Crest Haven Nursing And Rehabilitation Center
4 Moore Road, Cape May Court House, NJ 08210 · For profit - Individual · 180 certified beds · (609) 465-1260 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $83,230 in federal fines (most recent 2024-11-26)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| 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 | 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 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.5% | 4.6% | 5.4% | worse |
| 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 | 0.4% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 42.6% | 12.1% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.9% | 2.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 2.7% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.8% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.1% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.2% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.1% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 72.1% | 80.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.6% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 18.9% | 8.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.55 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.86 | 1.11 | 1.80 | typical |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
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 208 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.1% 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 61 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 0.17 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 36% 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 52.9–65.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 7.1–12.7 | 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 | 72.1% | 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 | 52.5% | 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 | 73.8% | 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 | 0.0% | 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 | 0.0% | 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 | 6.3%CMS range 3.6–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 180 beds and averages 95.8 residents a day — about 53% occupied, or roughly 84 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.08 hrs/resident/day on weekends vs 3.58 on weekdays — 14% thinner on weekends. RN hours go from 0.34 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-11-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 #: NJ00179530 Based on interviews, review of the medical records, and other pertinent facility documents on 11/15/24, 11/18/2024, 11/21/2024, and 11/25/2024, it was determined that the facility failed to properly notify a Resident's (Resident #1) Primary Physician (RPP) of a need for increased supervision that was recommended by the Psychiatric Nurse Practitioner (PNP) on 11/6/2024. Resident #1 was on Q (Every) 15 minutes checks that was being done by the staff. The NP recommended 1:1 supervision for one week until the next evaluation because Resident #1 would not contract to safety during the meeting. On 11/9/2024, Resident #1 was found in adjoining in a bathroom standing up with a yellow plastic bag over their head and gripping strings tightly around their neck with their hands. The Resident was transferred to an Acute Care Hospital (ACH) for a crisis evaluation. This placed Resident #1 and all residents who are recommended for increased supervision at risk for harm, serious injury and or death for 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #2563285 Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to develop and implement an individualized comprehensive care plan (ICCP) for a resident who was non-compliant with receiving treatments and meals prepared in the facility. This deficient practice was identified for 1 of 3 residents sampled (Resident #1) and was evidenced by the following:On 10/30/2025 at 8:30 AM, the surveyor reviewed Resident #1's medical record.A review of the admission Record face sheet reflected the resident had diagnoses that included but not limited to pressure ulcer of the sacral region (stage 4), malignant neoplasm of the rectum (cancer of the rectum), and fracture of the right fibula. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/28/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderately impaired cognition. The Resident Mood Interview indicated that the resident had little interest or pleasure in…
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 · D2025-10-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to revise an individual Comprehensive Care Plan for a resident with a change in code status. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed and was evidenced by the following:On [DATE] at 10:05 AM, the surveyor observed Resident #2 in the activities room lying in a recliner. The resident interview was not possible due to a diagnosis of dementia (memory loss). On [DATE] at 12:21 AM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record (an admission summary) reflected Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to; dementia, anxiety disorder, and protein-calorie malnutrition (inadequate intake of protein and calories). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of the Resident's care dated [DATE],…
