Voorhees Pediatric Facility
1304 Laurel Oak Road, Voorhees, NJ 08043 · For profit - Limited Liability company · 122 certified beds · (856) 346-3300 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Oct 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $33,579 in federal fines (most recent 2025-10-21)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 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 | 9.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.7% | 4.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 0.8% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 12.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.9% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 0.0% | 2.3% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 4.6% | 8.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 51.0% | 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 | 2.8% | 5.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 2.9% | 15.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.6% | 12.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Therapy staffing: this home’s payroll records show 0.90 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 122 beds and averages 108.1 residents a day — about 89% occupied, or roughly 14 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 6.36 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.14 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 0.91 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 5.72 hrs/resident/day on weekends vs 6.62 on weekdays — 14% thinner on weekends. RN hours go from 2.30 to 1.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2025-10-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Complaint: 2642805Based on interviews, review of the medical records, and review of other pertinent facility documents, it was determined that the facility failed to protect a severely cognitively impaired resident (Resident #1) from harm when a the Certified Nursing Aide yelled at and hit Resident #1, who was visibly upset after the encounter.This deficient practice was identified for 1 of 3 residents reviewed for abuse.The evidence was as follows:A review of the facility's policy titled Safety: Abuse, Neglect and Exploitation updated 5/21/25, included Policy: [name redacted] has an obligation to protect the welfare of its residents and to fully investigate and correct any circumstances bearing upon that welfare. The approach should be as proactive as possible. As such, all new employees shall be in-serviced about abuse and neglect as part of orientation, and all current employees shall review this information at least annually thereafter [.] VI. Protection of the Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as…
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 before2026-01-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, medical records and review of other pertinent facility documentation on 1/30/26, it was determined that the facility failed to ensure clinical records were complete and accurately documented. This failure had the potential to affect the facility's ability to monitor the resident's nutritional status. This deficient practice was identified for 1 of 3 residents reviewed for resident records (Resident #2), and was evidenced by the following:According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a clinical condition where a patient with a pre-existing, long-term (chronic) respiratory impairment experiences a new, sudden (acute) worsening of their ability to exchange oxygen and carbon dioxide. This diagnosis, often referred to as acute on chronic respiratory failure, is used when documentation confirms both conditions coexist, but the specific type of blood gas abnormality-low oxygen…
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 · F2025-05-23 · 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
Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that there was sufficient competent staff to ensure a) all residents were provided with appropriate and timely incontinence care and were consistently available to provide appropriate care to maintain residents highest practicable physical, mental, and psychosocial well-being and b) the minimum staffing requirements per the New Jersey Department of Health based on acuity of the residents was maintained. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: Refer to 677F, 688D A. On 05/18/25 at 7:17 PM, the Registered Nurse Nursing Supervisor for the B -Wing Unit, informed the survey team the B- Wing Unit had 60 residents. When the surveyor asked how many Certified Nurse Aides (CNAs) were assigned to the unit, a CNA at the nursing station stated she was the only CNA on the unit and she was assigned ten residents. The CNA explained that the nurses were responsible for providing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-23 · 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 a) ensure the formula preparation process and nourishment area was implemented in a clean and sanitary manner, b) food items were labeled with a use by date, and c) appropriate cleaning items were utilized to prevent potential contamination. The deficient practice had the potential for development of food borne illness and was evidenced by the following: On 5/19/25 at 8:43 AM, the surveyor conducted a tour of the kitchen with a Food Service Director (FSD) from another facility, the District Manager for the Food Service Management Company was present, and did not join the tour. Findings include: 1. A package of undated frozen pancakes was stored in the freezer and was not tightly wrapped. The surveyor asked about a use by date, and the FSD stated she could not tell when the package was opened and discarded it. 2. A metal table, with a sink and a shelf above the sink contained three plastic containers that were appeared stained and were stored with the opening directly on red cleaning…
