Cambridge Rehabilitation And Healthcare Center
255 East Main St, Moorestown, NJ 08057 · For profit - Limited Liability company · 201 certified beds · (856) 235-1214 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $24,911 in federal fines (most recent 2023-09-07)
- 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 | 3.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.0% | 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 | 2.3% | 12.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.5% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.0% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.8% | 18.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.2% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.9% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.0% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.2% | 80.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 27.8% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.0% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.40 | 2.07 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.62 | 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.
51.8% 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 314 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.3% 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 142 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | 51.8%CMS range 44.9–57.1 | 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 | 11.4%CMS range 8.8–14.1 | 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 | 75.3% | 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 | 67.6% | 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 | 71.1% | 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 | 98.5% | 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 | 99.3% | 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 | 0.3% | 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 | 4.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.1%CMS range 4.1–8.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 201 beds and averages 157.3 residents a day — about 78% occupied, or roughly 44 beds typically open. It usually has some room. 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 3.07 hrs/resident/day on weekends vs 3.40 on weekdays — 10% thinner on weekends. RN hours go from 0.58 to 0.35 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%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-10-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ165363, NJ165497, NJ168316 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/17/2023 and 10/19/2023, it was determined that the facility failed to provide a safe environment and supervision of a ambulatory cognitively impaired resident on a secured unit. The facility failed to identify that a staff member didn't follow the policy for storage of personal items. It was determined on 9/7/2023 that an Activity Assistant (AA) left her Cambridge fanny pack (a facility issued fanny pack with zipper provided to staff during orientation to carry around items securely.) unsupervised on the second shelve of a three-tier activity cart and the resident ( Resident #2) took it. Resident #2 was found by a Certified Nursing Assistant (CNA) with an opened bottle of Hydroxyzine 50 miligram (mg) (a medication used to treat anxiety) that belonged to the AA. The AA and Licensed Practical Nurse (LPN) counted the pills in the bottle and confirmed there were three…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-11-06 · 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
Based on interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident's plan of care was followed and communicated to all facility staff to prevent falls. Resident #2 fell and sustained head trauma with a laceration to the head with active bleeding which required transferring Resident #2 to the hospital. This deficient practice was identified for one of three residents (Resident #2) reviewed for accidents and incidents. This deficient practice was evidenced by the following:On 11/6/25 at 10:15 AM, the surveyor reviewed Resident #2's closed electronic Medical Record (EMR).A review of the Face Sheet (an admission summary) reflected that Resident #2 was admitted to the facility with diagnoses which included but were not limited to; Parkinson's disease, need for assistance with personal care, hemiplegia unspecified affect, muscle wasting and atrophy and unspecified dementia.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 7/21/25, reflected that Resident #2 scored 7 out of 15 on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-06 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of pertinent documents it was determined that the facility failed to ensure a thorough investigation was conducted to identify the causal factor of a fall for a severely cognitively impaired resident who was found lying on the floor in a pool of blood, that resulted in a hematoma and laceration to the head, and required emergent transfer to the hospital on 9/5/25. This deficient practice occurred for 1 of 3 residents (Resident #2) reviewed for accidents and incidents, and was evidenced by the following:On 11/6/25 at 11:30 AM, the surveyor reviewed the closed medical record (Electronic and Paper) for Resident #2.According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to; Parkinson's disease, need for assistance with personal care, hemiplegia unspecified affect, muscle wasting and atrophy, unspecified dementia.A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-06 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and review of other pertinent facility documentation it was determined that the facility failed to treat and manage a resident's pain consistent with professional standards of practice. This was identified for 1 of 4 residents (Resident #1) reviewed for pain and was evidenced by the following:A review of the resident admission Record (admission summary) indicated that Resident #1 was admitted to the facility with the diagnoses which included but was not limited to Alzheimer's Disease, chronic obstructive pulmonary disease (COPD-a group of lung diseases that cause airflow obstruction and breathing difficulty) and osteoporosis (causes bones to become thinner, weaker and more likely to fracture). A review of the quarterly Minimum Data Set (MDS)-an assessment that facilitates a resident's care) dated 9/10/25, indicated that Resident #1 scored a 3 (three) out of 15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had severe cognitive impairment. The MDS also reflected that Resident #1 required maximum assistance with all…
