Wynwood Rehabilitation And Healthcare Center
1700 Wynwood Drive, Cinnaminson, NJ 08077 · For profit - Limited Liability company · 114 certified beds · (856) 829-9000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0610) — most recent Jul 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $103,300 in federal fines (most recent 2024-07-15)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
- about 22% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 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 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 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 | 5.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.2% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.5% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.1% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.0% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.7% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 30.3% | 15.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.2% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 69.6% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 35.0% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.5% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.03 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.90 | 1.11 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
52.6% 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 102 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.7% 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 63 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 0.25 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 66% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 52.6%CMS range 42.7–63.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 6.2–12.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.7% | 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 | 57.1% | 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 | 68.2% | 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 | 93.3% | 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 | 16.0% | 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 | 88.4% | 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 | 7.1%CMS range 3.6–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 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 114 beds and averages 107.9 residents a day — about 95% occupied, or roughly 6 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 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 3.37 hrs/resident/day on weekends vs 3.67 on weekdays — 8% thinner on weekends. RN hours go from 0.29 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 64% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
27 citations, most serious first. The 14 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · L2024-07-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespreadEnsure 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, record review, and review of pertinent documentation, it was determined that the facility failed to have a system in place to ensure a consistent and safe smoking process for 17 residents who were identified as smokers by failing to ensure a) provision of adequate and consistent supervision for residents who were assessed and identified as smokers, b) residents who required close monitoring when smoking, did not keep their own lighting materials and then used it to light other residents' cigarettes (Resident #30 and #72), c) residents who required close monitoring and supervision while smoking, were assisted and supervised to prevent embers from the cigarettes from causing burn holes and ensuring the lit cigarette was not rested on the smoking apron causing cinder type marks (Resident #29), and d.) extinguishing cigarettes into appropriate receptacles and that cigarette ashes were appropriately disposed of. This deficient practice was identified for 5 of 17 residents (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.
- Immediate jeopardy · K2024-07-15 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 interviews, review of medical records (MRs), other facility documentation, and review of facility policy, it was determined that the facility failed to a.) protect residents from physical and sexual abuse as well as b.) ensure adequate supervision for a severely cognitively impaired resident (Resident #84) with a history of wandering, from wandering into other resident rooms, leading to physical altercations and sexual abuse involving other residents. Due to the vulnerable nature of the nursing home population, there is a potential for serious injury or serious physical or psychosocial impairment from being physically shoved by Resident #152 and Resident #94 as well as Resident #84 sexually abusing residents. This required immediate action to prevent further events of physical and sexual abuse by or to Resident #84 or other residents. This deficient practice was identified for 1 of 9 residents reviewed for abuse. The Immediate Jeopardy (IJ) situation began on 06/04/24, and was identified on 07/01/24.…
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.
- Actual harm · H2024-07-15 · 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 Complaint #s NJ 163250, NJ 170219 Based on observation, interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a thorough and complete investigation was completed to determine the causal factor of injuries of unknown origin to ensure that resident abuse or neglect had not occurred for: a) a resident (Resident #150) who was found on 12/05/23, with an infected wound that required hospitalization on 12/05/23, and was diagnosed with osteomyelitis, and again observed during routine wound rounds on 12/19/23, with exposed bone and required transfer to the hospital on the same day, and was diagnosed with a acute fractures of the right proximal tibia and fibular diaphyses (two long thigh bones) on 12/19/23, b) an allegation of sexual abuse by Resident #94 that was reported to the Licensed Practical Nurse on 6/28/24 at 7:30 AM, the facility did not investigate the allegation until 7/1/24, c) and for a resident who had a history of being combative with 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.