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 · F2025-05-23 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure all residents received the care and services needed to maintain residents highest practicable physical, mental, and psychosocial well-being by failing to ensure: a) a thorough investigation of an injury of unknown origin was completed, b) staffing was appropriate to meet resident needs to provide incontinence care in an appropriate and timely manner and according to the facility policy, c) staff followed the Center for Disease Control (CDC) guidelines and the facility's infection control policy to prevent the spread of potential infection, d) there was a process in place to ensure staff completed their annual competency evaluations. This deficient practice affected all facility residents and was evidenced by the following: Refer to F610, F677, F725, F730, F880 A review of the Administrator's job description provided by the facility revealed the following under position summary: Directs and…
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 · E2025-05-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 2 of 4 residents (Resident #82 and #58) reviewed for Activities of Daily Living (ADLs) on 1 of 2 resident units, (B Wing Unit). The deficient practice was evidenced by the following: 1. On 5/18/25 at 7:45 PM, the surveyor toured the B Wing Unit, and observed a strong feces and urine odor in the hallway. All the residents were observed in bed at that time. On 5/18/25 at 8:29 PM, the surveyor observed Resident #82 in an enclosure bed (a complete bed system resembling a tent, designed to provide safety). The resident was facing the window. From a clear unobstructed view through the open door, the surveyor observed the resident's incontinence brief was bulging from the back. The surveyor then observed the resident was asleep, and there was no sheet to cover the bed. The Surveyor then observed 3 incontinence pads on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-23 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of Certified Nurse Aides (CNA) at least every 12 months. The deficient practice was identified for 4 of 5 Certified Nurse Aides reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by: A review of the facility-provided CNA annual performance evaluations revealed that 4 of the 5 CNAs did not have an annual performance evaluation for 2024. On 05/22/25 09:41 AM during an interview with the surveyor, the Liscensed Nursing Home Administrator (LNHA) confirmed there were no performance evaluations for 2024 for 4 out of 5 CNA's. The LNHA stated, I know we should have them, but we don't, the place fell apart. The LNHA stated they have had two Director of Nursing's and an interim DON in the past year. The LNHA had no further information to provide. A review of an undated facility provided policy titled Employee Evaluation revealed: Each employee will have a written evaluation of their job…
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 · E2025-05-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review it was determined that the facility failed to ensure a) appropriate Personal Protective Equipment was utilized while providing care to a resident who required Enhanced Barrier Precautions (EBP), b) soiled linens were appropriately handled, and c) appropriate hand hygiene was performed per facility and Center for Disease Control Guidance. The deficient practice occurred on 1 of 3 resident units (The Annex) and was evidenced by the following: On 05/21/25 at 9:54 AM, the surveyor entered the Annex Unit and observed Resident #103 was in the room, the curtain was pulled, and staff were heard talking to resident while providing care. On 05/21/25 at 9:59 AM, the surveyor observed a sign posted outside of Resident #103's door that revealed Enhanced Barrier Precautions, Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Ativities. Dressing, Bathing/Showereing, Transaferring, Changing Linens, Providing…
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 · D2025-05-23 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 it was determined that the facility failed to ensure a) the required ambient air temperature (between 71-81 degrees Farenheight) was maintained in all resident areas, and the shower room with an adjacent storage area was maintained in a clean and sanitary manner. The deficient practice was identified for 1 of 2 shower areas on the B-Wing Unit, for the 6 bed Annex Unit and was evidenced by the following: On 5/18/25 at 7:29 PM, during a tour of the B-Wing Unit shower room the surveyor observed what appeared to be a brown feces covered washcloth wrapped around the bath sprayer nozzle which was below the bath stretcher that was on top of the bath. The surveyor showed the Registered Nurse Supervisor (RNS) who stated, she was not sure what happened. The surveyor then entered the attached store room and a tub of urine cups was stored directly on the floor and what appeared to be a mop or broom handle was stored inside the tub. The RNS stated someone must have dropped them (urine cups) there. On 05/21/25 at 9:54 AM, the surveyor entered the Annex Unit and…
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 before2025-05-23 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
REPEAT DEFICIENCY Based on interview, medical record review and review of other facility documents, it was determined that the facility failed to complete a thorough investigation of an injury of unknown origin, and to rule out abuse. This deficient practice was identified for 1 of 4 residents reviewed for abuse, Resident #37 and was evidenced by the following: On 5/22/25 at 10:08 AM, the surveyor reviewed the electronic medical record for Resident #37. According to the admission Record, Resident #37 was admitted to the facility with diagnoses which included, but were not limited to; Spastic quadriplegic cerebral palsy (is a severe type that is characterized by paralysis of both arms and both legs, with muscle stiffness), Contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility) and Septo-optic dysplasia of brain (is a disorder of early brain and eye development). A review of Resident #37's Quarterly Minimum Data Set (an assessment tool used to facilitate the management of care) dated 03/27/25, reflected…
