Atlas Healthcare At Seashore Gardens
22 West Jimmie Leeds Road, Galloway Township, NJ 08205 · For profit - Limited Liability company · 151 certified beds · (609) 404-4848 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- 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
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
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 | 2 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 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 | 3.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.2% | 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 | 10.4% | 12.1% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.3% | 2.3% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 6.7% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.2% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.1% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.0% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.5% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 40.2% | 80.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.6% | 24.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.3% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.39 | 2.07 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.46 | 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.
55.0% 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 335 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 76.6% 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 205 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 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.0%CMS range 49.1–61.0 | 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 | 9.8%CMS range 7.3–12.9 | 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 | 76.6% | 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 | 82.9% | 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 | 72.7% | 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 | 99.3% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.9% | 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 | 0.7% | 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 | 7.2%CMS range 4.9–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 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 151 beds and averages 139.5 residents a day — about 92% occupied, or roughly 12 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 4.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 3.87 hrs/resident/day on weekends vs 4.22 on weekdays — 8% thinner on weekends. RN hours go from 0.47 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 unchanged from the previous inspection. 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.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #: 2710717, 2791836 Based on interviews, medical record reviews, and review of other pertinent facility documentation it was determined that the facility failed to update the care plan (CP) with interventions for a resident (Resident #2) who's family expressed preferences related to incontinence care. This deficient practice was identified in 1 of 5 residents reviewed for care plans and was evidenced by the following:According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses including but not limited to benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostrate that is not obstructing the urethra or irritating the bladder); muscle weakness; and cognitive communication deficit (communication difficulty caused by disrupted brain function). According to the Comprehensive Minimum Data Set (MDS), an assessment tool dated 01/29/2026, Resident #2 had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident's cognition was impaired. Further review of the MDS revealed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-07-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's reach in refrigerator, ice machine, ice scoop holder, shelves, floor fan, rack, and the microwave ovens located in the pantry and snack rooms clean and sanitized. Additionally, the facility failed to ensure kitchen food preparation pans were dry when stored and failed to keep stored foods closed in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 139 residents who consumed food prepared from the facility's kitchen.Findings include: Review of the facility's policy titled, Sanitation dated 11/22 indicated, Policy Statement The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen area and dining areas shall be kept clean . 2. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning . 7. Food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-24 · tag F0561 — failed to honor residents' choices — patternHonor 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 observations, interviews, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 102) reviewed for choices and food preferences were honored, Specifically, 27 out of 28 residents residing in the secure dementia unit were not offered choices of food, beverages, and condiments at meals. This failure could lead to dissatisfaction with meals, weight loss, or malnutrition.Findings include:Review of R102's admission Record located under the Profile tab in his electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia, mood disorder, chronic kidney disease, and anemia.Review of R102's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated R102 had severely impaired cognition. The resident did not exhibit any mood or behavioral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-24 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
