Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coral Harbor Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with significant mobility limitations fell and reported pain, but only an LPN assessed the resident; there was no RN assessment or documented ROM comparison, and the resident was later found to have an acute right hip fracture. Another resident with sepsis-related diagnoses had a sudden decline with shaking, altered responsiveness, and abnormal vital signs, but the LPN delayed escalation and recheck of vitals before calling 911, and the resident was later admitted to the hospital for sepsis.
The facility failed to fully implement its antibiotic stewardship program by not consistently documenting McGeer's criteria or tracking all antibiotic starts. Review of multiple residents treated for UTIs, respiratory infections, cellulitis, wound infection, and sepsis protocol showed missing surveillance documentation, and one resident's McGeer's form was completed only after surveyor inquiry. The DON stated that residents had to be qualified for antibiotics and that McGeer's criteria should be started before antibiotics were given.
A facility failed to provide respiratory care for two residents. One resident receiving O2 via NC had an undated humidification bottle and an NC that was exposed to air, not in a protective bag, and not dated; staff confirmed the bottle and tubing should have been dated and stored properly. Another resident had an oxygen mask and tubing left on the bed, exposed to air, not in a protective bag, and not dated, and the EMR contained no physician order for supplemental oxygen even though the resident reported using oxygen at bedtime and staff confirmed the missing order.
A resident with dependence on dialysis, CKD anemia, and ESRD had repeated missed doses of Clonidine and Sevelamer because medication times were not adjusted around the dialysis schedule. The MAR showed doses not given when the resident was at dialysis or when pharmacy delivery was pending, and there was no documented physician notification for the missed doses. RN, DON, and CP interviews confirmed that missed meds should be communicated to the physician and that dialysis schedules should be considered when timing medications.
A resident with diabetes and a BIMS score of 13/15 had an order for insulin lispro at 8:30 AM and 4:30 PM, but the medication audit showed the morning insulin was repeatedly given well after the ordered time, sometimes by several hours. The facility policy required medications to be administered within one hour of the prescribed time unless otherwise specified, and the DON acknowledged that one specific nurse was giving medications late.
A significant change MDS was not completed for a resident when the hospice provider changed from one agency to another. The resident had inclusion body myositis, HTN, chronic pain syndrome, moderate cognitive impairment, and was receiving hospice services for a terminal prognosis. The EMR did not show a significant change MDS for the hospice change, and the RMDSC confirmed that a significant change assessment is supposed to be done when hospice companies change.
A resident on contact precautions for MRSA had a care plan that listed the diagnosis but did not include the required TBP or the specific contact precautions being used, despite signage and PPE outside the room and staff confirming the precautions. Another resident was observed wearing an abdominal binder and a heel relief shoe, but the care plan did not include these devices and there were no physician orders documented for either item, even though the resident had gait problems and an unhealed heel pressure injury.
A resident was admitted with a peripheral IV, but the chart lacked a physician order for IV care and the care plan did not address the IV access. Another resident was observed using a heel relief shoe and an abdominal binder, but the record had no physician orders for either device and the care plan was not updated to include them. Staff interviews confirmed that orders and care plan documentation were expected for these items.
Unlabeled and undated medications and biologicals were found on a medication cart, including Hydrocortisone cream, Sodium Chloride 5% eye ointment, Cyclosporine eye droppers, Refresh eye drops, and an opened bottle of Magnesium Citrate. An LPN present during the observation acknowledged the items were unlabeled and undated and said they should have labels. Pharmacy cart audits also noted that drugs were not properly labeled.
A resident receiving hospice services had no hospice communication record or CNA care plan available in the chart or on the unit. The resident was observed in bed, reported being paralyzed and needing the hospice aide, and the record showed hospice consent, hospice orders, and an ICCP focus on terminal prognosis, but the ADON could not locate hospice documentation and was unsure the aide was care planned. The hospice care plan was only obtained later by fax after surveyor inquiry.
An RN performed wound care for a resident with a stage 4 pressure ulcer without consistent hand hygiene or glove changes, while also handling clean and soiled materials in the same treatment. The facility also failed to post EBP signage or keep PPE available for a resident with a wound and IV antibiotics. In addition, an LPN used the same automated BP cuff on two residents without cleaning it between uses and did not perform hand hygiene after resident contact before preparing medications.
