No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Excel Care At Egg Harbor

6818 Delilah Road, Egg Harbor Township, NJ 08234 · For profit - Limited Liability company · 120 certified beds · (609) 453-3200 Medicare & Medicaid certified

Call the home — (609) 453-3200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jan 20251 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$18,119 in federal fines
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)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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 recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $18,119 in federal fines (most recent 2025-01-31)
  • 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 (71%) 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1127 N New Rd · (609) 377-8516 · Call to confirm hours
Pharmacy
900 N New Rd · (609) 272-3002 · Call to confirm hours
Grocery
2545 Fire Rd · (609) 677-6090 · Call to confirm hours
Park
400 Woodland Ave · 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 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased0.9%8.7%15.4%better
Long-stay residents who lose too much weight4.2%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
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 symptoms3.9%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%2.3%3.3%better
Long-stay residents whose ability to walk worsened0.0%8.2%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication13.5%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine98.8%97.2%95.3%typical
Long-stay residents with pressure ulcers10.2%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control7.0%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.4%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine94.1%80.1%79.4%better
Short-stay residents rehospitalized after admission20.6%24.9%22.6%typical
Short-stay residents with an outpatient ER visit9.1%8.1%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

56.5% 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 287 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.5%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
58.7%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

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 218 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 SNF56.5%CMS range 50.1–61.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 6.7–12.010.7%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 discharge58.7%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 discharge44.5%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 discharge50.0%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 identified98.7%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 setting99.5%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 discharge75.6%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 stay0.6%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 worsened1.0%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 hospitalization8.8%CMS range 6.1–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 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

0.54
RN hours/ resident / day
0.97
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.53
Total nurse hours/ resident / day
0.42
RN hoursweekends
70.8%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 117.5 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.19 hrs/resident/day on weekends vs 3.67 on weekdays — 13% thinner on weekends. RN hours go from 0.60 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 71% 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

8
deficiencies at the latest standard inspection (2025-01-31)
10
at the previous standard inspection (2023-04-03)

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-01-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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

    C/O # NJ 182995 Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to provide adequate supervision for a cognitively impaired resident with a known history of aggressive exit seeking which resulted in the resident eloping on 12/12/2024. This deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #160). Resident #160, who was cognitively impaired with a known history of aggressive exit seeking, eloped from the facility on 12/12/2024. The staff reported last seeing Resident #160 in the dining room between 05:00 PM and 05:30 PM on 12/12/2024. The resident wore a wander guard to their left ankle that the physician ordered to be checked for placement and function every shift, and was last checked on 12/12/2024 at 02:00 PM. On 12/12/2024 at 07:40 PM, the Registered Nurse (RN #1) reported that the resident was not in their room to receive their medication. Between 08:00 PM and 09:00 PM, the Certified Nursing Assistant (CNA #3) could not locate Resident #160,…

    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 · Past Non-Compliance
  • Potential for harm · E2026-01-05 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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

    Complaint #: 2601823, 421288, 2646782Based on interviews, medical record review, and review of pertinent facility documentation on 1/2/26 and 1/5/26, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) as being provided to residents for 5 of 5 residents reviewed for ADLs. The facility also failed to follow its policy titled, Activities of Daily Living (ADLs)/Maintain Abilities. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: End Stage Renal Disease (ESDR) and Dialysis.According to the Minimum Data Set (MDS), an assessment tool dated 12/29/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) that was not completed at the time of survey due to recent admission. A review of Resident #1's Care Plans (CP) with a focus of Decline in functional status reveals an initiation date of 12/30/2025 and an intervention of provide and assist with ADL.A review of Resident #1's December 2025 Documentation Survey…

    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 · E2025-01-31 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to ensure that the residents' leisure experience was provided in a manner to promote the dignity and respect of the residents, a) who were seated in the dayroom where a television program broadcast contained profanity and vulgar language was observed for 1 of 2 dining rooms, first floor, b.) the facility failed to maintain Resident dignity when staff were observed standing while feeding Residents their meals on 3 of 3 dining rooms observed for dining and c.) did not serve all residents seated at the same table at the same time for 1 of 3 dining areas, 2nd floor. This deficient practice was evidenced by the following: During the initial tour of the facility on 01/27/2025 at 7:15 PM, Surveyor #1 entered the first-floor dayroom. There were four residents and one staff member in the room. For entertainment the staff had the television playing. The surveyor observed on the television was a comedian using curse words and racial slurs repeatedly. At 7:19 PM, Surveyor #1 approached the Registered Nurse (RN)…