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 before2025-08-05 · 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, interview, and record review, 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 7/25/2025 from 09:49 AM to 10:14 AM the surveyor accompanied by the Food Service Director (FSD), observed the following in the kitchen:1. In the walk-in freezer a frozen lasagna was wrapped in plastic wrap with a use by date of 7/25/25. When asked if lasagna should be used, the FSD replied No, I'm going to take it out right now. The expired food was removed by FSD.2. In the walk-in refrigerator a container of chicken noodle soup wrapped in plastic wrap with a use by date of 7/28/25. The expired food was removed by FSD.On 7/30/2025 at 10:36 AM on the [NAME] unit in the pantry 11 plastic cups labeled for 7/30 7-3 were seen stacked facing up and exposed to the air. Licensed Practical Nurse, (LPN) #1 accompanied surveyor to the [NAME] unit…
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 · E2025-08-05 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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, the facility failed to ensure that food brought to residents by family and other visitors were stored, handled, and consumed in a safe and sanitary manner. This deficient practice was identified for 4 of 6 residents (Resident # 9, Resident # 13, Resident # 26 and Resident # 51) who had personal refrigerators in their bedrooms.The deficient practice was evidenced by the following:On 07/31/2025 at 10:23 AM, the surveyor observed that Resident # 26's personal refrigerator, located in room [ROOM NUMBER]-W temperature log had not been filled out since July 18th.On 07/31/2025 at 10:24AM, the surveyor observed that Resident # 9's personal refrigerator, located in room [ROOM NUMBER]-W, was missing temperature log entries for the whole month of July.On 07/31/2025 at 10:42 AM, the surveyor observed that Resident #51's personal refrigerator, located in room [ROOM NUMBER]-D had no temperature log was on the refrigerator for the month of July.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.
- Potential for harm · D2025-08-05 · 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
Number of residents sampled:Number of residents cited:This deficient practice was evidenced by the following:A review of Resident # 14's admissions record revealed that, Resident # 14 was admitted with but not limited to Heart Failure, and Peripheral Vascular Disease (a condition in which narrowed arteries reduce blood flow to the arms or legs).A review of Resident #14's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 06/27/2025 revealed under section N that the resident was ordered an anticoagulant (a medication that helps thin the blood).A review of Resident #14's Electronical Medical Record revealed a physician's order with a state date of 05/26/2025 for apixaban (a medication that helps thin the blood) 5 milligrams to be given every twelve hours. A review of the current Care Plan (CP) for Resident #14 did not include documentation of a CP focus area or interventions for the use of an anticoagulant.During an interview on 08/01/2025 at 09:58 AM with the surveyor the Unit Manger Registered Nurse (UMRN)# 1 said that care plan…
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 · D2025-08-05 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living specifically by not turning the resident in bed every two hours to prevent skin deterioration. The deficient practice was identified for 2 of 5 residents (Resident # 179, 152) investigated for Activities of Daily Living. The deficient practice was evidenced by the following: A review of Resident # 179’s Minimum Data Set (MDS; an assessment tool) dated 9/15/2024 revealed under section “GG” that he/she has lower extremity impairment on both sides. Further, the MDS revealed under section, “M” that he/she is at risk of pressure ulcers/injury. A review of Resident # 179’s Care Plan revealed a focus of an Activity of Daily Living (ADL) Self Care Performance deficit related to deconditioned status post hospitalization, pain, and weakness. The Care Plan revealed an intervention for “Bed Mobility” that Resident # 179 requires the assistance of one staff member…
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 before2025-08-05 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and other pertinent facility documents, it was determined that facility to failed to ensure residents received the appropriate pain management by administering pain medications according to the physician's ordered pain level parameters. This deficient practice was identified in 2 of 4 residents reviewed for pain (Resident #7 and #49) and was evidenced by the following: 1.On 7/29/2025 at 10:47 AM, during the initial tour Resident #7 was in the room in bed. The resident's left leg was elevated on pillows and the resident appeared comfortable to the surveyor. The surveyor reviewed the medical record for Resident #7.A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; fracture of the lower extremity, diabetes (high blood sugar), and depressive disorder.A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/11/25, section C for cognitive patterns revealed 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.