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, record review, document review and policy review, the facility failed to ensure concerns regarding food temperatures voiced by eight of eight residents who participated in the Resident Council meeting (R19, R34, R43, R89, R92, R105, R129, and R143) in a total sample of 36 residents were acted upon in a timely manner in an attempt to resolve the group's concerns. This failure had the potential to lead to resident dissatisfaction with the facility's Resident Council and grievance resolution processes.Findings include:Review of the facility's April 2024 through June 2025 Resident Council meeting minutes provided on paper revealed ongoing grievances regarding palatable food temperatures:June 2024: Residents stated the food/waffles are cold. There was no follow up to this concern documented in the June 2024 or July 2024 meeting minutes/resolutions.September 2024: The food could be a lot warmer. The response, Temp [temperature] logs checked.November 2024: Residents expressed food is cold when it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-24 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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, document review, and facility policy review, the facility failed to serve food that was palatable and hot to three (Resident (R) 85, R158, and R159) of four residents reviewed for food palatability and eight of eight residents who participated in the Group meeting (R19, R34, R43, R89, R92, R105, R129, and R143) in a total sample of 36 residents.Findings include: Review of the facility's policy titled Food and Nutrition Services dated 10/17 indicated, Policy Statement, each resident is provided with a nourishing. Palatable, well-balanced diet that meets his or her daily nutritional and special dietary need, food likes, dislike, eating habit, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 1. Review of R85's electronic medical record (EMR) revealed an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/25 located under the MDS tab indicated a Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-24 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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, admission agreement review and interviews, the facility failed to explicitly inform residents or their representative of their right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility; failed to explicitly state that neither the resident nor their representatives were required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility; failed to ensure that the agreement was explained to the residents and their representatives in a form and manner that they understood; failed to ensure that the residents or their representatives acknowledged that they understood the agreement; failed to explicitly grant the residents or their representatives the right to rescind the agreement within 30 calendar days of signing it for three of three (R)23, R33, and R5) reviewed for binding arbitration agreements. The failure had the potential for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-24 · tag F0848 — patternProvide a neutral and fair arbitration process and agree to arbitrator and venue.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interviews, the facility failed to provide for the selection of a neutral venue that is convenient to both parties in the binding arbitration agreement embedded in the facility's admission agreement signed by 131 of 139 residents currently residing in the facility. The failure had the potential for residents not to be aware of their legal right to have their disputes resolved in a court of law.Findings include:Review of the facility's admission Agreement revealed: .16. The Home and Resident or Resident's Representative agree that any claim, controversy, or dispute relating directly or indirectly to this Agreement, except for the Home's action to collect for non-payment of fees, shall be resolved by a single arbitrator in an arbitration association. The Arbitrator will be appointed by the mutual Agreement of the Home and Resident. If the Home and Resident cannot agree as to the identity of the Arbitrator, the Arbitrator will be appointed by the American Arbitration Association. The arbitration will be held in the county of the location of the Home. 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 · Ecited before2025-07-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on document review, interview and policy review, the facility failed to develop an effective infection surveillance program in order to conduct appropriate prevention or control activities and antibiotic stewardship for two (Resident (R)80 and R45) out of four residents reviewed for antibiotic stewardship. This failure had the potential to cause avoidable spread of infection or increase antibiotic resistance throughout the facility.Findings include: During an interview on 07/24/25 at 3:54 PM, the Infection Preventionist (IP) stated her monthly infection surveillance included tracking of the resident's location, diagnosis, need for isolation, whether the infection was facility or community-acquired, and the antibiotic order. Review of the June 2025 Infection Control surveillance log, provided on paper, revealed a total of 37 urinary tract infections listed, and all 37 residents had documented antibiotic treatment. Of those 37, only three had the organism listed. During the interview on 07/24/25 at 3:54PM, The IP stated if no organism was listed, it meant that there was no lab…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-24 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
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, interview, and policy review, the facility failed to ensure that antibiotics were used only in the presence of a diagnosed/confirmed infection for two of four residents (Resident (R) 80 and R45) reviewed for antibiotic stewardship out of a total sample of 36 residents. These failures had the potential to lead to increased antibiotic resistance or adverse side effects related to unnecessary antibiotic usage. Findings include: 1. Review of R80's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE]. Review of R80's Medication Administration Record (MAR), dated June 2025 and located under the Orders tab of the EMR, revealed a physician's order, dated 06/02/265, for Fosfomycin tromethamine (an antibiotic), 3 grams one time only on 06/02/25 for urinary tract infection (UTI). Review of R80's EMR under the Progress Notes tab revealed there was no documentation of symptoms, including increased incontinence.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure timely reporting of an injury of unknown origin for one out of five residents reviewed for abuse (Resident (R) 97). This failure had the potential to contribute to further abuse or injury, which could result in mental anguish, physical harm, or fear. Findings include: Review of R97's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and anxiety. Review of R97's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/25 and located under the MDS tab of the EMR revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed with severely impaired cognition. The resident had short and long-term memory problems and exhibited physical behaviors toward others almost daily and other behavioral symptoms and rejection 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.
