Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Millville Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported that a CNA, described as an obese white female with brown hair and arm tattoos, punched and pulled the hair of their nonverbal roommate. The DON and SW limited the investigation to showing the reporting resident small headshot photos of three CNAs, after which no perpetrator was identified, and they did not conduct or document interviews with CNAs or other residents. The CNA who matched the description and was assigned to the alleged victim on the shift in question was neither informed of the allegation nor suspended or removed from duty, despite the facility’s abuse policy requiring immediate removal of an alleged abuser and a thorough, documented investigation.
A resident with clearly documented allergies to mayonnaise, ketchup, and vinegar was repeatedly served meals containing these allergens despite accurate information being present in the EMR, care plan, diet reports, and tray card. The resident, who was cognitively intact and reported prior discussions with dietary staff about these allergies, received a meal tray with mayonnaise and was offered ketchup by a CNA who could not locate the tray card. Later, the same resident was served a meal including creamy coleslaw made with mayonnaise and vinegar, with the coleslaw in contact with other foods on the plate. Dietary leadership and the RD confirmed that these items should not have been provided based on the resident’s documented allergies.
A facility failed to update the PASARR Level One for a resident diagnosed with bipolar disorder, as the existing PASARR from 2017 did not reflect this diagnosis. Despite the resident's medical record indicating the diagnosis in 2023, the PASARR was not updated, which was acknowledged by the Social Services Director and Admissions Director. This oversight could potentially delay necessary assistance for the resident.
A facility failed to create a comprehensive care plan for a resident who began hemodialysis, only noting basic dialysis scheduling without detailed interventions. Despite the resident's intact cognition and specific dialysis needs, the care plan lacked instructions for monitoring the dialysis site or managing the resident's condition. Staff interviews revealed expectations for more detailed care plans, aligning with facility policy and agreements.
The facility failed to implement an effective antibiotic stewardship program, lacking protocols to monitor extended antibiotic use. A resident on long-term doxycycline therapy for septic arthritis was not tracked, as the facility's electronic system did not support monitoring prophylactic antibiotic use. The Infection Preventionist and Medical Director acknowledged the oversight, but no measures were in place before the survey.
The facility failed to report and investigate allegations of verbal abuse by CNAs towards two residents. One resident reported being yelled at by a CNA, which was not investigated or reported as required. Another resident felt belittled by staff, a concern documented in Resident Council minutes without a response. Staff interviews revealed communication gaps and non-compliance with the facility's abuse reporting policy.
Facility staff failed to report allegations of verbal abuse involving two residents to the administration and NJDOH as required by policy. A resident reported being yelled at by a CNA, leading to distress, but the incident was not investigated or reported. Another resident felt belittled by staff, but this concern was not documented or addressed. The facility's policy mandates immediate reporting of suspected abuse, but this was not followed, indicating a breakdown in communication and reporting procedures.
The facility failed to investigate verbal abuse allegations involving two residents. One resident reported being yelled at by CNAs, and another felt belittled by staff. The Social Worker did not collect additional statements, and the DON was unaware of concerns raised in a Resident Council meeting. The facility's abuse policy was not followed, resulting in a deficiency.
The facility failed to meet the required CNA staffing ratios during day shifts, as mandated by New Jersey law. Over several weeks, the number of CNAs on duty was consistently below the required ratio of one CNA to every eight residents, with specific instances showing significant shortfalls in staffing levels.
A facility failed to report an allegation of verbal abuse by a CNA to the SSA within the required timeframe. The incident, initially treated as a grievance, involved a resident being called a liar by a CNA. The delay in reporting occurred because the incident was not immediately recognized as abuse, and it was only reported after the DON spoke with the resident's daughter and received guidance from corporate.
A resident with diabetes and other health conditions did not want an LPN to administer their medication. When the LPN couldn't reach a supervisor or another nurse, she asked a CNA to administer insulin and an oral medication, which the CNA did while the LPN observed. The LPN signed off on the medication administration despite not administering it herself. Other staff confirmed they would not allow a CNA to administer medications.
