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Barclays Rehabilitation And Healthcare Center

1412 Marlton Pike East, Cherry Hill, NJ 08034 · For profit - Partnership · 108 certified beds · (856) 428-6100 Medicare & Medicaid certified

Call the home — (856) 428-6100 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Aug 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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 (57%) 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.

4/5
CMS overall
4 of 5
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

Urgent care / clinic
1034 Marlton Pike · (856) 429-4922 · Call to confirm hours
Pharmacy
1415 Marlton Pike E · (856) 667-9000 · Call to confirm hours
Grocery
1503 Marlton Pike E · (856) 429-1707 · Call to confirm hours
Park
209 Barclay Ln · (856) 795-6225 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.5%8.7%15.4%better
Long-stay residents who lose too much weight3.6%4.6%5.4%better
Long-stay residents with a catheter left in their bladder1.3%0.6%0.9%worse
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms17.5%12.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.1%2.3%3.3%better
Long-stay residents whose ability to walk worsened8.1%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.1%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine98.7%97.2%95.3%typical
Long-stay residents with pressure ulcers6.1%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control24.6%15.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table1.0%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.9%80.1%79.4%better
Short-stay residents rehospitalized after admission33.0%24.9%22.6%worse
Short-stay residents with an outpatient ER visit8.5%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.202.071.67worse
Long-stay outpatient ER visits per 1,000 resident days1.501.111.80better

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.

55.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 172 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.2%U.S. median 51.5%
Got home and stayed home
12.6%U.S. median 10.7%
Went back to hospital
58.8%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 58.8% 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 85 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.2%CMS range 48.6–62.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.6%CMS range 9.7–17.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge58.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge48.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.7%CMS range 4.9–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.281.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.49
RN hours/ resident / day
1.10
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.69
Total nurse hours/ resident / day
0.18
RN hoursweekends
57.1%
Total nursing turnover
62.5%
RN turnover

How full it usually is: this home is certified for 108 beds and averages 94.2 residents a day — about 87% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 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 3.16 hrs/resident/day on weekends vs 3.91 on weekdays — 19% thinner on weekends. RN hours go from 0.62 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% 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

7
deficiencies at the latest standard inspection (2025-08-20)
12
at the previous standard inspection (2024-02-23)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · E2025-08-20 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that the facility failed to provide necessary treatment services consistent with professional standards of practice by not ensuring a resident received blood sugar monitoring and insulin medication according to a physician's order for 1 of 5 residents (Resident #24) reviewed for unnecessary medications. The deficient practice was evidenced by the following.On 8/15/2025 at 11:45 AM, the surveyor observed Resident #24 self-propelling in the hallway, was talking to themselves, and appeared confused. The surveyor attempted to interview Resident #24, but they did not respond. A review of the medical record revealed the following:A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Dementia with agitation, major depressive disorder and Type 2 diabetes mellitus (DM).A review of the most recent comprehensive Minimum Data Set (MDS), (an assessment tool used to facilitate the management of care), dated July 23, 2025, reflected that the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-20 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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 and document review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from May, June and July 2025, for 1 of 5 residents (Resident #24) reviewed for unnecessary medications. The deficient practice was evidenced by the following: On 8/15/2025 at 11:45 AM, the surveyor observed Resident #24 seated in a wheelchair self-propelling with their feet down the hallway. The resident was talking to themselves and appeared confused. The surveyor attempted to interview the Resident #24, but they did not respond.A review of the medical record revealed the following information: The admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included dementia with agitation, major depressive disorder and Type 2 diabetes (DM). A review of the Order Summary Report (OSR) (physician's order sheet) dated August 2025 revealed a Physician's order (PO) dated 7/1/25 for insulin lispro (medication used to lower blood sugar), inject as…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-20 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 documentation, it was determined that the facility failed to inform and offer educational material regarding Advance Directives (AD) written instruction including but not limited to living will, medication restrictions, and treatment restriction for the provision of healthcare when an individual is incapacitated) with a resident and/or legal representative. This deficient practice was identified for 2 of 2 residents (Resident #24, and Resident #25) reviewed for AD and was evidenced by the following: On 8/12/2025 at 10:31 AM, the surveyor observed Resident #25 in bed with tube feeding (food provided via a tube into the stomach) infusing. in room [ROOM NUMBER]-1. The surveyor attempted to talk to the resident, but the resident did not respond. On 8/12/2025 at 10:31 AM the surveyor reviewed the medical record for Resident #25 which revealed the following: A review of the admission Record (an admission summary) reflected that the resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and review of facility documentation, the facility failed to maintain a resident's wheelchair, wheelchair right armrest, and bathroom in a clean and homelike condition. This deficient practice was identified for 1 of 2 residents reviewed for equipment and environmental care (Resident #44), and was evidenced by the following:Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to maintain a resident's wheelchair, wheelchair right armrest, and bathroom in a clean and homelike manner. This deficient practice was identified for 1 of 2 residents reviewed for environment (Resident #44), and was evidenced by the following:On 8/12/2025 at 9:32 AM, during the initial tour, the surveyor interviewed Resident #44 in their room and was seated in their wheelchair. The resident stated that their wheelchair was pretty dirty and was unsure when it was last cleaned. The surveyor observed visible debris 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to immediately report an allegation of misappropriation of resident property for 1 of 1 residents (Resident #11) reviewed for personal property to the New Jersey Department of Health (NJDOH). This deficient practice was evidenced by the following: A review of the admission Record (admission summary) indicated that Resident #11 was admitted to the facility with the diagnoses which included but was not limited to end stage renal disease (kidney failure) and hypertension (high blood pressure). A review of the quarterly Minimum Date Set (MDS) and assessment that facilitates a resident's care dated 8/8/25, reflected that Resident #11 scored a 10 of 15 on the basic interview for mental status (BIMS) which indicated that the resident had moderate cognitive impairment and exhibited behaviors such as refusal of care. A review of the Care Plan (CP) did not reflect that the resident had accusatory behavior or fabricated stories.On 8/13/2025 at 8:45 AM, the surveyor interviewed Resident #11 who stated that agency Certified Nursing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-20 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy and thoroughly and timely investigate an allegation of misappropriation of property by 1 of 1 resident (Resident #11) who reported missing property to the Licensed Nursing Home Administrator (LNHA). This deficient practice was evidenced by the following:A review of the admission Record (admission summary) indicated that Resident #11 was admitted to the facility with the diagnoses which included but was not limited to end stage renal disease (kidney failure) and hypertension (high blood pressure). A review of the quarterly Minimum Date Set (MDS) and assessment that facilitates a resident's care dated 8/8/25, reflected that Resident #11 scored a 10 of 15 on the basic interview for mental status (BIMS) which indicated that the resident had moderate cognitive impairment and exhibited behaviors such as refusal of care. A review of the Care Plan (CP) did not reflect that the resident had accusatory behavior or fabricated stories.On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to provide the necessary care and services for one (1) of 1 resident (Resident #71) reviewed for respiratory care and was evidenced by the following:Review of the admission Record (admission summary) reflected that Resident #71 was admitted to the facility with the diagnoses that included but was not limited to; chronic obstructive pulmonary disease (COPD) (a chronic lung condition that makes breathing difficult) and depression.A review of the admission Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 6/25/2025, indicated that Resident #71 had a Brief Interview for Mental Status (BIMS) of 10 out of 15 which indicated that the resident had moderate cognitive impairment. The MDS also indicated Resident #71 was dependent on staff for all