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Complete Care At Arbors

1750 Route 37 West, Toms River, NJ 08757 · For profit - Corporation · 120 certified beds · (732) 914-0090 Medicare & Medicaid certified

Call the home — (732) 914-0090 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 22 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (22) — 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 payroll-based staffing rating is low (2/5)
  • about 23% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
1163 Route 37 W · (732) 736-1000 · Call to confirm hours
Pharmacy
Walgreens1.3 mi
1311 Route 37 W · (732) 349-0517 · Call to confirm hours
Grocery
713 Manchester St · (732) 473-1569 · Call to confirm hours
Park
1401 Broadway Blvd · (609) 971-1635 · Typically dawn to dusk

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 improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.6%8.7%15.4%better
Long-stay residents who lose too much weight2.1%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.0%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms7.7%12.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.0%2.3%3.3%better
Long-stay residents whose ability to walk worsened3.7%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.7%18.8%18.9%worse
Long-stay residents given the seasonal flu vaccine93.9%97.2%95.3%typical
Long-stay residents with pressure ulcers2.4%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control19.5%15.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table7.9%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine25.7%80.1%79.4%worse
Short-stay residents rehospitalized after admission19.8%24.9%22.6%better
Short-stay residents with an outpatient ER visit7.7%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.282.071.67worse
Long-stay outpatient ER visits per 1,000 resident days0.991.111.80better

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

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

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

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

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

56.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 305 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.6%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
81.0%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 81.0% 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 126 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 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.6%CMS range 51.1–61.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 9.5–14.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge81.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge75.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge78.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 5.0–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.58
RN hours/ resident / day
0.91
LPN hours/ resident / day
1.68
Aide hours/ resident / day
3.17
Total nurse hours/ resident / day
0.40
RN hoursweekends
49.5%
Total nursing turnover
53.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 107.6 residents a day — about 90% 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.68 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 2.77 hrs/resident/day on weekends vs 3.33 on weekdays — 17% thinner on weekends. RN hours go from 0.65 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

8
deficiencies at the latest standard inspection (2025-03-27)
8
at the previous standard inspection (2024-05-17)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Ecited before2025-03-27 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of medical records, it was determined that the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not a.) securing medications during medication administration observation for 1 of 3 nurses; b.) notifying a physician regarding a resident's refusal of medication for 1 of 1 residents (Resident #31); c.) applying skin protective devices as ordered by a physician for 1 of 2 residents (Resident #8) reviewed for pressure ulcers; and d.) destroying unused medication properly during medication observation for 1 of 3 nurses. Reference: New Jersey Statutes, 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…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ175184, NJ176084, NJ179637 Based on observations, interviews, and review of pertinent facility documents, the facility failed to ensure residents who required assistance with their daily activities of living (ADLs) a.) received incontinence care and b.) staff answered resident call systems to provide care and services. This deficient practice was identified for 1 of 4 residents reviewed for bowel and bladder (Resident #65); 2 of 8 residents observed during incontinence rounds (Resident # 29 and Resident #63); and on 1 of 2 nursing units (Rosewood). The evidence was as follows: 1. On 3/23/25 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated the unit today had five certified Nurse Aides (CNA) for 48 residents. On 3/23/25 at 10:26 AM, during the initial tour of the unit, the surveyor interviewed Resident #65 who was lying in their bed. The resident stated that they were saturated and had not been changed yet that morning. Resident #65 stated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 Based on observations, interviews, record review and other pertinent facility documentation it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection by ensuring a.) proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) for 2 of 2 residents reviewed for EBP (Resident #81 and #397), b.) label and date piston syringe irrigation kit (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) in a manner to prevent contamination for infection control identified for 1 of 1 resident reviewed for tube feeding (Resident #64), and c.) respiratory device tubing and mouthpiece/ mask were stored in protective covering identified for 1 of 2 residents (Resident #17) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. A review of the admission Record (AR) face sheet (admission summary) indicated that Resident…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) maintain infection control to reduce the risk of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice during a wound care treatment and b.) ensure a treatment was administered in accordance with a physician order. This deficient practice was identified for 1 of 3 residents reviewed for pressure ulcer (Resident #46), and was evidenced by the following: Reference: CDC Recommendations for Hand Hygiene, updated 2/27/24, Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services 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 observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure dialysis communication forms between the facility and the contracted dialysis facility were consistently completed. This deficient practice was identified for 2 of 2 residents reviewed for dialysis (Resident #25 and Resident #45), and was evidenced by the following: 1. On 3/23/25 at 10:32 AM, during initial tour of the facility, the surveyor observed Resident #45 seated in their wheelchair in the hallway. Resident #45 stated that they go to dialysis three times a week. On 3/24/25 at 12:52 PM, the surveyor reviewed the medical record for Resident #45. A review of the Transfer/Discharge Report face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (kidneys have permanently lost their ability to function), dependence on renal dialysis (relies on dialysis machine to filter their…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent records, it was determined that the facility failed to a.) ensure the accountability of the narcotic shift count logs were completed and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 2 of 3 medication carts (Rosewood #1 and #4) reviewed and was evidenced by the following: On 3/25/25 at 10:20 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN), reviewed the Rosewood nursing unit's medication cart #1. The following was observed when the narcotic logbook was reviewed: The nurse's signature for the going off duty was missing on: 3/8/25 the 3:00 PM to 11:00 PM (evening) shift; 3/13/25 the 7:00 AM to 3:00 PM (day) shift; and 3/19/25 the evening shift. The nurse's signature for the coming on duty was missing on the 3/8/25 night shift. A further review of the declining inventory logs indicated that Resident #56 should have had 30 tablets of phenobarbital 32.4 milligram (mg) (a controlled medication used to treat seizures), but only 29…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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