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 · D2025-05-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure a system was in place to ensure devices used to prevent contractures were consistently applied per physician order. The deficient practice occurred for 1 of 6 residents reviewed for positioning (Resident #84) and was evidenced by the following: On 5/18/25 at 8:00 PM, the surveyor observed Resident #84 in bed sleeping with both hands visibly contracted and there was no device inside both hands. There were two posters on the wall above Resident #84's bed detailing the use of Resident #84's right and left hand roll (a device used to prevent the hands from closing into the palms). On 5/19/25 at 9:30 AM, the surveyor reviewed the medical record for Resident #84 which revealed the following: - The admission Record revealed the resident had diagnoses which included, but were not limited to; Localization-related (Focal)(Partial) symptomatic epilepsy and epileptic syndromes with simple…
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 16 citations
- Potential for harm · Dcited before2025-05-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview and record review, it was determined that the facility failed to ensure that nurses administer all prescribed medications according to the physician's order. This deficient practice occurred to 1 of 7 residents (Resident #85) observed during the medication pass observation and was evidenced by the following: On 5/21/25/25 at 9:45 AM, during the medication administration observation the Licensed Practical Nurse (LPN ) informed the surveyor that Resident #85's Propanolol dose was not available. The surveyor inquired regarding the facility's protocol to reorder medications. The LPN informed the surveyor that the medication should be reordered before reaching the remaining 8 doses on the Bingo cart or remaining 3 doses left in multidose bottle. The LPN stated that she had not been on the medication cart and could not comment when the medication was reordered. On 5/21/25 at 10:15 AM, the surveyor reviewed the medical record which revealed: Resident #85 had diagnoses…
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 before2025-05-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
REPEAT DEFICIENCY Based on observation, interview and record review it was determined that the facility failed to properly label, dispose and store medication in 1 of 2 medication storage areas. The deficient practice was evidenced by the following: On 5/20/25 at 10:45 AM, the surveyor inspected the Unit 2 Medication Room in the presence of the Registered Nurse Unit Manager (RN #7) found a bottle of iron liquid with an expiration date of 2/2025. RN #7 informed the surveyor that the Nursing Supervisor checked the storage room daily and could not provide the rationale for the expired medication to be among other medications. On 5/20/25 at 11:00 AM, the surveyor inspected the Unit 2 Medication Cart #1 in the presence of the Licensed Practical Nurse (LPN#3) and noted a vial of Lantus Insulin that was opened and not dated. LPN #3 stated that all insulin vials and Pen should be dated upon opening. LPN #3 added that the 7:00 PM-7:00 AM used the Lantus Insulin and should have been dated. A review of the Manufacturer's Specifications for Lantus Insulin revealed the following: Lantus Insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-22 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation for seven of seven unsampled residents reviewed for misappropriation (Resident (R) 39, R36, R35, R94, R6, R87, and R70). Specifically, nursing staff borrowed medications from the residents and administered the medications to other residents. Findings include: 1. Review of R39's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was admitted to the facility on [DATE] with the diagnoses of epilepsy, and spastic quadriplegic cerebral palsy. Review of R39's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 and located in the resident's EMR under the MDS tab revealed R39 was in a persistent vegetative state with no discernible consciousness. Review of R39's Physician Orders located under the Orders tab in the EMR revealed an order dated 12/23/23 for R39 to receive lorazepam concentrate (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-22 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to identify and investigate misappropriation of residents' narcotic medications for seven of seven unsampled residents (Resident (R) 39, R36, R35, R94, R6, R87, and R70). This placed all residents at risk for further incidents of misappropriation. Findings include: 1. Review of R39's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was admitted to the facility on [DATE] with the diagnoses of epilepsy, and spastic quadriplegic cerebral palsy. Review of R39's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed 15 doses of the resident's lorazepam concentrate (a narcotic antianxiety medication) were misappropriated. 2. Review of R36's undated admission Record located under the Profile tab in the EMR revealed R36 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and autonomic dysreflexia. Review 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 · Ecited before2024-02-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility staff failed to: 1. have correct labels on medications and failed to obtain pharmacy labels to affix to the Controlled Drug Receipt/Record/Disposition Form for three of 19 residents (Resident (R)94, R55, and R15); 2. waste a narcotic medication after the physician's order end date for one of 19 residents (R6); and 3. failed to have a pharmacy label on an opened bottle of liquid lorazepam (antianxiety medication) stored in the medication refrigerator on one of three units (Annex unit). Findings include: 1.Review of R94's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R94 was readmitted to the facility on [DATE] with the diagnosis of epilepsy and cerebral palsy. Review of R94's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R94 had short term and long-term memory problems and was severely impaired in daily decision making. Review 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 · D2024-02-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to develop a care plan for intermittent urinary catheterization for one of three residents (Resident (R) 24) reviewed for a urinary catheter. Findings include: Observation