activities of daily living (ADLs) and was not on continuous and intermittent oxygen (O2) treatments.On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-23 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 9 of 10 days reviewed. This deficient practice was evidenced by the following: Review of the PBJ Staffing Data Report for Quarter 1 2023 (October 1 - December 31) revealed the facility had no RN hours for the following dates: -10/01/23 (Saturday) -10/02/23 (Sunday) -10/09/23 (Sunday) -10/15/23 (Saturday) -10/16/23 (Sunday) -10/29/23 (Saturday) -10/30/23 (Sunday) -11/12/23 (Saturday) -11/13/23 (Sunday) -12/24/23 (Saturday) 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: -10/01/22 -10/02/22 -10/09/22 -10/15/22 -10/16/22 -10/29/22 -10/30/22 -11/12/22 -12/24/22 During an interview with the surveyor on 02/23/24 at 10:32 AM, the Staffing Coordinator (SC) stated that they were to have staffed one…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to maintain a safe clean, comfortable, and homelike environment by a.) ensuring that the resident's wheelchairs were cleaned and repaired in a timely manner and b.) ensuring that each resident had their own waste receptacle (trash can) in their room. This deficient practice was observed for 8 out of 8 residents (Resident #2, #6, #25, #29, #44, #65, #72 and #78) and 3 out of 9 rooms (Rooms 106, 125 and 130) observed during environmental rounds. This deficient practice was evidenced by the following: 1.) On 02/16/24 at 09:14 AM, the surveyor observed Resident #65's wheelchair in the hallway folded but the bottom portion of the wheelchair where the footrest attached and to lock the wheelchair appeared to be dusty and have brown rust on it. On 02/16/24 at 09:16 AM, the surveyor observed Resident #72's wheelchair right arm rest was ripped, the bottom portion of the wheelchair where 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-23 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop a person-centered comprehensive care plan to include a resident's indwelling urinary catheter for 1 of 2 residents (Resident #75) reviewed for urinary catheter. This deficient practice was evidenced by the following: On 02/15/24 at 10:13 AM, the surveyor observed Resident #75 in a geriatric (Geri) chair (a padded, reclining wheelchair). The resident stated he/she had a urinary catheter (a tube placed in the body to empty urine) that was recently changed. The surveyor observed the resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and the bottom of the bag was touching the floor. According to the admission Record, Resident #75 had diagnoses which included, but were not limited to, acute kidney failure (sudden kidney damage), hemiplegia and hemiparesis (paralysis of one side of the body), chronic kidney disease stage 3, and benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Ecited before2024-02-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of foodborne illnesses, and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination. This deficient practice was observed and evidenced by the following: On 02/15/24 from 09:45 AM until 10:45 AM, the surveyor toured the kitchen in the presence of the Food Services Director (FSD) and observed the following: 1. At handwashing sink #1, there was a step lid trashcan that contained used paper towels, with no inner plastic bag. The FSD had no response when asked if the trashcan should have had a plastic bag to contain the trash. 2. In the walk-in refrigerator, there was one 2-inch half pan, that contained a ham sandwich, with clear plastic wrap partially covering the pan. The sandwich was visible and exposed to air. The FSD stated it was important that the pan should have been fully covered to prevent bacteria growth…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-23 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of facility documents, it was determined that the facility failed to accurately utilize an infection assessment tool for 5 of 5 residents (Resident #12, #53, #66, #139, and #286) reviewed that were prescribed antibiotic medications in the facility. This deficient practice was evidenced by the following: Review of the facility's Antibiotic Stewardship line list for January and February 2024, revealed the following residents were prescribed antibiotics while at the facility: 1. Resident #12 was prescribed an antibiotic on 01/05/24 for five days for pneumonia. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria met. 2. Resident #66 was prescribed an antibiotic on 01/09/24 for five days for an upper respiratory infection. The line list did not indicate whether an infection assessment tool was completed. 3. Resident #139 was prescribed an antibiotic on 01/10/24 for three days for a urinary tract infection (UTI). The line list further indicated that an infection assessment tool was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to revise a resident's comprehensive care plan (CCP) for one (1) of 19 residents reviewed (Resident #78). This deficient practice was identified by the following: On 02/15/24 at 10:55 AM, during the initial tour the surveyor observed Resident #78 lying in bed watching TV. Resident #78 stated that he/she was fine and had no concerns at that time. The surveyor reviewed the medical record for Resident #78. A review of the admission Record (AR) reflected that the resident was admitted to the facility with diagnoses that included, malignant neoplasm of prostate (prostate cancer), hypertension (high blood pressure, muscle weakness and dysphagia (difficulty swallowing). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 02/07/24, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. A review of the Order Summary Report (OSR) for February 2024…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 4 of 6 residents (Residents #17, #35, #39, #63) observed for incontinence care on 1 of 4 units (B hall). This deficient practice was evidenced by the following: On 02/20/24 at 09:04 AM, the Long Term Care Unit Manager provided the surveyor with a list of incontinent residents in the facility. On 02/21/24 at 07:49 AM, the surveyor met with the Certified Nursing Assistant (CNA#1) on B hall to complete an incontinence tour. At that time, CNA#1 stated it was the previous CNA's responsibility to do incontinence rounds before they finished their shift. On 02/21/24 at 07:59 AM, the surveyor and CNA#1 greeted Resident #35 in their room and the resident was made aware of the incontinence rounds. Resident #35 was observed to have worn two diapers, with the inner diaper saturated with urine 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 facility documents, it was determined that the facility failed to a.) ensure an indwelling urinary catheter drainage bag did not touch the floor or geriatric chair wheel, and b.) ensure the urinary catheter drainage bag was kept below the level of the bladder for 1 of 2 residents (Resident #75) reviewed for urinary catheter. This deficient practice was evidenced by the following: On 02/15/24 at 10:13 AM, the surveyor observed Resident #75 in a geriatric (Geri) chair (a padded, reclining wheelchair). The resident stated he/she had a urinary catheter (a tube placed in the body to empty urine) that was recently changed. The surveyor observed the resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and the bottom of the drainage bag was touching the floor. On 02/16/24 at 12:39 PM, the surveyor observed Resident #75 in a Geri chair. The resident's urinary catheter drainage bag was secured to the Geri chair without a privacy cover and was touching the wheel of the Geri chair. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services for 1 of 1 resident (Resident #139) reviewed for respiratory care. The deficient practice was evidenced by the following: On 02/15/2024 at 10:04 AM, Surveyor #1 observed Resident #139 resting in bed, reading a book and was fully dressed for the day. Surveyor #1 observed that Resident #139 had oxygen (O2) being administered via (by way of) nasal cannula at three (3) liters/minute. The oxygen tubing was not labeled or dated. Resident #139 stated that he/she had pulmonary fibrosis (a condition in which the lungs are scarred, causing difficulty breathing) and required O2. Resident #139 further stated that he/she was not sure how often the staff changed the tubing. On 02/16/2024 at 12:34 PM and on 02/20/2024 at 10:24 AM, Surveyor #1 observed Resident #139 with O2 being administered via nasal cannula at 3 liters/minute and the oxygen tubing was not labeled or dated. On 02/22/2024 at 09:37 AM, Surveyor #2 conducted a review of the medical…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were accurate and consistent for 2 of 19 medical records reviewed (Resident #17 and #24). This deficient practice was evidenced by the following: 1). The surveyor reviewed Resident #17's Electronic Medical Record (EMR) which revealed the following: According to the admission Record, Resident #17 had diagnoses which included, but were not limited to, Alzheimer's Disease. Review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/20/24, included the resident had a Brief Interview for Mental Status score of 03 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was receiving hospice care. Review of the Order Summary Report, as of 02/21/2024, included a physician's order for Do Not Resuscitate (DNR) dated 02/08/24. Review of the Care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 pertinent facility documentation it was determined that the facility failed to a.) ensure the infection control practices for residents on transmission-based precautions (TBP) were followed to prevent the potential spread of infection by not utilizing droplet precautions in accordance with facility policy and accepted national standards for 1 (one) of 1 (one) resident (Resident #140) reviewed for TBP, and b.) follow appropriate infection control practices and perform hand hygiene as indicated during meal tray pass for 1 of 4 units (Cart 1 unit) observed. This deficient practice was evidenced by the following: 1.) On 02/15/24 at 10:09 AM, Surveyor #1 observed the outside of Resident #140's room and observed a sign posted on the resident's door that the resident was on Droplet Precautions [Infections transmittable through air droplets by coughing, sneezing, talking, and close contact with an infected patient's breathing. Droplets are about 30 to 50 micrometers in size]. The sign also indicated that