    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 · E2025-01-31 · 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

    Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a homelike environment by serving meals on trays on 1 of 2 floors (2nd floor). This deficient practice was evidenced by the following: On 01/28/2025 at 11:53 AM, Surveyor #1 observed Certified Nursing Assistant (CNA #4) in the feeding dining room on the 2nd floor during lunch, feeding a resident their meal without removing the food items from the meal tray. On 01/28/2025 at 11:54 AM, Surveyor #1 observed a facility staff member in the feeding dining room on the 2nd floor during lunch bringing in a meal tray for a resident and began feeding the resident without removing the food items from the tray. The Quality Assurance Director and Staff Educator (QAD/SE) entered the dining room and intervened, instructing the staff member to remove the food items from the tray while feeding the resident. On 01/29/2025 at 12:26 PM, Surveyor #2 observed CNA #5 in the feeding dining room on the 2nd floor during lunch, uncovering a resident's meal, setting it up, 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 · Dcited before2025-01-31 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification, (Resident #1 and Resident #27). This deficient practice was evidenced by the following: On 01/28/2025 at 01:25 PM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #1 and Resident #27 as follows; 1.The SNFBPNR indicated Resident # 1 last covered Medicare day was 10/15/2024 and Resident # 1 remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #1. Under 1. Was a SNFABN, Form CMS-10055 provided to the resident? No was checked. If no explain why the form was not provided: was hand written Resident remained in the facility is Medicaid pending. 2. The SNFBPNR indicated Resident #27 last covered Medicare day was 11/11/2024 and Resident #27 remained in the facility. The SNFBPNR further…

    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 · D2025-01-31 · 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

    Refer to F 689 C/O # NJ 182995 Based on interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to report and submit the facility investigation to the New Jersey Department of Health (NJDOH) within 5 days, specifically when a resident eloped for 1 of 3 residents reviewed for elopement (Resident #160). This deficient practice was evidenced by the following: A review of the EMR on 01/30/2025 at 2:20 PM revealed the following: According to the admission Record Resident #160 was admitted with diagnoses including but not limited to: unspecified Dementia. A review of the most recent comprehensive Minimum Data Set (MDS) an assessment tool dated 09/26/2024 revealed Resident #160 had a Brief Interview for Mental Status (BIMS) score of 4/14 indicating Resident #160 was cognitively impaired. A further review of the MDS indicated the resident was independently ambulatory with no assistive device and used a wander/elopement alarm daily. A review of the Order Summary Report revealed a physician order dated…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-31 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C/O # NJ 177719, 180562 Based on observation, interview, and review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to a.) ensure medications were administered in accordance with a physician's orders, b.) failed to follow physician order specifically for obtaining a urine culture, and c.) ensure physician's medication order was transcribed accurately. This deficient practice was identified for 3 of 32 sampled residents (Resident # 311, Resident #312, and Resident #414). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision 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
  • Potential for harm · Dcited before2025-01-31 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 01/29/2024 at 09:23 AM during a tour of the second-floor pantry the surveyor observed no thermometer in the freezer. There were 5 plastic containers of food in the freezer. The temperature log was marked with NA for the whole month of January. During that same tour the surveyor observed a paper wrapped sandwich labeled with a resident's room number and dated for 01/25/2025 in the refrigerator. During an interview on 01/29/2025 with the surveyor, the Quality Assurance Director (QAD) said that night shift nursing staff were responsible for the cleaning the refrigerator and checking the temperature. The QAD said she was not sure how long food was allowed to be in the refrigerator and she would have to check the policy. The QAD also said that she didn't think the freezer needed a thermometer unless there was food in there. During…