Surveyors found multiple deficiencies including soiled floors, clogged shower drains, soiled side rail padding, debris in bathtubs, peeling furniture surfaces, loose handrails, and missing end cap brackets on door push bars. Neither the Director of Environmental Services nor the Maintenance Director was aware of these issues, despite their responsibility for daily rounds and environmental oversight.
A facility failed to investigate a verbal abuse allegation reported by a resident and their representative. The emails containing the allegations were found in the Social Worker's spam/junk folder and were not addressed until a surveyor's inquiry. The resident, who was cognitively intact and had a history of COPD and chronic pain, reported the abuse, but the facility did not adhere to its policy of prompt investigation.
A facility failed to maintain a homelike environment by not repairing a resident's bathroom door, which was deformed and allowed visibility into the bathroom. The Director of Maintenance was aware of the issue but had not developed a plan to address it, despite having a system for reporting maintenance issues. The Licensed Nursing Home Administrator confirmed that staff were trained to use the repair order system.
A facility failed to report an abuse allegation within the required timeframe to the NJDOH. A resident, who was cognitively intact and had a history of COPD, reported verbal abuse via email, which was found in the Social Worker's spam folder. The LNHA admitted the delay in reporting the abuse allegation, which was only addressed after surveyor inquiry.
The facility failed to document the personal preferences of three residents with urinary and bowel incontinence in their care plans. One resident preferred a towel in their brief, another requested double briefs, and a third wanted double briefs and a towel at night. These preferences were not reflected in their care plans, despite being known to staff. The facility's policy requires comprehensive, person-centered care plans, which was not followed in these instances.
A facility failed to obtain a physician's order for a substitute nutritional supplement due to a shortage, leading to incorrect documentation of supplement administration. Additionally, there was inconsistent documentation of a resident's peritoneal dialysis site care, lacking proper physician orders for dressing changes. Furthermore, a resident did not receive a scheduled IV antibiotic dose due to unavailability, with no communication to the physician or pharmacy to address the issue.
A resident with severe cognitive impairment and a stage 3 pressure ulcer did not have documented wound care on two consecutive days, as required by physician's orders. The absence of signatures on the Treatment Administration Record (TAR) indicated that the care was not documented as completed, which was confirmed by interviews with nursing staff. This failure to document care is a deviation from the facility's Wound Care policy and professional standards.
A facility failed to consistently complete dialysis communication forms for a resident with end-stage renal disease, impacting communication between the facility and the dialysis center. The resident required dialysis on specific days, and the facility's protocol included monitoring and documenting the resident's condition before and after dialysis. However, several forms were not completed by the facility's nurse, and one form was not completed by the dialysis center, as confirmed by interviews with staff, including an LPN and the DON.
The facility failed to maintain a sanitary environment in the medication room, with debris and discoloration observed in various areas. Despite having an electronic system for reporting maintenance and cleaning issues, no service tickets were submitted for the observed problems. Interviews with staff revealed that the cleaning schedule and procedures were not followed, resulting in unsanitary conditions.
A resident with multiple medical conditions and a high risk for malnutrition was admitted without a physician's diet order being entered into the EMR. Although the kitchen provided a double meat diet based on a diet slip, this was not supported by a formal physician's order, as confirmed by the RD, LPN, ADON, DON, and LNHA. Facility policy required a physician's order for diet at admission, but this step was missed, resulting in a deficiency.
Delayed Assessment After Fall and Acute Change in Condition
Penalty
Summary
The facility failed to ensure timely nursing assessment and treatment after a resident with a history that included fracture of the right femur, quadriplegia, and cognitive intactness had an unwitnessed fall. The resident reported pain after the fall, including pain in the right knee and hamstring area, and stated that only one nurse checked on them afterward. The record showed that an LPN responded to the fall, checked vital signs, assessed skin and pain, gave acetaminophen 650 mg, initiated neuro checks, and notified the physician, but there was no documentation that an RN assessed the resident or that range of motion was assessed and compared to baseline. The resident’s care plan called for fall mats at the bedside and transfers with assistance from 2 staff members, and the facility’s fall protocol required assessment of vital signs, musculoskeletal function, neurological status, pain, and other factors. The resident was later transferred to the hospital for an unrelated concern and was diagnosed with an acute impacted right hip fracture. The facility’s investigation concluded that the fracture was sustained from the fall and went undetected because of the resident’s comorbidities. Interviews with staff showed that the RN on duty was not called to assess the resident after the fall, and the DON stated that LPNs can assess residents who fall if no RN is in the building, but when RNs come in they could assess at that time. The record also showed that the resident had refused morning medications before the fall and had physician contact for decreased urine output, but the fall assessment documentation did not include an RN evaluation. The facility also failed to timely assess and treat another resident who had an acute change in condition. That resident had diagnoses including acute respiratory failure with hypoxia, heart failure, sepsis, ESBL resistance, difficulty walking, and an indwelling urinary catheter, and had care plan interventions for monitoring oxygen saturation and signs of UTI. An LPN documented finding the resident shaking very seriously, slightly unconscious, not responding to verbal commands, with BP 165/111, HR 111, RR 24, and inability to obtain oxygen saturation. The note stated that after one and a half hours the vitals were rechecked with another nurse, the physician could not be reached, and 911 was called. The resident was transported to the hospital and later documented as admitted for sepsis. Interviews with the LPN, LPN/UM, ADON, and DON confirmed that the resident should have been escalated immediately, that the delay in care was inappropriate, and that the resident’s presentation required immediate medical attention.