- Actual harm · G2024-07-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) implement interventions to prevent the development of a stage IV facility acquired pressure injury, b.) ensure individualized comprehensive care plan interventions were implemented to prevent facility acquired pressure injury wound from worsening, and c.) ensure daily observation during wound care was documented according to professional standards of Nursing practice to follow continuity of care, and d) alert physician of any change in the wound condition. This deficient practice occurred for 1 of 2 closed records reviewed for wounds (Resident #150). Resident #150 was identified as having a skin tear to the left lower leg at the facility on 10/09/23, which measured 2 centimeters (cm) x 2 cm x 0.2 cm which progressed to necrotic exposed bone protruding through the right lower extremity which was identified during routine wound rounds by a consultant on 12/19/23, and which resulted in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of facility documents it was determined that the facility failed to provide a safe, clean, and comfortable environment in resident rooms and designated facility utility areas. The deficient practice was identified on 2 of 3 units. The deficient practice was evidenced by the following: On 12/01/2025 at 1:14 PM while in Resident # 89's room, the surveyor observed linens on the floor and a pile of debris that appeared to be swept but was left and not discarded. On 12/02/2025 at 12:17 PM, in the Soiled Utility room near room [ROOM NUMBER], the surveyor observed filled trash bags left on the floor in the room and not in the container. On the same date at 12:26 PM, the surveyor observed a linen cart outside of room [ROOM NUMBER] with personal bags, including a purse, on the top shelf among the clean linens and incontinence briefs. On 12/04/2025 at 11:12 AM, the surveyor observed a trash can with no bag liner in room [ROOM NUMBER]-1. On 12/05/2025 during an interview with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-09 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 and record review, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 2 of 11 residents (Residents #30 and Resident #40) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status and not less than…
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 · D2025-12-09 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
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 and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (QMDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 11 residents (Resident #4) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and; 2). the completion date was no later than 14 days after the ARD. The following…
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 · D2025-12-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 2 of 32 residents reviewed, Resident #8 and Resident #51. This deficient practice was evidenced by the following:A review of the admission Record for Resident #8 which reflected that the resident was admitted with diagnoses that included Schizophrenia and Depression. A review of the level II Preadmission Screening and Resident Review (PASRR) revealed Resident #8 was positive for a mental illness. A review of Resident #8's Significant Change MDS dated [DATE] revealed that the section indicating if the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as zero (0), indicating that Resident #8 does not currently have a mental illness or intellectual disability. When interviewed on 12/05/2025 at 10:07AM, the Regional…
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 · D2025-12-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to ensure that medications for a discharged resident were properly removed from the medication storage area. The deficient practice was identified for 1 of 3 medication carts inspected during the Medication Storage and Labeling task. The deficient practice was evidenced by the following: On 12/02/2025 at 12:48 PM, the surveyor inspected Medication Cart 1 located outside of room [ROOM NUMBER]. At that time, in the presence of Licensed Practical Nursing # 1 (LPN # 1), the surveyor discovered a medication card for Gabapentin 100 milligram capsules located behind the bottom drawer of the cart. The medication card contained 16 remaining capsules and belonged to a resident who had been previously discharged from the facility. At that time, LPN # 1 said they should not have been in there because discharged resident's medications are returned to the pharmacy. The facility did not provide a policy regarding medication storage. N.J.A.C.…
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 · D2025-12-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
Complaint # 408484Based on observation, interview and record review, the facility failed to ensure resident records were accurate and complete for 1 of 3 residents (Resident # 9 reviewed for activities of daily living (ADL) care, specifically related to shower documentation. The deficient practice was evidenced by the following:A review of Resident #9's medication administration record (MAR) for the month of November 2025 revealed that nurses had documented that Resident #9 received showers on the following dates:11/04/202511/07/202511/11/202511/14/202511/18/202511/21/202511/25/202511/28/2025 A review of Resident # 9's documentation survey report for the month of November 2025 revealed that the Certified Nursing Assistants (CNA), had documented that Resident # 9 had refused a shower on 11/04/2025.The CNA's documented that Resident # 9 received showers on 11/18/2025 and 11/21/2025. The rest of the November dates were documented as not applicable (NA). During an interview on 12/04/2025 at 10:12 AM with the surveyor, the unit manager (UM) and assistant director of nursing (ADON) said…
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 · D2025-12-09 · tag F0917 — isolatedMake sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview the facility failed to ensure resident beds and mattress were properly positioned and adjusted to meet residents' needs and ensure safety and comfort foe 1 of 2 residents (Resident # 118) observed for positioning. The deficient practice was evidenced by the following: During initial tour on 12/01/2025 at 10:04 AM the surveyor observed Resident #118 in bed with their feet extended over the mattress and their ankles resting on the foot board.Resident #118 stated he/she can't sleep at night because his/her feet are always hanging off the bed. Resident #118 said he/she thinks the told a nurse about the bed being too small.A review of Resident # 118 admission Minimum Data Set (MDS) dated [DATE] revealed under section C that Resident # 118 had a BIMS score of 14 indicating intact cognition. The MDS also revealed under section K that Resident # 118 had a height of 72 inches. During an interview on 12/04/2025 at 10:06 AM with the surveyor, the Assistant Director of Nursing (ADON) said…
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 · D2025-12-09 · tag F0924 — isolatedPut firmly secured handrails on each side of hallways.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations on 12/02/2025 in the presence of the facility's Maintenance Assistant (MA), it was determined that the facility failed to provide hand rails on both sides of the corridor. This deficient practice had the potential to affect all 104 Residents in the facility.Observation on 12/02/2025 the surveyor observed, measured and recorded a six foot- nine inch (6'-9) section of wall in the South wing adjacent to the Physical Therapy area with no evidence of a hand rail for Residents to use.The MA confirmed the finding at the time of observation.The Administrator and MA were informed of the Life Safety Code deficiency during the survey exit at approximately 1:30 PM.NJAC 8:39-31.4 (a).
