Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Redbank Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
The facility failed to provide activities according to care plans for five residents, affecting their social and mental status. Residents with severe cognitive impairments and physical dependencies were not invited to or engaged in activities, despite care plans indicating the need for scheduled and one-on-one activities. Documentation of activities was inconsistent, and staff were unaware of residents' specific needs, such as broken equipment or language barriers.
A cook in the facility's kitchen failed to change gloves and wash hands after touching his face and contaminated items, then proceeded to handle food directly with the same gloves. Despite being alerted by the Dietary Manager, the cook continued to use his gloved hands improperly, violating the facility's handwashing policy and potentially risking the spread of infection among 132 residents.
The facility failed to follow infection control Enhanced Barrier Precautions (EBP) for two residents and did not handle medications properly for another. Staff did not consistently sanitize hands or use appropriate PPE when entering rooms with EBP signage. An LPN did not wear a gown while administering tube feeding to a resident on EBP, and isolation supplies were not readily available. Additionally, an LPN improperly handled medication by picking up a pill with an ungloved hand. These deficiencies put residents at risk of infection.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential unmet care needs. One resident's MDS inaccurately documented no oxygen therapy or tracheostomy care, despite evidence to the contrary. Another resident's discharge MDS was incorrectly coded, indicating discharge to a hospital instead of a private home. A third resident's MDS failed to reflect existing pressure areas and risk for further ulcers, despite documented skin assessments. These inaccuracies were confirmed through interviews with facility staff.
The facility failed to conduct timely PASARR screenings for two residents with psychiatric diagnoses. One resident was admitted without a psychiatric diagnosis, but later diagnosed with schizoaffective disorder, and no new PASARR Level I screen was completed. Another resident had a positive Level I PASARR screening for mental illness, but the required Level II screening was delayed. The facility's policy mandates reporting and evaluation of such issues by Social Services.
The facility failed to develop comprehensive care plans for three residents, resulting in unaddressed needs for vision impairment, oxygen use, and protective boots. Despite documented diagnoses and physician orders, care plans lacked necessary interventions, and staff were unaware of these needs. This deficiency highlights a lack of communication and documentation in the facility's care planning process.
A resident with multiple health conditions, including quadriplegia and incontinence, was found to be double briefed on several occasions, contrary to facility policy. Staff confirmed that this practice could lead to skin breakdown and pressure sores. The resident's care plan required pericare after each incontinent episode and immediate changing of wet briefs, which was not followed.
The facility failed to follow physician orders for two residents, leading to risks of skin breakdown and infection. One resident did not receive prescribed heel protector and Multipodus boots, while another had discrepancies in PICC line dressing changes. Staff interviews revealed communication and documentation issues, resulting in non-compliance with care protocols.
A resident with a history of bronchiectasis and acute respiratory failure was not administered oxygen at the physician-prescribed dose of 2 LPM. Observations showed the resident receiving higher doses of 5 LPM and 3.5 LPM. An LPN confirmed the incorrect settings and adjusted them. The DON emphasized the importance of following oxygen orders, as high settings could be problematic for residents with certain conditions.
A resident receiving dialysis three times a week did not receive adequate care, as the facility failed to document vital signs before dialysis and did not provide meals or snacks before early morning sessions. The dialysis communication forms were inconsistently filled out, and staff interviews revealed confusion about responsibilities. The facility's policy for coordinating with the dietary department and maintaining communication with the dialysis center was not effectively implemented.
A facility failed to document a rationale for extending a PRN psychotropic medication beyond 14 days for a resident with anxiety and depression. The resident's Clonazepam order lacked an end date, and the medication was administered multiple times despite a psychiatric evaluation showing no acute issues. The DON confirmed the oversight, acknowledging the regulatory requirement for an end date.
A resident received medications incorrectly, including late administration of gabapentin, incorrect dosage of estradiol, and discontinued calcium acetate, leading to a medication error rate above 5%. The LPN involved confirmed the errors, and the facility's policy requires adherence to prescribed orders and timing.
Medication carts on multiple floors were left unlocked and unattended by staff, posing a potential risk to resident safety. An RN and an LPN admitted to leaving carts unsecured, contrary to facility policy and expectations. Observations confirmed these lapses, with residents in proximity to the carts.
