Cycle 1
Health 2025-02-25 · Fire 2025-02-25
6 health deficiencies
Top issue: Administration (3 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Medford, NJ
Medford Leas
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
One Medford Leas Way, Medford, NJ
(609) 654-3000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
24
Certified beds
Average residents
8
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1973-04-01
CMS approved date
Coverage
Medicare
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
34
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
94.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0276
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 22.56% · Performance 16.02% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.49
Baseline 4.75% · Performance 5.30% · Measure score 8.49 · Achievement 8.49 · Improvement 0
Total nurse turnover
10
Performance 10.53% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.35% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 193 · Observed rate 6.74% · Lower 95% interval 6.83% |
| Discharge to community | 82.78% |
50.57%
32.2 pts better
|
Better than the National Rate · Eligible stays 193 · Observed rate 81.87% · Lower 95% interval 76.82% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 84.96% |
95.27%
10.3 pts worse
|
Numerator 113 · Denominator 133 |
| Falls with major injury | 1.5% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 133 |
| Discharge self-care score | 70.49% |
53.69%
16.8 pts better
|
Numerator 86 · Denominator 122 |
| Discharge mobility score | 71.31% |
50.94%
20.4 pts better
|
Numerator 87 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 133 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.3% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 1.65% · Lower 95% interval 2.63% |
| Staff COVID-19 vaccination coverage | 3.33% |
8.2%
4.9 pts worse
|
Numerator 1 · Denominator 30 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 32 · Denominator 32 |
| Discharge function score | 71.31% |
56.45%
14.9 pts better
|
Numerator 87 · Denominator 122 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 55 · Denominator 55 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 76 · Denominator 76 |
| Resident COVID-19 vaccinations up to date | 42.62% |
25.2%
17.4 pts better
|
Numerator 26 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.0% |
78.7%
20.7 pts worse
|
81.7%
23.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 52.4% · Q2 59.6% · Q3 62.0% · Q4 58.1% · 4Q avg 58.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
8.2%
2.6 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 4.6% · Expected 9.2% · 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 | 84.4% |
80.1%
4.3 pts better
|
79.7%
4.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.6% |
25.4%
12.8 pts better
|
23.9%
11.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 9.3% · Expected 17.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-09 · Fire 2023-01-09
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-01-29 · Fire 2021-01-29
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2025-02-25
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-02-25
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-02-25
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-02-25
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-02-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-02-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-02-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-02-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-25
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
2025-02-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-11
D · Potential for more than minimal harm
2023-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-25
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 2025-05-06
E · Potential for more than minimal harm
2025-02-25
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-02-25
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-25
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
D · Potential for more than minimal harm
2023-01-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-01-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-28
Penalties and ownership
What sits behind the stars
Ownership
Driscoll, Haley
Corporate Officer · Individual
Hall, Marlene
Corporate Officer · Individual
Johnson, Marianne
Corporate Officer · Individual
Jones, Scott
Corporate Officer · Individual
Loftus, Abby
Corporate Director · Individual
Melroy, Francis
Corporate Officer · Individual
Symcak, Diane
Corporate Officer · Individual
Vickers, Jeremy
Corporate Director · Individual
Vickers, Jeremy
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
The Pines At Medford
Medford, NJ
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $300,000 in total fines with 20 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
#2
Wiley Mission
Marlton, NJ
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Complete Care At Voorhees, LLC
Voorhees, NJ
3-star overall rating with 2-star inspections with $41,098 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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