- Potential for harm · D2025-08-05 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # NJ00172812Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide access to the call system while a resident was in bed. The deficient practice was identified for 2 of 8 residents investigated under the Environment Task. (Resident # 2 and Resident # 77)On 07/29/2025 at 10:29 AM, during the initial tour of the facility, the surveyor observed Resident # 2 asleep in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On the same date at 10:37 AM, the surveyor observed Resident # 77 awake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On 07/30/2025 at 10:29 AM, the surveyor observed Resident # 77 wake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On 07/31/2025 at 09:40 AM, the surveyor observed Resident # 2 asleep in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On the same date at 09:42…
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 · E2024-01-24 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed a.) conduct quarterly Interdisciplinary Care Plan (ICP) meetings and b.) to consistently maintain documentation showing that the resident's representative (RR) was invited or attended ICP meetings in accordance with the facility practice and policy. This deficient practice was identified for two (2) of 36 residents (Resident #67, #81) reviewed, and was evidenced by the following: On 01/22/23 at 10:30 AM, the surveyor reviewed the admission Record (AR) for Resident # 67 which reflected that the resident was admitted to the facility with diagnoses that included but was not limited to dementia with mood disturbances, major depressive disorder, recurrent and cognitive communication deficit. It further reflected that resident had a Power of Attorney (POA) with contact information listed on the AR. The surveyor reviewed Resident #67's medical record which revealed the following information: A review of Resident #67's Care Plan Meeting Review…
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 · E2024-01-24 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain the resident's environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for one (1) of four (4) units ([NAME] Glen) was evidenced by the following: The surveyor conducted a tour of the [NAME] Glen Unit on 1/10/24 at 9:52 AM. The surveyor interviewed Registered Nurse/Unit Manager (RN/UM #1) who explained that the [NAME] Glen Unit was comprised of dementia (cognitively impaired) residents and some residents that had behavioral disturbances related to dementia. RN/UM #1 informed the surveyor that Housekeeping was responsible for cleaning/maintaining the resident rooms and daily touch surfaces and the certified nursing assistants (CNAs) were responsible for making beds, changing bed linens, and general cleanliness of the rooms. During the tour the surveyor identified the following: 1.) In room [ROOM NUMBER], beneath 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.
Show the remaining 13 citations
- Potential for harm · Ecited before2024-01-24 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ#: 165482 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to a.) ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Residents #65, #84, #89) observed for incontinence care on 1 of 2 units ([NAME] Glen and Laurel Creek units) and b.) provide nail care to a resident who required extensive assistance from the staff for activities of daily living (ADLs) for 1 of 5 residents, (Resident #114) reviewed for ADLs. a.) ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Residents #65, #84, #89) observed for incontinence care on 1 of 2 units ([NAME] Glen and Laurel Creek units). This deficient practice was evidenced by the following: 1. On 01/12/24 at 12:30 PM, the [NAME] Glen Unit Manager (UM) provided the surveyors with a list of incontinent residents on the unit. On 01/18/23 at 07:38 AM, the surveyor met with…
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 before2024-01-24 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
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 pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice related to pain management. Specifically not a.) obtaining a physician's order for severe pain and administering pain medication according to the appropriate pain level, b.) administering pain medications as ordered by a physician and c.) appropriately assessing, monitoring, and recognizing verbal and non-verbal signs and symptoms of pain during a wound care treatment. This deficient practice was identified for three (3) of 3 residents (Resident #52, #114 and #200) reviewed for pain management. The deficient practice was evidenced by the following: a.) On 01/10/24 at 11:07 AM, during the initial tour, the surveyor observed Resident #52 lying in bed watching the television. When asked if they had any concerns, Resident #52 stated that he/she did not feel like their pain was managed well. Resident #52 stated they had a standard oxycodone…
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 before2024-01-24 · 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
