facility failed to follow their Resident and Family Concerns and Grievances policy and procedure by failing to conduct a formal investigation of a grievance filed by a resident regarding care to determine if abuse had occurred. This deficient practice was identified for 1 of 1 residents (Resident #159) reviewed for a grievance and was evidenced as follows: A review of the closed record revealed that Resident #159 was admitted to the facility with diagnoses which included but were not limited to; fracture of the neck of the left femur, difficulty in walking, unsteadiness on feet, and muscle weakness. A review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate resident care dated 12/26/21, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 15/15 which indicated intact cognition. Section G documented the resident required extensive assistance of at least one staff member for toileting. Section GG documented that 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.
- Potential for harm · D2023-12-13 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ 149879 Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure a resident was provided with a discharge summary at the time of discharge, including a documented mediation reconciliation and post discharge instructions per the facility policy. The deficient practice occurred for 1 of 1 closed records reviewed (Resident #157) for appropriate discharge and was evidenced by the following: On 12/02/23 at 8:49 AM, the surveyor reviewed the closed electronic medical record (EMR) for Resident #157 which revealed a Physician Progress Note, titled Discharge Summary, Signed by a Nurse Practitioner on 10/19/21 at 9:04 PM. The note revealed that Resident #157 was being discharged home with a family member on 10/20/21. The EMR revealed a General type of progress note signed by a Licensed Practical Nurse (LPN), Effective Date: 10/20/2021 at 19:07 [7:07 PM]. The note revealed, resident discharged with medications, scripts and belongings to home with [family member] in personal vehicle. There was a Social Services,…
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 · D2023-12-13 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ 152112 Based on interview and document review it was determined that the facility failed to ensure that resident colostomy care was performed in accordance with physician orders for 1 of 1 closed medical records reviewed (Resident #354) for colostomy care. On 12/07/23 at 9:33 AM, the surveyor reviewed the closed electronic medical record (EMR) for Resident #354 which revealed Resident #354 had Medical Conditions which included, but were not limited to; unspecified lack of expected normal physiological development in childhood, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and irritable bowel syndrome without diarrhea. The Care Plan revealed a Focus area that the resident has an alteration in gastro-intestinal status due to a colostomy, initiated 12/22/2021. The Goal was the resident will remain free from discomfort, complications or signs/symptoms related to gastro-intestinal alterations through review date, initiated 12/22/21. A review of the Order Summary Report, dated 01/01/2022 revealed active physician orders dated 12/22/2021 which included: Colostomy…
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 before2021-07-29 · 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
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.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 7/20/21 at 09:35 AM, the surveyor toured the kitchen in the presence of the Temporary Account Manager ([NAME]) and observed the following: 1. The surveyor washed hands at handwashing sink #1 and observed the paper towel dispenser was empty. The [NAME] stated more paper towels were coming from the stock room. The surveyor also observed the foot pedal trash can had no trash bag with trash and debris in the can. The [NAME] acknowledged the debris and stated it usually has a trash bag. 2. 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.