the proper…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-11-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/22/2021 from 9:09 to 10:24 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On a middle shelf in the walk-in refrigerator, a can of pineapple crushed had a significant dent on the upper seam. The FSD stated, I'm removing that to the dented cans. 2. On an upper shelf of the walk-in refrigerator 6 unopened containers of plain non fat yogurt had a Best if used by date of 11/7/2021. On interview the FSD stated, I usually check the dates in the morning but we don't use these anymore. They should have been thrown out. 3. On a prep table next to the stove a box of plastic wrap had its lid removed and the plastic wrap was exposed to contamination. On interview the FSD stated, It needs to be covered when not in use. 4. In the walk-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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and other facility documentation, it was determined that the facility failed to maintain a clean and sanitary environment on 1 of 2 Units, Unit 1. This deficient practice was evidenced by the following: a.) On 11/22/21 at 10:39 AM, during the initial tour of the facility, in Resident #58's room, the surveyor observed a dried, brown substance on the floor under a portable pole that had nutritional formula hanging from it. On the same date at 10:47 AM in Resident #75's room, the surveyor observed a dried, brown substance on the floor under a portable pole that had nutritional formula hanging from it. On 11/23/21 at 8:47 AM in Resident #58's room, the surveyor observed a disposable under-pad (highly absorbent bed pad) on the floor over the area where the brown substance was observed the previous day. The disposable pad had brown stains on it. At that time, the surveyor lifted the the corners of the disposable under-pad revealing the dried, brown substance observed the previous day.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 interview, record review, and review of other facility documentation, it was determined that the facility failed to monitor and follow-up on comments/recommendations made by the Consultant Pharmacist (CP) regarding a medication error in accordance with its established policy. This was identified for 1 of 5 residents reviewed for unnecessary medications, (Resident #20). This deficient practice was evidenced by the following: 1. A review of the 9/18/2021 quarterly Minimum Data Set (MDS), an assessment tool revealed that Resident #20 had a Brief Interview for Mental Status score of 12, which indicated moderate cognitive impairment. According to section I Resident #20 had an active diagnosis of depression and section N revealed that Resident #20 received a daily antidepressant. 2. A review of a psychiatry evaluation, dated 7/1/2021 in the general progress notes revealed that the nurse practitioner (NP) made the following recommendation for Resident #20: Recommend increasing Zoloft (Sertraline HCl) from 50 milligrams (mg) to 75 mg QD (every day) for 5 days and then increase to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-30 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    FACILITY Kitchen 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 2 of 2 garbage dumpsters and 1 of 1 recycling dumpsters. This deficient practice was evidenced by the following: On 11/22/2021 between 9:09 to 10:04 AM, the surveyor, accompanied by the Food Service Director (FSD) observed the following during the initial kitchen tour: 1. During the observation of the garbage area located outside of the facility, the surveyor observed 3 garbage dumpsters. 2 dumpsters were designated as trash dumpsters and 1 dumpster was designated for cardboard recyclables, per the FSD. Dumpster #1 (trash dumpster) was observed to have a door open on the side of the dumpster, exposing the trash contents. Dumpster #2 (trash dumpster) was observed to have 1 of 2 top lids open that exposed the garbage contents and dumpster #3 was observed to have 1 of 2 top lids open and exposed the recycling contents. On interview 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-30 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to a) maintain a Hospice communication record and b) initiate a care plan to address the Hospice services the resident was receiving, for 1 of 2 residents reviewed for Hospice services, (Resident #49). This deficient practice was evidenced by the following: During the initial tour of Unit 2 on 11/22/21 at 10:49 AM, Resident #49 was observed to be lying in bed with the head of bed elevated, on nasal oxygen with 2 people at the bedside who identified themselves as the Hospice nurse and the Residents daughter. A review of the admission Record revealed Resident #49 was admitted to the facility with diagnosis including but not limited to; Cerebral Infarction (stroke). A review of the admission Minimum Data Set (MDS) and assessment tool dated 10/20/21, revealed under section O that Resident #49 received Hospice services while a resident. A review of the Order Summary Report dated 11/25/21 revealed a physician order dated 10/8/21 for Hospice as 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, and review of other