Failure to Monitor Antibiotic Use and Document Surveillance Criteria
Penalty
Summary
The facility failed to fully implement its antibiotic stewardship program, including ongoing monitoring and use of surveillance criteria when antibiotics were prescribed. During an interview, the Infection Preventionist stated that the facility used McGeer's and Loeb's criteria for each resident when an antibiotic was prescribed and that nursing should document signs and symptoms of infection so the system could determine whether the resident met criteria. However, review of the antibiotic log and medical records for 10 residents prescribed antibiotics from October 2025 through April 2026 showed that the required McGeer's criteria were not documented for multiple residents, and some antibiotic events were not entered on the tracking log at all. Specific examples included a resident started on amoxicillin-clavulanate for a UTI with no documented McGeer's criteria, another resident whose McGeer's form for cephalexin was completed only after surveyor inquiry, and several other residents treated for UTIs, respiratory infections, cellulitis, wound infection, or sepsis protocol with no documented evidence that McGeer's criteria had been completed. The DON stated that residents had to be qualified to receive antibiotics and that McGeer's criteria should be initiated before antibiotics were started. The facility's written antibiotic stewardship policy stated that all resident antibiotic regimens would be documented on the facility-approved antibiotic surveillance tracking form.
Respiratory Care Deficiencies: Missing Oxygen Order and Improper Storage/Dating of Equipment
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice for two residents. One resident was observed receiving oxygen via nasal cannula at 2 lpm from a concentrator, but the humidification bottle was not labeled or dated. The resident stated staff did not change the bottle and that the resident took care of it personally. The resident’s nasal cannula was also observed hanging off the wheelchair, connected to a portable oxygen tank, exposed to air, not in a protective bag, and not dated on multiple observations. That resident’s record showed diagnoses including COPD, acute respiratory failure with hypercapnia, and chronic respiratory failure with hypercapnia. The resident’s care plan included oxygen therapy interventions and orders for oxygen at 2 liters continuous via nasal cannula and for oxygen tubing to be changed and dated weekly, but the care plan did not include interventions for the humidification equipment. During interview, an LPN confirmed the humidification bottle was not dated and stated it should be dated, and also stated the nasal cannula should be dated and stored in a dated bag when not in use. The DON later stated the nasal cannula should have been dated and stored in a bag and the humidification bottle should have been changed and dated. A second resident was observed on multiple occasions with an oxygen mask and tubing lying on the bed, exposed to air, not in a protective bag, and not dated. The resident’s record showed diagnoses including sleep apnea and heart failure, and the MDS indicated the resident was on oxygen therapy. The care plan stated the resident used supplemental oxygen at bedtime and included interventions to add humidity as needed and keep respiratory equipment clean, but the Order Summary Report contained no physician’s order for supplemental oxygen. The resident stated oxygen had been used at bedtime as needed for about six months after an episode of shortness of breath and an emergency room visit. An LPN, an LPN/UM, and the DON each confirmed there was no oxygen order in the record and stated there should have been an order for oxygen and for the tubing to be changed weekly and as needed.