    Based on observation, interview, and review of facility policy, it was determined that the facility failed to properly store and secure medications. This deficient practice was observed in 1 of 3 medication carts reviewed (Rosewood #4), and was evidenced as follows: On 3/25/25 at 11:35 AM, the surveyor observed the Rosewood nursing unit's medication cart #4. The medication cart was next to the nurse's station and was unattended by any nursing staff. The cart was observed to be unlocked and had a bottle of acidophilus with pectin (a probiotic medication used to treat diarrhea) left unattended on top of the cart. At that time, the surveyor requested that the nurse assigned to the cart to be paged to come to the cart. The Registered Nurse (RN) assigned to the cart came out of a resident's room down the hall and approached the surveyor at the cart. The surveyor interviewed the RN who stated that medication should not have been left unattended and unsecured. The RN also confirmed that the medication cart should have been secured since it was left unattended. The RN further stated 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 3/23/25 at 9:23 AM, during initial tour of the kitchen, the surveyor accompanied by the Head Chef, and observed the following: An opened container of bulk beef base. The beef base was not labeled with a use by date and contained a coffee mug that was used as a scooper in the beef base. A large, opened container of flour that contained a coffee mug left inside the flour to be used as a scooper. On 3/23/25 at 10:05 AM, the surveyor interviewed the Assistant Food Service Director (AFSD), who stated that the bulk beef base should have had a use by date on the container and the coffee mugs should not be used as scoopers. The AFSD acknowledged that scoopers should not be left in the flour or beef base for infection control purposes. On 3/27/25 at 10:13 AM, the Licensed Nursing Home Administrator (LNHA), 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-17 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to ensure that the infection control practices for residents on transmission-based precautions (TBP) were followed to prevent the potential spread of infection by not utilizing contact precautions in accordance with facility policy and accepted national standards for 1 (one) of 2 (two) resident (Resident #79) reviewed for TBP and was evidenced by the following: According to the admission Record, Resident #79 was admitted to the facility with the diagnoses that included but was not limited to C-diff (infection of the large intestine (colon) caused by the bacteria Clostridium difficile) and MRSA (methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics). A review of the quarterly Minimum Data Set (MDS) an assessment tool that facilitated a resident's care dated 02/22/24 indicated that the resident was cognitively intact. On 05/01/24 at 10:28 AM, the surveyor observed a sign posted on 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and implement a baseline person-centered care plan to meet a resident's medical needs and b.) implement a focus and interventions that are specific to the resident's respiratory needs for 1 of 1 (Resident #148) investigated for respiratory care. The deficient practice was evidenced by the following: On 05/01/24 at 11:02 AM, during the initial tour, the surveyor observed Resident #148 lying in bed asleep receiving oxygen (O2) at two (2) liters per minute (lpm) via nasal cannula. On 05/02/24 at 11:03 AM, the surveyor observed Resident #148 lying in bed awake receiving oxygen at 2 lpm via nasal cannula. At that time, the surveyor interviewed the resident who stated that she received oxygen most the time. The surveyor reviewed the medical record for Resident #148. According to the admission Record, Resident #148 was admitted to the facility with diagnoses that included, but were not limited to, congestive heart failure (heart muscle does not pump 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-05-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and medical record review, the facility failed to follow professional standards of clinical practice with respect to a.) obtaining a physician's order for the application of a treatment device utilized to manage a resident's edema, and b.) update the care plan to reflect a device utilized to manage edema for 1 of 22 residents reviewed (Resident #64). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the admission Record (AR), Resident #64 was admitted to the facility with the diagnoses which included but…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 166493 Based on interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly investigate a facility acquired pressure ulcer for 1 of 3 residents (Resident #146) reviewed for pressure ulcers. This deficient practice was evidenced by the following: The surveyor reviewed the closed record for Resident #146. According to the admission Record, Resident #146 was admitted with diagnoses which included, but were not limited to, COVID-19, major depressive disorder, severe protein-calorie malnutrition, and unspecified dementia. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, included the resident had a Brief Interview for Mental Status score of 06, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident did not have any unhealed pressure ulcers upon admission to the facility. Review of a progress note, dated 07/04/23, revealed, opened area to left buttock noted . new treatment of Santyl…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy. This deficient practice was identified for 1 of 1 resident (Resident #148) reviewed for respiratory care. This deficient practice was evidenced by the following: On 05/01/24 at 11:02 AM, during the initial tour the surveyor observed Resident #148 lying in bed sleeping receiving oxygen (O2) at two (2) liters per minute (lpm) via nasal cannula. On 05/02/24 at 11:03 AM, the surveyor observed Resident #148 lying in bed awake receiving oxygen at 2 lpm via nasal cannula. At that time, the surveyor interviewed the resident who stated that she received oxygen most the time. The surveyor reviewed the medical record for Resident #148. According to the admission Record, Resident #148 was admitted to the facility with the following but not limited to diagnoses: congestive heart failure (heart muscle does not pump blood as well as it should), pulmonary hypertension (high blood pressure that affects the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-17 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 label, date, and store potentially hazardous foods appropriately to prevent food borne illness. This deficient practice was evidenced by the following: On 05/01/24 at 10:24 AM, the surveyor in the presence of the Food Service Director (FSD), toured the kitchen and observed the following in the dry storage pantry: 1. Two (2) packs of 12 bread that was identified as hamburger buns, had a used by date of 4/25/24. 2. A bag of [NAME] couscous toasted pasta was opened and not dated. 3. A bag of instant nonfat dry milk was opened with a used by date of 4/27/24. On 05/08/24 at 11:08 AM, the surveyor interviewed the FSD who stated that everything should have an opened date, used by date, and received by date on it. He stated that anything that came into the kitchen should have a sticker with the date it was received on it, a sticker for when it was opened and a used by date sticker. He explained…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Complaint #: NJ 166943 Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to accurately document in the medical records for 3 of 26 residents (Resident #146, #147, and #245) medical records reviewed. This deficient practice was evidenced by the following: 1.) The surveyor reviewed the closed record for Resident #146. According to the admission Record, Resident #146 was admitted with diagnoses which included, but were not limited to, COVID-19, major depressive disorder, severe protein-calorie malnutrition, and unspecified dementia. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, included the resident had a Brief Interview for Mental Status score of 06, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident did not have any unhealed pressure ulcers upon admission to the facility. Review of a progress note, dated 07/04/23, revealed, opened area to left buttock noted . new treatment of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-11 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure equipment was in good repair by A.) providing fall mats (safety mats that are placed on the floor along the side of the bed) that had rips along the seams exposing the foam interior and B.) failed to ensure medication carts and Emergency carts were free of dust and debris on the wheels and shelves. The deficient practice was identified for 2 out of 7 residents (Residents #63 and #73), 3 medication carts, and 2 emergency carts reviewed for the Environmental Task. The deficient practice was evidenced by the following: On 4/20/22 at 10:09 AM during the initial tour of the facility, surveyor #1 observed Resident #63 in bed. At this time, the surveyor observed a fall mat next to Resident #63's bed. The fall mat had a rip along the seam exposing the foam interior. On the other side of the bed was another fall mat. Surveyor #1 observed dried, yellow matter and stains on the surface of the mat. On 4/28/22 at 10:04 AM, surveyor #1 observed Resident #73 in bed. At…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 ensure the the call bell was within reach of the residents. The deficient practice was identified for 