Complete Care At Kresson View, LLC
2601 Evesham Road, Voorhees, NJ 08043 · For profit - Limited Liability company · 240 certified beds · (856) 596-1113 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 2 actual-harm citations
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $34,515 in federal fines (most recent 2024-01-23)
- its facility-reported quality-measure score sits well above its independent inspection score
- 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 | 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 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.
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 | 5.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.2% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.0% | 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 | 1.6% | 2.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.7% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.6% | 18.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.1% | 15.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.6% | 12.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 90.2% | 80.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.6% | 24.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.2% | 8.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.64 | 2.07 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.40 | 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.
48.7% 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 117 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.0% 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 70 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 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 48.7%CMS range 39.7–59.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 6.9–14.8 | 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 | 70.0% | 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 | 67.1% | 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 | 47.1% | 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 | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.2% | 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 | 0.0% | 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 | 3.8% | 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 | 6.5%CMS range 4.0–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 240 beds and averages 217.4 residents a day — about 91% occupied, or roughly 23 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 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 3.03 hrs/resident/day on weekends vs 3.37 on weekdays — 10% thinner on weekends. RN hours go from 0.34 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% 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.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2024-01-23 · 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 #152805, #153069 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure: a) there was no delay for physician ordered wound treatment that was not initiated for 17 days, b) Care Plan (CP) interventions to prevent skin breakdown were consistently implemented, c) ensure staff were competent to administer physician ordered wound treatments, and d) a comprehensive assessment was completed to ensure thorough identification of PU risk. The facility also failed to follow the facility pressure ulcer policy to accurately assess and prevent the worsening for a resident assessed as being at risk for pressure ulcers who was initially identified with a full-thickness Stage 3 (tissue loss-fat may be visible) pressure ulcer (PU) to the left gluteus and Stage 2 PU to the sacrum. The deficient practice occurred for 1 of 2 residents (Resident #39) reviewed for PU, who was initially identified with the PU's on 04/19/23 (over eight months prior) and was evidenced by the following: On 01/05/24 at 11:57…
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 · G2024-01-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # 150996 Based on interview, and review of medical records it was determined that the facility failed to ensure a laboratory value to monitor a therapeutic value for a blood thinner was carried out per physician order which resulted in a sub-therapeutic laboratory value determined upon transfer to the Emergency Department on 12/28/21. This deficient practice occurred for 1 of 1 closed medical records reviewed for physician orders (Resident #311) and was evidenced by the following: On 01/10/24 at 10:05 AM, the surveyor reviewed the closed medical record for Resident # 311 which revealed: a Care Plan dated 12/2021 with a Care Plan Focus for Resident is at risk for injury or complications related to the use of anticoagulation therapy medication: Coumadin (blood thinner), Date Initiated: 12/17/21; Goal: Resident will not exhibit signs/symptoms of bleeding X 90 days, Date Initiated 12/17/2021 with a target date of 03/16/2022, Interventions included Labs as ordered, Date Initiated 12/17/2021. A review of the Order Summary Report 12/2021 revealed the following Physician Orders:…
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 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 pertinent facility documentation, it was determined that the facility failed to: (a) maintain a homelike environment that was clean, safe, and sanitary, and (b) ensure pantry ice machines were maintained in a sanitary condition. This deficient practice was identified for 4 of 4 units (100-unit, 200-unit, 300- unit, and 400 -unit) and was evidenced by the following: 1.) On 7/29/2025 at 10:39 AM, in room [ROOM NUMBER], the surveyor observed the following: Food in clear packaging on the floor next to the resident’s bed. Foil lid from a juice container on the floor near the radiator. An empty soda bottle, a fork, a used paper towel, and dried liquid spillage were found under the resident’s bed. Brown dried substance on the outer part of the footboard. An accumulation of dust and brown and black substances on the low-air-loss mattress (mattress used to prevent pressure ulcers) hose. On 7/29/25 at 10:51 AM, in room [ROOM NUMBER], the surveyor observed the following: Three (3)…
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 F0755 — failed to provide safe pharmacy services — isolatedProvide 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 accurately account for and document the administration of controlled medications. This deficient practice was identified on 1 of 5 medication carts (4th floor Cart #1) reviewed and was evidenced by the following:On 7/31/25 at 11:45 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN #1), reviewed the 4th floor nursing unit's medication cart #1. The following was observed when the declining inventory log was reviewed: Resident #123 should have had 29 tablets of tramadol HCL 50 milligram (mg) (a controlled medication used for pain management), but 28 tablets were on hand. LPN #1 at that time, stated she administered the medication during the morning medication pass (8 AM) and failed to sign it out. LPN #1 further stated that controlled medications should be signed out immediately for each dose administered so that the narcotics were accounted for. LPN #1 acknowledged that the narcotic bingo card (medication packaging method) had 28 doses of tramadol HCL 50 mg…
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 F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that the resident's dietary preferences were accurately implemented for 1 of 10 residents (Resident #14) reviewed for nutrition, and was evidenced by the following:On 7/31/25 at 12:15 PM, the surveyor observed Resident #14 sitting upright in a geriatric chair (a specialized recliner designed to provide comfort, support, and positioning for individuals with mobility limitations) in the 400 Unit dining room being assisted by the Certified Nurse Assistant (CNA). The resident's diet slip indicated large portions of ground cheesy ham and macaroni casserole, poultry gravy, sauteed spinach with garlic, crustless bread, margarine, vanilla ice cream, chocolate milk, and apple juice. The meal ticket further indicated, No green vegetables. At that time, the surveyor observed Resident #14's tray included a large portion of sauteed spinach.On 7/31/25 at 12:30 PM, the surveyor reviewed the medical record for Resident #14.A review of the admission Record, 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.