Show the remaining 20 citations
- Potential for harm · D2025-07-24 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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, interview, and policy review, the facility failed to send a written notification of transfer to the hospital and a bed hold notification with the daily rate to the resident and resident representative (RR) for two (Resident (R)97 and R130 ) of two residents reviewed for hospital transfer and bed hold notification. This failed practice had the potential to affect the resident and their resident representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired or to make an informed decision on the bed hold. Findings include:Review of the facility's undated policy titled Admission, Transfer, and Discharge does not provide guidance related to providing the written notification of transfer to the resident and RR.Review of the facility's policy titled Bed-Holds and Returns indicated, All residents/representatives are provided written information regarding the facility and state bed -hold policies, which address holding or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · 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 interview, record review, and policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of three residents (Resident (R)97, R45, and R154) out of a total sample of 36. These failures created potential for an incomplete or ineffective plan of care related to alarm use for R97 and behavioral symptoms for R45 and R154.Findings include: Review of the facility's policy titled, Certifying Accuracy of the Resident assessment dated [DATE] revealed, The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. 1. Review of R97's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and anxiety. Review of R97's annual MDS with an Assessment Reference Date (ARD) of 06/12/25 and located under the MDS tab of the EMR, revealed she was unable to complete…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview and review of facility policy, the facility failed to maintain a medication error rate below five percent. During medication administration on one (2 South) of four wings, two errors/omissions occurred out of 25 opportunities for error for one (Resident (R)66) of six residents. The facility's medication error rate was 8%.Findings include: Review of the facility's policy titled Administering Medications dated April 2019 revealed, .4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of R66's physician's orders located on the Orders tab of the Electronic Medical Record (EMR) revealed, Metoprolol Tartrate Oral Tablet 25 MG [milligram ] [Metoprolol Tartrate] - Give 1 tablet by mouth two times a day for HTN [hypertension] Hold for Systolic blood pressure <110 dated 06/25/25 and Potassium Chloride ER [Extended Release] Tablet 10 MEQ…
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 · E2024-02-08 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review and review of facility documentation, it was determined that the facility failed to properly execute its food and nutrition services by not following the established portion control procedure. This deficient practice was evidenced by the following: On 01/30/24 at 11:17 AM, the surveyor interviewed the Director of Dietary (DD) who stated that the facility utilized a four week cycle menu and that they were in week three. On 02/05/24 at 12:22 PM, in the presence of the DD, the surveyor observed the cook at the steam table plating food for the lunch meal. The cook was wearing a hair covering, surgical mask and gloves. The cook was observed to use the food scoop and tongs to plate the food, rested her hands on the counter, used the scoop and tongs again, then used her gloved hand to remove whole green beans from the steam table and placed them on a plate, rested her hands on the counter, touched the front of her surgical mask, then used the scoop to plate food again. On 02/02/24 at 12:24 PM, the surveyor interviewed the cook who stated her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination, and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 01/30/24 at 10:01 AM, the surveyor arrived in the kitchen and was informed by the [NAME] that the Director of Dietary (DD) was not on location. At 10:06 AM, in the presence of the Cook, the surveyor toured the kitchen and observed the following: 1. On a rolling metal rack in the dairy refrigerator, there were four trays containing oval tan patties, that the [NAME] identified as hash browns, that were uncovered with no label or dates. The [NAME] acknowledged the trays should have been covered, labeled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ # 165358 Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated: a) during a meal tray pass observation for 1 of 4 units, (2 North unit), b) during medication administration for 1 of 3 residents observed (Resident #143), and c) during wound care for 1 of 3 residents observed (Resident #65). The deficient practice was evidenced as follows: 1. On 01/30/24 at 12:34 PM, the covered food cart arrived on The [NAME] hallway on Unit 2 North. At 12:51 PM, surveyor #1 observed a Certified Nursing Aide (CNA #1) who approached the food cart, removed a tray from the cart, entered Resident # 302's room and placed it on their bed side table (BST). CNA #1 then removed the lid from the foam cup, removed the lid from the orange soda bottle that was previously resting on the Resident's BST, poured the soda into the foam cup and replaced the lids on the soda and the foam…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility documents, it was determined that the facility failed to develop a person-centered comprehensive care plan to include residents' a.) preference for activities and b.) risk for pain. This deficient practice was identified for 1 of 1 resident (Resident #253) reviewed for activities and for 2 of 2 residents (Resident #145 and #301) reviewed for pain management and was evidenced by the following: 1. On 01/30/24 at 10:39 AM, the surveyor observed Resident #253 sitting in a wheelchair in his/her room. The resident stated that he/she would like to go to activities, but that there is no one to take him/her. According to the admission Record, Resident #253 had diagnoses which included, but were not limited to, unspecified hearing loss, muscle weakness, and altered mental status. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated, 01/10/24, included the resident had a Brief Interview for Mental Status…