Missed Medications Not Adjusted Around Dialysis Schedule
Penalty
Summary
The facility failed to adjust a resident’s medication administration schedule to accommodate dialysis treatments for a resident with dependence on dialysis, anemia in chronic kidney disease, and end-stage kidney disease. The resident’s record showed orders for Clonidine HCl 0.3 mg every 8 hours for high blood pressure and Sevelamer carbonate 800 mg three times daily for high phosphate, along with a Monday/Wednesday/Friday dialysis schedule with a 10:00 AM chair time. The MAR showed multiple missed doses of Sevelamer and Clonidine because the resident was at dialysis or because the medication was pending delivery from the pharmacy. The record also showed no documented communication to the physician about the missed doses of Sevelamer and Clonidine. During interview, RN #1 stated that when residents missed medications, nurses had to reorder the medications, notify the physician, and document the missed doses in the EMR. The DON stated that residents who go out for dialysis should have separate medication orders for dialysis days and non-dialysis days, and that missed medications required physician notification. The CP stated that medication administration schedules should work around the dialysis schedule. The facility’s medication policy stated that medications are administered within one hour of the prescribed time unless otherwise specified.
Late Insulin Administration and Medication Timing Failure
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards and did not ensure a prescribed medication was administered within the required timeframe for one resident receiving insulin. Resident #15 had diagnoses including diabetes, low back pain, and an anxiety disorder. The resident’s MDS dated 3/3/26 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact, and the care plan included an intervention to give diabetes medication as ordered by the doctor. The physician’s order dated 3/13/26 directed insulin lispro injections two times a day at 8:30 AM and 4:30 PM, with blood sugar checks before meals and at bedtime. A review of the medication audit report for April and May 2026 showed repeated late administration of the resident’s 8:30 AM insulin dose, including times such as 10:10 AM, 11:30 AM, 12:20 PM, and 2:10 PM. The facility policy titled Administering Medications stated medications are to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified. During interview, the DON acknowledged the late medication administration and stated that one specific nurse was administering medications late.
Failure to Complete Significant Change Assessment When Hospice Provider Changed
Penalty
Summary
A significant change assessment was not completed for Resident #43 when the resident’s hospice provider changed from one hospice service provider to another. Resident #43 had diagnoses including inclusion body myositis, hypertension, and chronic pain syndrome, and the most recent MDS dated 3/31/26 showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The resident’s comprehensive care plan identified a terminal prognosis and included hospice services as an intervention, and the admission hospice documentation showed the resident had been admitted under one hospice provider on 3/24/26. Further record review showed that on 4/13/26 the physician ordered hospice to evaluate and treat using a different hospice provider, and the facility notification to admit to the new hospice provider was also dated 4/13/26. The surveyor reviewed the EMR MDS list and could not locate a significant change MDS when the hospice companies changed. During an interview on 5/7/2026, the Regional MDS Coordinator stated that a significant change MDS is supposed to be done when a resident changes hospice companies.
Care Plans Missing Contact Precautions and Assistive Device Details
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan for a resident who was on contact precautions for MRSA in the blood and receiving IV antibiotics. On observation, transmission-based precaution signage was posted on the resident’s door and a PPE cart was placed outside the room. The resident’s admission record listed bacteremia and COPD, and the Medication Administration Audit Report reflected a physician’s order for contact precautions every shift related to MRSA. However, the interdisciplinary comprehensive care plan documented the diagnosis of MRSA without including that the resident was on contact precautions or specifying the type of transmission-based precautions in use. During interviews, an LPN stated she was unsure whether the care plan should include contact precautions or TBP, while the ADON stated that care plans should be individualized and include resident-specific interventions, including transmission-based precautions when used. The Infection Preventionist stated that transmission-based precautions should be included in the resident’s plan of care and confirmed that the resident was on contact precautions, but the care plan did not reflect this. The DON later confirmed that the resident’s care plan had not been developed and updated to include contact precautions. The facility also failed to include a resident’s abdominal binder and heel relief shoe in the care plan and did not have physician orders documented for either device. The resident was observed wearing a partially secured abdominal binder and a black medical shoe on the right foot, later identified by the DOR as a heel relief shoe. The resident had difficulty walking, gait and mobility abnormalities, and an unhealed pressure ulcer with a care plan focus for a deep tissue injury to the right heel that included heel offloading and treatments. Staff interviews indicated that assistive devices should have been ordered, documented, and included in the care plan, and the DON stated that an order was needed for both the abdominal binder and heel relief shoe.