The facility failed to follow infection control practices during wound care for two residents, leading to potential cross-contamination. A nurse placed supplies on a resident's bed without a protective barrier and did not wear a gown, while another resident's wound care was conducted without a gown and lacked proper signage for Enhanced Barrier Precautions. The facility's policy on PPE and signage was not adhered to, despite previous training.
Failure to Thoroughly Investigate Alleged CNA Abuse and Remove Alleged Perpetrator From Duty
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident physical abuse and to act in accordance with its abuse prohibition policy after one resident reported witnessing abuse of a roommate. One resident with moderate cognitive impairment (BIMS score 9/15) reported that on a Saturday a CNA hit and pulled the hair of their roommate, who was unable to complete a BIMS due to being unable to speak or be understood. The reporting resident described the CNA as a white, heavyset female with brown hair and arm tattoos and stated that this CNA provided care to the roommate but not to them. The allegation was documented on a reportable event survey, and the facility’s summary noted that the resident reported seeing the CNA punch and pull the roommate’s hair. The facility’s response to the allegation was limited to showing the reporting resident small, headshot photos of three CNAs who fit the general description, including the CNA assigned to the alleged victim on the date in question. The resident did not identify any of the faces, later stating the photos were too small to correctly identify the perpetrator. There was no documentation of interviews with staff or other residents, and no evidence that the CNA who matched the description and was assigned to the alleged victim was suspended or removed from duty during the investigation. The DON stated she did not interview any CNA or other staff because the resident could not identify the alleged perpetrator from the photos and that she ruled out other staff based on the description. Subsequent interviews confirmed that the CNA fitting the description had been assigned to the alleged victim on the shift in question and had not been informed of any allegation, interviewed, or suspended. Other CNAs who worked that shift and one who had switched resident assignments with the implicated CNA reported they were not interviewed and stated that only this CNA matched the description given by the reporting resident. The facility’s abuse policy required immediate removal of the employee alleged to have committed abuse from duty pending investigation, initiation of an investigation within 24 hours, and thorough documentation of interviews in the risk management portal, but the investigation lacked documented staff and resident interviews and did not include removal of the alleged perpetrator from duty.
Removal Plan
- Staff training
- Suspension of staff
Failure to Prevent Allergen Exposure in Resident Meals
Penalty
Summary
The deficiency involves the facility’s failure to prevent a resident with documented food allergies from being served foods containing known allergens. The resident had allergies recorded in the EMR, care plan, diet type report, and tray card to dill, dill oil, mushrooms, ketchup, lactose, radishes, acetic acid (vinegar), and mayonnaise. The resident was cognitively intact with a BIMS score of 15 and reported that their mouth and tongue would swell when consuming allergens. Despite this, the resident stated they had spoken with the Dietary Manager multiple times and continued to receive foods containing allergens. Surveyors observed that during a noon meal, the resident was served a cheeseburger and potatoes with a sealed packet of mayonnaise on the tray, and a CNA offered ketchup, which the resident refused. The CNA confirmed she served the tray, offered ketchup, and that a mayonnaise packet was present, and she was unable to locate the resident’s tray card at that time. The Dietary Manager confirmed the resident’s allergies to ketchup and mayonnaise and acknowledged that mayonnaise should not have been on the plate and ketchup should not have been offered. Later, during the evening meal, the resident was served a cheeseburger, creamy coleslaw, cubed potatoes, and cookies, with the coleslaw in contact with other foods on the plate. Review of the coleslaw recipe showed it contained mayonnaise and vinegar, and the Registered Dietitian confirmed it was an error that the resident received mayonnaise and creamy coleslaw despite allergies documented in Meal Tracker and on the tray slip.
