Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Complete Care At Ocean Grove Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to consistently document ADL bladder care for two residents, one with spinal stenosis and Parkinson’s disease and another with chronic pulmonary embolism and type 2 DM. Review of the electronic POC records for a specific month showed multiple blank entries for bladder documentation across various shifts, indicating care was not recorded as completed. A CNA and an LPN confirmed that facility expectations require ADL documentation to be completed before the end of each shift, and the DON acknowledged the blanks and reiterated that CNAs are expected to accurately and fully complete ADL logs in accordance with the facility’s ADL policy.
Surveyors found that kitchen staff failed to properly label, date, and store potentially hazardous foods, and did not maintain kitchen equipment in a clean and sanitary manner. Observations included spoiled produce in refrigerators, an ice machine with condensation, unidentified substances, and makeshift repairs, as well as an oven with greasy residue. Opened food items were not labeled or dated as required, and facility policies for cleaning and food safety were not consistently followed.
Medication Administration Error Rate Exceeded 5%: Surveyors observed three medication errors during 30 opportunities, resulting in a 10% error rate. An LPN selected the wrong aspirin form and wrong multivitamin for one resident, and selected the wrong aspirin strength for another resident. The DON stated the nurse should have clarified the order to ensure what was poured matched the physician order.
A resident with DM received the wrong insulin and wrong dose, and the record also showed multiple late insulin administrations and missing documentation for ordered insulin. Another resident with DM had repeated late doses of insulin lispro, insulin glargine, and Humalog. A third resident reported receiving Baclofen without an order, and the chart documented that an agency nurse administered the unprescribed medication.
An LPN discarded unused meds in a trash container before later retrieving them for disposal, and two other LPNs left medications and a bulk liquid protein bottle on top of the med cart while entering residents’ rooms. The DON confirmed meds must always be secured, and the facility policy required drugs and biologicals to be stored in locked compartments or kept under direct observation during med pass.
During incontinence rounds, two residents dependent on staff for ADLs were found wearing double incontinence briefs, both of which were wet. An LPN confirmed this was not appropriate practice. Both residents had significant medical conditions and were assessed as always or frequently incontinent, with care plans lacking specific interventions in one case. Facility policy and staff confirmed that double briefing was not acceptable.
A resident room wall had light brown splattered debris near a resident's bed, and the 1st floor shower room had a shower chair with a hospital gown, towel, and wet blanket on it, plus loose trash in the drain. The HD said rooms and shower areas are cleaned daily, the Interim DON said splattered debris should never be on resident walls, and the LNHA said shower areas should be thoroughly cleaned and sanitized after each use.
The facility failed to complete and document thorough investigations for medication errors involving two residents. One resident with DM and intact cognition had an insulin error in which Novolog was given instead of Novolin, with missing MAR documentation, missing BG documentation, and an incomplete incident report lacking key details and staff statements. Another resident with DM, hemiplegia, and intact cognition reported receiving Baclofen that was not ordered; the incident report identified a wrong-resident med error, but the facility did not obtain the nurse’s statement or the resident’s statement, and QAPI was not initiated.
Failure to follow hold parameters for Droxidopa: A resident with ESRD, hypotension, and dialysis treatments had a physician order for Droxidopa with instructions to hold for SBP > 140, but the MAR showed multiple doses were given when SBP was above the ordered limit. An LPN/UM confirmed the MARs did not reflect the ordered parameters, and the PC and regional nurse identified this as a medication error.
RN coverage was not maintained for the required 8 consecutive hours on one day reviewed. Staffing reports showed no RN coverage for all shifts, and the LNHA confirmed that no RN was in the building for the required time. Facility policy required sufficient staffing with appropriate competencies and skill sets based on resident needs and facility assessment.
Improper Storage and Labeling of Food in Resident Refrigerators: Two residents with personal refrigerators had missing temp log entries, no documented month/year/location on the logs, and one refrigerator had no thermometer. Surveyors also found open, unlabeled food items, and one refrigerator had ice buildup and black debris in the ice box. The HD and LNHA stated staff were responsible for daily checks, complete logs, and discarding unlabeled or expired items.
Improper handling of trash, soiled linen, and laundry PPE: Housekeeping staff were observed leaving trash and soiled linen bags on the floor outside resident rooms, with additional untied bags and a glove on the floor inside one room and no cautionary sign noted. In the laundry area, an HSK was observed loading soiled laundry with bare hands, wearing an untied gown, and washing hands for only 5 seconds instead of the expected 20 seconds; the IP confirmed the PPE and hand hygiene were not appropriate.
The facility did not have an RN present for at least eight consecutive hours on one day, as required. An RN was scheduled but called out, and although the agency was contacted, an LPN was sent instead. The absence of an RN was not discovered until the next shift, resulting in a lapse in required RN coverage for resident care and assessments.
A resident's medical record was found to be incomplete when the facility could not provide the full Controlled Drug Administration Record (CDAR)/Declining Sheet for a prescribed medication, despite repeated requests and searches by the DON. Only a partial record was available, resulting in a deficiency for failure to maintain complete and accurate documentation as required.