Missing Orders and Care Plan Updates for IV Access and Assistive Devices
Penalty
Summary
The facility failed to obtain a physician order for nursing care related to IV access for a resident admitted with a peripheral IV in the right antecubital area. The resident’s admission record and preadmission packet documented chronic kidney disease and symbolic dysfunctions, and the social services assessment showed a BIMS score of 10 out of 15, indicating moderately impaired cognition. The nurse’s note documented that the resident arrived to the unit via stretcher with a 20-gauge IV catheter to the right antecubital area, but the resident’s comprehensive care plan did not include IV access and the order summary report did not contain physician orders for IV care. During interviews, the admitting RN stated that when a resident is admitted from a hospital, the nurse takes report and checks the IV site and date, and the ADON confirmed that the resident had been sent with peripheral IV access and that the handwritten transfer information in the EMR noted a right antecubital 20-gauge catheter. The DON stated that if a resident is admitted with IV access, the doctor should be called for orders to remove the IV if it is not being used, and that this should occur during the admission assessment. No physician order for IV care was found in the record reviewed for the resident. The facility also failed to obtain physician orders and update the care plan for assistive devices used by another resident. That resident had difficulty walking, abnormal gait and mobility, and an unhealed pressure ulcer, with a BIMS score of 13 out of 15 indicating intact cognition. The resident was observed wearing a black medical shoe on the right foot and an abdominal binder, but the physician orders did not include either device and the comprehensive care plan did not address them. Staff interviews identified the shoe as a heel relief shoe and the binder as support while awaiting a back brace, and staff stated that orders and care plan updates should have been obtained for both devices.
Unlabeled and Undated Medications in Cart
Penalty
Summary
Medication storage and labeling were found deficient on medication cart #1 on the second floor when the surveyor, with LPN #1 present, observed multiple medications and biologicals that were unlabeled and undated. The items included one tube of Hydrocortisone cream 2.5% that was more than half used, Sodium Chloride 5% eye ointment tubes, two Cyclosporine 0.05% eye droppers with no resident names, three Refresh eye drop tubes, and one opened 10-ounce bottle of Magnesium Citrate with approximately one quarter remaining. During the observation, LPN #1 acknowledged that the items were unlabeled and undated and stated they should have labels. The surveyor also reviewed consultant pharmacy medication cart audits for the first and second floors dated 5/3/26, which were marked No for all drugs properly labeled, and reviewed the facility policy titled Medication Storage, which stated that all medications will be kept in their original containers and properly labeled and identified.
Missing Hospice CNA Care Plan and Communication Record
Penalty
Summary
The facility failed to maintain a Hospice Communication Record that included a CNA care plan for one resident receiving hospice services. Resident #43 was observed in bed, stated they did not get out of bed because they were paralyzed, and appeared well groomed and dressed in personal clothing. The resident said a hospice aide came to the facility to provide care. The resident’s record showed diagnoses including inclusion body myositis, hypertension, and chronic pain syndrome, and the most recent MDS dated 3/31/26 indicated a BIMS score of 12 and that the resident was receiving hospice services. During review of the paper chart, the surveyor found a hospice consent form and hospice physician orders, along with a communication sheet with a nursing recommendation dated 3/24/26, but could not locate a hospice care plan or other documentation related to hospice services. The resident’s ICCP included a focus area of terminal prognosis with an intervention for hospice services through the hospice agency, and the ADON stated the hospice CNA usually came four to five times per week but was not sure the aide was care planned. The resident stated it was hard to say how often the hospice CNA came and reported the hospice nurse said the agency was short staffed and trying to get help. The facility later received a copy of the hospice care plan by fax after surveyor inquiry, and the DON stated the hospice care plan should be available on the nursing unit.