Removal Plan
- Audit of all resident diet orders
- Staff education on checking meal tickets
- Staff education on not providing food items to residents to which they are allergic
Failure to Update PASARR for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to initiate a new PASARR Level One for a resident diagnosed with bipolar disorder, which was not reflected in the existing PASARR documentation. The resident, identified as R22, was originally admitted with a PASARR Level One dated 2017, which did not list bipolar disorder as a diagnosis. Despite the resident's medical record indicating a diagnosis of bipolar disorder as of February 2023, the PASARR was not updated to reflect this change. This oversight was confirmed during interviews with the Social Services Director and the Admissions Director, who acknowledged that the PASARR should have been updated to reflect the resident's current mental health diagnosis. The facility's policy requires that all residents with mental disorders or intellectual disabilities receive appropriate pre-admission screenings. However, the policy was not followed in this case, as the PASARR for R22 was outdated and inaccurate. The Admissions Director admitted that the discrepancy should have been identified at the time of admission, and a new PASARR should have been completed. The failure to maintain an accurate PASARR Level One had the potential to delay or limit necessary assistance for the resident should they experience a bipolar episode.
Failure to Develop Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who began receiving hemodialysis. The resident, who had intact cognition, was admitted to the facility after a hospital stay and was diagnosed with encephalopathy, acute kidney failure, and required hemodialysis. Despite the resident's return from the hospital with a permacath placement and a schedule for dialysis on Mondays, Wednesdays, and Fridays, the care plan only included a basic intervention to prepare the resident for dialysis on those days. The care plan lacked detailed interventions related to dialysis care, such as monitoring the dialysis site for complications or specific instructions on managing the resident's condition. Interviews with facility staff, including an LPN, the Unit Manager, and the DON, revealed that the care plan was expected to include detailed information about the resident's dialysis needs, such as the type of line, program, and any dietary or fluid restrictions. The Unit Manager acknowledged that the care plan could be more comprehensive, and the DON expected more detailed information to be included when dialysis started. The facility's policy and the Dialysis Services Agreement also emphasized the need for a comprehensive care plan tailored to the resident's needs, which was not adequately implemented in this case.
Failure to Monitor Extended Antibiotic Use
Penalty
Summary
The facility failed to establish an effective antibiotic stewardship program, specifically lacking protocols to monitor extended antibiotic use. This deficiency was identified during a review of the facility's practices and policies, which revealed that the facility did not track residents on long-term prophylactic antibiotic therapy. The Infection Preventionist (IP) admitted that the current electronic system did not allow for tracking of prophylactic antibiotic use unless it was a new admission with a new antibiotic order. The Medical Director acknowledged the need to track all residents on long-term prophylactic antibiotics, but this had not been implemented before the recertification survey. The deficiency was highlighted in the case of a resident who was on doxycycline for right shoulder septic arthritis. The resident's medical records indicated ongoing suppressive therapy with doxycycline, yet there was no evidence of monitoring or tracking of this extended antibiotic use. The facility's policy on antibiotic stewardship did not address standards for extended antibiotic use, and the responsibility for the program was not effectively executed by the Infection Preventionist, Director of Nursing, and Medical Director, as required by the facility's policy.
Failure to Report and Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse Prohibition policy when staff did not report an allegation of verbal abuse by a CNA towards a resident. A resident reported that a CNA yelled at them for requesting their hair to be washed twice, which led the resident to cry. The resident informed the Social Worker about the incident, but no further investigation was conducted, and the incident was not reported as required by the facility's policy. The resident was cognitively intact and dependent on assistance with ADLs, with medical conditions including left-sided weakness and paralysis due to a cerebrovascular accident, hypertension, and multiple sclerosis. Another resident, who was also cognitively intact and required supervision with ADLs, expressed feeling belittled by staff across the facility. This concern was documented in the Private Resident Council minutes, but no response was recorded, and the issue was not reported as verbal abuse. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident was not reported, indicating a failure to adhere to the facility's policy on abuse reporting. Interviews with facility staff, including the Social Worker, DON, ADON, and Administrator, revealed gaps in communication and reporting processes. The Social Worker did not collect statements from other residents involved, and the DON was not informed of the concerns raised in the Resident Council minutes. The facility's policy mandates immediate reporting of suspected abuse, but this was not followed, resulting in a deficiency in the facility's handling of abuse allegations.