The facility did not meet required CNA-to-resident staffing ratios on multiple day shifts over several weeks, with staffing levels consistently below state-mandated minimums for the number of residents present. This deficiency was identified through interviews and review of facility records, and had the potential to affect all residents.
Two residents in an LTC facility did not receive their medications at the scheduled times, as required by the facility's policy. Despite the late administration of medications for hypertension and pain, there was no documentation of notifying the residents' PCPs or evidence of harm. Interviews with nursing staff confirmed the expectation of timely medication administration and proper documentation, aligning with the facility's policy.
The facility staff failed to document ADL care for two residents as per policy. One resident, with muscle weakness, lacked documentation of necessary interventions like rolling and toileting over several days. Another resident, with severe cognitive impairment, also had missing documentation for bed mobility and toileting care. Staff interviews revealed CNAs were responsible for documenting care in the POC system by shift end, even if care was refused.
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) included the required information of the name of the Quality Improvement Organization (QIO) and the TTY number for three residents. This omission was identified during a review of the NOMNC forms, and the Director of Social Services was unaware of the requirement.
The facility failed to protect residents from physical abuse, as evidenced by incidents where a resident with severe cognitive impairment hit another resident with a fly swatter, and another incident where a cognitively impaired resident kicked a cognitively intact resident. The facility conducted abuse training and had policies in place, but these incidents still occurred.
The facility failed to report resident-to-resident incidents and injuries of unknown origin in a timely manner to the state survey agency. Incidents involving a resident being hit with a fly swatter, a resident with a bruised wrist, and a resident with multiple bruises and an abrasion were either reported late or not reported at all. Staff interviews revealed a lack of awareness regarding the required reporting timeframes.
The facility failed to investigate injuries of unknown origin for a resident. Despite reporting the incidents to the DON, no skin audits, resident interviews, or camera footage reviews were conducted. The facility did not follow its policy for thorough investigations.
The facility staff failed to complete a baseline care plan within 48 hours for a resident admitted with diabetes mellitus, spinal stenosis, and quadriplegia. The resident, moderately cognitively impaired, did not have a care plan until 14 days post-admission, contrary to the facility's policy.
The facility failed to provide scheduled showers twice a week for two dependent residents due to staff shortages, despite the residents' preferences and cognitive awareness. Documentation and staff interviews confirmed the inconsistency in providing the scheduled showers.
The facility staff failed to maintain a medication error rate below five percent, as evidenced by two incidents where an LPN administered the incorrect dosage of acetaminophen to a resident and an RN held a dose of spironolactone without physician orders to do so.
The facility failed to ensure medical records were readily accessible for a resident admitted with hypertension, diabetes, and dementia. Despite multiple requests and attempts to retrieve the records from a previous EMR system, the facility was unable to provide the necessary medical information, including critical wound care documentation. This highlights a significant deficiency in maintaining and retrieving resident medical records.
The facility failed to ensure proper infection control practices: a hospitality aide did not wear an N-95 mask and eye protection in a COVID-19 positive room, a CNA doffed PPE outside a room with strict contact precautions, and an LPN cleaned a glucometer without gloves.
Failure to Consistently Document ADL Bladder Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to consistently document Activities of Daily Living (ADLs), specifically bladder care, for two residents. For one resident with spinal stenosis and Parkinson’s disease and a BIMS score of 8/15 indicating moderate cognitive impairment, review of the December 2025 Documentation Survey Report (POC) showed blank entries for bladder documentation on multiple shifts and dates, indicating the task was not documented as completed. For another resident with chronic pulmonary embolism and type 2 diabetes mellitus and a BIMS score of 15/15 indicating intact cognition, the December 2025 POC similarly contained numerous blank bladder documentation entries across day, evening, and night shifts, again indicating the task was not documented as completed. During interviews, a CNA stated that ADL care is documented on the POC and that the expectation is to complete documentation within two hours before the end of the shift, acknowledging that documentation serves as proof of care provided. An LPN stated that all documentation should be completed before staff leave the facility. When presented with the POC records for both residents, the DON acknowledged the blanks and stated that staff are expected to document accurately according to the numerical log and to complete ADL logs in their entirety so the facility can know and perform residents’ needs and expectations. Review of the facility’s ADL policy, implemented 09/01/24, stated that residents unable to carry out ADLs will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, which the facility failed to follow as evidenced by the incomplete ADL documentation.