Infection Control Failures During Wound Care, EBP Use, and Equipment Handling
Penalty
Summary
The facility failed to use appropriate infection control practices during care for a resident with a stage 4 pressure ulcer. During wound treatment, the RN and CNA performed hand hygiene and donned gown and gloves outside the room, but the treatment was carried out with multiple breaks in aseptic practice. The RN removed soiled gauze, left the room to retrieve supplies, returned without first performing hand hygiene, and handled clean supplies after touching contaminated materials. The RN also used the same gloves while cleaning and packing the wound, did not change gloves or perform hand hygiene between contaminated and clean tasks, and applied the dressing while the resident’s wound remained exposed on a washable linen beneath the resident. The resident’s record showed a stage 4 sacral pressure ulcer, and the facility’s wound treatment policy included steps for hand hygiene, glove changes, and clean technique during wound care. The facility also failed to implement Enhanced Barrier Precautions for a resident with a wound and IV antibiotic treatment. Surveyors observed no EBP signage on the resident’s door and no PPE readily available outside the room on multiple observations. The resident had diagnoses including a wound and was receiving IV ceftriaxone for osteomyelitis and topical wound care to the right heel. Staff interviews confirmed the resident required direct care, had a midline and wound, and that EBP should have included signage and PPE outside the room. The facility’s EBP policy stated that residents with wounds or indwelling medical devices who are not known to be infected or colonized with a targeted MDRO are to use targeted gown and glove use during high-contact care activities. The facility further failed to clean and disinfect reusable equipment and perform hand hygiene during medication pass. An LPN used an automated wrist blood pressure cuff on one resident, placed it on the medication cart without cleaning it, then accessed the EMR and prepared medications without first performing hand hygiene. The same cuff was then used on another resident without being cleaned or disinfected between uses. The LPN later acknowledged forgetting to clean the cuff between residents and not performing hand hygiene after obtaining the first resident’s blood pressure. Facility staff and the DON confirmed that the cuff should have been cleaned between residents and that hand hygiene should have been performed after resident contact. The facility policy identified blood pressure cuffs as non-critical reusable resident-care items that are to be cleaned and disinfected according to CDC recommendations, and the hand hygiene policy listed hand hygiene after touching a resident or the resident’s environment.
Failure to Maintain Safe and Sanitary Environment Across Facility Units
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a safe and sanitary environment across both units reviewed. During a unit tour, surveyors observed a soiled floor with a dried, unknown substance in one room, a clogged shower drain in another resident's bathroom, and soiled side rail padding with dried tube feeding formula in a room where a resident was present in bed with a feeding tube machine. Additional observations included dark colored debris and a piece of wet brown paper in a bathtub that was reportedly out of order, as well as peeling laminated paper on the surfaces of nightstands and television stands in another room. Loose handrails were noted in the hallways on both floors, and push bars on double doors were missing end cap brackets, leaving sharp-edged openings. Interviews with the Director of Environmental Services and the Maintenance Director revealed that neither was aware of the observed deficiencies, despite their stated responsibilities for conducting daily rounds and addressing environmental concerns. The facility's Homelike Environment policy, which requires a clean, sanitary, and orderly environment, was not adhered to as evidenced by these findings. The surveyors communicated these concerns to facility management, highlighting the lack of reporting and awareness regarding the environmental issues present in resident rooms and common areas.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to investigate allegations of verbal abuse reported by a resident and their representative. The allegations were emailed to the facility, but the emails were not discovered until the surveyor's inquiry, as they were found in the Social Worker's spam/junk folder. The Licensed Nursing Home Administrator (LNHA) acknowledged that the allegation was considered verbal abuse and stated that the facility began an investigation only after the surveyor's inquiry. The facility's policy requires that all allegations of abuse be investigated promptly, but this was not adhered to in this case. The resident involved had a history of chronic obstructive pulmonary disease (COPD), required assistance with personal care, and experienced chronic pain. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite the resident's cognitive status, the facility did not investigate the verbal abuse allegation until prompted by the surveyor. The LNHA and the Director of Nursing (DON) admitted to the delay in addressing the complaint, and the Regional Director of Operations acknowledged that the system inhibited the facility's ability to respond to the complaint in a timely manner.
Failure to Maintain Homelike Environment Due to Bathroom Door Disrepair
Penalty
Summary
The facility failed to maintain a homelike environment by not ensuring that the bathroom door in a resident's room was in good repair. During an initial tour, a surveyor observed that the bathroom door was deformed, with the top and bottom corners bowed out from the frame, allowing visibility into the bathroom even when the door was closed. Additionally, the door had multiple holes drilled into it, and the door handle was loose. This issue was noted in one of the two nursing units surveyed. The Director of Maintenance (DM) acknowledged awareness of the door's disrepair but admitted that no plan had been developed to address the issue. The DM was uncertain about how long the door had been in its current state and mentioned that some doors, particularly on the second floor, needed replacement. Despite having a system in place for staff to report maintenance issues, the facility had not taken action to repair or replace the door until after the surveyor's inquiry. The Licensed Nursing Home Administrator confirmed that staff were trained to use the repair order system and that regular facility rounds were conducted to address repairs.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the New Jersey Department of Health (NJDOH). This deficiency was identified during a survey when the Licensed Nursing Home Administrator (LNHA) was unable to provide documentation of all reportable events for a resident. Upon further inquiry, it was discovered that emails containing grievances and an accusation of verbal abuse from the resident and their representative were found in the Social Worker's spam/junk folder. The LNHA acknowledged that the allegation was considered verbal abuse and that the facility had initiated an investigation only after the surveyor's inquiry. The resident involved had a history of chronic obstructive pulmonary disease (COPD), required assistance with personal care, and experienced chronic pain. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). Despite the facility's policy requiring immediate reporting of abuse allegations, the LNHA admitted that the abuse allegation was not reported to the NJDOH until several months later, following the surveyor's investigation. The Regional Director of Operations acknowledged the delay and attributed it to a system failure that inhibited timely response to the complaint.