Plan Of Correction
1. Corrective Action: CNA 1 and 2 were immediately educated on NJ Exec Order 26.4[R] during patient care and abuse and neglect. CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 NJ Exec Order 26.4[R] with the reassignment of staff. Resident number 6 was interviewed regarding being belittled and he states he really did not want to talk about it but that it is when they dont let me do what I want to do outside. 2. All residents in the facility have the potential to be affected by this deficient practice. 3. Department heads were in-serviced on the difference between grievances and reportable events by the Director of Nursing. Staff will be re-inserviced on the Abuse and Neglect policy. Staff will be re-inserviced on the grievance policy. 4. The administrator or designee will audit all grievances to ensure they are handled/reported accordingly. The administrator or designee will audit all partner rounds to ensure all are handled/reported accordingly. The administrator or designee will audit all resident council meeting minutes to ensure all are handled/reported accordingly. The audits will be completed and turned into the DON weekly for tracking and trending. Outcomes will be reviewed at the monthly Quality Assurance Process Improvement Committee Meeting for three months or until the committee agrees the problem is corrected.
Failure to Report Allegations of Verbal Abuse
Penalty
Summary
The facility staff failed to report an allegation of verbal abuse involving two residents to the administration and the New Jersey Department of Health as required by their Abuse Prohibition policy. Resident #3 reported an incident where a CNA yelled at them for requesting their hair to be washed twice, which led to the resident crying. This incident was reported to the Social Worker, but no further investigation was conducted, and the incident was not reported to the appropriate authorities. Additionally, Resident #6 expressed feeling belittled by staff across the facility, but this concern was not documented or addressed in the Resident Council minutes. Resident #3, who was admitted with conditions such as left-sided weakness and paralysis due to a cerebrovascular accident, hypertension, and multiple sclerosis, was cognitively intact and dependent on assistance with activities of daily living. The Social Worker collected a statement from Resident #3 but did not interview other residents on the staff member's assignment. The Director of Nursing was not informed of the concerns raised in the Resident Council minutes, and no investigation was initiated for the verbal abuse allegations. The facility's policy mandates immediate reporting of suspected abuse, but this was not adhered to in these cases. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident involving Resident #6 was not reported. The Assistant Director of Nursing and the Administrator were also unaware of the concerns raised, indicating a breakdown in communication and reporting procedures within the facility.
Plan Of Correction
Reporting of Alleged Violations 1. Corrective Action CNA 1 and 2 were immediately educated on being considerate during patient care and abuse and neglect. CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 is very happy with the reassignment of staff. Partner Rounds were initiated where every patient is assigned to a department head to see several times weekly to handle/report any concerns. Resident number 6 was interviewed regarding being [R] and states really NJ Exec Order 26.4b1 but that it is NJ Exec Order 26.4b1[R]. 2. All residents in the facility have the potential to be affected by this deficient practice. 3. Department heads were in-serviced on the difference between grievances and reportable events by the Director of Nursing. 4. The administrator or designee will audit all grievances to ensure they are handled/reported accordingly. The administrator or designee will audit all partner rounds to ensure all are handled/reported accordingly. The administrator or designee will audit all resident council meeting minutes to ensure all are handled/reported accordingly. The audits will be completed and turned into the DON weekly for tracking and trending. Outcomes will be reviewed at the monthly Quality Assurance Process Improvement Committee Meeting for three months or until the committee agrees the problem is corrected.
