Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Deptford Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with multiple chronic conditions received a physician-ordered dose of levothyroxine, but the LPN who administered the medication failed to sign the MAR at the time of administration. The omission was discovered during a review, and the MAR was signed weeks later, contrary to facility policy and professional standards, as confirmed by the DON.
Kitchen equipment was found dirty and not maintained in a sanitary manner during survey observation with the FSD present. The microwave, convection ovens, stove, oven, griddle, fryer, and can opener all had visible debris, baked-on soil, or buildup, and the FSD acknowledged the equipment had not been cleaned according to facility policy. The LNHA, A LNHA, RCD, and DON later reviewed the findings and acknowledged the concerns.
A facility failed to provide written notice when residents’ PNA balances neared the Medicaid/SSI limit and failed to return or convey resident funds within 30 days after discharge or death. Staff said quarterly statements were sent, but the LNHA and RDF acknowledged that the required notification letter was not being used. Several residents who were discharged or deceased still had funds in their accounts, and the RDF acknowledged the money should have been returned before surveyor inquiry.
A resident at risk for impaired skin integrity had a physician order and care plan for a low-air-loss mattress to be checked for function and set to the resident's weight. Surveyors observed the mattress not turned on during one visit and later set to 250 lbs despite the resident weighing 193 lbs; staff confirmed the mattress should be functioning and set according to weight, and the LPN/UM acknowledged the setting was incorrect.
An LPN failed to accurately document controlled medication administration and the shift narcotic count was incomplete, with blank count verification fields and illegible signatures. During inventory review, discrepancies were found between the declining inventory sheet and actual tablet counts for clonazepam, pregabalin, and alprazolam after the LPN stated she had administered doses to residents but had not signed them out because the narcotic book remained with the off-going nurse. The LPN/UM and DON stated controlled meds must be counted together at shift change and signed out immediately when removed from the bingo card.
A resident received fludrocortisone for an indication listed as "syndromes" even though that diagnosis was not documented on the order summary. The CP recommended clarifying the order, and the prescriber signed in agreement, but the issue was not addressed in the following monthly reviews. Staff interviews confirmed the recommendation was forwarded for review, yet the order was not clarified as expected.
A resident with GERD and anxiety disorder did not receive a physician-ordered gastric emptying scan after the initial appointment was unsuccessful due to vomiting. Communication failures between nursing and medical records staff led to the test not being rescheduled, and the nurse practitioner was not informed of the missed procedure, resulting in the resident not receiving the required diagnostic care.
A resident with a history of aggressive behavior was involved in multiple incidents of abuse against four other residents, all of whom were at high risk for experiencing abuse due to cognitive impairments. Despite these incidents, the facility's investigations did not substantiate abuse, citing the events as isolated and unavoidable due to the resident's psychiatric diagnosis and recurrent UTIs. Staff interviews revealed a lack of understanding that resident-to-resident abuse could occur.
The facility failed to report the results of abuse and neglect investigations to the State Survey Agency (SSA) within the required five working days for multiple residents. Although initial allegations were reported within the required two-hour timeframe, the investigation results were not submitted within the five-day period. The facility's policy did not specify this requirement, and interviews revealed a lack of evidence for submission, with emails being deleted after 30 days.
Failure to Timely Document Medication Administration
Penalty
Summary
A deficiency was identified when a physician-ordered medication for a resident was not signed as administered at the time of administration, contrary to professional standards of practice. The resident, who had diagnoses including acute right heart failure, diabetes, major depressive disorder, and muscle weakness, was cognitively intact according to a recent assessment. The medication in question was levothyroxine sodium, ordered to be given orally each morning for hypothyroidism. Review of the Medication Administration Record (MAR) for September revealed that the administration entry for a specific morning dose was left blank. Further investigation showed that the MAR was later signed for this dose several weeks after the scheduled administration date, as confirmed by the Medication Admin Audit Report. The LPN responsible for administering the medication stated during interview that she had given the medication but forgot to sign the MAR at the time. Facility policy requires that the individual administering medication must initial the MAR immediately after giving each medication and before administering the next. The DON confirmed that the expectation is for medication administration to be documented at the time of administration.
Kitchen Equipment Not Maintained in a Clean and Sanitary Manner
Penalty
Summary
Kitchen equipment was observed to be unclean and not maintained in a sanitary manner during an inspection with the Food Service Director (FSD) present. The microwave had multicolored dried debris on the interior ceiling. The convection ovens had baked-on brown soil on the glass doors that made them opaque, along with baked-on debris in the interior corners. The six-burner stove top and oven were not clean, with food sediment and buildup on the interior door, and the catch tray lined with foil contained burnt liquid and food debris with peeling foil. The griddle top and splash guard surround had crusted, hardened, scrapeable black debris. The fryer had food debris on the oil well ledge and dark brown oil during the ladle check. The can opener blade had a metal chip on the right side and brown, sticky food debris on the shaft near the blade and holder.
