Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seacrest Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Food Service and Hydration Station Sanitation Deficiencies: A kitchen tour found a steamer top visibly soiled with food debris and splashes and a gas oven with grease and burnt food particles on interior surfaces. A tour of the hydration station and nourishment area found a missing PM refrigerator temp log entry and initials, plus an undated water pitcher containing cloudy water. The FSD and RFSD acknowledged the equipment should be kept clean and sanitary, and that hydration pitchers should be dated and filled with fresh water daily.
A resident with depression and schizoaffective disorder had inaccurate MDS coding. The quarterly MDS showed severe cognitive impairment but no behaviors, even though the resident was observed confused and wandering into other residents’ rooms and the care plan documented wandering, medication refusal, and physical behaviors during care. The annual MDS also incorrectly stated that no GDR of Seroquel had been attempted, despite records showing the dose was reduced and later increased after increased behaviors were documented.
A resident with bladder and bowel incontinence had no ICP focus or interventions for incontinence, and another resident with stroke-related hemiplegia, contracture, and limited ROM had no ICP goals or interventions for the affected arm and hand. Staff interviews and record review confirmed the missing care plan elements, despite MDS findings, OT history, and observed positioning concerns.
A resident with impaired skin integrity had ordered wound care for skin tears on both arms, but the daily treatment was not performed as scheduled and old dressings remained in place on consecutive observations. During the dressing change, an RN brought the wound cart into the room without ABHR, touched the bedside table while gloved, changed gloves without hand hygiene, and finished the treatment without hand hygiene after glove removal. The DON confirmed the expected glove and hand hygiene sequence and that the cart should not have been brought into the room.
A resident with NSTEMI and pulmonary HTN was observed receiving O2 at 2 LPM via NC with humidification, but the OSR contained no physician orders for O2 therapy, tubing, NC, humidification, or O2 monitoring. The TAR did not document continuous O2 use or O2 checks, and the ICP did not reflect the resident’s respiratory needs. An LPN/UM, LPN/IP, and DON all confirmed that orders, monitoring, and care plan guidance should have been in place.
A resident with arthritis and low back pain, and moderate cognitive impairment, had a pain regimen that was not followed as ordered. MAR review showed tramadol and acetaminophen were given for pain scores outside the prescribed parameters, and the hydrocodone-acetaminophen order was not administered according to the physician’s directions; the RN and LPN Unit Manager acknowledged the medications were given outside the ordered ranges.
Late Administration of Ordered IV Antibiotic: A resident with acute osteomyelitis, bacteremia, and MRSA had an order for daily IV Daptomycin at 6:00 PM, but the dose was administered outside the facility’s 1-hour medication window on multiple occasions. The Medication Audit Report showed repeated late administrations, and the UMRN confirmed there was no documentation that the MD or ID had been contacted about the recurring delays.
A resident with COPD and acute respiratory failure had an inhaler and nasal spray left on the bedside table even though the record had no physician order, evaluation, or care plan for self-administration. Surveyors also found expired hypodermoclysis kits in a medication storage room, and staff confirmed expired items should not have been there.
RN License and Compact Residency Rule Noncompliance: The facility failed to ensure an RN maintained valid licensure to practice in NJ under the NLC 60-day residency rule. Record review showed the RN had NJ residency documented in both her application and driver’s license, yet she continued working under a FL multistate RN license. The HR Manager and DON confirmed the RN was an active per-diem employee scheduled to work, and the file contained no Florida address.
A resident with chronic respiratory failure with hypoxia, COPD, and OSA had a CPAP mask observed laying open to air on the nightstand instead of being stored in a bag when not in use. The MAR included an order for a new bedside bag weekly for CPAP, and an LPN and the IP stated that CPAP tubing and masks should be stored in a bag and not left open to air.
A resident with Parkinson's Disease and Alzheimer's Disease sustained a femur fracture after being pushed in a wheelchair without leg rests by a CNA, resulting in the resident's legs becoming trapped under the chair. The incident was not reported to nursing staff at the time, and the injury was only discovered later when the resident exhibited pain and swelling, leading to a diagnosis of a complex femur fracture requiring surgery. Staff interviews confirmed that leg rests should have been used and that the facility lacked a specific wheelchair safety policy.
The facility did not provide current COVID-19 vaccine educational materials to residents or their representatives, resulting in no residents being offered or administered the vaccine. Interviews with the IP, Medical Director, and DON confirmed the lack of updated materials and absence of outreach to obtain them, despite policy requiring education and informed consent prior to vaccination.