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 · E2025-04-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 a.) nephrostomy (a type of urinary catheter inserted through the skin into the kidney to drain urine when there is blockage) care was consistently performed and documented in accordance with a physician order; b.) nephrostomy flushing was consistently performed and documented in accordance with a physician order; c.) urine output from nephrostomy tube was consistently monitored and documented according to physician orders; d.) urine output from Foley catheter was consistently monitored and documented according to a physician order; and e.) large catheter bag (a bag used to collect urine) was consistently changed to a leg bag when the resident was out of bed according to a physician order. This deficient practice was identified for 2 of 3 residents reviewed for urinary catheter (Resident #1 and Resident #72), and was evidenced by the following: 1. On 4/8/25 at 8:30 AM, the surveyor observed Resident #1 in bed during an incontinence…
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 before2025-04-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: NJ184231 Based on interview, review of the closed medical record, and review of pertinent facility documents, it was determined that the facility failed to notify a resident's family after a change of condition. This deficient practice was identified for 1 of 21 sampled residents (Resident #178), and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #178. A review of the admission Record face sheet (admission summary) revealed the resident was admitted to the facility with diagnoses including; dementia (a decline of cognitive function) and primary hypertension (high blood pressure). A review of the Progress Notes revealed the following: On 1/20/24 at 6:09 AM, the resident was feeling warm and was noted with a non- productive cough. There was no documentation that the family was notified. On 1/22/25 at 5:26 PM, the resident received Tylenol for a temperature of 101 degrees Fahrenheit, was flushed, warm to the touch, and was unable to verbalize symptoms. There was no documentation that the family was notified. On 1/23/25 at 10:38…
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 · D2025-04-14 · 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
Complaint #: NJ184231 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure there was a physician's order (PO) for oxygen administration and b.) administer nebulizor therapy (a method of delivering medications to the lungs by inhaling a mist created by a nebulizer) consistently according to the physician order. This deficient practice was identified for 2 of 3 residents reviewed for respiratory care and services(Resident #178 and Resident #44), and was evidenced by the following: A review of Resident #178's electronic Medical Record (EMR) revealed two progress notes. On 1/23/2025 at 10:45 AM, and on 1/23/25 at 11:00 AM, which indicated the resident was currently on 2 liters of oxygen. A review of Resident #178's admission Record face sheet (an admission summary) revealed they were admitted to the facility with diagnoses which included; dementia (a decline of cognitive function) and primary hypertension (high blood pressure). A review of Resident #178's Order summary report 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 · D2025-04-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 documents, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations. This deficient practice was identified for 1 of 5 residents (Resident #16) reviewed for unnecessary medications, and was evidenced by the following: On 4/10/25 at 10:40 AM, the surveyor observed Resident #16 in bed. The resident stated to the surveyor they were taking pain medications because they had three different types of cancer. The resident further explained acetaminophen (Tylenol) usually did not work and after taking it, they would still be in pain. The resident had tried other pain medications like opioids with some success. The surveyor reviewed Resident #16's medical records. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included; depression, rheumatoid arthritis (chronic inflammation of the joints), malignant neoplasm of the isthmus uteri (cancer of 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 before2025-04-14 · 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, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications used in the facility were labeled and stored in accordance with professional standards to preserve their integrity. This deficient practice was observed in 1 of 2 medication storage rooms (East wing) inspected and was evidenced by the following: On 4/7/25 at 10:42 AM, the surveyor, in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM #1), inspected the East Unit Medication Room. Observed on the counter was two one-liter opened and removed from the protective packaging Intravenous (IV) solutions for dextrose 5% with 0.45% normal saline (D5/1/2 NS). LPN/UM #1 stated they were for a resident who had been discharged and she was unsure how long the solutions were good for once removed from the protective overwrap. During inspection of the medication room refrigerator, an opened bottle of Tuberculin Purified protein derivative (PPD) 5 TU/0.1 ml (5 tuberculin units/0.1 milliliter) labeled house stock was dated opened 2/26/25.