- Potential for harm · Dcited before2021-07-29 · 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
Based on observation, interviews, and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for the residents. This deficient practice was identified in 3 rooms on 2 of 3 nursing units and was evidenced by the following: 1. During the initial tour on 07/20/2021 at 11:14 AM of E wing the following was observed: In Room E10: 1. The wall on the left was missing wallboard leaving an open area above the floor trim and a large area of stripped wallpaper. 2. Further down on the left side there was another area of stripped wallpaper and an open area with a black cable protruding from the hole. 3. The wall between the heater and the window had a large area of stripped wallpaper. 4. The wall to the right of the bed had a large area with stripped wallpaper from around the red emergency outlets to the floor trim. 5. On the left side of the room, there was a dresser with a missing bottom drawer. 6. In the corner on the right side of the bed, there was a dresser with two missing drawers, the first and third drawers. In Room…
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 before2021-07-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Based on observation, interview, and record review, it was determined that the facility failed to apply geri sleeves (a protective sleeve that is used on the arms or legs) for a resident who was at high risk for bruising, for 1 of 1 resident reviewed for skin conditions (Resident #16). This deficient practice was evidenced by the following: According to the facility's admission Record, Resident #16 was admitted to the facility in 05/2016 with medical diagnoses which included, but not limited to; Hypertension (high blood pressure), Cerebral infarction (damage in the brain due to a loss of oxygen), hemiplegia (severe paralysis of one side of the body) and hemiparesis (mild or partial paralysis to one side of the body). Review of a Minimum Data Set (MDS), an assessment tool dated 04/22/2021, revealed that Resident #16 had a Brief Interview for Mental Status (BIMS) of 13 which indicated the resident was cognitively intact. The MDS also revealed that the resident required extensive assist of one with dressing. Review of the resident's care plan dated 06/09/2016 revealed that 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 · D2021-07-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, review of clinical records and facility policies and procedures, it was determined that the facility failed to a.) provide a timely and adequate nutritional assessment and/or intervention to impede an unplanned significant weight loss and improve the nutritional parameters for 1 of 6 residents reviewed for nutrition (Resident #132). Resident #132 had a unplanned significant weight as follows: Resident #132 experienced a 14.6 pound (lb.) 6 % weight loss in one week between 6/08/21 to 6/15/21, a 10.5% weight loss of 23.9 lbs. in one month from 6/08/2021 to 7/06/21, and a 31.6 lb. weight loss in seven weeks from 6/08/21 to 7/28/21. This deficient practice was evidenced by the following: According to the facility's admission Record, Resident #132 was admitted to the facility in 6/2021 with medical diagnoses which included, but were not limited to; Hemiplegia (paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength) affecting the right side, Vascular Dementia (brain damage caused from interruption of the blood…
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 · D2021-07-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that the facility failed to a.) maintain an accurate accountability and reconciliation for controlled medications in 1 of 1 automated medication dispensing system storage units and b.) maintain an active Drug Enforcement Agency registration, that was not expired, to order and purchase schedule 1 and 2 controlled substances. This deficient practice was evidenced by the following: On [DATE] at 12:25 PM, the surveyor inspected the automated medication dispensing system storage unit (AMDSSU) in the presence of the Assistant Director of Nursing (ADON). The ADON ran a discrepancy report from the AMDSSU which identified that the medication count was accurate and there were no irregularities identified. At that time, the surveyor interviewed the ADON who stated that a second licensed nurse was required to gain access to controlled medications that were contained within the AMDSSU. He then called for a Licensed Practical Nurse (LPN) to assist and access…
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
$63,469 in federal fines across 1 penalty.
- $63,469 — penalty dated 2023-12-13
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 84 homes this chain runs (chain average 3.1★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PC NJ1 OPCOS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2021 |
| PC WTA OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| SMS 2021 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| STEIN, SHALOM | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 07/01/2021 |
| WELLTOWER INC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 07/01/2021 |
| HOCH, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| GOLDMAN, ELIYAHU | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2021 |
| MERCADO, WANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2021 |
| ROSENZWEIG, ALAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2021 |
| SOLARZ, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| AURORA GUARDIAN HOLDCO II CO-BORROWER, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| AURORA GUARDIAN HOLDCO II MEZZ BORROWER, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| AURORA GUARDIAN HOLDCO II, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| AURORA GUARDIAN II REALTY, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| AURORA GUARDIAN PARTNERS II LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| BURLINGTON WOODS REALTY, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| J & R FAMILY INVESTMENTS, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| L FRIEDMAN 2018 FAMILY TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| L FRIEDMAN FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| LANDAU FAMILY INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| M FRIEDMAN 2018 FAMILY TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| PC WTA ACQUISITION LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| PC WTA MULTI-STATE LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| PEACE CAPITAL HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| R&J FAMILY INVESTMENTS LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| BEVANS, SAKIA | Individual | ADP OF THE SNF | — | since 07/01/2021 |
CMS files one row per role, so the 35 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.
19 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.
About 79% 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 $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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 315050. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-04, 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 →
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