Nurses failed to properly count and document controlled substances for three residents, resulting in discrepancies in lorazepam, tramadol, and hydrocodone counts. An LPN admitted to not performing required counts, signing out medications for one resident but administering to another, and destroying medication without a witness. The DON confirmed that staff did not follow policy for narcotic accountability, and some signed off on counts they did not actually perform.
The facility failed to handle potentially hazardous foods safely, as observed by a surveyor. Expired raw fish, pork, and corned beef were found in the refrigerator and freezer, and unlabeled salad plates and iced tea were in the prep refrigerator. The Regional Food Service Director acknowledged these issues and removed the items. The facility's policy requires all foods to be covered, labeled, and dated, which was not followed.
A facility failed to document a resident's skin cancer diagnosis on the MDS, despite the presence of visible lesions and a known diagnosis for three years. The MDS inaccurately recorded the absence of open lesions, which was inconsistent with weekly skin checks. The MDS Coordinator acknowledged the oversight, highlighting a lapse in the assessment process.
A resident with hypertension and atherosclerotic heart disease was found nonresponsive and later pronounced dead. The facility failed to complete and transmit the required MDS assessment for the resident's death, as acknowledged by the MDS Coordinator. The facility's policy requires timely submission of assessments, but this was not adhered to.
A facility failed to provide appropriate care for a resident's leg splint, which was observed multiple times without a corresponding physician's order or care plan intervention. The resident, with a history of stroke and hemiplegia, chose to wear the splint from a prior hospital stay, but the facility did not document or plan for its use upon the resident's arrival, contrary to facility policy.
A resident with an indwelling urinary catheter experienced improper care as the drainage bag was found on the floor and unsecured to the bed frame, violating infection control policies. Additionally, the facility failed to document the resident's urinary outputs as ordered, with multiple instances of missing entries in the Treatment Administration Record. These deficiencies were confirmed during a surveyor's inspection and an interview with the DON.
A resident with COPD, dementia, and pneumonia was observed with improper storage and use of their oxygen delivery system. The nasal cannula was not stored in a protective container, and the oxygen concentration was set incorrectly. The facility's policy requires the cannula to be kept in a plastic bag when not in use, but this was not followed, leading to a deficiency in respiratory care.
The facility failed to consistently monitor and document the behaviors of two residents on psychotropic medications as per physician's orders and care plans. Observations revealed incomplete documentation in the MAR and TAR, with unrecognized codes and blank areas. The facility's policies on charting and behavioral assessment were not followed, leading to inadequate documentation and communication regarding the residents' conditions.
The facility failed to monitor and document side effects of psychotropic medications for two residents, as required by physician's orders and care plans. Observations and record reviews revealed numerous undocumented shifts and improper use of an 'X' in place of approved documentation codes. Interviews with the DON and ADON confirmed the documentation was incomplete, violating facility policies.
Food Service and Hydration Station Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food service and hydration station equipment in a clean and sanitary manner. During a kitchen tour with the Food Service Director, the top of the steamer was observed to be visibly soiled with food debris and splashes, and the gas oven had splashes of grease and burnt food particles on interior surfaces. The Food Service Director acknowledged both findings and stated that, per facility policy, the equipment should be cleaned when visibly soiled. During a tour of the third-floor hydration station, nourishment room, and dining rooms with the Activities Aide, the surveyor observed that the nourishment room refrigerator temperature log was missing the evening temperature entry and employee initials for 12/15/25. The hydration station water pitcher was also observed to be undated and contained cloudy water. The Activities Aide acknowledged the missing documentation and the condition of the pitcher, and stated that refrigerator temperatures should be checked and documented daily during both AM and PM shifts, while the pitcher should be dated and the water should be clear. The Food Service Director and Regional Food Service Director later confirmed that kitchen equipment should be maintained in a clean sanitary manner and that hydration station pitchers should be dated, cleaned, and filled with fresh water daily.
Inaccurate MDS Coding for Resident Behaviors and GDR Documentation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for Resident #9, who was admitted with diagnoses including depression and schizoaffective disorder. The quarterly MDS dated 9/23/2025 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, yet it also indicated that the resident exhibited no behaviors during the assessment reference period. During the survey, the resident was observed confused and wandering into other residents’ rooms, and staff were seen redirecting the resident. The interdisciplinary care plan documented behaviors including wandering, refusing medications, and physical behaviors during care. The annual MDS also contained inaccurate coding in Section N regarding gradual dose reduction (GDR) of antipsychotic medication. Progress notes showed that Seroquel was reduced from 25 mg daily to 12.5 mg daily on 6/5/25, and later increased back to 25 mg daily after the psychiatrist documented increased behaviors following the GDR. However, the annual MDS indicated that a GDR had not been attempted, despite documentation confirming that a GDR was attempted on 6/6/25 and later found contraindicated on 6/26/25, which was three days after the assessment reference date. The MDS coordinator stated that assessments are completed using resident interviews, electronic records, and staff communication, and that the DON signs the MDS after completion by the LPN.