Deficient Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including improper labeling, dating, and storage of potentially hazardous foods, as well as inadequate cleaning and maintenance of kitchen equipment. During kitchen inspections, condensation and an unidentified yellow substance were found on the ice machine, which also had duct tape and a white bonding material applied to damaged areas. The Food Service Director (FSD) was unable to identify the yellow substance or provide a satisfactory explanation for the use of duct tape and bonding material. The oven was observed to have a greasy, brown substance on its inner surface, and the FSD acknowledged that the oven should be kept clean and free of such substances. Additionally, wilted and partially decomposed lettuce, wilted and yellow celery, and cucumbers with visible spoilage and leaking juice were found in the walk-in refrigerators. The FSD stated that produce is checked during meal preparation rather than daily, which contributed to spoiled items remaining in storage. Further observations revealed an opened, unlabeled, and undated box of sausage and a container of cottage cheese in the walk-in refrigerator, both of which lacked required labeling and dating. The FSD confirmed that these items should have been covered and labeled with opened or used-by dates to ensure food safety. Facility policies reviewed by surveyors required regular cleaning and sanitizing of the ice machine and ovens, as well as proper labeling and dating of food items, but these procedures were not consistently followed. The deficiencies were acknowledged by facility leadership during the survey.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure that medications were administered without an error rate of 5% or greater. During a medication administration observation on 7/18/25, surveyors observed three nurses administer medications to five residents and identified three medication errors out of 30 opportunities, resulting in a 10% error rate. The deficient practice was identified for two residents, Resident #16 and Resident #56, and involved one of the three nurses observed. For Resident #56, an LPN prepared aspirin 81 mg and a multivitamin medication from the wrong stock bottles. The nurse selected aspirin 81 mg enteric coated tablets instead of the ordered chewable aspirin, and selected a plain multivitamin instead of the ordered multivitamin with minerals. For Resident #16, an LPN prepared aspirin 81 mg enteric coated tablets instead of the ordered aspirin 325 mg tablet for DVT prophylaxis. When the surveyor and nurse reviewed the orders, the nurse acknowledged the wrong aspirin and wrong multivitamin selections for Resident #56 and the wrong aspirin strength for Resident #16. The DON stated the nurse should have clarified the order to ensure what was poured matched what the physician ordered.
Significant Medication Errors Involving Insulin and an Unprescribed Drug
Penalty
Summary
The facility failed to ensure residents received medications as prescribed and within the required time frame, resulting in significant medication errors involving insulin and an unprescribed medication. For one resident with diabetes mellitus and intact cognition, the record showed an incident in which the resident reported receiving 24 units of Novolog instead of the ordered 24 units of Novolin N plus a sliding-scale dose of Novolog at bedtime. The resident stated they became dizzy, could not see straight, checked their own blood glucose, drank orange juice, and received glucose gel before feeling better. The chart also contained a nurse's note stating that the nurse gave Novolog instead of Novolin, and an incident report documented that the resident received the wrong insulin and wrong dose. Record review for that same resident showed multiple insulin administrations outside the facility's stated one-hour window, including both Novolog and Novolin N given late on several occasions in July 2025. The MAR also showed that on one date there was no documentation that the ordered Novolin N and Novolog were administered at 9 PM, and no blood sugar documentation was present for that time. Facility interviews confirmed that insulin is a high-risk medication, that Novolin N and Novolog are not interchangeable, and that medications should be administered according to the prescriber's orders and the five rights of medication administration. For another resident with type 2 DM and orthopedic aftercare following surgical amputation, the audit report showed repeated late administration of ordered insulin products, including insulin lispro, insulin glargine, and Humalog, with several doses given well beyond the scheduled time. Facility staff stated that scheduled medications should be given within one hour before or after the scheduled time and that insulin given two hours late should not have been administered and the physician should have been notified. A third resident reported receiving Baclofen that was not prescribed; the record contained a nurse's note stating that Baclofen was administered even though no order existed for that resident, and an LPN/UM confirmed that an agency nurse gave 20 mg of Baclofen without a physician's order.
Medication Disposal and Storage Lapses During Passes
Penalty
Summary
Medication disposal and storage practices were not followed during three separate medication pass observations involving three LPNs. During one observation, an LPN poured aspirin 81 mg and a multivitamin for Resident #56, then discarded the unused medications in the trash attached to the medication cart. When questioned, the nurse stated the medications were over-the-counter and could be thrown away, then retrieved them from the trash with a gloved hand and placed them in the drug disposal solution on the cart. During another observation, an LPN poured five medications and liquid protein for Resident #16, then left the liquid protein bulk bottle on top of the medication cart while she locked the cart and walked into the resident’s room. During a third observation, an LPN prepared nine medications for Resident #63 and left acetaminophen 500 mg and saccharomyces boulardi capsules on top of the medication cart before attempting to enter the resident’s room. The survey team met with facility administration later that day, and the DON stated medications must always be secured and should not be left on top of a medication cart. The LNH administrator agreed with that statement. Review of the facility’s Medication Storage policy showed that all drugs and biologicals are to be stored in locked compartments, and during medication pass they must be under the direct observation of the person administering them or locked in the medication storage area or cart.
Deficient Incontinence Care Due to Use of Double Briefs
Penalty
Summary
Surveyors identified a deficiency in incontinence care during rounds on one of two nursing units, where two residents who were dependent on staff for activities of daily living were found to be wearing double incontinence briefs. In both cases, a staff member exposed the front of the resident's brief, which was wet, and upon further inspection, a second, also wet, incontinence brief was discovered layered underneath. The staff member present acknowledged that applying two briefs was not appropriate. Both residents had significant medical histories, including congestive heart failure, type 2 diabetes mellitus, and acute respiratory failure, and were assessed as always or frequently incontinent and dependent on staff for toileting hygiene. The medical records and individualized care plans for these residents documented their incontinence and dependence on staff, but one care plan did not include specific interventions for incontinence. The facility's policy on incontinence care required appropriate treatment to prevent infections and restore continence to the extent possible. The surveyor confirmed with facility staff and policy that the use of double briefs was not acceptable practice, and the deficiency was cited based on these observations and record reviews.