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 · D2024-02-08 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a resident with meaningful activities that reflected the resident's preferences for 1 of 1 resident (Resident #253) reviewed for activities. This deficient practice was evidenced by the following: On 01/30/24 at 10:39 AM, the surveyor observed Resident #253 sitting in a wheelchair in his/her room. The resident stated that he/she would like to go to activities, but that there is no one to take him/her. On 02/01/24 at 9:45 AM, the surveyor sat in the lounge outside of Resident #253's room. There was an Activities Calendar on the table in the lounge that included a 10:00 AM sing-along activity. The calendar did not indicate where the activity was located. At 10:15 AM, the surveyor did not observe any sing-along activities on the unit, and staff did not enter the resident's room to offer to take her to an activity. Further review of the Activities Calendar included a 10:45 AM Communion activity. At 10:49 AM, the surveyor was still seated in the lounge…
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 · D2024-02-08 · 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
Complaint #NJ168566 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure a pressure reducing device was used correctly and b.) failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development specifically by not providing protective boots to heels as ordered. This deficient practice was identified for two (2) of four (4) residents (Resident #3 and #104) reviewed for pressure ulcer management. This deficient practice was evidenced by the following: 1. On 1/30/24 at 11:57 AM, during the initial tour, Resident #104 was not in their room. A staff member identified Resident #104 in the dayroom, sitting in a high back wheelchair, with a chair alarm on the back of the wheelchair. The surveyor reviewed the medical record for Resident #104. According to the admission Record (AR), Resident #104 had diagnoses which included: unspecified dementia with behavioral disturbance, hypertension (high blood…
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 · D2024-02-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint #NJ168222 and NJ168566 Based on observation, interview, and record review it was determined that the facility failed to ensure an environment was free from accident hazards by failing to place assistive devices, specifically bilateral floor mats, to prevent avoidable accidents for 1 of 7 residents (Resident # 97) investigated for Accidents. The deficient practice was evidenced by the following: On 01/30/2024 at 10:55 AM, during the initial tour of the facility, the surveyor observed Resident # 97 in their room in bed. The surveyor observed two blue floor mats folded and leaning against the wall on either side of the room. At that time, Resident # 97 replied, They haven't used them. when the surveyor asked if the facility had used the floor mats while he/she was in bed. On 02/05/2024 at 09:46 AM, the surveyor observed Resident # 97 in their room in bed. The surveyor observed the two blue floor mats folded and leaning against the wall on either side of the room. At that time, Resident # 97 replied, No when the surveyor asked if the facility had used the floor mats while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-08 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 pertinent facility documents, it was determined that the facility failed to ensure the medication error rates are not 5 percent or greater. This deficient practice was identified for 2 of 5 residents (Resident #143 and Resident #147), and 1of 2 nurses on the second-floor nursing unit during the Medication Administration task. The deficient practice was evidenced by the following: On 02/01/2024 at 08:55 AM, during the medication administration, the surveyor observed the Licensed Practical Nurse (LPN) prepare and administer medications to Resident #143 which included Metformin HCL (a medication used for managing high blood sugar levels) 500 milligrams (mg). That medication had a pharmacy label on the package which instructed to give with food. The surveyor observed Resident #143 in their room as the LPN administered the medication. At that time, the surveyor did not observe any food available in the vicinity of the resident. The LPN did not offer the resident any food…