The facility failed to maintain complete medical records for two residents, leading to deficiencies in documentation related to a death in the facility and a discharge to the community. For one resident, the EMR lacked details about the death, including notifications and a physician's order to release the body. For another resident, the EMR was missing progress notes for the discharge date, and the LPN responsible forgot to document the discharge. The facility's policy requires comprehensive documentation for transfers and discharges, which was not followed.
Failure to Provide Activities According to Care Plans
Penalty
Summary
The facility failed to provide activities according to assessments and care plans for five residents, potentially affecting their social and mental status. Resident 5, who had severe cognitive impairment and was dependent on staff for transfers, expressed a desire to participate in activities but was not invited to any. Despite a comprehensive care plan indicating the need for scheduled activities compatible with her needs, she did not attend any activities in January or February. The Activity Director acknowledged that Resident 5 had not been invited to activities she enjoyed, such as music or dancing, and the Recreation Aid attempted to involve her but faced challenges in getting her up for activities. Resident 87, who was rarely understood and required one-on-one bedside activities, did not attend any activities in January or February. Although room visits were documented, the logs did not specify the activities conducted. Observations revealed that Resident 87 was often lying in bed without any engagement, and family members noted that he enjoyed music but was not involved in activities. The Activity Director and Recreation Aid admitted to inconsistencies in providing and documenting activities for Resident 87. Similarly, Resident 92, who had severe cognitive impairment and a tracheostomy, did not participate in any activities outside his room. Although room visits were recorded, the documentation lacked details on the activities performed. Observations showed that Resident 92 was frequently in bed without engagement, and family members reported that his Geri-chair was broken, preventing him from attending activities. The Activity Director was unaware of the broken chair and the resident's tracheostomy, leading to inaccurate documentation of activities. Residents 112 and 121 also experienced similar issues, with inadequate documentation and lack of engagement in activities, despite their care plans indicating the need for one-on-one visits and activities compatible with their preferences.
Improper Hand Hygiene and Glove Use in Kitchen
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use by kitchen staff, which could lead to the spread of infection and foodborne illness among residents. During an observation, a cook was seen touching his face and nose with gloved hands and then serving food without changing gloves. The cook handled food items directly with his gloved hands, including fried fish filets, sandwiches, and chicken strips, without using utensils. Additionally, the cook used visibly soiled oven mitts over his gloves to handle hot pans and continued serving food without changing gloves or washing hands. The Dietary Manager was informed of the issue and observed the cook's actions, confirming the failure to change gloves. Despite being provided with serving utensils, the cook continued to use his gloved hands to touch food, his pants, and his face. The facility's policy on handwashing requires staff to wash hands before working, after touching any part of the body, and between working with foods, which was not followed in this instance. This deficiency affected 132 of 141 residents consuming food in the facility.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to adhere to infection control Enhanced Barrier Precautions (EBP) for two residents, R92 and R107, and did not handle medications properly for resident R101. Observations revealed that staff, including a Certified Nurse Aide (CNA) and Licensed Practical Nurses (LPNs), did not consistently sanitize their hands or use appropriate personal protective equipment (PPE) such as gowns and gloves when entering rooms with EBP signage. Specifically, CNA2 did not sanitize her hands when passing meal trays to rooms with EBP signage, and LPN5 and LPN6 did not follow proper hand hygiene or PPE protocols when providing care to R92, who had a tracheostomy and was on EBP. For resident R107, who had a feeding tube and was on EBP, LPN5 did not wear a gown while administering tube feeding, contrary to the facility's infection preventionist's guidance that a gown should be worn during such high-contact procedures. The facility's Director of Nursing (DON) also confirmed that the expectation was for staff to use EBP, including wearing gowns and gloves when handling feeding tubes. Additionally, the facility failed to ensure that isolation supplies, such as face shields and goggles, were readily available on the third floor, where several residents with tracheostomies were located. In the case of resident R101, an LPN was observed picking up a pill that had fallen onto the medication cart with an ungloved hand and placing it back into the medication cup, which was then administered to the resident. This action was against the facility's policy, which required a no-touch technique for medication administration. The infection preventionist and DON both stated that gloves should be worn if touching medications, and hand hygiene should be performed before putting on gloves. These deficiencies in infection control practices put all residents at risk of infection.