4 of 7 residents (Residents #63, Resident #28, Resident #11, and Resident #70) reviewed for the Environmental Task. The deficient practice was evidenced by the following: On 4/20/22 at 10:08 AM during the initial tour, surveyor #1 observed Resident #63 lying in bed. At that time, the surveyor observed the call bell on the ground behind the bed headboard out of reach from the resident. On 4/20/22 at 10:37 AM during the initial tour, surveyor #1 observed Resident #28 lying in bed. At that time the surveyor observed the call bell behind the bed headboard out of reach from the resident. On the same date and time, surveyor #1 observed Resident #11 lying in bed. At that time, the surveyor on observed the resident's call bell attached to the call bell wall input out of reach from the resident. On 4/21/22 at 12:02 PM, surveyor #2 observed Resident #70's call bell 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-11 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following a physician's order for 1 of 19 sampled residents, (Resident #52). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the admission record, Resident #52 was admitted to the facility with diagnoses including, but not limited to, periprosthetic fracture (fracture associated with implant) around internal prosthetic right hip joint and Cerebral Infarction. A review of the most…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-11 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that it was free of a medication error rate of five percent or greater by failing to ensure three medications were given within sixty minutes before or after the scheduled administration time. The deficient practice was observed for 1 of 7 residents (Resident #5) during the Medication Administration Task. The deficient practice was evidenced by the following: On 4/25/22 at 9:34 AM on the Rosewood Unit, the surveyor observed Licensed Practical Nurse (LPN) #1 prepare Resident #5's medication for administration. At that time, LPN #1, removed one Exelon capsule (Cognition-enhancing medication), one Metformin tablet (used to treat high blood-sugar) and one Carvedilol tablet (used to treat high blood pressure) and place them in the medication cup. At that time, the surveyor observed the Electronic Medical Administration Record (EMAR) on the medication cart computer with LPN #1. The EMAR revealed that the Exelon capsule was scheduled 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-11 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 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 4/25/2022, at 3:15 PM, the Surveyor observed the following in the Rosewood Nourishment Room: 1. On the refrigerator door, located on the bottom shelf, one opened 24 ounce (oz) jar of kosher pickles was observed with resident's name and room number identified on lid. No use by date observed. Located on the same shelf, one opened 8 oz jar of sliced olives with resident's name and room number. No use by date observed. Throughout the bottom of the shelf, dried liquid was observed. 2. On the refrigerator door, located in the beverage hold, one TwoCal HN 8 oz Vanilla Carton, opened with no date identified, and One [NAME] Ready Care 8 oz carton, opened with no date identified. 3. On the bottom of the refrigerator, located…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and other pertinent facility documents, it was determined that the facility failed to ensure that A.) staff implemented appropriate hand hygiene after direct patient care by not performing hand hygiene for a minimum of 20 seconds, B.) failed to ensure medical waste was properly disposed of by staff leaving a used surgical drain on a resident's (Resident #426) bedside table and C.) failed to ensure a urinary drainage leg bag was properly cleaned for reuse according to the manufacturer's instructions. The deficient practice was identified for two residents (Resident #374 and Resident #426) during the Medication Administration Task and 1 of 2 residents (Resident #46) investigated for Catheters. The deficient practice was evidenced by the following: A.) On 4/25/22 at 8:28 AM, after medication was administered to Resident #374, surveyor #1 observed Licensed Practice Nurse (LPN) #2 prepare to perform hand hygiene using soap and water in the resident room bathroom. At that time, surveyor #1 started an electronic timer to verify that a minimum…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-05-17 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to make survey results readily accessible to residents and visitors. This deficient practice was evidenced by the following: On 05/02/2024 from 11:02 AM to 11:37 AM, the surveyor conducted the resident council task with five (5) long-term care residents, who regularly attend resident council meetings. When asked if the residents were