Unclean resident room wall and shower area
Penalty
Summary
The facility failed to maintain a homelike environment that was clean, safe, and sanitary on the 1st floor. On 07/17/2025 at 9:19 AM, the surveyor observed light brown splattered debris on the wall near a resident's bed in room [ROOM NUMBER] A. The report also states that the facility's housekeeping and maintenance services were expected to maintain a sanitary, orderly, and comfortable environment under the facility policy titled, Safe and Homelike Environment, dated 09/01/2024. On 07/17/2025 at 9:30 AM, the surveyor inspected the 1st floor shower room and observed a shower chair inside the shower stall with a hospital gown, towel, and wet blanket placed on top of the chair, along with loose particles of trash visible inside the drain. During interviews on 07/22/2025, the Housekeeping Director stated that resident rooms and shower areas are cleaned daily, with additional cleaning as needed when unsanitary conditions are reported, and that spills are discouraged in resident rooms to support infection control and a homelike environment. The Interim DON stated that splattered debris should never be present on residents' walls, and the LNHA stated that shower areas are expected to be thoroughly cleaned and sanitized after each use.
Incomplete Investigation of Medication Errors
Penalty
Summary
The facility failed to maintain documentation and conduct a complete and thorough investigation for medication errors involving two residents. One resident with diabetes mellitus, intact cognition, and orders for Novolin N at bedtime plus Novolog sliding-scale insulin before meals and at bedtime had a medication error on 8/9/2024. The MAR did not document administration of Novolin N or Novolog at 9:00 PM, and there was no blood sugar documentation at that time. A nurse note stated the primary nurse gave Novolog instead of Novolin, that the resident was monitored, and that the nurse practitioner was notified. The incident report for this insulin error was incomplete. It did not identify the medication administered, the time it was given, the dose administered, or the nurse who gave it, and there were no written statements obtained. The nurse practitioner later documented that over the weekend a nurse accidentally gave more short-acting insulin units, glucose and orange juice were given, and the event was uneventful, but the surveyor could not locate a progress note from the LPN who administered the incorrect medication and dose. The Regional DON confirmed the incident report lacked pertinent details and that a thorough investigation should have been conducted. A second resident with DM, hemiplegia, and hemiparesis, and intact cognition, reported receiving Baclofen that was not prescribed. The resident’s record did not contain an order for Baclofen. A nurse note documented that Baclofen was administered even though it was not ordered for the resident, and the incident report identified a wrong-resident medication error involving Baclofen 20 mg. The facility did not provide a progress note or written statement from the nurse who administered the medication, and did not provide a written statement from the resident. The IDON confirmed that a complete investigation should include nursing and resident statements, a summary and conclusion, and QAPI involvement, and acknowledged that the resident statement was not obtained and QAPI was not initiated for this event.
Failure to Follow Hold Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to follow the hold parameters for administration of Droxidopa for one resident with end stage renal disease and hypotension. The resident was admitted with diagnoses including end stage renal disease and hypotension, had a BIMS score of 13 out of 15 indicating intact cognition, and received dialysis treatments three times a week. The care plan included giving medications according to physician orders and monitoring for elevated blood pressure. The physician ordered Droxidopa 200 mg by mouth three times daily on specified days, with instructions to hold the medication for systolic blood pressure greater than 140. Review of the MAR showed the resident received Droxidopa on multiple occasions when the systolic blood pressure was above 140 and the medication should not have been administered. These administrations occurred across the May, June, and July 2025 MARs at scheduled times including morning, midday, and evening doses. During interview, the LPN/UM reviewed the MARs with the surveyor and confirmed the nurses were not following the physician's hold order parameters for Droxidopa on multiple dates. The pharmacy consultant stated that giving Droxidopa beyond the SBP parameter of 140 could cause elevated blood pressure, and the regional nurse stated that not following medication parameters as ordered by the physician would be considered a medication error.
RN Coverage Not Maintained for Required Daily Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 1 of 6 days reviewed during the period of 02/02/2025 to 02/08/2025. Review of the Nurse Staffing Reports for the week of 02/02/2025 through 02/08/2025 showed that the facility had no RN coverage for all shifts on 02/08/2025. During an interview on 07/21/2025 at 12:04 PM, the Licensed Nursing Home Administrator reviewed the staffing reports and confirmed that there was not a registered nurse in the building for 8 consecutive hours on 02/08/2025. A facility policy titled Nursing Services and Sufficient Staff, implemented 9/1/14, stated that the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, based on resident assessments, individual plans of care, census, acuity, diagnoses, and the facility assessment.