- Potential for harm · F2024-07-15 · tag F0677 — failed to help fully-dependent residents with daily care — widespreadProvide 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 documentation, it was determined that the facility failed to ensure dependent residents were provided with routine and appropriate incontinence care and nail care in a timely manner. This deficient practice was identified for 8 of 8 residents reviewed for Activities of Daily Living Care (Residents #27, #30, #37, #41, #82, #94,# 95, and #155) and was evidenced by the following: 1) On 6/27/24 at 10:48 AM, surveyor #1 entered Resident #94's room and noted a strong odor of feces in the room. Resident #94 informed the surveyor that staff refused to assist with incontinence care. Upon request, Resident #94's roommate activated the call bell. The Licensed Practical Nurse/ Unit Manager (LPN/UM) reported to the room immediately, and confirmed that Resident #94 needed to be changed. 2) On 6/27/24 at 11:06 AM, surveyor #1 observed Resident #82 in bed with fingernails long, jagged with a black coated substances underneath the fingernails. The resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-15 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #167264 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to a) provide timely and appropriate incontinence care for residents who were dependent on staff for Activities of Daily Living (ADL's) care (Residents #94, #30, #37, #41, #95, and #27), b) provide nail care for a resident who was dependent of staff for ADL's (Resident #82) and c) ensure staff were competent to accurately document an allegation of sexual abuse and alert the supervisor. The deficient practice had the potential to affect all residents and was evidenced by the following: Refer to 600 K and 677F a) On 6/27/24 at 10:48 AM, surveyor #1 was doing the initial tour of the facility and was informed by Resident #94 that staff refused to change them. The surveyor noted a foul odor in the room. The call bell was activated by the roommate and the Unit Manager Licensed Practical Nurse (UMLPN) reported to the room immediately and confirmed Resident #94 was soiled with excrement. 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.
Show the remaining 13 citations
- Potential for harm · F2024-07-15 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 administrator failed to ensure the facility operated in a manner to ensure residents were consistently provided with care to maintain their highest practicable physical, mental, and psychosocial well-being by failing to ensure: a) a process was in place to ensure a resident (Resident #84) with known wandering behaviors was effectively supervised to prevent the resident from sustaining an injury and preventing the resident from sexually abusing another resident (Resident # 94, b) adverse and significant events were thoroughly investigated (Resident #81 and #150, Resident #94), c) wound care was consistently documented to ensure that staff were able to identify and report any change in a wound condition to the physician. Resident #150 developed a wound at the facility which progressed to the bone protruding which then required an amputation. d) an elopement was reported to the Department of Health as required, e) staffing was adequate to meet dependent residents activity of daily living care including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-15 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review it was determined that the facility failed to have an effective systems and procedures for feedback in place to self identify areas for Quality Assurance and Perforamance Improvement (QAPI) for: a)a resident documented as a known wanderer that wandered into other resident rooms since 02/22/24, had a history of being injured by another resident after wandering into another resident room and then sexually abused another resident (Resident #94) on 07//01/24, b) residents who smoked, held their own lighting materials, lit other residents, cigarettes, burned their own clothing, staff disposing of cigarette waste inappropriately(Resident #29, #39, #72, #87 and #32), c) ensuring residents were provided with appropriate incontinence and activity of daily living care for 8 of 8 residents reviewed (Residents #27, #30, #37, #41, #82, #94,# 95, and #155), and d) adverse events and reportable events for residents with fractures requiring hospitalization (Resident #81 and #150) . This…
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 · E2024-07-15 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) prescription medications were labeled and accounted for, b.) expired supplies were identified and removed from active inventory, c.) supplies that required dating were dated and d.) to consistently maintain accurate administration, reconciliation, and accountability of dispensed controlled dangerous substance (narcotic medication) stored within the electronic back-up machine (EBM). This deficient practice was identified for one (1) of two (2) medication rooms, two (2) of eight (8) medication carts and one (1) of one (1) EBM inspected for the medication storage and labeling. The evidence was as follows: Reference: 21 CFR 1306.24(b) If the prescription is filled at a central fill pharmacy, the central fill pharmacy shall affix to the package a label showing the retail pharmacy name and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-15 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 document review, it was determined that the facility failed to ensure they reported to the Department of Health (DOH) as required, a resident who was confused, wandered, identified as being exit seeking, and