pertinent documentation, it was determined that the facility failed to perform hand hygiene after direct patient contact when a.) a Certified Nurse Assistant (CNA #1) placed her bare hands on the bare legs of Resident #41 to readjust them, then wiped the resident's mouth with a napkin, followed by touching clean utensils to feed the resident, and b.) when a CNA placed a clothing protector that was retrieved from the floor onto a resident (Resident #41). The deficient practice occurred for 1 of 9 residents observed for dining. This deficient practice was evidenced by the following: a.) On 11/23/21 at 11:59 AM, the surveyor observed CNA #1 in Resident #41's room. Resident #41 was seated in a chair while the CNA was preparing to assist in feeding him/her. CNA #1 adjusted Resident #41's legs by placing her bare hands on his/her bare skin. At this time, CNA #1 used a napkin to wipe Resident #41's mouth. CNA #1 then removed clean utensils from a plastic wrap on the meal tray and began to feed Resident #41. b.) On the same date at 12:02…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-30 · tag F0912 — isolated
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 on 12/01/2021 in the presence of facility management, it was determined that the facility failed to ensure that 12 of 39 double occupancy resident rooms were provided with the minimum of 80 square feet of useable living space per bed. This deficient practice was evidenced by the following: During the previous facility survey on 2/10/2020, the facility had 30 rooms that did not meet the 80 square feet per resident in a multiple resident room requirement. The following double occupancy resident rooms did not meet the required 80 square feet per resident, - Resident room [ROOM NUMBER] measured 152.033 square feet. - Resident room [ROOM NUMBER] measured 155.971 square feet. - Resident room [ROOM NUMBER] measured 149.662 square feet. - Resident room [ROOM NUMBER] measured 153.281 square feet. - resident room [ROOM NUMBER] measured 156.243 square feet. - Resident room [ROOM NUMBER] measured 156.621 square feet. - Resident room [ROOM NUMBER] measured 153.714 square feet. - Resident room [ROOM…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Waiver has been granted
  • No harm found · B2024-02-23 · tag F0637 — pattern
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of facility documents, it was determined that the facility failed to complete a Significant Change in Status Assessment within 14 days for a resident who was admitted to hospice services. This deficient practice was identified for 1 of 1 resident (Resident #17) reviewed for hospice and was evidenced by the following: According to the admission Record, Resident #17 had diagnoses which included, but were not limited to, Alzheimer's Disease. Review of the Long Term Care Facility - Change in Billing form, dated 02/02/24, revealed, This is to advise that, effective 02/02/24, [Resident #17] is: admitted to [hospice]. Review of the Care Plan, revised 02/06/24, included, Patient started on Hospice services 2/2/2024. Review of the Social Services progress note, dated 02/06/24, included, Family initiated referral for hospice services. [Resident #17] was picked up by [hospice company] effective 2/2/2024, care plan updated. Review of the Significant Change in Status Minimum Data Set (MDS), an assessment used to facilitate the management of care,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MB HEALTHCARE — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.7+0.3 vs chain
Health inspection 3 of 53.1-0.1 vs chain
Staffing 2 of 52.9-0.9 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 11 homes this chain runs (chain average 3.7★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BARCLAYS PARENT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 11/01/2015
BRODT, MOSHEIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNFsince 11/01/2015
BRODT, YISROELIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2015
DORFMAN, YAAKOVIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2015
FARKOVITS, JOSHUAIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2015
LAHASKY, EPHRAMIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2015
PILLER, MENDYIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2015
RUBIN, JOSHUAIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2015
SOMMERS, DOVIDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2015
TEITELBAUM, YOELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2015
MB HEALTHCARE SERVICES LLCOrganizationADP OF THE SNFsince 11/01/2015
SHACK, TIMOTHYIndividualADP OF THE SNFsince 08/01/2022

CMS files one row per role, so the 22 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$10.8M
Net patient revenuemost recent cost report
-3.5%
Operating marginrevenue minus expenses
$1.5M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 15%Other / private 15%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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

$367per resident / day
operating cost
$11,146per month
≈ monthly operating cost
$354per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315013. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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