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. This deficient practice was observed and evidenced by the following: On 01/10/24 at 09:43 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD#1) for the Assisted Living unit and the Regional Director of Dining Services (RDDS). FSD#1 stated that the FSD#2 for the Long-Term Care unit would be on site shortly. The tour commenced and the following was observed: 1. At handwashing sink #1, there was a step-lid trashcan with no plastic trash bag, with trash and debris observed inside the can. During an interview at that time, FSD#1 acknowledged the unlined trashcan and stated that there should have been a plastic bag in the can. FSD#1 stated that a plastic bag would have made it easier for the trash to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ #: 168814 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) follow appropriate hand hygiene practices during a wound treatment observation by One (1) of two (2) nursing staff observed for 1 of 1 resident reviewed for wound treatments (Resident # 114); b.) follow isolation precautions for a resident who was on Enhanced Barrier Precautions by 1 of 3 nursing staff for 1 of 2 Residents (Resident #102) reviewed for transmission-based precautions c.) follow facility policy regarding not wearing gloves in the hallway by 2 of 2 nursing staff observed transporting soiled linens and trash on the Hartford Glen Unit and d.) clean and disinfect multiuse medical equipment prior to resident use for 1 resident (Residents #38) by 1 of 2 nurses on 1 of 2 nursing units observed during medication pass. This deficient practice was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · 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
Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) for 1 of 2 residents (Resident #103) reviewed for abuse. This deficient practice was evidenced by the following: On 01/16/24 at 10:25 AM, the surveyor observed Resident #103 ambulate into the day room and begin conversing with the other residents. At that time, the Assistant Director of Nursing (ADON) entered the day room and redirected the resident. According to the admission Record, Resident #103 had diagnoses which included, but were not limited to, encephalopathy (condition that causes brain dysfunction), unspecified dementia with agitation, depression, cognitive communication deficit, anxiety, and insomnia. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/08/23, included the resident had a Brief Interview for Mental Status score of 6, which indicated the resident's cognition was severely impaired. Further review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-24 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 residents (Resident #103) reviewed for abuse. This deficient practice was evidenced by the following: On 01/16/24 at 10:25 AM, the surveyor observed Resident #103 ambulate into the day room and begin conversing with the other residents. At that time, the Assistant Director of Nursing (ADON) entered the day room and redirected the resident. According to the admission Record, Resident #103 had diagnoses which included, but were not limited to, encephalopathy (condition that causes brain dysfunction), unspecified dementia with agitation, depression, cognitive communication deficit, anxiety, and insomnia. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/08/23, included the resident had a Brief Interview for Mental Status score of 6, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified resident behavior and preferences. This deficient practice was identified for 1 of 36 residents (Resident #45) reviewed for care plans and evidenced by the following: On 1/10/24 at 10:44 AM, the surveyor observed the resident lying in bed, but permitted the surveyor to enter. The surveyor observed the bottom of the room's radiator unit broken, open and exposed. The surveyor located the resident's call bell in the bottom, closed nightstand drawer. The surveyor also observed a sign that depicted a call bell on Resident #45's closet door that stated, press the red button for help from nurse. On 1/11/24 at 11:08 AM, the surveyor observed Resident #45's call bell in the bottom, closed nightstand drawer and the bottom of the radiator was broken, open and exposed. On 1/12/24 at 11:22 AM, the surveyor observed Resident #45's call bell in 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 · D2024-01-24 · 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 NJ #: 168814 Based on interview, record review, and review of facility documents, it was determined that the facility failed to address recommendations from the Wound Care Consultant (WCC) in a timely manner for 1 of 5 residents (Resident #502) reviewed for pressure ulcers. This deficient practice was evidenced by the following: According to the admission Record, Resident #502 had diagnoses which included, but were not limited to, COVID-19, diabetes mellitus, and dementia with anxiety. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/12/23, included the resident's Brief Interview for Mental Status score was 14, which indicated the resident's cognition was intact. Further review of the MDS included the resident had three unstageable - deep tissue injury (DTI) pressure ulcers that were present upon admission to the facility. Review of the Care Plan, initiated 10/12/23, included a focus of, the resident has a pressure ulcer development r/t [related to] immobility, with an intervention 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 · D2024-01-24 · 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 Complaint #160989 Based on observation, interview and review of the medical record and other facility documentation, it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practices for one (1) of 36 residents reviewed (Residents #505). This deficient practice was evidenced by the following: On 1/10/24, the surveyor team entered the facility for the annual recertification survey. Resident #505 was not a resident in the facility and was discharged on 01/20/23. The admission Record (AR) indicated that Resident #505 was admitted to the facility with the diagnoses which included but was not limited to retention of