of R24 on 02/19/24 at 12:47 PM revealed the resident was in bed on his back with tubing from a urinary catheter coming from under his clothes, going off the side of his bed to a urine collection bag. Review of R24's Physician Order, dated 01/09/24, located in the resident's electronic medical record (EMR) under the Orders tab revealed Texas Cath (catheter) a condom style catheter, apply at 0600 [6:00 AM]), remove at 1800 [6:00 PM]. Review of R24's Care Plan dated 04/21/17, revealed a problem related to .episodes of retaining urine. The goal was for R24 to empty his bladder every eight hours and the interventions included documenting the amount, color, and clarity of the urine. The care plan did not include the use of a catheter. During an interview on 02/22/24 at 3:24 PM, the Director of Nursing (DON) revealed her it was her expectation a 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 · D2024-02-22 · 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 staff interview, record review, and facility document review, the facility staff failed to follow professional standards of practice regarding the signing of the on coming and off going nurse when narcotics were counted for each shift. This occurred on two of three units in the facility (B wing medication cart 1 and 2, and A wing high side medication cart). Findings include: During observation of the Medication Storage and Labeling Task, performed on 02/21/24 and 02/22/24, revealed the narcotic count sheets were missing two licensed nurses' signatures for the following dates and areas: 1.For January 2024 on the B wing medication cart 1, the narcotic and barbiturate count log were missing two nurses' signatures on 01/04/24 7:00 PM, 01/06/24 7:00 AM, 01/09/24 at 7:00 PM, 01/10/24 at 7:00 AM, 01/15/24 at 7:00 PM, and 01/26/24 at 7:00 AM. 2.For February 2024 on the B wing medication cart 1, the narcotic and barbiturate count log were missing two nurses' signatures on 02/20/24 at 7:00 PM. 3.For November 2023 on the B wing medication cart 2, the narcotic and barbiturate count log…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure appropriate techniques were used for a residents who were dependent on respirators during for one of three residents reviewed for respiratory care (Resident (R) 20). R20 had an episode of apnea when a respirator therapist performed a sternal rub on the resident even though the resident was conscious. R20 sustained a bruised area to the chest. Findings include: Review of R20's admission Record, located in the resident's electronic medical record (EMR) under the Profile revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute and chronic respiratory failure, tracheostomy status, dependence on respiratory (ventilator) status, and dysphasia. Review of R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/23, located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS), was unable to be completed since R20 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 · Dcited before2024-02-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure medications were acquired and dispensed for one of three residents reviewed for medication administration (Resident (R) 58). The facility failed to notify the resident's family timely to ensure the medication was ordered and delivered to the facility. Findings include: Review of R58's undated admission Record, located in the resident's EMR under the Profile tab revealed to the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Lennox-Gastaut syndrome no intractable without status epilepticus. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/24, located in the resident's ERM under the MDS tab revealed a Brief Interview for Mental Status (BIMS), was unable to be completed since R58 was rarely understood. Review of R58's Care Plan, dated 08/28/16, and located in the resident's EMR under the Care Plan tab revealed, The resident was 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.
- Potential for harm · D2023-10-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ# 166667 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility's administration failed to ensure that the facility's policy Reportable Events was followed and implemented for an incident that occurred at the facility on 7/24/23. The incident involved a Certified Nursing Assistant (CNA) who performed a procedure outside of her scope of practice. The facility also failed to report the actions of the CNA to the New Jersey Department of Health (NJDOH). This deficient practice was identified for Resident #3, 1 of 6 sampled residents and was evidenced by the following: According to the admission Record, Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system), spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing limitation on all four limbs),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C#: NJ#166667 Based on interviews, medical records review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility failed to ensure that a Certified Nursing Assistant (CNA) worked within her scope of practice. The deficient practice was identified for Resident #3, 1 or 6 sampled residents reviewed and was evidenced by the following: According to the admission Record (AR), Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system), spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing limitation on all four limbs), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain), artificial opening of gastrointestinal tract, and constipation. Review of Resident #3's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/20/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ 166667 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility failed to maintain a complete MR which contained a Universal Transfer Form (UTF) for a resident who was sent to the hospital. The deficient practice was identified for Resident #3, 1 of 6 sampled residents, and was evidenced by the following: According to the admission Record, Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system), spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing limitation on all four limbs), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain), artificial opening of gastrointestinal tract, and