Improper Storage and Labeling of Food in Resident Refrigerators
Penalty
Summary
The facility failed to ensure that food brought to residents by family and other visitors was stored, handled, and consumed in a safe and sanitary manner for 2 residents with personal refrigerators in their bedrooms. On 07/16/2025, the surveyor observed Resident #20’s personal refrigerator in bedroom [ROOM NUMBER]B with missing temperature log entries for the 4th, 5th, 6th, 8th, and 11th of the month, no documentation of the current month, year, or refrigerator location, and no thermometer inside the refrigerator. The refrigerator contained an open 28-ounce black container of ham, an open 4-ounce container of orange juice, a 5-ounce lidded container with an unidentified white food product, and an open 5-gram container of whipped butter spread, and none of the items were labeled with open dates or use-by dates. On 07/17/2025, the surveyor observed Resident #1’s personal refrigerator in bedroom [ROOM NUMBER]A with the same missing temperature log entries for the 4th, 5th, 6th, 8th, and 11th of the month, no documentation of the current month, year, or refrigerator location, and ice buildup and black debris inside the ice box. Later that same day, Resident #20’s refrigerator was again observed with the same missing log entries, no thermometer, and the same unlabeled food items. During interviews on 07/22/2025, the Housekeeping Director stated staff perform daily checks of residents’ personal refrigerators and thermometers, that temperature logs must be fully completed with no blanks, and that unlabeled opened food items are discarded. The Licensed Nursing Home Administrator stated housekeeping staff are responsible for keeping refrigerator temperatures within a safe range and ensuring food is properly labeled and dated, with expired, unlabeled, or spoiled items discarded immediately.
Improper Handling of Trash, Soiled Linen, and Laundry PPE
Penalty
Summary
The facility failed to handle trash and soiled linen appropriately during room cleaning for two housekeeping staff. During the initial tour, a cleaning cart was observed outside two residents’ room with tied plastic bags containing trash and soiled linen placed on the floor, along with a blue disposable glove on the floor. Inside the room near the doorway, two more untied plastic bags with trash and another blue disposable glove were also observed on the floor. No cautionary sign was noted inside or outside the room, and a housekeeper was cleaning the room. In a separate observation, a plastic bag containing trash was seen on the floor by the doorway outside another resident’s room while a housekeeper was cleaning that room. The facility also failed to follow appropriate hand hygiene and PPE practices for one housekeeping staff member while handling soiled laundry. In the laundry area, the staff member was observed putting on a yellow washable gown without tying it at the back, loading soiled laundry into the washing machine from the soiled linen cart with ungloved hands, and then washing hands for 5 seconds. The staff member stated they had used gloves, but the surveyor observed bare-hand contact with soiled laundry. The Infection Preventionist stated the staff member should have worn gloves when touching dirty laundry and should have washed hands for 20 seconds. The facility policy titled Laundry, implemented 9/1/2024, did not specify the PPE to be used when handling soiled laundry or how housekeeping staff would wash their hands when handling soiled laundry.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for at least eight consecutive hours on one of the days reviewed. Specifically, review of the facility's Nurse Staffing Reports showed that there was no RN coverage for any shift on a particular day. During interviews, facility staff confirmed that an RN was scheduled but called out, and although the agency was contacted to provide a replacement, a Licensed Practical Nurse (LPN) was sent instead. The error was not identified until the next shift, resulting in a full day without RN coverage. The facility's policy requires sufficient staffing, including RNs, to provide nursing care in accordance with resident care plans. However, on the day in question, the absence of an RN meant that there was no RN available to assist with assessments and overall care of the residents, as confirmed by staff interviews. The deficiency was identified through document review and staff interviews, with staff acknowledging the oversight and the failure to ensure RN coverage as required by federal regulations.
Plan Of Correction
1. The facility failed to ensure there was a Registered Nurse working for at least 8 consecutive hours on 1 of 21 days reviewed. 2. All residents have the potential to be affected by this practice. 3. The Facility continues to actively fill all open Registered Nurse positions to comply with Federal Nursing Regulation to have 8 consecutive hours a day, 7 days a week. Staff requirements and facility policy were reviewed with Human Resources and the Staffing Coordinator, who were able to reiterate minimum staffing requirements. The facility will take the following measures to ensure this deficient practice does not occur. The facility will focus on recruitment and retention strategies as follows: identify vacant Registered Nurse positions daily and attempt to fill positions with current Registered Nurses staff or agency; work diligently with the Administrator, Director of Nursing, and Corporate Recruiter to advertise, recruit, and hire sufficient Registered Nurse staff. 4. The Staffing Coordinator will review schedules daily to ensure that at least 8 RN hours are scheduled and will review with the Director of Nursing. The Administrator or designee will audit the schedules weekly for 4 weeks and monthly for 2 months to ensure there is an RN scheduled for 8 consecutive hours 7 days a week. Results and audits will be reviewed at the monthly Quality Assurance Meeting for 3 consecutive meetings. Based upon the results of these audits, a decision will be made regarding the need to continue submission and reporting.