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-14 · 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, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) (designed to reduce transmission of multidrug-resistant organisms in nursing homes), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of infection control practice. This was observed for 1 of 2 unsampled resident (Resident #39) reviewed for EBP. This deficient practice 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. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html On 4/9/25 at 10:59 AM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-11-17 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to provide mail delivery services on Saturdays for residents who resided in the facility. The deficient practice was identified for 5 of 5 residents, (Resident #12, #39, #41, #63, and #72) interviewed during the Resident Council Facility Task (a meeting with residents). The deficient practice was evidenced by the following: On 11/08/2023 at 10:33 AM, during the Resident Council Meeting, the surveyor interviewed Residents #12, #39, #41, #63, and #72 regarding mail delivery services. The five residents reported that the mail was not delivered on Saturdays. On 11/08/2023 at 12:45 PM, during an interview with the surveyor, the Director of Activities stated that residents' mail was delivered to the administrative building (building at a different location from the facility) where it got sorted. Then, an activity person picked up the mail and delivered it to the residents. During the same interview, the Activity Aide who was also present in the room, stated that letters were not delivered on Saturdays and Sundays because 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 · E2023-11-17 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an accident/incident for 3 of 6 residents (Resident #22, #55, and #78) reviewed for accident/incidents. This deficient practice was evidenced by the following: 1.) On 11/03/23 at 10:23 AM, during the initial tour, the surveyor observed Resident #22 sitting in a wheelchair in their room. Resident #22 stated that he/she did not have any complaints about the facility. The surveyor reviewed the medical records for Resident #22. According to the Resident Face Sheet, Resident #22 was admitted with diagnoses that included dementia, high blood pressure, muscle weakness, and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body.) A review of the quarterly Minimum Data Set (MDS), an assessment tool utilized to facilitate care, dated 09/26/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 09 out…
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 7 citations
- Potential for harm · E2023-11-17 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to follow professional standards of practice for 2 of 19 residents (Resident #55 and # 195) by not a.) obtaining physicians' orders for treatments for (Resident #55 and #195), b.) providing treatments as ordered by a physician (Resident #55), c.) accurately assessing a resident's skin during weekly skin checks (Resident #55), d.) implementing interventions to protect a resident's skin identified as having frail, fragile skin (Resident #55) and e.) accurately assessing a resident's skin during a admission physical (Resident #195). This deficient practice was evidenced by the following: 1.) According to Resident #55's Face Sheet, the resident was admitted to the facility with the diagnoses which included but was not limited to dementia, osteoporosis (porous bones), and coronary artery bypass graft (CABG) is a procedure used to treat coronary artery disease. The quarterly…
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 · E2023-11-17 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of pertinent facility documentation, it was determined that the facility failed to: a.) provide in-service education at least once every 12 months for 2 out of 5 Certified Nursing Aides (CNA)s personnel files reviewed, (CNA#1 and CNA#4) and b.) complete annual performance reviews for 5 out of 5 CNA personnel files reviewed, (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5). This deficient practice was evidenced by the following: On 11/16/23 at 9:09 AM, the surveyor reviewed the five CNA personnel files which revealed the following: - CNA#1 in-service education was dated 02/10/22. CNA#1 did not receive a performance evaluation. - CNA#2 did not receive a performance evaluation. - CNA#3 did not receive a performance evaluation. - CNA#4 in-service education was dated 02/10/22. CNA#1 did not receive a performance evaluation. - CNA#5 did not receive a performance evaluation. On 11/16/23 at 09:20 AM, the surveyor interviewed the Director of Human Resources for the county who stated that she oversaw the Human Resource Department for the entire county which consisted 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 · E2023-11-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of facility documentation it was determined that the facility failed to: a.) ensure that food items were labeled, dated, and stored properly, b.) ensure that ice machines were cleaned and in safe operating condition, and c.) ensure that equipment was cleaned and maintained to prevent foodborne illnesses. This deficient practice was evidenced by the following: On 11/03/23 at 9:56 AM, the surveyor met with the Food Service Director (FSD) to begin the kitchen tour. 1. One gallon opened container of lemon juice was on the shelf on the seasoning rack. The FSD stated that the container did not belong there and it should have been refrigerated. The FSD immediately disposed of the container. 2. On the Salad Dressing Rack, located next to seasoning rack across from 3 compartment sink in the main kitchen, the surveyor observed a 2.5 feet by 1.5 feet sheet pan that contained food particles and stains. Two knives, a cardboard box, and an unknown kitchen appliance were on top.…