PNA Notification and Timely Return of Resident Funds
Penalty
Summary
The facility failed to ensure that residents with Personal Needs Accounts (PNA) received written notification when their balances were approaching the limit that could affect Medicaid or SSI eligibility. A review of the facility’s trial balance showed 12 residents with PNA balances ranging from $1,964.18 to $39,870.91. During interviews, the RDF stated that quarterly PNA statements were sent to residents or representatives and that these statements informed them when balances were high, but the LNHA stated the facility sent quarterly statements and not a written notification letter. He also stated he had just learned that such a letter could be sent. The RDF later stated she was not aware of any letter being sent to notify residents they were approaching the resource limit and said residents were expected to know from enrollment that they were not to exceed $2,000.00. The deficiency affected residents including those whose quarterly statements were mailed to representatives, emailed to the Office of Public Guardianship, or left at the front desk for pickup. The RDF confirmed that the facility did not provide the specific written notification letter described in the policy. The facility’s Resident Funds Account policy stated that residents receiving Medicaid benefits must be notified when their account reaches $200.00 less than the Medicaid/SSI resource limit and that the criteria for possible loss of eligibility must be explained. The facility also failed to convey resident funds and provide final accounting within 30 days of discharge or death for multiple residents. The census and Resident Activity List showed residents who had expired or been discharged, including residents whose balances remained in the account and were not returned to Medicaid, the State, or the proper party within 30 days. The RDF stated that funds should generally be returned within 30 to 60 days and that the process should begin right away, but acknowledged that several residents’ funds had not been returned on time and that the funds should have been returned before surveyor inquiry. The policy stated that upon discharge or death, resident funds were to be refunded or conveyed within 30 days.
Low-Air-Loss Mattress Not Set Correctly
Penalty
Summary
The facility failed to ensure that a low-air-loss mattress was operating and set according to the resident's weight, as ordered by the physician, for a resident identified as being at risk for impaired skin integrity. Resident #7 had diagnoses including obesity, edema, and muscle weakness, and the comprehensive care plan identified the resident as at risk for impaired skin integrity related to fragile skin. The care plan directed that a low-air-loss mattress be used and that the air mattress be checked for functioning every shift. The physician's order dated 4/10/2025 specified a low-air-loss mattress and to check the setting closest to the resident's current weight, along with checking mattress functionality. During observation, the resident was found lying in bed while the mattress was inflated, but the air-loss mattress was not on, and tape on the machine indicated a setting of 235 lbs. On a later observation, the mattress was set to 250 lbs. The resident's weight was documented as 193 lbs on 8/12/2025. Staff interviews confirmed that the mattress should be checked daily and every shift, should be functioning, and should be set according to the resident's weight; the LPN/UM confirmed the setting was 250 lbs and should have been set to 200 lbs. The MAR/TAR showed the low-air mattress was signed off as administered on both observation dates.
Controlled Medication Count and Documentation Errors
Penalty
Summary
The facility failed to ensure an accurate account of the administration and documentation of controlled medications. During a medication administration observation on 8/12/25, an LPN administered six medications to Resident #128, then the surveyor reviewed the shift count narcotic inventory log for the 7 AM to 3 PM shift and found the sections for whether the count was correct and whether the EDK was sealed were left blank. The signatures for the incoming and outgoing nurses were also illegible, and the LPN stated she did not sign the shift count because the 11 PM to 7 AM nurse still had the book to sign out medications. When the surveyor requested a full controlled medication inventory, the LPN counted several controlled medications and found discrepancies between the declining inventory sheet and the actual remaining tablets. For Clonazepam 0.25 mg, the sheet showed 21 tablets remaining but only 20 were present; the LPN stated she had administered the medication to Resident #99 but had not signed it out because the book was still with the 11 PM to 7 AM nurse. For Lyrica 75 mg, the sheet showed 55 tablets remaining but only 54 were present, and the LPN stated she had administered it to Resident #152 but could not sign the book. For Alprazolam 1 mg, the sheet showed 58 tablets remaining but only 57 were present, and the LPN gave the same explanation. The LPN/UM stated that the incoming and outgoing nurses must count controlled medications together and sign the book upon completion, and that controlled medications should be signed out immediately when removed from the bingo card. The DON stated the incoming nurse should have obtained the narcotic book at shift change and that the nurse was required to sign the book the moment the drug was popped out of the bingo card. The facility policy required controlled substances to be accurately maintained on a declining inventory record, reconciled by the incoming and outgoing nurse, and counted at each shift change.