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to potential unmet care needs. Resident 107's MDS inaccurately documented that the resident did not receive oxygen therapy or tracheostomy care, despite records and observations indicating otherwise. The resident had a tracheostomy tube with oxygen flowing at 4 liters per minute, and the care plan noted the tracheostomy related to impaired breathing mechanics. Interviews with the Regional Nurse and Director of Nursing confirmed the expectation for accurate MDS coding, which was not met in this case. Resident 129's discharge MDS was incorrectly coded, indicating the resident was discharged to a short-term general hospital, while in reality, the resident was discharged to a private home with home health services. This discrepancy was confirmed through interviews with a Licensed Practical Nurse and the Regional Nurse, who acknowledged the coding error. The resident's actual discharge location was either her mother's or grandmother's home, not a hospital. Resident 92's admission MDS failed to reflect existing pressure areas and the risk for further pressure ulcers. The resident had a documented history of quadriplegia, hypertension, and sepsis, with skin assessments revealing redness and a pressure area on the sacrum. Despite this, the MDS did not indicate any unhealed pressure ulcers or risk for pressure ulcers. The Regional Nurse verified the inaccuracies, noting that the MDS should have included the pressure area on the sacrum and buttock, as well as the risk for further pressure areas. The facility's policy and the Resident Assessment Instrument Manual emphasize the importance of accurate and timely MDS completion, which was not adhered to in these cases.
Failure to Conduct Timely PASARR Screenings for Residents with Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) for a resident (R20) when a psychiatric diagnosis of schizoaffective disorder was identified. Initially, R20 was admitted without a psychiatric diagnosis, and the hospital's PASARR Level I Screen documented no major mental illness. However, the facility later entered a diagnosis of schizoaffective disorder into the electronic medical record (EMR) without conducting a new PASARR Level I screen. Interviews with the Regional Nurse and the Director of Nursing confirmed that a new PASARR Level I screening should have been completed following the addition of the new psychiatric diagnosis. Another resident (R101) was admitted with a history of mental and behavioral disorders and had a positive Level I PASARR screening for mental illness, indicating the need for a Level II screening. Despite this, the facility did not ensure a Level II screening was conducted in a timely manner. The Social Services Director acknowledged the positive screening and stated that the facility was working to schedule the Level II screening. The Assistant Director of Nursing confirmed that the Level II screening was only requested after the surveyor's inquiry. The facility's policy requires that any issues identified in the PASARR process be reported to the Director of Social Services for further evaluation.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which led to deficiencies in addressing their specific needs. One resident, who was admitted with end-stage renal disease and heart failure, had impaired vision documented in their Minimum Data Set (MDS) but lacked a care plan addressing this issue. Despite having an order for an ophthalmology consult due to blurry vision, the care plan did not include interventions for vision impairment, which was confirmed by interviews with the resident and staff. Another resident, who had been hospitalized and returned with a diagnosis of bronchiectasis and acute respiratory failure, required supplemental oxygen. However, their care plan did not document the need for oxygen, even though orders were in place for oxygen delivery. Observations and interviews revealed discrepancies in the oxygen settings, and staff were unaware of the care plan details, indicating a lack of communication and documentation. The third resident had impaired range of motion and was at risk for pressure sores, requiring heel protector boots and Multipodus boots. Despite physician orders for these interventions, the care plan did not include them, and staff were not informed of the need for these boots. Interviews with staff highlighted a lack of responsibility in updating care plans and ensuring that interventions were communicated to those providing direct care. The facility's policies required comprehensive care plans based on thorough assessments, but these were not followed, leading to potential impacts on resident care.