    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 before2025-01-31 · 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 review of other facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices for 3 of 3 staff observed during medication pass and lunch service, respectively b.) implement infection control measures for the handling and storage of respiratory equipment for 3 of 3 residents reviewed for respiratory care (Residents # 23, #315, and #413). This deficient practice was evidenced by the following: 1. On 01/28/2025 at 08:06 AM, Surveyor #1 observed Licensed Practical Nurse (LPN) #4 during medication pass. LPN#4 did not perform hand hygiene including not using Alcohol Based Hand Rub (ABHR) after administration of medications. On 01/28/2025 at 08:20 AM, Surveyor #1 observed LPN #4 administer medication to Resident #82. LPN #4 did not perform hand hygiene prior to administering the medications. During an interview with Surveyor #1 on 01/28/2025 at 08:27 AM, LPN #4 was asked about hand hygiene practices during medication pass. LPN #4 stated that she should have practiced hand…

    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 before2023-04-03 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a) maintain professional standards of clinical practice by not following the physician's order for blood pressure (BP) parameters for 1 of 28 sampled residents (Resident # 29) and b) follow professional standards of nursing practices and facility policy by not notifying the Licensed Independent Practitioner of a prescribed medication that was not administered as ordered for 1 of 2 residents during a medication pass observation. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45 Chapter 11, Nursing Board. The Nurse Practice Act for the State of New Jersey states; the practice of nursing as a Registered Professional Nurse is defined as diagnosing, and treating human response to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to restorative of life and wellbeing, and executing…

    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 · E2023-04-03 · 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 interview, record review, and review of other facility documentation, it was determined that the facility a)failed to ensure that the Consultant Pharmacist (CP) reported irregularities of drug regimen to the physician, and b.) failed to act upon the CP report of irregularities found while reviewing the drug regimen. This deficient practice was identified for 1 of 28 sampled residents, (Resident #29) and was evidenced by the following: There was no adverse effects to Resident #29. According to the admission Face Sheet Resident #29 was admitted with diagnoses including but not limited to: Cerebral Vascular Accident (stroke) and hypotension. According to the March 2023 Physician Order Sheet, resident #29 had an order dated 12/17/2022 for an anti-hypotensive medication; Midodrine HCI Oral Tablet 5 MG (milligram) tablet, 1 tablet by mouth 3 times daily with Special Instructions, (parameter) to hold the medication when the Systolic Blood Pressure (SBP) (top number in BP) is greater than 120. On 03/27/2023 at 10:26 AM, the surveyor reviewed the Consultant Pharmacist's Medication…

    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
Show the remaining 10 citations
  • Potential for harm · Ecited before2023-04-03 · 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 03/21/2023 from 9:33 to 10:13 AM, the surveyor accompanied by the Director of Dietary (DOD), observed the following in the kitchen: 1. In the pot and pan drying rack area of the kitchen a stack of third pans on a middle shelf were in the inverted position and stacked upon each other. The surveyor removed the top third pan from the stack and observed a wet, watery substance on the outside of the pan below. The DOD stated, That's wet nesting. The DOD removed the third pans from the drying rack. Next to the third pans the surveyor removed a sixth pan from the top of approximately 6 pans that were inverted and stacked upon each other. The surveyor and DOD observed a wet and watery substance on the external surface of the pan below. The DOD removed the sixth pans from the drying rack 2. 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 · D2023-04-03 · tag F0656 — failed to write and follow a full care plan — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered care plan for 3 of 28 sampled Residents, (Resident # 189, Resident #48, and Resident #135). This deficient practice was evidenced by the following: 1.) During the initial tour of the facility on 03/21/2023 at 10:54 AM, Resident # 189 was observed in bed with nasal oxygen at 2 liter/minute in use. Resident #189 said he/she does not use oxygen at home and has only used since being hospitalized . A review of the admission Face Sheet revealed Resident #189 was admitted to the facility with diagnoses including but not limited to: Shortness of Breath. A review of the most recent Minimum Data Set (MDS) an assessment tool used to facilitate care, dated 3/16/2023 revealed under section C a Brief Interview for Mental Status score of 6/15, indicating Resident #189 had severe cognitive impairment. Under section O the MDS indicated Resident #189 used…

    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 before2023-04-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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

