Complete Care At Court House, LLC
144 Magnolia Drive, Cape May Court House, NJ 08210 · For profit - Limited Liability company · 120 certified beds · (609) 465-7171 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
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 | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 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 | 2.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.8% | 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 | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.2% | 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 | 1.4% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.8% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.8% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.5% | 15.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.7% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.8% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.7% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.6% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.88 | 2.07 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.76 | 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.
59.2% 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 261 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 91.4% 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 105 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 35% 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 | 59.2%CMS range 53.1–64.1 | 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 | 11.2%CMS range 8.5–15.4 | 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 | 91.4% | 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 | 95.2% | 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 | 87.6% | 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 | 99.1% | 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 | 1.1% | 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 | 2.2% | 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 | 6.1%CMS range 3.7–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 120 beds and averages 99.5 residents a day — about 83% occupied, or roughly 20 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.25 hrs/resident/day on weekends vs 3.65 on weekdays — 11% thinner on weekends. RN hours go from 0.39 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · D2025-12-29 · 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
Complaint #: 2695513 Based on interviews, medical record review, and review of pertinent facility documents on 12/19/25 and 12/23/25, it was determined that the facility failed to adequately assess and implement measures to protect a resident (Resident #3) who was identified as a high risk for elopement on their initial admission nursing assessment. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed for elopement risk.This was evidenced as follows:Resident #3 was not at the facility at the time of the survey and a closed record review was conducted. According to the admission Record face sheet (an admission summary), Resident #3 was admitted to the facility with diagnoses which included but were not limited to: cognitive communication deficit, type II diabetes, metabolic encephalopathy (brain dysfunction from a chemical imbalance in the body), and acute kidney failure. A review of the Facility Reported Event (FRE) dated 12/14/25, revealed the following:At 2:30 AM on 12/14/25 while conducting rounds, a Certified Nursing Assistant (CNA #1) observed that…
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 · E2025-03-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (2nd and 3rd floor) and was evidenced by the following: On 03/06/2025 at 11:06 AM, in the 3rd floor shower/bathroom the surveyor observed the toilet paper holder was rusted and the toilet paper roll was on the floor. There was no roller observed on the toilet paper holder. On 03/11/2025 at 08:45 AM, the surveyor completed environmental rounds on the 3rd floor as follows: *Door trim on all rooms of the 3rd floor noted with chipped paint and black colored marks. *cove base board between rooms [ROOM NUMBERS] has areas bubbled out. *bottom of exit door at both ends of hallway has brown colored marks and what appears to be rust. *resident doors on bottom tan color have black colored scuff type marks on all rooms. *room [ROOM NUMBER], 313 and 315 floor with gap in flooring joints upon entering. *door casings on bathroom…
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 · D2025-03-13 · 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
NJ 173198 Based on observation, interview and record review, and review of other facility documentation, it was determined that the facility failed to; a) ensure proper administration of medication during medication pass observation for 1 of 5 residents observed (Resident #43); b) document the administration of a medication in the Electronic Medication Administration Record (EMAR) for 1 of 2 residents sampled for pain (Resident #196); c) clarify physician's admitting medication orders for 1 of 1 post orthopedic surgery residents admitted for rehabilitation services sampled for anticoagulation therapy (Resident #196), in accordance with professional standards of practice. This deficient practice was evidenced as follows: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching,…
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 · D2025-03-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 Based on observation, interview, review of medical record and other facility documentation, it was determined that the facility failed to follow a physician's order to promote the prevention of pressure ulcer development. This deficient practice was identified for 1 of 1 resident reviewed for pressure ulcer (Resident #86) and was evidenced by the following: On 03/10/2025 at 8:25 AM, the surveyor observed Resident #86 in bed with eyes opened. The resident was lying on their left side with both legs bent on the knees. The surveyor did not observe any heel boots on the resident or visible in the room. On 03/10/2025 at 10:39 AM, the surveyor observed the resident in bed with eyes opened. The resident laid in bed on their left side with both legs bent on the knees. The surveyor did not observe any heel boots on the resident or visible in the room. On 03/06/2025 at 1:27 PM, a review of the electronic medical record (EMR) revealed the following: A review of the admission Record reflected the resident had diagnoses that…