Incomplete Medical Record for Controlled Drug Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of four sampled residents. Specifically, the surveyor requested the complete Controlled Drug Administration Record (CDAR)/Declining Sheet for a resident's medication, but the facility was unable to provide the entire documentation. The only available record was a single sheet with a specific date issued, and despite further requests and searches by the Director of Nursing, the full CDAR/Declining Sheet could not be located. An email response confirmed that the document was still missing at the time of the survey. This deficiency was identified through observations, interviews, and review of medical records and facility documentation. The resident involved had multiple diagnoses and was receiving medication as ordered, but the lack of a complete CDAR/Declining Sheet meant that the facility did not have a full record of the administration of a controlled drug as required by federal and state regulations.
Plan Of Correction
1. Resident #2 was discharged from the facility. 2. All residents who have orders for medications that require a Controlled Drug Administration Record/Declining Sheet have the ability to be affected by this practice. 3. The Medical Record staff was re-educated on the procedure for maintaining accurate, complete, readily accessible, and systematically organized records by the Director of Nursing or designee. The Drug Administration Record Declining sheet will be reviewed for accuracy and placed in residents' charts. 4. The Director of Nursing/Designee will audit the Controlled Drug Administration Record/Declining Sheet on each cart weekly x 4 and monthly x 2. The results of the audit will be reviewed at the Monthly Quality Assurance Meeting for three months. Continuation of the audits, reporting, and frequency after three months will be determined by the QA Committee.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during multiple day shifts over several weeks. According to the report, for the week of 06/23/2024 to 06/29/2024, the facility did not provide the minimum required number of CNAs on 5 out of 7 day shifts, with staffing levels ranging from 7 to 11 CNAs for 94 residents, when at least 12 were required. Additionally, for the two weeks prior to the survey (04/20/2025 to 05/03/2025), the facility was deficient in CNA staffing on 13 out of 14 day shifts, with CNA numbers consistently below the required minimum for the number of residents present. These deficiencies were identified through interviews and review of facility documents, and the lack of adequate CNA staffing had the potential to affect all residents in the facility. The report does not mention any specific residents or their medical histories, nor does it describe any direct harm or incidents resulting from the staffing shortages. The findings are based solely on the facility's failure to comply with the mandated CNA-to-resident ratios during the reviewed periods.
Plan Of Correction
1. The facility failed to ensure staffing ratios were met to maintain the required minimum staff to resident as mandated by the state of New Jersey. 2. All residents have the potential to be affected by this deficient practice. 3. The facility continues to actively fill all opened CNA (Certified Nursing Assistant) shifts to comply with New Jersey State mandated ratios. Minimum staffing requirements were reviewed with the Staffing Coordinator who was able to reiterate minimum staffing requirements for nursing homes. The facility Labor Management Team is focusing on recruitment and retention strategies by identifying vacant positions and attempting to fill positions with current CNA staff or agency. The Labor Management Team collaborates with the Corporate Recruiter to advertise, recruit, and hire sufficient CNA staff. The Labor Management Team continues to develop programs to attract and retain Certified Nursing Assistants. Examples of which include shift bonuses and collaborating with CNA schools to offer facility paid schooling. Partner with local CNA class instructors to identify potential students. In addition, the facility Labor Management Team promotes in-house programs to increase retention of current staff. 4. The facility Labor Management Team meets weekly to review the effectiveness of recruitment and retention programs and open labor positions. The findings from these meetings will be reviewed monthly for three months by the Quality Assurance Committee. Based upon the results of the findings, the Quality Assurance Committee will determine whether ongoing submission and reporting is needed.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications in accordance with the acceptable standard of nursing practice and its own policy on administering medications for two residents. Resident #1, who was admitted with diagnoses including hypertension and pain, had medication orders for Clonidine and Gabapentin to be administered at specific times. However, the Medication Administration Audit Report revealed that these medications were consistently administered late, with no documentation indicating that the resident's primary care physician was notified of these deviations. Despite the late administration, there was no documented evidence of harm to the resident. Similarly, Resident #2, admitted with hypertension and dermatitis, had medication orders for Cozaar and Hydroxyzine to be administered at specific times. The Medication Administration Audit Report showed that these medications were also administered late on multiple occasions. Again, there was no indication in the progress notes that the resident's primary care physician was informed of the late administration, and no documented evidence of harm was noted. Interviews with nursing staff, including a registered nurse and a unit manager, confirmed that medications were expected to be administered within one hour of the scheduled time. They also stated that if medications were not administered on time, the physician should be notified, and the incident documented in the medical records. The facility's policy on medication administration, dated October 2022, supports these expectations, emphasizing the importance of timely administration and proper documentation.
Failure to Document ADL Care for Residents
Penalty
Summary
The facility staff failed to consistently document the Activities of Daily Living (ADL) status and care provided to two residents, as per the facility's policy and protocol. For one resident, who was admitted with muscle weakness and required assistance with ADLs, the documentation survey report (DSR) did not indicate that necessary interventions such as rolling, turning, repositioning, and toileting were provided during specific shifts over several days in April 2024. This resident had intact cognition and required assistance due to impaired balance and musculoskeletal impairment, as noted in their care plan. Another resident, admitted with Parkinsonism, Alzheimer's Disease, and Dementia, required total assistance with ADLs due to severe cognitive impairment. The DSR for this resident also lacked documentation of bed mobility, turning, repositioning, and toileting care provided during various shifts in May and June 2024. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Unit Manager/Registered Nurse (UM/RN), revealed that CNAs were responsible for documenting ADL care in the Point of Care (POC) system by the end of each shift, even if care was refused. The facility's policy emphasized the importance of documenting all services provided to residents to facilitate communication among the interdisciplinary team.
