Cycle 1
Health 2024-07-12 · Fire 2024-07-12
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Brick, NJ
Willow Springs Rehabilitation And Healthcare Ctr
5-star overall rating with 4-star inspections with $8,512 in total fines with 3 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
1049 Burnt Tavern Road, Brick, NJ
(732) 840-3700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
164
Certified beds
Average residents
144
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Health Services
Operator or chain grouping
Approved since
1985-01-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
81 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
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
0.43
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
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
10,862
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.68
Baseline 21.33% · Performance 21.12% · Measure score 0.68 · Achievement 0.68 · Improvement 0
Healthcare-associated infections
0
Baseline 9.53% · Performance 9.63% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.86
Baseline 47.22% · Performance 35.64% · Measure score 6.86 · Achievement 6.86 · Improvement 4.68
Adjusted total nurse staffing
0
Baseline 3.01 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.65% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 389 · Observed rate 9.25% · Lower 95% interval 7.94% |
| Discharge to community | 58.05% |
50.57%
7.5 pts better
|
Better than the National Rate · Eligible stays 378 · Observed rate 49.74% · Lower 95% interval 53.53% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.43% |
95.27%
4.2 pts better
|
Numerator 347 · Denominator 349 |
| Falls with major injury | 0.29% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 349 |
| Discharge self-care score | 48.62% |
53.69%
5.1 pts worse
|
Numerator 88 · Denominator 181 |
| Discharge mobility score | 58.56% |
50.94%
7.6 pts better
|
Numerator 106 · Denominator 181 |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 12 · Denominator 348 · Adjusted rate 3.34% |
| Healthcare-associated infections requiring hospitalization | 9.63% |
7.12%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 267 · Observed rate 11.99% · Lower 95% interval 6.61% |
| Staff COVID-19 vaccination coverage | 0.66% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 151 |
| Staff flu vaccination coverage | 98.75% |
42%
56.8 pts better
|
Numerator 158 · Denominator 160 |
| Discharge function score | 61.33% |
56.45%
4.9 pts better
|
Numerator 111 · Denominator 181 |
| Transfer of health information to provider | 99.48% |
95.95%
3.5 pts better
|
Numerator 190 · Denominator 191 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 98 · Denominator 100 |
| Resident COVID-19 vaccinations up to date | 3.43% |
25.2%
21.8 pts worse
|
Numerator 6 · Denominator 175 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.1
About the same
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
93.0%
10.1 pts worse
|
93.4%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 86.1% · Q3 87.1% · Q4 74.0% · 4Q avg 82.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.2% |
97.2%
12 pts worse
|
95.5%
10.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
2.4%
0.1 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 2.2% · Q4 3.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
11.4%
8.1 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 4.4% · Q3 1.2% · Q4 2.1% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
4.6%
3.3 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 1.3% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
19.0%
1.1 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 22.4% · Q3 18.2% · Q4 19.8% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
13.5%
1.6 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 13.2% · Q3 14.1% · Q4 12.1% · 4Q avg 11.9% · 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 | 4.3% |
9.8%
5.5 pts better
|
16.3%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 0.0% · Q3 1.9% · Q4 7.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.2% |
9.7%
4.5 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 6.0% · Q3 0.0% · Q4 7.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
15.9%
0.4 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 15.7% · Q3 10.2% · Q4 10.2% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
6.0%
3.1 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.3% · Q3 1.3% · Q4 1.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.9% |
78.7%
42.8 pts worse
|
81.7%
45.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 37.9% · Q3 46.0% · Q4 29.0% · 4Q avg 35.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
8.2%
1.8 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 6.6% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 1.3% · Q4 0.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.0% |
80.1%
38.1 pts worse
|
79.7%
37.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.2% |
25.4%
6.8 pts worse
|
23.9%
8.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.2% · Observed 34.8% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-20 · Fire 2022-12-20
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-10-07 · Fire 2020-10-07
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
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
2024-07-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-09-11
F · Potential for more than minimal harm
2024-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-22
E · Potential for more than minimal harm
2024-07-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-07-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-07-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-12
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-07-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-26
E · Potential for more than minimal harm
2024-07-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-07-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-07-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-12
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-07-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-12
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-07-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-17
G · Actual harm
2024-07-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-07-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-05
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-29
B · Minimal harm
2023-11-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-22
E · Potential for more than minimal harm
2022-12-20
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 2023-01-19
D · Potential for more than minimal harm
2022-12-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-20
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 2023-01-19
D · Potential for more than minimal harm
2022-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-20
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-01-19
E · Potential for more than minimal harm
2020-10-07
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-10-30
E · Potential for more than minimal harm
2020-10-07
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 2020-10-30
B · Minimal harm
2020-10-07
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 2020-10-26
B · Minimal harm
2020-10-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2020-10-30
Penalties and ownership
What sits behind the stars
$8,512
2024-07-05
Fine
Fine · fine $8,512
Fine
Ownership
Quinto Guardian LLC
5% Or Greater Direct Ownership Interest · Organization
Ukr Consulting LLC
5% Or Greater Direct Ownership Interest · Organization
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Kohn Fam Tr Gst Exempt Uad 3-25-13
5% Or Greater Indirect Ownership Interest · Organization
Marquis Limited LLC
Operational/Managerial Control · Organization
Nfr 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Posen, Mindee
Corporate Officer · Individual
Pramnauth, Omkar
Operational/Managerial Control · Individual
Pramnauth, Omkar
Corporate Director · Individual
Reliant Pro Rehab LLC
Operational/Managerial Control · Organization
Rothberg, Michael
Operational/Managerial Control · Individual
Rsbrmk Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sk 2013 Investment Tr Ua 03252013
5% Or Greater Indirect Ownership Interest · Organization
Tryko Guardian Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Uak 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Yr 2013 Investment Trust U/A/D 3/25/13
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Complete Care At Laurelton, LLC
Brick, NJ
3-star overall rating with 2-star inspections with $38,120 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Complete Care At Brick LLC
Brick, NJ
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Concord Healthcare & Rehabilitation Center
Lakewood, NJ
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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