made aware of the location of the most recent survey results, 4 out of 5 residents (Resident #28, #55, #62, and #79) responded that they were not aware of where the most recent survey results were located. The surveyor reviewed the April 17th, 2024, resident council meeting minutes. Under standards to be discussed at each meeting, standard #5 revealed: The location of the State Survey Book is in the reception area. On 05/02/2024 at 12:01 PM, the surveyor went to the reception area of the facility, which was located at the main entrance. The surveyor did a thorough observation of the reception desk and the reception area. The surveyor did not observe any survey result book in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to COMPLETE CARE — 85 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.1+0.9 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 84 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Complete Care At Chestnut Hill LLCPassaic, NJ 1 of 5Complete Care At HagerstownHagerstown, MD 1 of 5Complete Care At Harston Hall LLCFlourtown, PA 1 of 5Complete Care At Kimberly Hall NorthWindsor, CT 1 of 5Complete Care At Laplata LLCLaplata, MD 1 of 5Complete Care At Milford Manor LLCWest Milford, NJ 1 of 5Complete Care At Wayne Hills Rehab & Resp CenterWayne, NJ 1 of 5Complete Care at Care AgeBrookfield, WI 1 of 5Complete Care at KensingtonWaukesha, WI 1 of 5Complete Care at Maple Grove LLCMadison, WI 1 of 5Complete Care at Margate ParkChicago, IL 1 of 5Complete Care at the BoulevardChicago, IL 2 of 5Complete Care At Brakeley ParkPhillipsburg, NJ 2 of 5Complete Care At Fox HillVernon, CT 2 of 5Complete Care At Harborage LLCNorth Bergen, NJ 2 of 5Complete Care At Harrington CourtColchester, CT 2 of 5Complete Care At HyattsvilleHyattsville, MD 2 of 5Complete Care At Inglemoor, LLCEnglewood, NJ 2 of 5Complete Care At Monmouth, LLCLong Branch, NJ 2 of 5Complete Care At Ocean Grove LLCOcean Grove, NJ 2 of 5Complete Care At Prospect Heights LLCHackensack, NJ 2 of 5Complete Care At Regent LLCHackensack, NJ 2 of 5Complete Care at Christian Home LLCWaupun, WI 2 of 5Complete Care at Grande PrairiePleasant Prairie, WI 2 of 5Complete Care at Heritage LLCDundalk, MD 2 of 5Complete Care at Linwood, LLCLinwood, NJ 2 of 5Complete Care at Nazareth LLCStoughton, WI 2 of 5Complete Care at Voorhees, LLCVoorhees, NJ 2 of 5Complete Care at Wall LLCWall, NJ 3 of 5Complete Care At Fair Lawn EdgePaterson, NJ 3 of 5Complete Care At Holiday CityToms River, NJ 3 of 5Complete Care At Lehigh LLCMacungie, PA 3 of 5Complete Care At Oak Ridge LLCCharleston, WV 3 of 5Complete Care At Orange ParkEast Orange, NJ 3 of 5Complete Care At Phillipsburg, LLCPhillipsburg, NJ 3 of 5Complete Care At Severna Park LLCSeverna Park, MD 3 of 5Complete Care At Shrewsbury LLCShrewsbury, NJ 3 of 5Complete Care At Silver Lake LLCDover, DE 3 of 5Complete Care At SpringbrookSilver Spring, MD 3 of 5Complete Care at Brick LLCBrick, NJ

Showing 40 of 84; 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 / managerTypeRoleShareSince
NJ OC HOLDCO OPCO II LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2019
EEF CAPITAL LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 09/01/2019
NJ OC MEZZCO OPCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/01/2019
PEACE CAPITAL LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 09/01/2019
SCHLAFF, BENNYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 09/01/2019
SCHLAFF, NACHUMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 09/01/2019
HOCH, ROBERTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
STEIN, SHALOMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNFsince 09/01/2019
ISSA, MOUSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
MERCADO, WANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
PATEL, AKSHAYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
SHAPIRO, MENACHEMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/03/2023
ARBORS PROPCO LLCOrganizationADP OF THE SNFsince 09/01/2019
NJ OC HOLDCO PROPCO LLCOrganizationADP OF THE SNFsince 09/01/2019
BOYLE, JACQUELINEIndividualADP OF THE SNFsince 09/01/2019

CMS files one row per role, so the 26 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$14.3M
Net patient revenuemost recent cost report
+5.7%
Operating marginrevenue minus expenses
$3.1M
Related-party expense23% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 19%Other / private 17%

This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 23% 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

$367per resident / day
operating cost
$11,163per month
≈ monthly operating cost
$390per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315333. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-27, 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.

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