Failure to Include Required Information on NOMNC Forms
Penalty
Summary
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) included the required information of the name of the Quality Improvement Organization (QIO) and the TTY (teletypewriters) number for three residents. This omission was identified during a review of the NOMNC forms for three residents, who were either discharged or remained in the facility for long-term care. Specifically, the NOMNC for Resident 23, who was admitted for therapy and discharged home, did not contain the name of the QIO or the TTY number. Similarly, the NOMNCs for Residents 188 and 189, who remained in the facility for long-term care, also lacked this required information. The NOMNC for Resident 188 was issued by phone to the resident's daughter, who handled all business matters, but still did not include the necessary details for filing an expedited appeal. The NOMNC for Resident 189 was issued without the QIO name or TTY number as well. During an interview, the Director of Social Services (DSS) stated she was unaware that the name of the QIO and the TTY number had to be included on the NOMNC. A review of the facility's policy, dated 2022, confirmed that the NOMNC should inform beneficiaries of their right to an expedited review by a QIO. This failure to include the required information could prevent Medicare beneficiaries with hearing impairments from being able to file an appeal in a timely manner.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by incidents involving four residents. One incident involved a resident with severe cognitive impairment who entered another resident's room and hit her with a fly swatter. The resident who was hit did not sustain any injuries and did not believe the other resident intended to harm her. The staff had attempted a gradual dose reduction of the aggressive resident's psychotropic medication, which led to increased behaviors, and the medication was subsequently resumed at the original dose. Despite the use of a wander guard and staff supervision, the incident occurred, and there were no further incidents reported with this resident. Another incident involved a resident who was cognitively intact and was kicked in the leg by another resident who mistakenly entered her room. The cognitively impaired resident believed he was in his own room and became adamant about staying. The cognitively intact resident attempted to push the other resident out of her room, leading to the altercation. The facility's investigation noted a small purpuric area on the resident's leg as a result of the kick. The cognitively impaired resident was placed on half-hour behavior checks following the incident. Interviews with staff revealed that the facility conducted abuse training annually and in-services throughout the year. Staff were expected to report any concerns to the DON and ensure resident safety. The DON and Regional Administrator both emphasized the expectation for residents to be safe and have an abuse-free environment. The facility's policy on abuse, neglect, exploitation, or misappropriation required all reports of abuse to be thoroughly investigated and documented, with findings reported to relevant agencies.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report resident-to-resident incidents and injuries of unknown origin in a timely manner to the state survey agency for three of six incidents reviewed. In one instance, a resident reported being hit by another resident with a fly swatter, but the incident was not reported to the New Jersey Department of Health (NJDOH) until the following day. In another case, a resident was found with a bruise on her wrist, which was reported to the Director of Nursing (DON) and the former Administrator, but the incident was not reported to NJDOH until three days later. Additionally, a resident was found with multiple bruises and an abrasion, but this incident was not reported to NJDOH at all. Interviews with staff revealed a lack of awareness regarding the requirement to report abuse within two hours if it involves serious bodily injury, or within 24 hours if it does not. The facility's policy on reporting abuse, neglect, exploitation, or misappropriation of resident property was not followed, as incidents were either reported late or not reported at all. The DON admitted to being unaware of the specific reporting timeframes, and the Regional Administrator confirmed that all incidents should be reported within the required two hours. The facility's failure to adhere to these reporting requirements resulted in deficiencies in their handling of abuse and injury incidents.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of an unknown origin for a resident. On one occasion, a resident was found with a bruise on the left wrist, and although the incident was reported to the Director of Nursing (DON) and the former Administrator, no skin audit or resident interviews were conducted. Additionally, the facility did not review camera footage or complete additional body audits. On another occasion, the same resident was found with a bruised finger, a small bruise near the right elbow, and an abrasion on the right elbow. Despite reporting the incident to the DON, no investigation was conducted to determine the cause of the injuries. The facility's policy requires thorough investigations of all reports of resident abuse, including injuries of unknown origin. This includes reviewing documentation, interviewing staff and residents, and observing the alleged victim. However, the facility did not follow these procedures in the cases mentioned. The DON admitted that they were still learning their new electronic medical record (EMR) system and were unsure where to document the incidents. The Regional Administrator also stated that he expected all incidents to be thoroughly investigated, which was not done in these cases.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility staff failed to complete a baseline care plan within 48 hours of admission for one resident. The resident, who was admitted with diagnoses of diabetes mellitus, spinal stenosis, and quadriplegia, was moderately cognitively impaired with a BIMS score of 12 out of 15. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission, the care plan for this resident was not completed until 14 days after admission. Both the Director of Nursing and a registered nurse confirmed the delay during interviews. The facility's policy, dated 10/02/23, mandates the development of a baseline care plan within 48 hours of a resident's admission.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide showers twice a week as scheduled for two residents, R21 and R51, who were dependent on staff assistance for activities of daily living (ADLs). R21, who was admitted with diagnoses including end-stage renal disease, COPD, hemiplegia, and diabetes mellitus, did not receive scheduled showers on multiple occasions in January and February 2024. Despite being cognitively intact and expressing a preference for showers over bed baths, R21 reported not receiving her scheduled showers due to staff shortages. This was confirmed by the facility's documentation and staff interviews. Similarly, R51, who was admitted with diagnoses of cerebral infarction and hemiplegia, also did not receive scheduled showers on several occasions. R51, who was also cognitively intact, expressed a preference for showers and reported inconsistencies in receiving them as scheduled. The facility's documentation and staff interviews corroborated these claims, indicating that staff shortages were a contributing factor. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) responsible for R21 and R51 confirmed that the residents were scheduled for showers on Mondays and Thursdays but did not always receive them due to staffing issues. The Director of Nursing (DON) acknowledged the problem and stated that residents were supposed to receive bed baths if showers could not be provided. However, the documentation showed that the scheduled showers were not consistently provided, leading to the deficiency.