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 · D2024-02-08 · 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, interview, and review of pertinent facility documentation it was determined that the facility failed to maintain medications with appropriate dating of medications for 1 of 3 medication administration carts inspected and was evidenced by the following: On [DATE] at 10:43 AM, the surveyor inspected the medication storage cart labeled Cart A on the 2 (two) North Unit with the Licensed Practical Nurse (LPN). The surveyor identified that there was an undated opened foil package containing 17-unit dose vials of the medication Ipratropium Bromide/Albuterol (DuoNeb) used for nebulizer treatments. The surveyor interviewed the LPN at the time of the inspection who confirmed that the medication should have been dated when opened because the medication was only good for two weeks after the foil package was opened. On [DATE] at 10:53 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) for 2 North who stated that medications should have been dated when they were opened…
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 · D2024-02-08 · 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
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 ensure that a resident's medical record contained an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, specifically by failing to include pertinent information in the electronic medical record. The deficient practice was discovered for 1 of 1 resident (Resident # 150) reviewed for Medical Records. The deficient practice was evidenced by the following: A review of Resident #150's Electronic Medical Record (EMR) under Progress Notes revealed that he/she was discovered by staff not breathing. The note revealed that the Nurse Supervisor was notified and Resident #150 was declared deceased . The note concluded by revealing that the physician, family, funeral home, and facility administration were notified. A review of Resident #150's physician's orders in the EMR revealed that Resident #150 was 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 · Fcited before2021-10-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and 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 9/17/2021 from 9:58 to 10:55 AM, the surveyors, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. The FSD was observed to perform testing of the wash water temperature and the sanitizer level of the three-compartment sink. Upon completion of the temperature and sanitizer level the surveyor requested to see a copy of the temperature and chemical sanitization logs for the three-compartment sink. The FSD stated, I don't have a temperature log or sanitizer level log for the three-compartment sink. I've never had a log for that in 18 years. The FSD further stated, You're right, I should have one for monitoring purposes. We test for sanitizer and the maintenance department tests the water temperatures. We will have to start a log. 2. During 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 · E2021-10-04 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to A.) provide a duration of use for an order of Ativan gel (a psychotropic medication) as needed and B.) failed to follow the duration indicated on the controlled drug administration record by administering Ativan past the duration of the order for 2 of 5 residents reviewed for unnecessary medications, (Resident #19, Resident #16). The deficient practice was evidenced by the following: 1. According to a Minimum Data Set (an assessment tool), dated [DATE], Resident #19 had diagnoses including but not limited to; Non-Alzheimer's Dementia (cognitive impairment of the brain), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear), and Depression (condition associated with the lowering of a person's mood). A review of Resident #19's physician's orders revealed an order dated [DATE], for Ativan 0.5 milligram (mg) gel as needed every 4 hours. The directions for use…
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 · D2021-10-04 · 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, record review and review of other documentation, it was determined that the facility failed to ensure a right palm protector was applied and removed daily according to the physician's order, for 1 of 2 residents reviewed for limited range of motion, (Resident #53). This deficient practice was evidenced by the following: On 9/20/21 at 11:57 AM, the surveyor observed resident #53 in the residents' room, sitting in a wheelchair, neatly dressed and groomed. The residents' right arm was lying limp against his/her right side. Resident #53, using his/her left hand, positioned his/her right arm across his/her lap. The surveyor observed that the resident's right hand was tightly contracted; a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints. There was no palm protector in place. The resident stated that he/she is mostly independent but needs assistance transferring and getting dressed. The resident added that he/she does not use a brace or palm protector for her arm and said, If I…
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 · D2021-10-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
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 a) maintain a Foley catheter bag in manner to promote dignity, b) failed to ensure the catheter or privacy bag did not come into contact of the floor, c) change a resident leg bag daily as per facility policy for 2 of 2 Residents reviewed for Urinary Catheter (Resident #33 and Resident # 35) . This deficient practice was evidenced by the following: 1. During the initial tour of the [NAME] unit on 9/17/21 at 11:41 AM, Resident #33 was observed lying in bed. The Foley was attached to the bed and visible from the hallway and not in a privacy bag. On 09/21/21 at 11:31 AM, Resident #33 was observed in his/her room sitting in a wheelchair. The Foley was in a blue privacy bag attached under the seat of the wheelchair in contact with the floor. On 9/22/21 at 11:58 AM, Resident #33 was observed in his/her room sitting in the wheelchair. The Foley was in a blue privacy bag attached under…
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.