- Potential for harm · Dcited before2025-08-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices, specifically the use of Personal Protective Equipment (PPE) during incontinence tours to residents who required Enhanced Barrier Precautions (EBP)(an infection control strategy focused on reducing the spread of multidrug-resistant organisms in nursing homes), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was identified for 2 of 2 residents (Resident #180 and Resident #188) and was evidenced by the following:According to the CDC Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, EBP are recommended for residents with indwelling devices or wounds . because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO (multidrug-resistant organisms) and many residents colonized…
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 · F2024-01-23 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 #152805 Refer to F677, F697 Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to provide sufficient staff to provide nursing and related services to meet the resident needs. This deficient practice was identified for 5 of 35 residents (Resident #39, #11, #101, #106, and #144), and on 1 of 4 resident units with the potential to affect all residents. This deficient practice was evidenced by the following: Review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the facility was deficient in (Certified Nurse Aide ) CNA staffing as follows: For the 2 weeks of staffing prior to survey from 12/17/2023 to 12/30/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -12/17/23 had 17 CNAs for 210 residents on the day shift, required at least 26 CNAs. -12/18/23 had 18 CNAs for 208 residents on the day shift, required at least 26 CNAs.…
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 · F2024-01-23 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # 152906 Based on observation, interview, and document review it was determined that the meals were not served at a appetizing temperature and food items were not consistently palatable. The deficient practice was evidenced for 2 of 5 residents who attended a resident council meeting, on 4 of 4 resident units for 2 of 4 food items during a test meal observation, and for Resident #410, #144, #145 and #188. The deficient practice was evidenced by the following: On 01/05/24 at 10:17 AM, the surveyor interviewed Resident #144 about the meals provided. Resident #144 stated, Nothing to desire, food is lousy. On 01/05/24 at 11:00 AM, the surveyor interviewed Resident #410 while in the resident's room. The surveyor asked about the meals provided and the resident stated, the food is horrible. The resident stated, last night was open faced hot turkey with mashed potatoes and gravy. There was no bread, no gravy and one little piece of turkey. I didn't eat it. On 1/05/24 at 11:15 AM, the surveyor interviewed Resident #188 in sitting in the room. The resident stated the food was awful…
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 · F2024-01-23 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 # 153846 Based on observation, interview and review of facility documentation, it was determined that the facility failed to consistently offer residents evening/bedtime snacks. This deficient practice was identified for 3 of 5 residents (Resident #40, #128, and #142) during resident council meeting and for 4 of 4 nursing units, and was evidenced by the following: On 01/08/24 at 10:30 AM, the surveyor conducted resident council meeting with five residents. During that time, the surveyor inquired about evening/bedtime snacks. Three residents commented that they do not always get offered bedtime snacks and that only those with a physician ordered bedtime snack are given snacks nightly. On 01/11/24 at 08:30 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) for the first-floor unit who stated that evening snacks are provided by the kitchen and the nurses would sign a form when the snacks were delivered to the unit. 01/17/24 at 10:29 AM, the surveyor interviewed a Licensed Practical…
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 · F2024-01-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review it was determined that the facility failed to ensure the dish machine was operated in a manner to appropriately sanitize, and the large blender was stored appropriately, to limit the potential growth of bacteria and food borne illness. The deficient practice was evidenced by the following: On 01/05/24 at 10:00 AM, the surveyor toured the main kitchen with the Food Service Director (FSD) and observed the dish machine in use to wash tray items which included the tray food trays, insulated food lids and insulated bases. At that time the surveyor interviewed the FSD regarding what the type of dish machine was and how the dishes were sanitized. The FSD stated the machine was a low temperature machine, as the surveyor observed the rinse temperature was 140 degrees Fahrenheit and the FSD then pointed to a chemical bottle on the floor underneath the machine which was identified as the sanitizing agent for the machine and was not a hot water sanitizing machine. The surveyor asked the FSD how he would know if the sanitizing agent 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 · E2024-01-23 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint # 150996, #153069 Based on