who broke a latch on a window and exited to the outside. This deficient practice occurred for 1 of 9 residents reviewed for accidents (Resident #87) and was evidenced by the following: On 07/02/24 at 12:00 PM, the surveyor reviewed the electronic medical record for a resident identified as a smoker, Resident #87. A Nurses Progress Note, created by a Liscensed Practical Nurse (LPN) on 05/12/2024 at 21:48 [8:21 PM] revealed Informed by an aide that the resident had jumped out of window and primary nurse and aide was with the resident. The nurse remained with the resident while staff brought the wheelchair out and brought the resident back in. Director of Nursing (DON) informed of incident. Wanderguard to ankle still intact and functioning. On 07/02/24 at 1:15 PM, the surveyor asked the DON if a resident jumped out of a window. The DON confirmed that Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-15 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, it was determined that the facility failed to complete a Significant Change in Status Assessment using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits. This deficient practice was identified for 1 of 2 residents reviewed for hospice (Resident #44). This deficient practice was evidenced by: According to the Center for Medicare/Medicaid Services (CMS) - Resident Assessment Instrument (RAI) 3.0 Manual, A significant change in status assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later that the date of the hospice election statement, but not earlier than). The SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 follow a physician's order for the application of resting hand splint to the right hand for one resident. The deficient practice was identified for 1 of 1 resident (Resident #71) reviewed for positioning and mobility, and was evidenced by the following: On 6/27/24 at 10:30 AM, the surveyor toured the unit. During the tour of the facility, Resident #71 reported some concerns with lack of physical therapy and assistance with Range of Motion (ROM) to prevent further contractures to the right hand. The resident used the left hand to pick up the right hand under the cover and show the contracted hand to the surveyor. The right hand was contracted, the fingers were curled into the palm of the right hand. On 6/28/24 at 8:30 AM, the surveyor observed the resident in bed, the resident informed the surveyor that they did not get any assistance with ROM and the staff had not applied the resting splint for months. On 6/28/24 at 11:15 AM, the surveyor reviewed Resident #71's Electronic 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.
- Potential for harm · D2024-07-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure the facility followed-up regarding resident goals and preferences regarding nutrition, and to ensure a comprehensive nutritional assessment accurately reflected resident goals. The deficient practice was evidenced for 1 of 1 resident reviewed for receiving nutrition via a tube (Resident #75) and was evidenced by the following: Reference It is the position of the Academy of Nutrition and Dietetics that all Americans aged 60 years and older receive appropriate nutrition care; have access to coordinated, comprehensive food and nutrition services; and receive the benefits of ongoing research to identify the most effective food and nutrition programs, interventions, and therapies. Health, physiologic, and functional changes associated with the aging process can influence nutrition needs and nutrient intake. The practice of nutrition for older adults is no longer limited to those who are frail,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure adequate indication, and a gradual dose reduction (tapering towards an optimal dose) of an antipsychotic medication was attempted annually to establish an optimal dose, for a hemipelagic resident with congestive heart failure (Resident #62). This deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications and was evidenced as follows. Reference: A review of the manufacturer's specifications for Seroquel (quetiapine) under the black box warning reflected Warning: Increased Mortality In Elderly Patient with dementia related psychosis and suicidal thoughts and behaviors. Section 1 Indications and Usage included schizophrenia, bipolar disorder, and special considerations in treating pediatric schizophrenia and bipolar 1 disorder. Section 5.1 included, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death . Section 5.3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-15 · 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, and review of other facility documentation, it was determined that the facility failed to minimize the potential spread of infection to residents during medication administration for 1 of 2 nurses observed during the medication pass on 1 of 2 units (North Wing). This deficient practice was observed and evidenced by the following: On 6/28/24 at 7:00 AM, the surveyor observed signage posted at the entrance door which read: Enhanced Barriers Precautions Stop. Everyone must clean their hands before entering and exiting the room. Providers and suppliers must also wear gloves and gown during high contact Resident Cares activities, or devices care. On 06/28/22 at 7:15 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #71. The LPN opened the top drawer of the medication cart, retrieved the glucometer machine, don (put on) gloves and a Personal Protective Equipment (PPE) gown and entered Resident #71's room. The LPN went to the room, informed the resident of the procedure, and checked the resident blood sugar. 