- No harm found · Bcited before2024-02-08 · tag F0641 — patternEnsure 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 Complaint NJ #: 168222 and 168566 Based on interview, record review, and review of facility documents, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 2 of 7 residents (Resident #104 and 251) reviewed for accidents. This deficient practice was evidenced by the following: 1. On 1/30/24 at 11:57 AM, during the initial tour, Resident #104 was not in his/her room. A staff member identified Resident #104 in the dayroom sitting in a high back wheelchair with a chair alarm in place. The surveyor reviewed the medical record for Resident #104. According to the admission Record (AR), Resident #104 had diagnoses which included, but were not limited to, unspecified dementia with behavioral disturbance, hypertension (high blood pressure), and senile degeneration of brain (progressive decline in a person's ability to think and remember). A review of the quarterly MDS, dated [DATE], reflected the resident had a Brief…
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.
- No harm found · B2024-02-08 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 ensure that the required members were present during the quarterly Quality Assessment and Assurance (QAA) committee meetings. This deficient practice occurred during 1 of the 4 meetings and was evidenced by the following: On 02/07/24 at 09:52 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the Quality Assurance Performance Improvement (QAPI) process in the facility. According to the data provided by the facility, there was no physician, including the Medical Director (MD) or another designated physician, in attendance at the quarterly Quality Assurance (QA) meeting that was held on 05/11/23. On 02/07/24 10:30 AM, the surveyor reviewed the quarterly QA minutes in the presence of the LNHA. The LNHA stated that according to the attendance sign out sheet the MD did not sign that he was in attendance. The surveyor did observe that the minutes that were documented after the meeting were signed by the Medical Director. The LNHA stated that these minutes were typed by…
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.
- No harm found · Bcited before2021-10-04 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that an accurate Minimum Data Set (MDS), an assessment tool, was completed. This deficient practice was identified for 2 of 22 residents reviewed (Residents #2 and # 37) and was evidenced by the following: 1.Resident #37 was a resident in the facility with diagnoses which included heart failure and hypertension. During an interview on 9/20/21 at 01:05 PM, Resident #37 stated he/she said receives pain medication twice a day for pain said his/her pain is getting better every day. A review of the 7/5/2021 MDS for Resident #37, reflected that Resident #37 had a Brief Interview for Mental Status score of 12 when interviewed by staff. On the pain section of the MDS for the question should the pain assessment interview be conducted; it indicates a 0 no (resident is rarely/never understood). During an interview with the surveyor on 9/23/21 at 11:35 AM, the Registered Nurse MDS Coordinator acknowledged that the pain section for Resident #37's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| KLEIN, JANICE | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 08/01/2001 |
| RICCIARDI, LOUIS | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 10/31/2000 |
| PRICE, ALYSIA | Individual | CORPORATE DIRECTOR | since 06/25/2019 |
| HEBREW OLD AGE CENTER OF ATLANTIC CITY | Organization | OPERATIONAL/MANAGERIAL CONTROL | NO DATE PROVIDED |
CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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 $593K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 315340. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-24, 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.