observation and interview, it was determined that the facility failed to ensure that the resident dining experience was provided in a manner to promote the dignity and respect for all residents. The facility failed to have a system in place to ensure residents who resided in the same room were able to enjoy and share the meal experience at the same time. This deficient practice occurred on 1 of 4 resident units and for 1 of 1 residents reviewed for dignity related to dining (Resident #11) and was evidenced by the following: On 01/05/24 at 1:26 PM, Resident #11 reported to the surveyor that there were delays in the meal tray being delivered. When asked to elaborate, Resident #11 revealed that dinner would be delivered close to 6:30 PM. The resident stated, waiting for dinner that long, was unreasonable and that it made him/her feel anxious and unable to enjoy the meal. The resident added, it is too late. On 01/09/24 at 12:59 PM, the surveyor observed the resident sitting in the room, with the head down. The resident stated it would be almost 2:00…
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 · E2024-01-23 · tag F0657 — failed to keep the care plan current — patternDevelop 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
Complaint #152906 Based on observation, interview, record review and review of facility provided documents, it was determined the the facility Interdisciplinary Team failed to ensure the facility policy was followed to ensure the Person-Centered Care Plan was revised to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being by including interventions that accurately reflected the resident status and to ensure the resident was involved in the care planning process. The deficient practice was identified for 2 of 35 resident's reviewed for Comprehensive Care Plan (Resident #97 and Resident #101) and was evidenced by the following: a) On 01/10/24 at 8:45 AM, Surveyor #2 observed Resident #97 in their room sitting in a wheelchair. The surveyor observed a large disposable cup that was full of a clear liquid. Resident #97 refused to be interviewed at that time. On 01/11/25 at 8:48 AM, Surveyor #2 observed Resident #97 sleeping in bed. The surveyor observed there was a large disposable cup on the overbed table. The surveyor picked up the cup…
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 12 citations
- Potential for harm · E2024-01-23 · 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
Complaint # 152805, # 153069 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 3 of 5 residents (Resident #39, #106 and Resident #144) reviewed for Activities of Daily Living (ADL). The deficient practice was evidenced by the following: 1. On 01/05/24 at 11:57 AM, the surveyor observed Resident #39 in bed, the head of the bed was elevated, the resident smiled on approach and was mostly non verbal. The resident's hands were contracted and flexing toward the wrist. The nails were observed to be long and jagged with some yellow coating underneath the finger nails. On 01/09/24 at 9:41 AM, the surveyor observed the resident in bed, smiled when approached and was positioned on the left side. The bed was in a low position, the nails were noted to be long and jagged. 01/10/24 at 8:50 AM, the surveyor observed in bed, lying on back with knees bent up in an outward position. Head of bed elevated and hand rolls were in both hands. The finger…
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 before2024-01-23 · tag F0698 — failed to provide proper dialysis care — patternProvide 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
Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to ensure a resident on hemodialysis (artificial means of removing waste from nonfunctioning kidneys) was consistently assessed, documented and monitored before and after hemodialysis treatments. This deficient practice was identified for 1 of 2 residents (Resident #97) reviewed for hemodialysis and was evidenced by the following: On 01/05/24 at 11:05 AM, the surveyor was touring the fourth-floor unit. Resident #97 was not in their room, and the surveyor was informed the resident was out at hemodialysis. On 01/10/24 at 8:45 AM, the surveyor observed Resident #97 in their room. The resident declined to be interviewed at that time. On 01/11/24 at 8:48 AM, the surveyor observed Resident #97 sleeping in their bed. A review of the medical records revealed that Resident #97 had diagnoses which included but were not limited to; End Stage Renal Disease (ESRD), altered mental status, dependence on renal dialysis, and dysphagia (difficulty swallowing). A review of the Order…
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 · E2024-01-23 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
Based on interview and document review, it was determined that facility failed to ensure all medical records remained readily accessible. The deficient practice occurred during an on site survey conducted from 01/05/24 through 01/23/24 and was evidenced by the following: On 01/10/24 at 9:43 AM the surveyor reviewed the closed Electronic Medical Record (EMR) for Resident # 311 and could not locate any rehabilitation notes and on 10:05 AM, the surveyor requested the any additional closed medical records for Resident #311. On 01/10/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a Physical Therapy (PT) and Occupational Therapy dated (OT) Evaluations dated 12/16/21. On 01/10/24 at 12:33 PM, the surveyor interviewed the physical therapist who stated there was a transition from the former rehabilitation company to the present company and new evaluations were completed on 12/17/21 for OT and PT was completed on 12/18/21. The surveyor requested any treatment notes for the original evaluations. The PT stated that she did not have access to the former…