    Based on observation, interview, and review of pertinent facility documents, it was determined that facility failed to identify and eliminate a known and foreseeable accident hazard in the residents environment specifically by leaving an open lid garbage receptacle in the outside smoking area. The deficient practice was identified in 1 of 1 outside smoking areas and was evidenced by the following: On 03/31/2023 at 11:10 AM during an observation of the outside smoking area, the surveyor observed multiple extinguished cigarettes on the ground throughout the area. Further, the surveyor also observed a gray plastic garbage receptacle not fully covered by the lid. Within the garbage receptacle was a clear, plastic bag filled with combustible materials such as a paper cup. Also, within the garbage receptacle were extinguished cigarettes floating in small amount of water. On 03/31/2023 at 01:13 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) said that plastic garbage receptacles should not be in the outside smoking area. The LNHA also said 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 · D2023-04-03 · 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, review of the medical record and review of other facility documentation, it was determined that the facility failed to maintain resident dignity when the urine catheter drainage bag was visible from the hallway and in the unit dining room for 1 of 2 Residents reviewed for indwelling urinary catheters (Resident # 87). This deficient practice was evidenced by the following: On 03/22/2023 at 09:38 AM, the surveyor observed Resident #87 in the unit dining room with his/her spouse. The Foley leg bag (attaches directly to the catheter tube and collects urine produced during the day and becomes heavier as it fills) was observed to hanging next to the resident's leg under the wheelchair, not attached to Resident #87's leg and below the hem of their pants. The Foley leg bag was exposed, and urine was visible from the hallway and in the dining room. A review of the admission Face Sheet revealed Resident #87 was admitted to the facility with diagnoses including but not limited to: unspecified dementia and neuromuscular dysfunction of the bladder. A 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-03 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on interview and review of other facility documentation, it was determined that the facility failed to ensure that the incoming and outgoing nurses reconciled controlled substances at change of shift. This deficient practice was identified for 2 of 2 medication carts on 2 of 2 nursing units. The deficient practice was evidenced by the following: On 03/27/23 at 08:52 AM, the Surveyor reviewed the narcotic log book on the 2nd floor nursing unit Low Hall medication cart. A review of the Controlled Substance Inventory log for the 2nd floor Low Hall medication cart for the month of March revealed that the signature of the incoming nurse and/or signature of outgoing nurse was blank on the following days/times: 03/08/2023 10 PM Outgoing nurse 03/18/2023 10 PM Outgoing nurse 03/19/2023 6 AM Incoming nurse 03/19/2023 10 PM Outgoing nurse 03/26/2023 3-11 PM Incoming nurse 03/26/2023 3- 11 PM outgoing nurse 03/26/2023 11- 7 PM Outgoing nurse A review of the Controlled Medication Account Record for the 2nd floor Low Hall medication cart revealed that multiple sections were left blank 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-03 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 documents, it was determined that the facility failed to consistently provide a physician ordered nutritional supplement at mealtimes for 1 of 2 residents (Resident #102) reviewed for food. This deficient practice was evidenced by the following: On 03/21/2023 at 11:16 AM, while on the initial facility tour of the facility, Resident #102's spouse complained that the food is wrong when meals are delivered. Resident #102's spouse also complained that he/she won't eat sometimes and that he/she has lost about 26 pounds since January 9th of 2023. Resident #102's spouse stated, I'm here twice a day every day for lunch and dinner. On 03/23/2023 at 08:31 AM, the surveyor observed Resident #102 in their room during the breakfast meal. The surveyor reviewed Resident #102's breakfast meal ticket after receiving resident approval. The meal ticket revealed that Resident #102 was to receive a NAS-Chopped (no added salt) diet on 3/23/2023 at Breakfast. In addition, the meal ticket indicated that Resident #102…

    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 · D2023-04-03 · 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

    Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 1 of 2 garbage dumpsters. This deficient practice was evidenced by the following: On 3/31/2023 at approximately 10:00 AM, the surveyor, accompanied by the facility Director of Dietary (DOD went outside the facility to the designated garbage area. Upon arriving the surveyor observed 3 green dumpsters that had (2) black plastic lids on each dumpster to cover the contents. The DOD explained that 2 of the 3 dumpsters were designated for garbage and (1) dumpster was designated for recycling materials. The middle dumpster had 1 of 2 black plastic lids open. The surveyor visually inspected the contents of the dumpster and observed bagged garbage from the facility. On interview the DOD stated that the dietary department and housekeeping department were responsible for the maintenance of the facility garbage area. The DOD also stated that the garbage…