Improper Incontinence Care Due to Double Briefing
Penalty
Summary
The facility failed to provide proper incontinence care for a resident, identified as R92, who was found to be double briefed on multiple occasions. R92, who was admitted with multiple serious health conditions including quadriplegia and incontinence, was dependent on staff for all activities of daily living. The resident's care plan specified that pericare should be performed after every incontinent episode, and briefs should be changed immediately when wet or soiled. However, observations revealed that R92 was double briefed, with the inner brief soaked with urine, which was confirmed by both a family member and facility staff. Interviews with facility staff, including an LPN and CNA, confirmed that double briefing was against facility policy and could lead to skin breakdown and pressure sores. The Director of Nursing also stated that no residents should be double briefed unless requested, and R92 had not made such a request. The facility's policy on incontinence care emphasized the importance of checking residents for incontinence every two hours and changing briefs immediately when wet, which was not adhered to in R92's case.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to follow physician orders for two residents, R121 and R89, which put them at risk for skin breakdown and infection. R121 was admitted with multiple fractures and was at risk for pressure sores. Physician orders required R121 to wear heel protector boots while in bed and Multipodus boots when out of bed. However, observations over several days revealed that R121 was not wearing the boots as ordered, and the care plan did not include interventions for the boots. Interviews with staff indicated a lack of communication and documentation regarding the need for the boots, leading to their non-use. R89, who had a PICC line and was diagnosed with conditions including diabetes and MRSA, was observed with a bandage dated 02/14/25, despite orders for weekly dressing changes. The Medication Administration Record showed discrepancies in the dressing change schedule, and interviews revealed confusion about the orders and documentation errors. The facility's policy required verification of physician orders and proper documentation, which was not followed, resulting in the bandage not being changed as required. The deficiencies in both cases were due to failures in communication, documentation, and adherence to physician orders and facility policies. These lapses in care placed the residents at risk for adverse outcomes, such as skin breakdown and infection, due to the non-implementation of prescribed interventions and care protocols.
Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
The facility failed to administer oxygen at the physician-prescribed dose for a resident, identified as R56, who was reviewed for respiratory care. R56 had a history of bronchiectasis and acute respiratory failure with hypercapnia. The physician's order, dated 01/06/25, specified that R56 should receive oxygen at 2 liters per minute (LPM) via nasal cannula every shift. However, observations revealed discrepancies in the oxygen administration. On 02/23/25, R56 was observed receiving oxygen at 5 LPM, and on 02/24/25, the setting was at 3.5 LPM, both of which were higher than the prescribed dose. During an interview, an LPN confirmed the incorrect setting and adjusted the oxygen concentrator to the correct 2 LPM. The Director of Nursing (DON) stated that she expected oxygen orders to be followed, noting that high oxygen settings could be problematic for residents with conditions like COPD. The facility's policy on oxygen administration required staff to verify physician orders and ensure the proper flow of oxygen. The failure to adhere to the prescribed oxygen dose had the potential to cause respiratory distress for the resident.
Inadequate Dialysis Care and Communication for Resident
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident, identified as R13, who required dialysis three times a week. R13 was admitted with diagnoses including end-stage renal disease and heart failure. The care plan for R13 included interventions such as taking vital signs before and after dialysis and addressing the risk of altered weight status due to edema and fluid fluctuations. However, the facility did not consistently document vital signs before dialysis, and there was no record of meals or snacks being provided before dialysis sessions, which could affect the resident's nutritional status. The facility's dialysis communication process was also inadequate. The Dialysis binder, which contained communication forms for each dialysis day, was not properly filled out. Of the 19 forms reviewed, 15 lacked documentation of pre-dialysis vital signs, and none recorded any meal or snack provided. Additionally, 17 forms did not have boxes checked regarding medications taken or changes since the last dialysis treatment. Interviews with staff revealed confusion about who was responsible for filling out the forms, and it was noted that dietary staff did not send food for residents to eat before early morning dialysis sessions. The facility's policy required communication with the dialysis center through a communication book and coordination with the dietary department to provide meals or snacks as needed. However, this policy was not effectively implemented, as evidenced by the lack of documentation and communication regarding R13's care. Interviews with various staff members, including LPNs, the Unit Manager, and the Director of Nursing, highlighted inconsistencies in the process and a lack of clarity about responsibilities, contributing to the deficiency in providing safe and appropriate dialysis care for R13.