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 · D2024-01-23 · tag F0636 — isolatedAssess 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, record review, and review of facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool to facilitate resident care. This deficient practice was identified for 1 of 35 (Resident #49) reviewed for Resident Comprehensive Assessments and was evidenced by the following: On 01/05/24 at 10:51 AM, the surveyor observed Resident #49 in bed. Resident #49 was observed to have a tracheostomy (surgical opening that is made through the front of the neck into the windpipe, or trachea. A curved plastic tube, known as a tracheostomy tube, is placed through the hole allowing air to flow in and out of the windpipe) and an oxygen mask covering the tracheostomy tube. There was also an oxygen delivery system, an extra trach tube, a self-inflating bag to provide artificial breaths, suctioning equipment, and a humidifier bottle. On 01/09/24 at 10:16 AM, the surveyor observed Resident #49 in bed with the tracheostomy in place,…
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 before2024-01-23 · 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
Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to transcribe and document in the Medical Administration Record (MAR) or Treatment Administration Record (TAR) a physician's telephone order for fluid restriction. This deficient practice was identified for Resident #97, 1 of 2 residents reviewed for fluid restriction and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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 wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice…
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 · D2024-01-23 · 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
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 ensure a resident received pain medication in a timely manner and in accordance with a physician order. This deficient practice was identified for 1 of 2 residents reviewed for pain management (Resident #11) and was evidenced by the following: On 01/10/24 at 8:57 AM, the surveyor observed Resident #11 sitting in a chair in their room and was awake and alert. The surveyor attempted to interview the resident and the resident was holding his/her head and stated that he/she had a splitting headache and that he/she had informed the nurse that he/she would like to have pain medication. The surveyor asked about the resident's pain and the resident stated that the pain was bad and rated the pain as a 10 on a scale of 1 to 10. He/she confirmed the presence of the pain and stated that he/she was waiting for the nurse to bring the pain medication. Resident #11 requested the surveyor to alert the nurse again. At 8:58 AM, 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 before2024-01-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, it was determined that the facility failed to ensure that all staff were familiar with and adhered to infection control practices in accordance with facility policy guidelines and infection prevention protocol. This deficient practice was identified for 1 of 1 resident reviewed for wound care (Resident #39) and was evidenced by the following: On 01/09/24 at 12:10 PM, the surveyor observed Resident #39 in bed. Also noted on the bedside table was a bottle of Dakins solution (dilute solution use to cleanse wound) and a bottle of wound cleanser on the dresser. On 01/10/24 at 8:30 AM, the surveyor reviewed Resident #39's medical record. The admission Face Sheet (an assessment summary) reflected that Resident 39 was admitted to the facility with diagnoses which included but were not limited to: Parkinson's Disease, essential hypertension, abnormal posture, difficulty in walking, unspecified abnormality of gait (walking) and mobility. The Annual Minimum Data Set (MDS ) a resident assessment tool used by the facility to prioritize 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.
- Potential for harm · E2021-09-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to consistently document catheter care treatments according to physician orders. This deficient practice was identified for 2 of 3 residents (Residents #41 and #114) reviewed for urinary catheters and was evidenced by the following: 1. On 08/27/21 at 9:38 AM and on 08/31/21 at 9:10 AM, the surveyor observed Resident #41 lying in bed asleep, with a catheter bag in place. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/17/2021, included that Resident #41 was cognitively intact, had a diagnosis of obstructive uropathy and had an indwelling catheter. Review of the Physician's Order (PO) Sheets for June, July, and August of 2021 revealed the following orders related to urinary catheter care: Perform Foley Catheter care every 8 hours (order dated 06/07/20), Empty Foley Catheter drainage bag every shift and as needed 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.