    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 · Ecited before2021-04-21 · 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 foods and maintain kitchen sanitation in a safe consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 4/14/2021 from 9:08 to 9:54 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen area: 1. On a top shelf of a multi-tiered rack in the walk-in freezer, a bag of frozen chopped collard greens was removed from its original container. The bag had no dates. When interviewed the FSD stated, They should have put a date on it when they removed it from the original container. The FSD threw the frozen collard greens in the trash. On a middle shelf on top of a box of frozen lima beans, a frozen herb roasted chicken kosher dinner covered with clear plastic cellophane was removed from its original container. The frozen meal had no dates. The FSD stated, That's a frozen kosher meal that we used for a previous resident we had here. 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 · Dcited before2021-04-21 · 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 record review, it was determined that the facility failed to 1.) remove personal protective equipment (PPE) gowns when exiting resident rooms on the Persons Under Investigation unit (PUI) and 2.) wear gloves when entering resident rooms on the PUI unit to minimize the potential spread of infection. The deficient practice was observed on 1 of 2 hallways designated for PUI for COVID-19 (a potentially deadly respiratory virus). The deficient practice was evidenced by the following: On 4/15/21 at 11:40 AM, the surveyor observed CNA (Certified Nurse Aide) #1 and CNA #2 passing lunch trays on the Observation Unit that included rooms 101 through 112. The surveyor observed that there were COVID-19 Personal Protective Equipment for Healthcare Personnel signs outside each occupied room. The signs revealed that a gown, gloves, mask, and eye protection were to be used when entering the room. 1. The surveyor observed CNA #1 and CNA #2 wearing gowns, eye protection, and masks while in the hallway. They retrieved trays from the cart, entered rooms, and exited…

    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
  • No harm found · Bcited before2023-04-03 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notice for 1 of 3 residents (Resident #193) reviewed for the Beneficiary Protection Notification. This deficient practice was evidenced by the following: On 03/22/2023 at 11:32 AM the surveyor requested (3) random residents, (1) of whom discharged to home (Resident #193) and (2) who remained in the facility to determine if the facility provided documentation of appropriate notifications On 3/24/2023, the surveyor reviewed the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident # 193. The SNFBPNR indicated Resident # 193's last covered Medicare day was 11/16/2022. A further review of the SNFBPNR further revealed that the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. The SNFBPNR indicated that a SNFABN form CMS-10055 was provided to the resident. The SNFBPNR also revealed that a Notice of Medicare Non-Coverage Form…

    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

“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

$18,119 in federal fines across 1 penalty.

  • $18,119 — penalty dated 2025-01-31

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 EXCELCARE — 8 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 52.3+1.7 vs chain
Health inspection 3 of 51.9+1.1 vs chain
Staffing 2 of 52.6-0.6 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 7 homes this chain runs (chain average 2.3★, 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
ZBL REGENCY OPCO, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF60%since 12/27/2021
FRANKEL, ELIYAHUIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF40%since 12/27/2021
TZUFON LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST12%since 12/27/2021
BERKOWITZ, SAMIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/27/2021
ORNSTEIN, MARTONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 12/27/2021
HENRY, DERRICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2023
KELLY, BRENDANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/27/2021
LOFFLER, ABRAHAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/13/2025
AMERICAN CARE NURSING SERVICESOrganizationADP OF THE SNFsince 12/27/2021
ATTENTIVE HEALTHCARE LLCOrganizationADP OF THE SNFsince 12/27/2021
MARTIN FRIEDMAN CPA, P.C.OrganizationADP OF THE SNFsince 12/27/2021
TWOMAGNETS LLCOrganizationADP OF THE SNFsince 12/27/2021

CMS files one row per role, so the 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$16.7M
Net patient revenuemost recent cost report
+8.1%
Operating marginrevenue minus expenses
$1.9M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 53%Medicare 25%Other / private 23%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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

$384per resident / day
operating cost
$11,659per month
≈ monthly operating cost
$417per 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 315514. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-31, 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.

What to do next