Windmere

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

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.

Staffing

CMS has not published payroll-based (PBJ) staffing hours for this facility yet — this can happen for newer, hospital-based, or recently-certified homes. It can also mean the home simply did not file, which CMS does not distinguish in this data, so treat the gap as unexplained rather than benign. Staffing is one of the three parts of the CMS star rating; where it’s missing, weigh the independent health-inspection score most, and ask the facility directly about its nurse-to-resident ratios and weekend RN coverage.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. 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.

• Potential for harm · F2026-03-03 · tag F0640 — widespread
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on interview and record review, it was determined that the facility failed to complete and transmit Minimum Data Sets (MDS) in accordance with federal guidelines. This deficient practice was identified for 17 of 17 residents reviewed for resident assessment (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 19, 20, and 21). This deficient practice was evidenced by the following:On 2/25/26 at 1:06 PM, the surveyor reviewed the MDS submissions for Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 19, 20, 21. The MDS's were completed yet they were not submitted/transmitted to CMS as required. The facility had submitted the MDS' exclusively as state-only assessments and did not the MDS's. As a result, the Residents are not showing up for the provider.At 1:40 PM, the surveyor interviewed the Administrator and Director of Nursing (DON), who stated that they were not aware that the MDS's were being submitted incorrectly and after surveyor inquiry, the DON stated that she now realized that the MDS's were not submitted correctly. NJAC 8:39-11.2

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-03-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview, record review and policy review, it was determined that the facility failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following:On 2/26/26 at 10:32 AM, in the presence of the Executive Sous Chef (ESC) and the Senior Director of Dining and Nutrition Services (DNS), the surveyor observed the following:On a shelf, in the area of the dishwashing area, near the 3 compartment sink, the surveyor observed 4 deep full sheet sized steam table pans, stacked with water between them, 5 deep half sized steam table pans stacked with water between them, and 2 shallow full size steam table pans stacked with water between them. The ESC stated that these pans should have been air dried prior to stacking them as to prevent wet nesting. On 2/26/26 at 12:40 PM, the surveyor discussed above concerns with the Administrator.On 2/26/26 at 2:05 PM, the Administrator stated that the facility had no policy in place for wet nesting of dishware. No further information was provided.NJAC 8:39-17.2(g)

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-03 · tag F0836 — isolated
  Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and 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 observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following:According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:(a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements:(1) Compliance with title XVIII of the Act and applicable Medicare regulations.(2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies the provider 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-08 · tag F0881 — failed to use antibiotics responsibly — widespread
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure: a) the Antibiotic Stewardship Program (ASP) Policy and Procedure, part of the facility Infection Prevention Control Program (IPCP) was reviewed at least annually and included a procedure for the reporting of multidrug- resistant organisms (MDRO), and communicable diseases to local/state public health authorities, b) a standardized infection assessment tool or management algorithm (IST) was consistently utilized for prescribed antibiotics (Resident #2), c) residents with chronic urinary tract infection with multiple prescribed antibiotics were tracked to prevent development and/or transmission of MDRO, d) staff were educated when a Multidrug-Resistant Organism was identified (Resident #7), and e) the facility maintained evidence of an ongoing analysis of surveillance data for organisms with a documented follow-up in response to the collected data. The deficient practices was identified for 2 of 7 sampled residents (Resident #2 and Resident #7) during…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-08 · tag F0940 — failed to train staff — widespread
  Develop, implement, and/or maintain an effective training program for all new and existing staff members.
  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 document review, it was determined that the facility failed to ensure that all licensed staff received training and competencies in accordance with the Facility Assessment, and to ensure facility policies and procedures for wound care competencies were met. This deficient practice was identified during an Initial Certification Survey for 1 of 7 Residents sampled for wound care (Resident #1) and one closed medical record (Resident #2). The deficient practice effected 2 of 2 Resident Units and was evidenced by the following: On 08/07/24 at 9:09 AM, during the facility entrance conference the surveyors requested a list of all the residents who received wound care. The Director of Nursing (DON) stated there was one resident (Resident #1) who received wound care treatments three times per week, and it was completed by the Wound Care Nurse. The DON stated there were no daily wound treatments provided at the facility. On at 08/07/24 at 9:45 AM, the surveyor toured the Long-Term 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.

  Administration Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 28 rows in the source record cover these 24 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.

What families pay in NJ