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 · D2023-11-17 · 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 review of medical records and other facility documentation, it was determined that the facility failed to implement Care Plan interventions to reduce the risk for injury for a resident with a known history of skin tears. This deficient practice was identified for Resident #78, 1 of 3 residents reviewed for accidents, and was evidenced by the following: The resident's Face Sheet (FS) indicated that Resident #78 was admitted to the facility with diagnoses that included but were not limited to dysphasia (difficulty swallowing) and Alzheimer's disease. The admission Minimum Data Set (MDS) an assessment tool utilized to facilitate care, dated 08/30/23, indicated that the resident had severe cognitive deficits and required extensive assistance with activities of daily living (ADLs). On 11/03/23 at 10:55 AM, during tour of the [NAME] Unit, the surveyor observed Resident #78 sitting up in a reclining chair. The resident's eyes were closed, and he/she was not able to be interviewed…
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 · D2023-11-17 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint NJ #: 157448, 158079, 162538, 162579, 163502 Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 6 of 13 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Report completed by the facility for the week of 08/21/22 to 08/27/22 revealed the facility had no RN coverage for all shifts on 08/24/22 and 08/26/22. Review of the PBJ Staffing Data Report for Quarter 3 2023 (April 1 - June 30) revealed the facility had no RN hours for the following dates: -04/08/23 (Saturday) -04/09/23 (Sunday) -04/22/23 (Saturday) -05/21/23 (Sunday) -06/03/23 (Saturday) -06/07/23 (Sunday) Review of the Employee Daily Schedule By Shift, provided by the facility, for the aforementioned dates verified that there was no RN scheduled to work 8 consecutive hours on the following days: -08/24/22 -08/26/22 -04/08/23 -04/22/23 -05/21/23 -06/03/23 During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-17 · 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, and review of facility documents, it was determined that the facility failed to properly label and date opened multidose medications for 2 of 3 medication carts (West Side 1 and East Side 1) inspected. This deficient practice was evidenced by the following: On 11/09/23 at 10:16 AM, the surveyor inspected the [NAME] Side 1 medication cart in the presence of Licensed Practical Nurse (LPN) #1. Inside the medication cart, the surveyor observed the following: -1 insulin lispro pen which was opened but not labeled with an opened date -1 insulin glargine pen which was opened but not labeled with an opened date At that time, the Assistant Director of Nursing (ADON) verified the insulin pens had been opened but not labeled with an open date. The ADON further stated that the pens should have been dated upon opening and that she would dispose of the insulin pens. On 11/09/23 at 10:30 AM, the surveyor inspected the East Side 1 medication cart in the presence of LPN #2. Inside the medication cart, the surveyor observed the following: -1 Breo Ellipta inhaler which…
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 before2023-11-17 · 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, medical record review and review of other pertinent facility documentation it was determined that the facility failed to a.) provide a safe environment to prevent the potential spread of infection by not following standards of infection control procedures for 1 of 6 residents reviewed for infection control (Resident #82) from 10/24/23 until 11/06/23, and b.) follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 3 units (West Wing) observed. The deficient practice was evidenced by the following: 1.) The surveyor reviewed Resident #82's Face Sheet (FS) which indicated that the resident had the diagnoses which included but was not limited to dementia and aphasia (a disorder that affects how you communicate). The admission Minimum Data Set (MDS) an assessment tool that facilitates a resident's care, dated 08/07/2023, reflected that the resident had severe cognitive deficits and required limited to extensive assistance…
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
$83,230 in federal fines across 1 penalty.
- $83,230 — penalty dated 2024-11-26
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HESS, JENNIFER | Individual | W-2 MANAGING EMPLOYEE | since 10/02/2017 |
| HOHENSTEIN, T. ZACHARY | Individual | W-2 MANAGING EMPLOYEE | since 10/02/2017 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 315294. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-14, 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.