Failure to Document Resident Preferences in Care Plans
Penalty
Summary
The facility failed to complete individual comprehensive care plans for three residents with urinary and bowel incontinence. During incontinence rounds, it was observed that Resident #47 had a towel within their incontinence brief, which was a personal preference not documented in their care plan. The resident was cognitively intact and had medical diagnoses including hemiplegia and diabetes mellitus. The care plan for this resident included interventions for bowel and urinary incontinence but did not reflect the resident's preference for a towel in the brief. Similarly, Resident #52 was found to be using double incontinence briefs, a preference that was also not documented in their care plan. This resident had moderately impaired cognition and medical conditions such as hemiplegia and cervical spine injury. The care plan included interventions for bowel and urinary incontinence but did not account for the resident's request for double briefing. Resident #42 expressed a preference for double briefs and a towel at night to prevent bed soaking, which was acknowledged by the staff but not included in the care plan. This resident was cognitively intact and had medical diagnoses of muscle wasting and atrophy. The care plan addressed bowel and urinary incontinence but failed to incorporate the resident's specific nighttime preferences. The facility's policy requires that care plans be comprehensive and person-centered, including residents' stated goals, which was not adhered to in these cases.
Deficiencies in Nutritional Supplement Orders, Dialysis Site Care, and IV Antibiotic Administration
Penalty
Summary
The facility failed to obtain a physician's order for a replacement nutritional supplement for a resident after identifying a national shortage of the prescribed supplement, Ensure Plus. The resident, who had multiple medical conditions including cancer, amputations, and a pressure ulcer, was supposed to receive Ensure Plus daily. However, due to the shortage, the facility provided a substitute, Mighty Shake, without obtaining a new physician's order. The Registered Dietitian and nursing staff documented that the resident received Ensure Plus, despite it being unavailable, and failed to notify the physician to update the order. Another deficiency involved the inconsistent documentation and assessment of a resident's peritoneal dialysis site. The resident, who was receiving dialysis treatments for end-stage renal disease, had a catheter site that required regular assessment and dressing changes. The facility's records showed a lack of consistent documentation regarding the site assessments and dressing changes, with only two notes recorded over several months. The Director of Nursing confirmed that there should have been a physician's order for dressing changes, which was not present. Additionally, the facility failed to appropriately administer an intravenous antibiotic to a resident with a methicillin-resistant staphylococcus aureus infection. The resident did not receive a scheduled dose of daptomycin because the medication was not available, and there was no documentation of communication with the physician or pharmacy to address the missed dose. The contracted Pharmaceutical Representative confirmed that the medication was delivered late, and the facility did not request a stat delivery or notify the physician of the delay, resulting in a prolonged delay in the resident's care.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to document the necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. The resident, who was admitted with diagnoses including dementia, diabetes mellitus, and severe protein-calorie malnutrition, had a stage 3 pressure ulcer on the left foot. The resident was dependent on staff for all activities of daily living and was at risk for developing pressure ulcers. Despite having a physician's order for daily wound care, the Treatment Administration Record (TAR) lacked signatures on two consecutive days, indicating that the wound care was not documented as completed. The surveyor observed the resident on an air mattress with a dressing on the left foot, dated incorrectly, suggesting a lapse in care documentation. Interviews with the nursing staff, including a Registered Nurse (RN), Licensed Practical Nurse/Unit Manager (LPN/UM), and the Director of Nursing (DON), confirmed that the absence of signatures on the TAR meant the wound care was not documented as completed. The LPN who worked on the days in question admitted to forgetting to sign the TAR, although she recalled performing the treatment. This oversight was acknowledged as a deviation from the standards of nursing practice, where documentation is crucial to confirm that care was provided. The facility's Wound Care policy requires detailed documentation of wound care, including the type of care given, date and time, assessment data, and the signature of the person recording the data. The lack of documentation on the TAR for the specified dates led to the conclusion that the wound care was not provided as ordered, highlighting a deficiency in the facility's adherence to professional standards of practice for pressure ulcer care.