constipation. Review of Resident #3's Progress Notes revealed a 7/24/23 at 7:01 PM Medical Progress Note completed by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-09-30 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to identify and address significant weight changes. This deficient practice was identified for 2 of 2 residents reviewed for nutrition (Residents #25 and #84) and was evidenced by the following: 1. On 09/24/21 at 1:09 PM, the surveyor observed Resident #25 lying in bed with his/her eyes closed. He/she was receiving Pediasure Peptide (a nutritional feeding formula) 1.0 at a rate of 95 milliliters (ml) per hour. According to the admission Record, Resident #25 was over three years of age and was admitted with diagnoses which included, but were not limited to, unspecified dysphagia (a difficulty or discomfort in swallowing), unspecified lack of expected normal physiological development in childhood, and failure to thrive. Review of the Order Recap Report, dated 08/01/21 - 09/30/21, for Resident #25 revealed an order to administer 290 ml of Pediasure Peptide 1.0 four times per day at a rate of 95 ml/hour via G-tube (gastrostomy tube, a surgically placed…
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 before2021-09-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) ensure food was stored in a manner to minimize the potential for cross contamination, b.) discard potentially hazardous foods past their date of expiration, c.) maintain kitchen equipment in a clean and sanitary manner to prevent microbial growth, and d.) ensure staff consistently covered hair to minimize the potential for contamination. This deficient practice was identified in the main kitchen and on one of two resident units (A-Wing Unit) and was evidenced by the following: On 09/22/21 at 10:33 AM, the surveyor, in the presence of the Dining Service Director (DSD), observed the following during the kitchen tour: 1. The surveyor observed the DSD with a hat on his head and hair exposed out of the back of his hat. When interviewed, the DSD stated it was alright because he had a hat on. The DSD failed to address the hair exposed out of the back of his hat. 2. In the reach-in freezer, the surveyor observed a container labeled pureed bisculli dated 07/19/21 with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-09-30 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that staff were tested for Coronavirus Disease 2019 (COVID-19) at a frequency per facility policy. This deficient practice was identified for 7 of 11 staff members reviewed for testing and was evidenced by the following: On 09/22/21 at 8:30 AM, the surveyor met with the Director of Nursing (DON), who stated that the facility was currently in an active COVID-19 outbreak (outbreak) and that there were two staff members that tested positive on 09/09/21 and 09/10/21. The DON stated that staff were being tested weekly and that she based the frequency of the testing on the COVID-19 Activity Level Index ([NAME]) Weekly Report (a report that provides data on COVID-19 transmission risk by regions). The DON further stated that no residents had tested positive for COVID-19 during the current outbreak. The surveyor requested the facility's testing plan, line listing and the two most recent COVID-19 test…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2021-09-30 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) assessments for 1 of 2 residents (Resident #84) reviewed for nutrition. This deficient practice was evidenced by: According to the admission Record, Resident #84 was admitted with diagnoses, that included but were not limited to, unspecified intellectual disabilities and dysphagia (difficulty swallowing). Review of the Quarterly MDS, dated [DATE], included coding that the resident did not have a significant weight loss of 5% or more in the last month or 10% or more in the last six months. Review of the Weights and Vitals Summary, dated 01/01/2020 - 12/31/2020, included the following weights: On 01/13/2020, the resident weighed 33.5 kg (kilograms) On 06/07/2020, the resident weighed 35.2 kg On 07/05/2020, the resident weighed 29.4 kg (a 12.2% weight loss in six months, and a 16.5% weight loss in one month) Review of the Nutrition/Dietary Note, dated 08/06/20, included, [Resident #84]…
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
$33,579 in federal fines across 1 penalty.
- $33,579 — penalty dated 2025-10-21
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 MILLENNIUM HEALTH SYSTEMS — 4 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 | 2 of 5 | 4.3 | -2.3 vs chain |
| Health inspection | 1 of 5 | 3.0 | -2.0 vs chain |
| Staffing | 4 of 5 | 4.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 3 homes this chain runs (chain average 4.3★, per CMS)
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 |
|---|---|---|---|---|
| 2012 LIPSCHUTZ FAMILY TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 12/16/2012 |
| BARRY M KANTROWITZ REVOCABLE TRUST DATED 12/17/2009 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 5% | since 01/01/2010 |
| MILLENNIUM CONSOLIDATED, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 15% | since 11/15/2019 |
| NONMARITAL TRUST UNDER THE HOWARD LIPSCHUTZ REVOCABLE TRUST 5/21/15 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 06/01/2021 |
| WEISMAN FAMILY HOLDINGS LP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 46% | since 08/31/2005 |
| NJ HEALTH SYSTEMS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/04/2013 |
| ANTONIO, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/09/2024 |
| KOVALCHIK, LAUREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/10/2025 |
| PIZZICHILLO, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/22/2020 |
CMS files one row per role, so the 17 rows in the source record cover these 9 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.
About 76% 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 $3.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NJ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315289. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-23, 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 →
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