Cycle 1
Health 2025-02-13 · Fire 2025-02-13
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Voorhees, NJ
Lions Gate
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1100 Laurel Oak Road, Voorhees, NJ
(856) 667-3100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
99
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-02-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.93
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.70
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
3.04
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
5.68
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.64
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
5.34
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
5.45
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
180
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
79.47
Composite VBP score used to determine payment impact.
Payment multiplier
1.0257
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.72
Baseline 24.84% · Performance 20.76% · Measure score 4.72 · Achievement 1.44 · Improvement 4.72
Healthcare-associated infections
10
Baseline 6.25% · Performance 4.72% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
7.07
Baseline 52.42% · Performance 34.78% · Measure score 7.07 · Achievement 7.07 · Improvement 5.90
Adjusted total nurse staffing
10
Baseline 4.61 hours · Performance 5.87 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.26% |
10.72%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 709 · Observed rate 14.1% · Lower 95% interval 11.63% |
| Discharge to community | 57.6% |
50.57%
7 pts better
|
Better than the National Rate · Eligible stays 704 · Observed rate 53.84% · Lower 95% interval 53.96% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.85% |
95.27%
3.6 pts better
|
Numerator 430 · Denominator 435 |
| Falls with major injury | 0.46% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 435 |
| Discharge self-care score | 34.93% |
53.69%
18.8 pts worse
|
Numerator 124 · Denominator 355 |
| Discharge mobility score | 32.96% |
50.94%
18 pts worse
|
Numerator 117 · Denominator 355 |
| Pressure ulcers or injuries, new or worsened | 1.38% |
2.29%
0.9 pts better
|
Numerator 6 · Denominator 435 · Adjusted rate 1.55% |
| Healthcare-associated infections requiring hospitalization | 4.72% |
7.12%
2.4 pts better
|
No Different than the National Rate · Eligible stays 403 · Observed rate 2.73% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 1.83% |
8.2%
6.4 pts worse
|
Numerator 7 · Denominator 382 |
| Staff flu vaccination coverage | 97.3% |
42%
55.3 pts better
|
Numerator 360 · Denominator 370 |
| Discharge function score | 28.45% |
56.45%
28 pts worse
|
Numerator 101 · Denominator 355 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 314 · Denominator 314 |
| Transfer of health information to patient | 98.89% |
96.28%
2.6 pts better
|
Numerator 89 · Denominator 90 |
| Resident COVID-19 vaccinations up to date | 32.57% |
25.2%
7.4 pts better
|
Numerator 71 · Denominator 218 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.1
0.1 pts worse
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
93.0%
5.6 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
97.2%
0.2 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
2.4%
0.4 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.2% · Q3 1.5% · Q4 1.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
11.4%
8.6 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.2% · Q3 1.8% · Q4 3.4% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.6%
1.7 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.8% · Q3 3.9% · Q4 2.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.3% |
19.0%
5.3 pts worse
|
19.6%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 29.1% · Q3 23.1% · Q4 18.9% · 4Q avg 24.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
13.5%
0.6 pts worse
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 13.6% · Q3 17.0% · Q4 12.2% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.1% |
9.8%
11.3 pts worse
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
9.7%
2.9 pts worse
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 21.3% · Q3 2.2% · Q4 7.0% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.7%
0.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
15.9%
6 pts worse
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 30.6% · Q3 23.7% · Q4 18.2% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.0%
0.6 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.1% · Q3 8.0% · Q4 4.3% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
78.7%
18.8 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 96.4% · Q3 98.9% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
8.2%
0.1 pts worse
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 6.9% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.1% |
80.1%
14 pts better
|
79.7%
14.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.7% |
25.4%
3.3 pts worse
|
23.9%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 22.7% · Expected 18.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-09 · Fire 2023-02-09
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-02-11 · Fire 2021-02-11
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-28
F · Potential for more than minimal harm
2023-02-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-21
F · Potential for more than minimal harm
2023-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-28
E · Potential for more than minimal harm
2023-02-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-09
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-03-21
D · Potential for more than minimal harm
2021-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-03-17
Penalties and ownership
What sits behind the stars
Ownership
Becker, Meredith
W-2 Managing Employee · Individual
Okoli Umeweni, Adaora
Contracted Managing Employee · Individual
Palella, Cristina
W-2 Managing Employee · Individual
Thompson, David
Corporate Director · Individual
Thompson, David
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Echelon Care & Rehab
Voorhees, NJ
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Voorhees Pediatric Facility
Voorhees, NJ
2-star overall rating with 1-star inspections with $285,780 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Autumn Lake Healthcare At Voorhees
Voorhees, NJ
2-star overall rating with 2-star inspections with abuse icon flag with $130,515 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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