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 · F2022-11-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policy review, the facility failed to: 1. monitor the level of sanitizer in the three-compartment sink; and 2. perform hand washing and change gloves in between tasks during the initial tour of the kitchen. These failures had the potential to increase the risk of food-borne illness for the 100 residents receiving food from the kitchen out of the 103 residents residing in the facility. Findings include: 1. The facility failed to measure the level of sanitizer in the three-compartment sink before completing the sanitizer log for breakfast, lunch, and dinner on 11/07/22 and 11/08/22. During the initial tour of the kitchen on 11/07/22 at 10:15 AM, pots and pans were observed in the sanitizer compartment of the three-compartment sink. The sanitizer compartment was dry. During this observation, [NAME] 2 stated the pots and pans were drying in the sanitizer compartment of the sink. When asked why the compartment did not contain sanitizer, [NAME] 2 shrugged her shoulders and walked away. Observation on 11/07/22 at 10:45 AM of the Three Compartment Sink…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-10 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 interviews, observations, record review, and policy review, the facility failed to honor a resident's request to attend activities during the administration of a tube feeding (liquid nutrition via a tube inserted through the abdomen into the stomach) for one of six residents (Resident (R) 88) reviewed for choices out of a total sample of 39 residents. Findings include: Review of the electronic medical record (EMR) Face Sheet revealed R88 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Further review of the Face Sheet revealed R88 had diagnoses which included cerebral infarction (stroke) resulting in aphasia (inability to formulate words), hemiplegia (partial paralysis) and hemiparesis (weakness) of the right side of the body. Review of a significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/26/22 revealed R88 was completely dependent on staff for locomotion on the unit such as going from her room to the activity room. Further review 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 · D2022-11-10 · 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 record review, interviews, and facility policy review, the facility failed to ensure resident care plan meetings were conducted routinely for three Residents (R) R19, R35, and R77 of 39 sampled residents. Findings include: 1. Review of R19's admission Record, dated 11/10/22 and found in the Electronic Medical Record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses including history of stroke, systemic lupus, and type 2 diabetes. The document indicated R19 was her own responsible party (RP). Review of R19's quarterly Minimum Data Set assessment, with and Assessment Reference Date (ARD) of 10/14/22 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15 indicating the resident was moderately cognitively impaired. Review of R19's comprehensive Care Plan located in the EMR under the Care Plan tab indicated the Care Plan was most recently revised with the resident's quarterly MDS assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-10 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interview, and review of facility policy, the facility failed to ensure appropriate care of a gastrostomy (g)-tube during medication administration for one resident (R) R 88 of one resident who were reviewed during medication administration with a tube feeding. The facility further failed to label the resident's tube feeding with the name of the formula, the date and time the formula was started, and/or the rate of infusion. Findings include: 1. Review of R88's admission Record, dated 11/10/22 and found in the electronic medical record (EMR) under the Profile tab indicated she was admitted to the facility on [DATE] with diagnoses including history of stroke. Review of R88's Order Summary Report dated 11/10/22 and found in the EMR under the Orders tab indicated orders for the resident to remain NPO (to consume nothing by mouth), Baclofen (a muscle relaxant) 20 MG (Milligrams) via gastric tube (G-tube) three times daily, and for 30 ML (milliliters) water flush prior to 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.
- 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
$103,300 in federal fines across 1 penalty.
- $103,300 — penalty dated 2024-07-15
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ATLAS HEALTHCARE — 29 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.6 | -1.6 vs chain |
| Health inspection | 1 of 5 | 3.1 | -2.1 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 28 homes this chain runs (chain average 3.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CINNAMINSON NURSING HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2019 |
| BAK, PINCHOS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 02/01/2019 |
| GOLDBERGER, SHLOMO | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 02/01/2019 |
| PENCOOK, SANDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2019 |
| REVELS, SHEKINAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2019 |
| SINKOFF, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2019 |
| SONNENSCHEIN, MOSHE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2019 |
| COOPER CARE HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 02/01/2019 |
| SPECTRUM PROPCO REALTY LLC | Organization | ADP OF THE SNF | — | since 07/17/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315047. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-09, 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.