Incomplete Dialysis Communication Forms
Penalty
Summary
The facility failed to ensure consistent completion of dialysis communication forms between the facility and the contracted dialysis center for a resident requiring dialysis services. This deficiency was identified for one resident who was admitted with diagnoses including end-stage renal disease, chronic kidney disease, and type two diabetes mellitus. The resident's care plan required dialysis on specific days, and the facility had a protocol for monitoring and documenting the resident's condition before and after dialysis sessions. However, the review of the dialysis communication book revealed that several forms were not completed by the facility's nurse upon the resident's return from dialysis, and one form was not completed by the dialysis center. Interviews with facility staff, including an LPN and the DON, confirmed the process for completing the dialysis communication forms and the importance of these forms in ensuring communication between the facility and the dialysis center. The DON acknowledged that the forms were not filled out completely on specific dates, and the facility's policy required documentation of dialysis-related observations and communications. The failure to complete these forms as required represents a breakdown in the communication process between the facility and the dialysis center, potentially impacting the continuity of care for the resident.
Failure to Maintain Sanitary Conditions in Medication Room
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment in the medication storage room on the Subacute unit. During a survey, debris was observed on the floor, and a brown substance had built up in the corners. Additionally, a tea bag was found in the sink drain, and there was brown discoloration in the basin, along the edge of the sink, behind the sink, and around the faucet. Inside the cabinet housing the sink, brown, black, and orange substances were observed towards the back under the pipes. These observations indicate a lack of adherence to the facility's cleaning schedule and procedures. Interviews with facility staff, including the Licensed Nursing Home Administrator, Director of Nursing, Maintenance Director, and Director of Housekeeping, revealed that an electronic request system was in place for reporting maintenance and cleaning issues. However, no service tickets were submitted for the observed issues in the medication room. The facility's cleaning policy outlined specific steps for cleaning and sanitizing areas, including the sink and floor, but these procedures were not followed, leading to the unsanitary conditions observed by the surveyor.
Failure to Obtain Physician's Diet Order for Nutritionally At-Risk Resident at Admission
Penalty
Summary
A deficiency was identified when a resident admitted with multiple complex medical conditions, including malignant neoplasm of the urethra, left upper arm amputation, right below-knee amputation, and a stage II pressure ulcer, did not have a physician's diet order entered at the time of admission. The resident was assessed as being at nutritional risk, requiring assistance with activities of daily living, and was confined to a wheelchair. The resident's admission records and assessments indicated the need for a therapeutic diet with supplementation, specifically double protein portions to support wound healing and address malnutrition risk. Despite these documented needs, a review of the physician's order report and interviews with facility staff confirmed that no diet order was entered by the physician upon admission. The Registered Dietitian and nursing staff acknowledged that the process required a physician's order for the diet to be entered into the electronic medical record (EMR) to ensure the resident received the appropriate therapeutic diet. However, the diet was not prescribed in the physician's orders, and the omission was confirmed by the RD, LPN/Unit Manager, Assistant Director of Nursing, Director of Nursing, and the Licensed Nursing Home Administrator during interviews. Although the kitchen staff provided the resident with a double meat diet based on a diet slip, this was not supported by a formal physician's order in the EMR. Facility policy required that nursing staff update the resident's diet upon admission based on hospital recommendations, with physician approval for any changes. The lack of a documented physician's diet order at admission constituted a failure to follow established procedures and ensure the resident's dietary needs were formally addressed.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Neptune City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jersey Shore Post Acute Rehabilitation And Nursing | 0.4 mi | ★★★★★ | 0 | 0 |
| King Manor Care And Rehabilitation Center | 0.8 mi | ★★★★★ | 26 | 0 |
| Complete Care At Ocean Grove Llc | 1.3 mi | ★★★★★ | 1 | 0 |
| Imperial Care Center | 2 mi | ★★★★★ | 17 | 0 |
| Tower Lodge Care Center | 2.3 mi | ★★★★★ | 20 | 0 |
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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 October 2026) and official state health department websites.