Failure to Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents. Resident #3 reported an incident where a CNA yelled at them for requesting their hair to be washed twice, which led to the resident crying. The resident also reported that another CNA yelled at them, expressing concern about getting people in trouble. Despite the resident's report to the Social Worker, the investigation was incomplete as no additional statements were collected from other residents on the CNAs' assignments. Resident #6, who declined to speak with the surveyor, had previously expressed feeling belittled by staff across the facility during a Private Resident Council meeting. The minutes from this meeting indicated that residents had concerns about staff attitudes, but no response was documented. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident was not reported or addressed. Interviews with facility staff, including the Social Worker, DON, and ADON, revealed gaps in the investigation process and communication. The Social Worker did not collect statements from other residents, and the DON was unaware of the concerns raised in the Resident Council minutes. The facility's policy on abuse prohibition requires immediate reporting and investigation of abuse allegations, but these procedures were not followed, leading to the deficiency.
Plan Of Correction
1. Corrective Action: CNA 1 and 2 were immediately educated on NJ NJ Ex Order 26.4(b) (1) during patient care and NJ Ex Order 26.4(b)(1). CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 NJ Exec Order 26.461 with the reassignment of staff. Partner Rounds were initiated where every patient is assigned to a department head to see several times weekly to handle/report any concerns. Resident number 6 was interviewed regarding NJ Ex Order 26.4(b)(1) and states really NJ Ex Order 26.4(b)(1) but that it is when they NJ Ex Order 26.4(b)(1). 2. All residents in the facility have the potential to be affected by this deficient practice. 3. Department heads were in-serviced on the difference between grievances and reportable events by the Director of Nursing. 4. The administrator or designee will audit all grievances to ensure they are handled/reported accordingly. The administrator or designee will audit all partner rounds to ensure all are handled/reported accordingly. The administrator or designee will audit all resident council meeting minutes to ensure all are handled/reported accordingly. The audits will be completed and turned into the DON weekly for tracking and trending. Outcomes will be reviewed at the monthly Quality Assurance Process Improvement Committee Meeting for three months or until the committee agrees the problem is corrected.
Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey state law, specifically during the day shifts. The deficiency was identified through a review of facility documentation, which revealed that the facility did not have the required number of Certified Nurse Aides (CNAs) on duty for 18 out of 21 day shifts. This failure to comply with staffing requirements was evidenced by specific instances where the number of CNAs was below the mandated ratio of one CNA to every eight residents. For example, during the week of August 4, 2024, to August 10, 2024, the facility was deficient in CNA staffing on five out of seven day shifts. On August 4, 2024, there were only 13 CNAs for 142 residents, whereas at least 18 CNAs were required. Similarly, in the two weeks prior to the survey from November 24, 2024, to December 7, 2024, the facility was deficient on 13 out of 14 day shifts. On December 7, 2024, there were only 8 CNAs for 127 residents, while at least 16 CNAs were needed. These deficiencies indicate a consistent failure to meet the staffing requirements set forth by the New Jersey Department of Health.
Plan Of Correction
Mandatory Access to Care 1. Corrective Action All residents have the potential to be affected by this deficient practice. Center is currently employing sign on bonuses, referral bonuses, and various other incentives for current staff to meet staffing standards. Nursing employees salaries were increased effective January 1, 2025. 2. All residents have the potential to be affected by this deficient practice. 3. Staffing coordinator was re educated on NJ staffing mandate. Center will continue recruiting functions, which drive various forms of media to increase the number of applicants. Continue to establish external partnerships with schools to train students and transition them into CNAs. Weekly labor management calls with regional support team. 4. The Labor management team will maintain a listing of current recruiting efforts, and document weekly the results of these efforts. The Administrator or designee will audit these efforts weekly x 4 weeks, then monthly x 2 to ensure the Center team is following up on all recruitment tasks. The Administrator or Designee will report findings to the Performance Improvement Committee monthly for three months. The Performance Improvement Committee will evaluate and determine the effectiveness of the plan to ensure substantial compliance is achieved and determine if further monitoring and evaluation is required.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required timeframe for a resident who was verbally abused by a Certified Nursing Assistant (CNA). The facility's policy mandates that any allegations of abuse must be reported no later than two hours after the allegation is made. However, in this case, the incident involving a CNA calling a resident a liar was not reported until nearly a month later. The delay in reporting was due to the incident being initially treated as a grievance rather than abuse, and it was only after the Director of Nursing (DON) spoke with the resident's daughter that the incident was reported to the state. The resident involved in the incident expressed distress over the verbal abuse, which was initially reported to the Social Services staff by the resident. The Assistant Director of Nursing (ADON) was informed, but the incident was not escalated appropriately at that time. The DON, who was on vacation during the initial report, later decided to report the incident as abuse after further discussions and guidance from corporate. This failure to report in a timely manner had the potential to allow suspected abuse to go unreported to the SSA, as noted in the facility's policy and the Elder Justice Act requirements.