- Potential for harm · Ecited before2021-09-07 · tag F0698 — failed to provide proper dialysis care — patternProvide 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
Based on observation, interview, and record review, it was determined that the facility failed to ensure medication administration times were sequenced to accommodate a resident's hemodialysis (HD) schedule in accordance with professional standards of practice. This deficient practice was identified for Resident #315, 1 of 1 resident reviewed for hemodialysis, and was evidenced by the following: On 08/25/21 at 11:48 AM, the surveyor observed Resident #315 resting in bed with the head of bed (HOB) slightly elevated. The resident was able to verbalize needs and stated that he/she went to dialysis three times a week. According to the admission Record, Resident #315 was admitted with diagnoses that included, but were not limited to: End Stage Renal Disease (ESRD), dependence on renal dialysis, and Type 2 Diabetes Mellitus with other diabetic kidney complication. Review of the resident's admission Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, dated 08/26/2021, included the resident was cognitively intact. Further review of the MDS included 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 · D2021-09-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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, record review, and review of facility documents, it was determined that the facility failed to maintain the call bell within reach for one resident. This deficient practice was identified for 1 of 2 residents (Resident #164) reviewed for falls and was evidenced by the following: On 08/25/2021 at 11:50 AM, the surveyor observed Resident #164 lying in bed, with the call bell on the floor. On 08/27/2021 at 9:25 AM, the surveyor observed Resident #164 sitting up on the side of the bed, with the call bell on the floor. On 08/30/2021 at 10:00 AM, the surveyor observed Resident #164 lying in bed with the call bell hanging over the side rail, away from the resident, and pointed down, towards the floor. The resident stated he/she knew how to use the call bell, but that he/she could not locate it to demonstrate the process to the surveyor. According to the admission Record, Resident #164 was admitted with diagnoses that included, but not limited to, Parkinson's Disease, other lack of coordination, need for assistance with personal care, muscle weakness,…
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 before2021-09-07 · 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
Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow professional standards of clinical practice during medication administration. This deficient practice was identified for 1 of 3 nurses on 1 of 3 Units (200 Unit) observed during medication pass and 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 state: 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, and executing a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice 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.
- Potential for harm · Dcited before2021-09-07 · 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
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: a.) apply heel pads to bilateral feet (a cushioned pressure relieving device for feet) and position a pillow between the resident's knees for one resident and b.) ensure that a low air loss mattress (an air mattress designed to prevent and treat pressure wounds) (air mattress) was accurately set in accordance with the physician order for one resident. This deficient practice was identified for 2 of 4 residents (Residents #101 and #161) reviewed for pressure ulcers and was evidenced by the following: 1. During the initial tour of the 300 Unit on 08/25/21 at 1:45 PM, the surveyor observed Resident #101 lying in bed with the head of bed (HOB) slightly elevated. The surveyor observed that Resident #101's bilateral lower extremities were not offloaded and that the resident's feet were lying directly on the mattress. When interviewed, at that time, Resident #101 was unable to provide answers about the heel pads…
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
$34,515 in federal fines across 1 penalty.
- $34,515 — penalty dated 2024-01-23
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 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 84 homes this chain runs (chain average 3.1★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PC NJ1 OPCOS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2021 |
| PC WTA OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| SMS 2021 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2021 |
| STEIN, SHALOM | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 07/01/2021 |
| WELLTOWER INC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 07/01/2021 |
| HOCH, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| MERCADO, WANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2021 |
| MIRZA, IMRAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2021 |
| SOLARZ, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2021 |
| AURORA GUARDIAN HOLDCO II CO-BORROWER, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| AURORA GUARDIAN HOLDCO II MEZZ BORROWER, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| AURORA GUARDIAN HOLDCO II, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| AURORA GUARDIAN II REALTY, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| AURORA GUARDIAN PARTNERS II LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| J & R FAMILY INVESTMENTS, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| KRESSON VIEW REALTY, LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| L FRIEDMAN 2018 FAMILY TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| L FRIEDMAN FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| LANDAU FAMILY INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| M FRIEDMAN 2018 FAMILY TRUST | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| PC WTA ACQUISITION LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| PC WTA MULTI-STATE LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| PEACE CAPITAL HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| R&J FAMILY INVESTMENTS LLC | Organization | ADP OF THE SNF | — | since 07/01/2021 |
| MCDERMOT, DYAN | Individual | ADP OF THE SNF | — | since 07/01/2021 |
CMS files one row per role, so the 33 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
19 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.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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 315207. 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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