Failure to Document Rationale for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were not prescribed beyond 14 days without documented rationale for a resident reviewed for unnecessary medications. The resident, who was admitted with diagnoses including depression, anxiety, and end-stage renal disease, had an order for Clonazepam 2MG to be administered as needed for anxiety. This order, which started on February 13, 2024, did not have an end date, contrary to regulatory requirements. The resident's medical records indicated that the medication was administered on multiple occasions in February 2025. Despite a psychiatric evaluation noting no acute behavioral issues or concerns, the facility did not document a rationale for continuing the PRN medication beyond the 14-day limit. The Director of Nursing confirmed the oversight, acknowledging the absence of an end date for the PRN medication, which is a requirement under the regulation.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as evidenced by several errors involving a resident identified as R101. R101, who was admitted with diagnoses including hypothyroidism and failure to thrive, had specific medication orders for estradiol, gabapentin, and calcium acetate. During an observation, an LPN administered gabapentin 1 hour and 39 minutes after the scheduled time, gave only one tablet of estradiol instead of the prescribed two, and administered calcium acetate despite it being discontinued. These actions were contrary to the facility's policy, which mandates medication administration within one hour before or after the scheduled time and as per the physician's orders. Interviews with the LPN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed the deviations from the prescribed medication orders. The LPN acknowledged the late administration of gabapentin and the incorrect dosage of estradiol, and was unaware of the discontinuation of calcium acetate. The ADON and DON reiterated the expectation for medications to be administered as ordered and within the specified time frame. The facility's policy on medication administration, reviewed in December 2024, outlines the procedure for verifying and administering medications, emphasizing adherence to physician orders and time frames.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts were securely locked when unattended, as observed on multiple occasions across different floors. On the third floor, a registered nurse (RN1) left a medication cart unlocked several times while attending to residents, with residents in close proximity to the cart. This occurred between 11:25 AM and 1:00 PM, during which RN1 admitted to leaving the cart unlocked and acknowledged the potential risk of residents accessing medications. Additionally, on the fourth floor, a medication cart was found unlocked and unattended near the nursing station, with residents nearby, and the unit manager confirmed the cart was not secure. Further observations on the second floor revealed another unattended and unlocked medication cart, which was subsequently locked by the Assistant Director of Nursing (ADON). Interviews with staff, including the ADON, Licensed Practical Nurse (LPN) 11, and the Director of Nursing (DON), confirmed the expectation that medication carts should be locked when unattended. The facility's policy on medication storage, revised in May 2024, also mandates that medication carts be locked or attended by authorized personnel. These lapses in securing medication carts posed a potential risk to resident safety.
Incomplete Documentation for Resident Death and Discharge
Penalty
Summary
The facility failed to maintain complete medical records for two residents, R127 and R129, which led to deficiencies in documentation related to a death in the facility and a discharge to the community. For R127, the electronic medical record (EMR) lacked documentation regarding the circumstances of the resident's death, including how it was discovered, who was notified, and the absence of a physician's order to release the body to the funeral home. Interviews revealed that the LPN on duty forgot to document the death after working a double shift, and the RN who pronounced the death did not document it either, assuming the floor nurse would handle it. For R129, the EMR was missing progress notes for the date of discharge, and the last note did not address the discharge. The LPN responsible for the discharge forgot to document it, including details about the resident's destination and whether discharge instructions or medications were provided. The facility's policy requires comprehensive documentation for transfers and discharges, including reasons for the action, notifications, and a summary of the resident's condition, which was not adhered to in these cases. The lack of documentation for both residents could lead to staff being unaware of the reasons for the residents' absence, whether proper notifications were made, and potential legal issues. The facility's failure to follow its own policy on documentation of transfers and discharges contributed to these deficiencies, as highlighted by the absence of critical information in the residents' medical records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Red Bank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atrium At Navesink Harbor, The | 1.2 mi | ★★★★★ | 20 | 0 |
| Complete Care At Shrewsbury Llc | 1.3 mi | ★★★★★ | 15 | 0 |
| De La Salle Hall | 2.8 mi | ★★★★★ | 1 | 0 |
| Shore Pointe Care Center | 3.3 mi | ★★★★★ | 1 | 1 |
| Jersey Shore Center | 4.7 mi | ★★★★★ | 0 | 0 |
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