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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atlantic Coast Rehab & Health during CMS and state inspections, most recent first.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
The facility failed to store nebulizer and BiPAP equipment in bags, leading to environmental exposure for three residents. Observations revealed uncovered nebulizer masks and a BiPAP mask, contrary to the facility's policy. Staff interviews confirmed the requirement to bag equipment when not in use for infection control. Residents involved had conditions such as COPD, Sleep Apnea, and Congestive Heart Failure.
The facility was found to have deficiencies in food handling and sanitation, including improperly stored eggs, uncovered souffle cups, and unlabeled or undated food items such as mixed fruit, hash brown patties, broccoli florets, and cranberry juice. These practices were not in accordance with the facility's policies on labeling, dating, and food storage.
A resident with dementia and muscle weakness was transported backwards in a geriatric chair by a CNA, which was observed by a surveyor. The facility lacked a specific policy on transport direction, although staff interviews indicated that transporting residents backwards is not standard practice and should be avoided for safety and comfort reasons.
The facility failed to develop comprehensive care plans for two residents, one requiring nebulizer treatments and another using an AFO brace. The care plans lacked necessary details despite physician orders and resident needs. Staff interviews revealed oversight and lack of adherence to facility policies, resulting in incomplete care plans.
The facility failed to provide proper urinary catheter care for two residents, as observed by surveyors. A resident's catheter drainage bag was found in contact with the floor, contrary to facility policy, and urinary outputs were not consistently documented. Another resident's catheter drainage bag lacked a privacy bag, violating care plan requirements. Staff interviews confirmed these deficiencies, and the DON acknowledged the issues when presented with the findings.
A facility failed to accurately document the dispensing of controlled drugs, specifically Oxycodone-Acetaminophen, on a medication cart. A surveyor found a discrepancy between the physical count and the Controlled Drug Sheet (CDS). An RN admitted to administering the medication without signing it out on the CDS. The DON confirmed that narcotics should be documented at the time of administration, as per policy.
The facility was found to have expired medical supplies in one of its medication storage rooms, including probe covers, colostomy bags, and medical tape. An LPN acknowledged the oversight and removed the items, while the DON admitted to being unaware of the expiration dates and committed to future checks. The facility lacked a policy on managing expired supplies.
The facility failed to maintain a sanitary garbage area, with items like pallets, plastic pieces, and chairs scattered around, and a garbage container left open with cardboard boxes spilling out. The LNHA acknowledged the issue and admitted the lack of a policy for managing outside garbage containers.
A facility failed to maintain a complete medical record for a resident regarding hospice care. Despite a physician's order for hospice evaluation, the electronic health record lacked documentation, and no paperwork was found in the hospice or consultation binders. Interviews with the Nurse Manager and DON confirmed the absence of necessary documentation, contrary to the facility's medical records policy.
A CNA was observed leaving a resident's room and walking down the hall while wearing a gown and gloves, despite enhanced barrier precautions requiring PPE removal before exiting. Interviews with staff confirmed the correct procedure, and the facility's policy supported this practice.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards by not storing nebulizer and BiPAP equipment in bags, resulting in environmental exposure for three residents. During the initial tour, surveyors observed nebulizer masks and a BiPAP mask left uncovered and exposed to the environment. Resident #89's nebulizer mask was found standing upright on the bedside table, not bagged, and exposed to the environment. Interviews with staff, including CNAs and LPNs, confirmed that nebulizer supplies should be stored in bags when not in use, as per the facility's Respiratory Equipment Policy and Procedure. Resident #22 was observed with a nebulizer mask lying open to air on the bedside table and an oxygen concentrator that was turned off and not functioning properly. The LPN confirmed that the resident should be on continuous oxygen and replaced the concentrator after noticing it was not working properly. The resident was admitted with diagnoses including Chronic Combined Systolic and Diastolic Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. The facility's policy required nebulizer equipment to be stored in a bag when not in use. Resident #34's BiPAP machine and mask were observed on the dresser, uncovered and exposed to the environment. The resident, who had diagnoses of Chronic Obstructive Pulmonary Disease and Sleep Apnea, confirmed using the BiPAP machine at night. Interviews with the DON and LPNs reiterated that respiratory equipment should be properly bagged for infection control purposes. The facility's policy, last reviewed in August 2024, stated that all nebulizer tubing and equipment should be dated and stored in an oxygen bag when not in use.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies in food handling and sanitation practices, which could potentially lead to foodborne illness. During an inspection, surveyors observed that shelled eggs were stored outside of their original cardboard box in refrigerator #1, which was acknowledged by the Prep Cook as incorrect. Additionally, souffle cups were left open and exposed to air on a storage shelf, contrary to the Regional Food Service Director's statement that they should be covered. Further observations revealed that in refrigerator #2, there were 20 small cups of mixed fruit labeled with a preparation date of 2/6/25 and a discard date of 2/8/25, which were not properly labeled according to the Regional Food Service Director. In freezer #4, hash brown patties were found opened and covered with plastic wrap without any labeling or dating, prompting the Regional Food Service Director to decide to discard them. Similarly, broccoli florets in refrigerator #3 were stored in an open bag without a label or date, and an opened case of cranberry juice in refrigerator #4 was also found without a label or date. The facility's policies on labeling, dating, and food storage were reviewed, highlighting the need for all foods to be covered, labeled, and dated, which was not adhered to in these instances.