Delayed Response to Consultant Pharmacist Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to Consultant Pharmacist recommendations for Resident #185. The resident had a physician order dated 4/9/25 for Fludrocortisone Acetate 0.1 mg by mouth daily for "Syndromes," but the resident's order summary report did not list a diagnosis of syndromes. The August 2025 MAR showed the medication was scheduled daily and administered from 8/1/25 through 8/15/25. A Consultant Pharmacist Inspection Report dated 5/2/25 included a recommendation to clarify fludrocortisone ordered for syndromes, and the prescriber response indicated agreement with the recommendation and included a signature. Despite that signed agreement, subsequent Consultant Pharmacist Consultation Notes dated 6/6/25 and 7/7/25 both stated that the medication regimen was reviewed and no recommendations were made. During interview, the LPN/UM stated that consultant pharmacist recommendations were forwarded by the DON, printed, and given to the NP for review, and that the recommendation should have been changed and returned by the next monthly review. The ADON stated that the recommendation should have been clarified when the NP agreed, and the facility supplier pharmacy supervisor stated that fludrocortisone had originally been ordered for syncope, but when it was reordered on 4/9/25 the indication of syndromes was not clarified.
Failure to Reschedule and Complete Ordered Diagnostic Procedure
Penalty
Summary
The facility failed to provide care in accordance with physician orders for one resident who required a gastric emptying scan. The resident, who had diagnoses of gastroesophageal reflux disease (GERD) and anxiety disorder, was scheduled for a gastric emptying scan following a gastroenterology appointment. On the day of the scheduled scan, the resident vomited prior to the procedure, resulting in the test not being completed. Although the resident and staff were aware that the test needed to be rescheduled, there was no documentation that the medical staff had been notified or that the appointment was rescheduled. Interviews with staff revealed a breakdown in communication between nursing and the medical records department. The LPN involved could not recall if she had alerted the medical records staff to reschedule the test, and the medical records person stated she was not notified that the test was not completed, assuming it had been done. The nurse practitioner was also unaware that the scan had not been completed or rescheduled. As a result, the resident did not receive the ordered diagnostic procedure, contrary to facility policy and physician orders.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect four residents from abuse perpetrated by another resident, identified as R5, who had a history of aggressive behaviors. R5, who was cognitively intact with a BIMS score of 13, was involved in multiple incidents of resident-to-resident abuse. These incidents included physical altercations with residents R6, R9, R25, and R30, all of whom had varying degrees of cognitive impairment and were at high risk for experiencing abuse. Despite these incidents, the facility's investigations concluded that the abuse could not be substantiated, citing the events as isolated and unavoidable due to R5's psychiatric diagnosis and recurrent UTIs. The first incident involved R5 hitting R6 on the shoulder, which was witnessed by staff. R6, who had severe memory impairment due to dementia, was at high risk for abuse. The second incident involved R5 punching R9 on the leg, with R9 reporting the incident to staff. R9 was cognitively intact but experienced delusions. In both cases, the facility's investigation deemed the events as isolated and not predictable, thus not substantiating abuse. Further incidents included R5 stabbing R25 with an ink pen, causing skin tears, and grabbing R30's arm, resulting in a scratch. Both R25 and R30 were severely cognitively impaired and at high risk for abuse. Despite these physical altercations, the facility's investigations consistently concluded that the incidents were isolated and unavoidable due to R5's psychiatric conditions. Interviews with staff, including the Unit Manager, CNAs, and the DON, revealed a lack of understanding that resident-to-resident abuse could occur, with the DON specifically stating that abuse was not substantiated as staff did not instigate the incidents.
Failure to Timely Report Investigation Results to SSA
Penalty
Summary
The facility failed to report the results of abuse and neglect investigations to the State Survey Agency (SSA) within the required five working days for 10 out of 13 residents reviewed for abuse. This deficiency was identified through interviews, document reviews, and examination of facility policies. The incidents involved various residents with different medical conditions, including vascular dementia, schizophrenia, Alzheimer's disease, lung cancer, and depression. In each case, the initial allegations were reported to the SSA within the required two-hour timeframe, but the results of the investigations were not submitted within the five-day period. For instance, one resident with vascular dementia alleged that a Licensed Practical Nurse (LPN) choked her. The facility suspended the LPN pending investigation and reported the allegation to the SSA within two hours. However, there was no evidence that the investigation results were submitted within five days. Similarly, another resident's family reported rough handling by a Certified Nursing Assistant (CNA), which was also reported timely, but the investigation results were not submitted as required. The facility's policy on abuse, dated December 2022, mandates the prevention and reporting of abuse, neglect, and mistreatment, assigning the responsibility of investigation and reporting to the Administrator and Director of Nursing. However, the policy did not specify the requirement to submit investigation results to the SSA within five business days, contributing to the deficiency. Interviews with the Director of Nursing and the Administrator revealed a lack of evidence for the submission of the final investigation reports, with emails being deleted after 30 days, further complicating compliance with reporting requirements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Deptford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlas Post Acute At Woodbury Country Club | 1.8 mi | ★★★★★ | 1 | 0 |
| Elmwood Hills Healthcare Center Llc | 3.1 mi | ★★★★★ | 1 | 1 |
| Advanced Subacute Rehabilitation Center At Sewell | 3.8 mi | ★★★★★ | 2 | 0 |
| Laurel Manor Healthcare And Rehabilitation Center | 5.2 mi | ★★★★★ | 10 | 0 |
| Shady Lane Gloucester Co Home | 6.1 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.