Medication Administration Errors
Penalty
Summary
The facility staff failed to ensure the medication error rate was below five percent, as evidenced by two observed incidents involving residents R22 and R6. For R22, who has diagnoses including diabetes mellitus, bipolar disease, and schizophrenia, the physician ordered two 500 mg tablets of acetaminophen to be administered in the morning for pain. However, during a medication administration observation, LPN7 was seen administering only one tablet. LPN7 later confirmed the error, acknowledging that she might have given only one tablet despite the order for two. The Director of Nursing (DON) confirmed that all medications should be given as ordered by the physician. In the case of R6, who has diagnoses of hypertension and congestive heart failure, the physician ordered 25 mg of spironolactone to be administered in the morning for edema, with no parameters to hold the medication based on blood pressure readings. During a medication administration observation, RN5 held the medication, citing a low blood pressure reading of 91/53, despite the absence of any such directive in the physician's orders. The DON confirmed that the nurse should have contacted the physician if they felt the blood pressure was too low to administer the medication. RN6 also confirmed that there were no parameters for holding the spironolactone for R6.
Failure to Maintain and Retrieve Resident Medical Records
Penalty
Summary
The facility failed to ensure medical records were readily accessible for one resident (R137) out of a sample of 25. R137 was admitted with diagnoses including hypertension, diabetes, and dementia. Upon review, the facility's current electronic medical record (EMR) system did not contain any information for R137. The Director of Nursing (DON) confirmed that R137's records were not accessible because the facility was previously owned by a different company that used a different EMR system. Despite multiple requests and attempts to retrieve the records, the facility was unable to provide the necessary medical information for R137 in a timely manner. The survey team made several requests for specific medical records, including physician's orders, treatment records, medication administration records, progress notes, and wound care documentation. The facility's Registered Nurse Consultant (RNC) and Administrator made efforts to contact the previous owner and IT department to gain access to the records. However, these efforts were unsuccessful, and the survey team was not provided with the requested information within the expected timeframe. The facility eventually provided a computer tablet containing over 1800 pages of R137's medical record in a portable document format (pdf), but key documents such as wound treatment records and care plans were still missing. Interviews with the facility's staff and a family member of R137 revealed that the resident had a wound care appointment where maggots were found in the foot wound. The family member had a copy of the wound care report, but the facility did not have this report in R137's medical records. The facility's inability to access and provide complete medical records for R137, including critical wound care documentation, highlights a significant deficiency in maintaining and retrieving resident medical records as required by state and federal law.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff members. One hospitality aide entered a COVID-19 positive resident's room wearing a surgical mask instead of the required N-95 mask and eye protection. The aide was unaware of the need for these specific PPE items. Additionally, a certified nursing assistant doffed his gown outside of a resident's room who was on strict contact precautions for Methicillin Susceptible Staphylococcus Aureus (MSSA) in a wound, instead of inside the room as required. The CNA admitted to rushing and not following proper protocol. Furthermore, a licensed practical nurse cleaned a glucometer without wearing gloves after administering insulin to a resident with diabetes mellitus. The nurse stated that he had not considered the need to wear gloves during the cleaning process. The Director of Nursing confirmed that the expectation was for staff to use gloves when cleaning medical equipment. These lapses in protocol could lead to exposure to COVID-19 and bloodborne pathogens among residents and staff.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 357 citations issued within 25 miles in the last 12 months — including the 11 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ocean Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coral Harbor Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 2 | 0 |
| King Manor Care And Rehabilitation Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Jersey Shore Post Acute Rehabilitation And Nursing | 1.7 mi | ★★★★★ | 0 | 0 |
| Imperial Care Center | 3.1 mi | ★★★★★ | 17 | 0 |
| Tower Lodge Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.