Resident Transported Backwards in Geriatric Chair
Penalty
Summary
The facility failed to ensure a resident was transported in a dignified manner, as observed by a surveyor. A Certified Nursing Assistant (CNA) was seen transporting a resident backwards in a geriatric chair from the resident hallway to the nurse station. The resident, who was admitted with diagnoses including dementia and muscle weakness, had long and short-term memory deficits and required maximal assistance with activities of daily living, as indicated by the Minimum Data Set (MDS) assessment tool. Interviews with the CNA, Unit Manager, and Director of Nursing revealed that transporting a resident backwards is not a standard practice and should be avoided for safety and comfort reasons. The facility's Resident Rights document and the CNA job description both emphasize the importance of treating residents with dignity and respect. However, there was no specific policy regarding the direction in which residents should be transported, leading to this deficiency.
Deficient Care Planning for Nebulizer and Brace Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #89, who had multiple diagnoses including metabolic encephalopathy and hemiplegia, was observed with a nebulizer mask that was not properly stored, and their care plan did not include nebulizer treatments despite physician orders for such treatments. Interviews with staff revealed uncertainty and oversight regarding the inclusion of nebulizer treatments in the care plan, which was confirmed by the Director of Nursing and the Licensed Nursing Home Administrator. Resident #96, who had hemiplegia and wore an ankle foot orthosis (AFO) brace, did not have specific instructions for the care of the brace included in their care plan. The resident confirmed wearing the brace daily, yet there were no physician orders or care plan entries addressing the brace. Interviews with staff, including the Director of Rehabilitation, highlighted a lack of communication and documentation regarding the need for a care plan and physician orders for the brace. The facility's policies on Admission and Baseline Care Plan and Splint and Brace Application were not adhered to, as they required immediate needs, including medications and ambulation aids, to be addressed in the care plan. The oversight in care planning for both residents indicates a failure to follow established procedures, resulting in incomplete care plans that did not meet the residents' needs.
Deficiencies in Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to adhere to current standards of practice for urinary catheter care, as evidenced by observations and documentation reviews. During an initial tour, a surveyor observed a catheter drainage bag in contact with the floor for Resident #100, which is against the facility's policy that requires the bag to be kept off the floor to prevent infection. Additionally, the facility did not consistently document urinary outputs for Resident #100, with several instances of missing documentation in the Treatment Administration Record, despite an order to monitor and document catheter output every shift. For Resident #89, the surveyor noted the absence of a privacy bag for the urinary catheter drainage bag, which was required by the resident's care plan to maintain dignity and privacy. The resident had multiple diagnoses, including metabolic encephalopathy and hemiplegia, and was identified as having moderately impaired cognition. The facility's policy and physician orders required the use of a privacy bag and documentation of urinary output every shift, but there were documented instances where the output was not recorded. Interviews with facility staff, including CNAs and LPNs, confirmed the expectations for catheter care and documentation. The Director of Nursing acknowledged the deficiencies when presented with the surveyor's findings, including the lack of a privacy bag and incomplete documentation of urinary outputs. The facility's policy on urinary catheters emphasized the importance of maintaining collection bags off the floor and using privacy bags to uphold resident dignity.