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 · D2025-03-13 · 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, interviews, record reviews and review of facility provided documents, it was determined that the facility failed to consistently implement a physician order for supplemental oxygen. This deficient practice was identified for 1 of 3 residents (Resident #249) reviewed for respiratory care. The deficient practice was evidenced by the following: On 03/06/2025 at 10:22 AM, during the initial tour of the facility, the surveyor observed Resident #249 seated in their wheel chair with the oxygen (O2) nasal cannula (n/c) (a device that delivers extra oxygen through a tube and into your nose) on his/her lap. The oxygen concentrator was in operation and was observed to be set at two (2) liters (L) per minute (min). Oxygen in use signage was posted on the door frame upon entry to the room. On 03/10/2025 at 11:20 AM, the surveyor observed Resident #249 seated in their wheelchair and playing a game on their tablet. Resident #249 did not have O2 on at this time and stated that it ran out when the surveyor asked why they were not receiving their supplemental oxygen. 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 · D2025-03-13 · 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, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to properly store medication for 1of 25 residents (Resident #352) reviewed. This deficient practice was evidenced by the following: On 3/10/2025 at 8:31 AM, the surveyor observed Resident #352 in their room seated on the bed and connected to an oxygen concentrator (a medical device that takes in air from the room and filter out nitrogen providing higher amount of oxygen) via nasal cannula (tube used to deliver oxygen through the nostrils) at 2 liters per minute. The resident was cognitively intact and indicated to the surveyor through nodding their head that they were good. The surveyor observed an inhaler (a portable device for administering a drug which is to be breathed in) beside a pink wash basin on top of the bedside table to the right. The surveyor pointed to the inhaler and asked the resident what it was. The resident took the inhaler from the bedside table, gave themselves one puff and put the inhaler inside the right pocket 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 before2025-03-13 · 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
Based on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to use appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice, specifically by a.) failing to transport soiled laundry appropriately and b.) failing to wear a the appropriate Personal Protective Equipment (PPE) while transferring a resident who was on Enhanced Barrier Precautions (EBP). The deficient practice was identified for 1 of 2 residents reviewed for EBP (Resident #86) and was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.…
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 before2023-02-02 · 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 record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/25/2023 from 9:47 to 10:43 AM, the surveyors, accompanied by the Director of Dining (DOD) observed the following in the kitchen: 1. Upon entry to the kitchen the surveyors observed a dietary aide (DA) in the cook's area. The female DA had a hair net that only partially covered their hair and the forehead to the middle of the head area was uncovered and exposed. On interview the DOD stated, The hair should be fully enclosed in the hair net. 2. On a lower shelf in the dry storage area, a previously opened bag of egg noodles had no open or use by dates. When interviewed, the DOD responded, It should be labeled with an open date and use by date. Pasta goes 30 days after being opened. I'm throwing it out. 3. In the walk-in refrigerator on an upper shelf a white plastic container contained grated parmesan cheese. The container was dated…
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 · D2023-02-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag is maintained off the floor in accordance with professional standards of practice and facility policy. This deficient practice was identified for 1 of 1 Resident reviewed for an indwelling urinary catheter (Resident # 75) and was evidenced by the following: During the initial tour of the unit on 1/25/2023 at 10:17 AM, Resident #75 was observed resting in bed with eyes closed and with an indwelling urinary catheter. The urinary catheter drainage bag was observed resting on the floor. On 1/27/2023 at 8:54 AM Resident #75 was observed awake, alert and nonverbal resting in bed. Resident #75's urinary catheter drainage bag was observed touching the floor. A review of the admission Record revealed that Resident #75 was admitted with a diagnosis including but not limited to: Neurogenic bladder or obstructive uropathy . A review of the Order Summary Report of active orders as of 2/2/2023, revealed…
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 · D2023-02-02 · 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
Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure nutritional formula connected to a feeding tube (surgically placed tube into the stomach to provide nutritional formula) was accurately labeled for 1 of 1 resident (Resident #26) reviewed for tube feeding. The deficient practice was evidenced by the following: On 1/30/2023 at 9:04 AM, the surveyor observed a bottle of nutritional formula hanging from a pole that was connected to a feeding pump that was attached to Resident #26's feeding tube while he/she was in bed. The feeding pump was operating. At that time, the surveyor observed that the date written on the bottle was 1/27, indicating that the nutritional formula was opened on January 27th. A review of Resident #26's Quarterly Minimum Data Set (an assessment tool) dated 11/25/22, revealed that he/she had a feeding tube while a resident in the facility. A review of Resident #26's physician orders located in the electronic medical record (EMR) revealed an order for Jevity 1.5…
