Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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.
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 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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Illustrative
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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 | ★★★★★ | 2 | 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 | ★★★★★ | 0 | 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 July 2026) and official state health department websites.