Controlled Drug Recordkeeping Deficiency
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs, specifically Oxycodone-Acetaminophen, on one of the medication carts inspected. During an inspection, a surveyor found a discrepancy between the physical count of the medication and the documentation on the Controlled Drug Sheet (CDS). The blister pack contained 15 pills, while the CDS indicated 16 pills were left. A Registered Nurse (RN) acknowledged administering the medication earlier but had not signed it out on the CDS at the time of administration. The Director of Nursing confirmed that narcotics should be documented on the CDS when removed from the blister pack, as per the facility's policy and federal and state regulations.
Expired Medical Supplies Found in Storage Room
Penalty
Summary
The facility failed to ensure that all medical supplies were stored in accordance with professional standards, as evidenced by the presence of expired supplies in one of the two medication storage rooms inspected. During an observation, a surveyor, accompanied by an LPN, found six unopened boxes of probe covers, two opened boxes of colostomy bags, and one unopened box of paper medical tape, all of which were past their expiration dates. The LPN acknowledged that expired supplies should not be present and removed the items. In a subsequent interview, the Director of Nursing (DON) admitted to being unaware of the expiration dates on supplies and committed to checking them in the future. The facility was unable to provide a policy regarding the management of expired supplies, further highlighting the deficiency in their storage practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain a sanitary environment in the garbage container area, as observed by the surveyor. On two separate occasions, the surveyor noted various items such as wooden pallets, broken plastic pieces, a recliner chair, a geriatric chair, a medical glove, a gray container labeled trash, and a commode scattered around the garbage area, not contained properly. Additionally, a green garbage container was observed with its cover open, exposing cardboard boxes inside, and on the following day, cardboard boxes were seen spilling out onto the ground and on top of the half-closed lid. The Licensed Nursing Home Administrator (LNHA) acknowledged the issue, stating that trash is picked up twice a week and that the facility contacts the company for overflow, but admitted that the cardboard should have been covered. The LNHA also confirmed that the facility lacked a policy addressing the management of outside garbage containers.
Incomplete Medical Record for Hospice Care
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for a resident, identified as Resident #70, who was under review. The deficiency was identified when a surveyor observed that the electronic health record for the resident lacked documentation regarding a hospice evaluation and treatment order dated 1/29/25. Despite the resident's admission diagnoses of dementia and malnutrition, and a minimum data set assessment indicating the resident was not cognitively intact and not on hospice, there was no documentation in the care plans or progress notes about hospice care. Further investigation revealed that there was no paperwork for the resident in the hospice or consultation binders at the nurse station. Interviews with the Nurse Manager and the Director of Nursing confirmed the absence of necessary documentation in the electronic health record. The Nurse Manager acknowledged that there should have been documentation following a meeting with the resident's family, who expressed a desire to pursue hospice care. The Director of Nursing also confirmed that documentation regarding the hospice consult should have been present. The facility's policy on medical records requires that consultation reports and explanations for unimplemented care plans be included in the medical record, which was not adhered to in this case.
Inadequate PPE Use in Infection Control
Penalty
Summary
The facility staff failed to adhere to proper infection control practices, specifically regarding the use of personal protective equipment (PPE) on one of the three units observed. During an initial tour, a surveyor observed a certified nursing assistant (CNA) exiting a resident's room, walking down the hall to the soiled utility room, and returning while wearing a gown and gloves. The resident's room had a sign indicating enhanced barrier precautions, which require targeted gown and glove use to reduce the transmission of resistant organisms. The resident had a physician's order for enhanced barrier precautions due to a G-tube. Interviews with the staff, including a Licensed Practical Nurse (LPN) and the CNA involved, confirmed that gowns should be removed before leaving the resident's room. The infection control preventionist also stated that an in-service had been conducted on the proper use of gowns, emphasizing that they should be removed before exiting the room and disposed of in covered trash cans. A review of the facility's policy on enhanced barrier precautions corroborated this procedure, indicating that solid linen and trash bins should be placed inside the resident's room for discarding PPE prior to exiting.
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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 Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountainview Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Leisure Chateau Rehabilitation | 1.1 mi | ★★★★★ | 15 | 0 |
| Harrogate Village | 2.1 mi | ★★★★★ | 15 | 0 |
| Concord Healthcare & Rehabilitation Center | 2.1 mi | ★★★★★ | 6 | 0 |
| Shore Gardens Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 2 | 0 |
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