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 5 citations
- Potential for harm · D2023-02-02 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #89 Based on observation, interview, record review and review of other pertinent facility records, it was determined that the facility failed to a.) accurately implement a physician prescribed fluid restriction order for 1 of 2 resident's (Resident #89) reviewed for dialysis, and b.) provide a meal or nourishment to a resident before or after completion of their dialysis treatment for 1 of 2 resident's (Resident #89) reviewed for dialysis. This deficient practice was evidenced by the following: On 01/26/2023 at 12:16 PM the surveyor observed and interviewed Resident #89 in his/her room accompanied by resident's lifelong friend. Resident #89 stated that he/she was up at approximately 4 AM for a 4:30 AM pick-up time to go to dialysis. Resident stated that he/she was provided an apple juice and a bag of Goldfish by nursing prior to leaving the facility, which he/she consumed. The surveyor questioned Resident #89 whether he/she received a breakfast meal on dialysis days. Resident #89 replied, It's usually…
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 · D2023-02-02 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
FACILITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 1 of 1 garbage dumpsters. This deficient practice was evidenced by the following: On 1/25/2023 at approximately 10:30 AM, the surveyors, accompanied by the Director of Dining Services (DODS) and the Senior Maintenance Director (SMD), observed the following in the facility designated garbage area: Two green dumpsters were behind a chain link fence with a gate. The dumpster closest to the building and designated as a garbage dumpster by the DODS and SMD was observed to have 1 of 2 black hinged lids opened and the bagged garbage was exposed. On interview the DOD stated that doors should be closed at all times to prevent access to rodents. When asked why it is important to keep the lids to the garbage closed the SMD also agreed doors are to be kept shut due to birds and the smell. A review of a facility policy titled Dispose of Garbage 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 before2023-02-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed a) to ensure proper use of personal protective equipment (PPE) for staff on 1 of 2 units (unit 2), a COVID-19 designated unit, in accordance with the Centers for Disease Control and Prevention guidelines for infection control and b). failed to implement infection control measures by maintaining the urine catheter drainage bag off the floor to prevent the spread of infection. This deficient practice was evidenced by the following: On 1/25/2023, during the entrance conference, the facility Assistant Director of Nursing (ADON) provided the surveyors a copy of the facility floor plan. The ADON coded rooms 229, 230, 231, and 232 yellow on the floor plan and stated that these are our COVID-19 positive rooms. On 1/26/2023 at 9:11 AM, the surveyor observed the following while touring the facility's 2nd floor unit. A Registered Nurse (RN#1) was observed to enter room [ROOM NUMBER].…
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 · D2023-02-02 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure their resident call system was intact, functioning properly and accessible in 1 of 9 rooms, as well as failed to follow their own facility policy, Call Lights. This deficient practice was evidenced by the following: On 1/25/2023 at 10:34 AM, Resident #61 was noted resting in bed, alert and awake. The cord belonging to the call device was noted attached to the wall, hanging and resting on the floor. On 1/26/2023 at 10:14 AM, a tour of the same room that both Resident #58 and Resident #61 resided in, revealed that the calling device was not functioning. The distal end of the call device was not intact. During an interview with the Surveyor, Resident #61 stated, It's broken, when asked, could you tell me where your call device is located. Resident #61 replied yes when asked, did you inform anyone. Resident #61 further stated that the call device was broken for approximately 1 to 2 weeks. During an interview with the surveyor on 1/26/2023 at 1:57 PM,…
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 before2021-02-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 2/4/2021 from 8:58 AM to 9:45 AM the surveyor, accompanied by the Director of Dining Services (DODS), observed the following in the kitchen: 1. In the dry storage area on a middle rack of a multi-tiered rack, a sleeve of plastic cups for resident use were opened and exposed. The DODS on interview stated, They are exposed, I usually just throw them away. The DOD threw the plastic cups in the trash. 2. A red bucket with a white label dated 2/4 and half filled with a water-like substance was observed on a lower shelf in the prep area. On interview the DODS stated, We use a quat (quaternary ammonium compounds, potent disinfectant chemicals commonly found in disinfectant wipes, sprays and other household cleaners that are designed to kill germs) sanitizer to disinfect our work…
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
No federal fines in the current CMS record.
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 | 5 of 5 | 3.1 | +1.9 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 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 |
| KLOCKE, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2023 |
| LIRIO, SIXTO | 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 |
| SABELLA, SABRINA | 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 |
| COURTHOUSE CONVALESCENT 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 |
| CILEONE, PATRICIA | 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.
This home reported $2.5M 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 315228. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.