urine, altered mental status and seizure disorder. The admission Minimum Data Set (MDS), an assessment tool dated 12/15/22, indicated that the resident was cognitively intact and required limited assistance with activities of daily living (ADL's). The MDS also indicated that the resident had an indwelling urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 Complaint #: NJ00159128 Based on observation, interview, and review of facility documentation on 09/06/23 and 09/07/23 it was determined that the facility failed to obtain a timely reweigh for a resident with an identified significant weight loss. and contact the Registered Dietitian in writing regarding a resident with an identified significant weight loss. The facility also failed to follow their policy for, Weight Assessment and Intervention for 1 of 3 residents (Resident #2) reviewed for weight loss. The deficient practice was evidenced by the following: Reference: New Jersey Statues, 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00159128 Based on interviews, medical record review, and review of other pertinent facility documentation on 09/06/23 and 09/07/23, it was determined that the facility staff failed to consistently document on the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents according to the facility policy, Activities of Daily Living (ADLs), Supporting for 1 of 2 residents (Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the admission Record (AR), Resident #2 was admitted on [DATE], with diagnoses that included but were not limited to Muscle Wasting and Atrophy (degeneration), Multiple Sites, Heart Failure (when the heart does not pump enough blood for the body's needs), and Encounter for Surgical Aftercare following Surgery on the Digestive System. The admission Minimum Data Set (MDS), an assessment tool used to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2021-09-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, 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 9/8/2021 from 9:14 AM to 10:12 AM the surveyors, accompanied by the Director of Dining Services (DODS) observed the following in the kitchen: 1. During observation of the high temperature dish machine the surveyor observed unidentified debris on the top of the dish machine, on the temperature gauge panel and below the power and motor switches. Unidentified white, dried, splash type stains were observed on the door of the machine. When interviewed the DODS stated, It gets cleaned weekly but should be wiped down daily. Review of the facility provided Daily/Weekly Cleaning Schedule for the kitchen revealed that cleaning of the dish machine is not listed as a daily procedure and is delimed on a weekly basis. 2. A stack of approximately 15…
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 · B2021-09-15 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical record and review of 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 1 of 23 sampled residents, (Resident #103). This deficient practice was evidenced by the following: During the initial tour of the Hartford Unit on 9/08/21 at 11:03 AM, Resident #103 was observed lying in bed on an air mattress. A review of the Electronic Medical Record (EMR) revealed Resident #103 was admitted to facility with diagnoses including but not limited to Fractured Hip. A review of the admission Nursing assessment dated [DATE], included documentation of right plantar (bottom of the foot) suspected deep tissue injury (DTI), left upper heel suspected DTI, left outer ankle healing scar, left 2nd toe black discoloration, left inner ankle scab, left heel suspected DTI. There was no documentation of a sacral wound. A review of an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$24,911 in federal fines across 2 penalties.
- $9,318 — penalty dated 2023-09-07
- $15,593 — penalty dated 2023-09-07
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 MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 2 of 5 | 2.6 | -0.6 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| QUINTO HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 89% | since 01/01/2022 |
| BOKF,NA | Organization | 5% OR GREATER SECURITY INTEREST | — | since 01/31/2020 |
| BAUER, GARY | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 01/31/2022 |
| JOHNSON, CELESTE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/18/2024 |
| POSEN, MINDEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/01/2022 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2021 |
| NUTRACO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/10/2025 |
| RELIANT PRO REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/10/2025 |
| BLANK, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/31/2020 |
| CAMBRIDGE PROPERTY 1 LLC | Organization | ADP OF THE SNF | — | since 01/31/2020 |
| NFR 2020 IRRV TR | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| RSBRMK HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| SK 2013 DELTA TRUST | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| SORA KOHN FAM TR UAD 120120 | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| TRYKO HOLDINGS, LLC | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| UAK 2020 IRRV TR | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| UKR CONSULTING LLC | Organization | ADP OF THE SNF | — | since 06/01/2020 |
| YR 2013 DELTA TR UA 03252013 | Organization | ADP OF THE SNF | — | since 01/01/2022 |
CMS files one row per role, so the 28 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 315201. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-05, 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 →
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