Improper Medication Administration by CNA
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) provided services according to accepted standards of clinical practice with medication administration for one resident. The resident, who was moderately cognitively impaired and had a history of diabetes, cirrhosis of the liver, anemia, and dependence on dialysis, was scheduled for dialysis when the incident occurred. The resident had previously expressed a preference not to have LPN1 as their nurse. On the day of the incident, LPN1 was unable to reach the nursing supervisor or another nurse to administer the resident's medication. With transportation for dialysis on the way, LPN1 asked CNA2 to check the resident's blood glucose and administer insulin and an oral medication, which CNA2 did while LPN1 observed from outside the resident's door. The July 2022 Medication Administration Record (MAR) showed that LPN1 signed off on the medication administration, despite not having administered the medications herself. Written statements from LPN1 and CNA2 confirmed the events as described in the facility's investigation. Interviews with other staff members, including LPNs and CNAs, revealed that they would not ask or agree to a non-licensed employee administering medications, as it was not within their training or scope of practice. The Director of Nursing confirmed the incident and the subsequent termination of both employees involved.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to adhere to basic infection control practices during wound care for two residents, which had the potential to cause the spread of infections. For the first resident, who was moderately cognitively impaired and had a diabetic ulcer on the left foot, the registered nurse (RN) placed wound care supplies directly on the resident's bed without using a protective barrier. The nurse also failed to wear a disposable gown during the procedure and did not post a sign indicating Enhanced Barrier Precautions on the resident's door. After completing the wound care, the nurse improperly placed the used supplies on her medication cart in the hallway. In the case of the second resident, who had a Stage IV pressure sore and severely impaired cognitive status, the RN conducted wound care without wearing a protective gown, despite the presence of a chronic wound. The supplies were placed on a protective barrier on the overbed table, but the nurse did not follow the protocol of wearing a gown. Additionally, there was no sign posted on the resident's door to indicate Enhanced Barrier Precautions, and the nurse mistakenly believed that the absence of the sign meant a gown was not required. Interviews with the RN and the Director of Nursing (DON) revealed that the nurse had received training on Enhanced Precautions and basic infection control practices but failed to apply them correctly. The DON confirmed that the facility had conducted an in-service on Enhanced Barrier Precautions, but the RN was not present at that time. The facility's policy required posting a sign on the patient's room door and using appropriate PPE for wound care, which was not followed in these instances.
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Illustrative
What surveyors actually found near you
We read the 91 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Millville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Vineland | 4.5 mi | ★★★★★ | 0 | 0 |
| Bishop Mccarthy Center For Rehab & Healthcare | 4.8 mi | ★★★★★ | 0 | 0 |
| New Jersey Veterans Memorial Vineland | 5.9 mi | ★★★★★ | 2 | 1 |
| Big Oak Rehabilitation And Healthcare Center | 6.6 mi | ★★★★★ | 8 | 0 |
| South Jersey Extended Care | 9.4 mi | ★★★★★ | 16 | 0 |
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