Failure to Develop Care Plans for Incontinence and Limited ROM
Penalty
Summary
The facility failed to initiate individualized care plans for two residents with identified needs. One resident was assessed as occasionally incontinent of bladder and frequently incontinent of bowel, but the current care plan contained no focus or interventions for incontinence or incontinence care. During interview, the Unit Manager RN and the DON both acknowledged that incontinence should be reflected in the care plan so staff are aware of the resident’s care needs. A second resident was observed with the left elbow maintained in a flexed position and the fingers of the left hand bent toward the palm, and the resident was not wearing an orthotic device. The resident had diagnoses including cerebral infarction, hemiplegia, and diabetes mellitus, and the MDS identified impaired functional ROM of one upper extremity on one side of the body. The EMR and care plan contained no documented goals or interventions addressing the resident’s left elbow or left hand related to limited ROM or contracture. Record review and interviews showed the resident had a history of left-sided hemiplegia and prior OT findings of impaired ROM and contracture affecting the left shoulder, elbow, wrist, and hand. Staff stated the resident required total assistance with ADLs and had previously used a brace and hand roll, but the surveyor could not locate documentation that the resident refused these devices. Multiple staff members, including the LPN, LPN/UM, DOR, OT, DON, and LNHA, confirmed that the care plan should have included preventive interventions and goals for the resident’s contracture and limited ROM.
Missed Wound Treatment and Breaks in Hand Hygiene During Dressing Change
Penalty
Summary
Physician-ordered wound treatments were not administered as scheduled for a resident with impaired skin integrity, muscle wasting and atrophy, unspecified convulsions, and anxiety disorder. The resident had an order for daily and as-needed wound care to clean skin tears on both arms with wound cleanser, apply xeroform, and cover with an abdominal dressing and Kling wrap. The care plan included an intervention to administer treatments as ordered and monitor effectiveness. On observation, the resident was found in bed with dressings on both forearms dated 12/14/2025, and the same dressings were still present the next day, indicating the daily treatment ordered for 12/15/2025 had not been performed. During the dressing change, the RN brought the wound cart into the room without alcohol-based hand rub on the cart, donned gloves, moved the resident's bedside table, and did not change gloves or perform hand hygiene before starting wound care. After removing the soiled dressings, the RN removed gloves and put on new gloves without hand hygiene, then applied the xeroform and clean dressings. After completing the treatment, the RN removed gloves and did not perform hand hygiene. The RN stated hand hygiene should be performed before and after resident contact but did not know exactly when gloves should be changed, and the DON stated staff should change gloves when they remove the dressing, perform hand hygiene, and reapply gloves. The DON also confirmed the RN should not have brought the treatment cart into the resident's room during the treatment.
Failure to Obtain Orders and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to obtain physician orders before administering continuous oxygen therapy to Resident #25, who was admitted with diagnoses including NSTEMI myocardial infarction and pulmonary hypertension. During the initial tour, the resident was observed lying in bed receiving oxygen at 2 LPM via nasal cannula with humidification in use. The resident’s admission record and quarterly MDS showed intact cognition with a BIMS score of 13 out of 15. The Order Summary Report did not include physician orders for oxygen therapy, oxygen tubing, nasal cannula, humidification, or monitoring of oxygen levels, even though the resident was receiving oxygen. The Treatment Administration Record for December 2025 also did not document continuous oxygen therapy or oxygen monitoring. Progress notes showed that the resident was receiving oxygen at 2 LPM via nasal cannula, and the nurse practitioner documented an oxygen saturation of 93% while confirming oxygen use. Review of oxygen saturation levels showed readings ranging from 93% to 97% on room air, with no oxygen measurements documented after 12/8/25. During interviews, the LPN/Unit Manager confirmed the resident was receiving oxygen without physician orders and stated that orders should have been in place for oxygen, tubing, humidification, and oxygen level monitoring. The LPN/Infection Preventionist also confirmed that physician orders should have existed and that the resident should have had a care plan addressing oxygen needs. The DON acknowledged that nurses should have obtained physician orders before administering oxygen and that the Interdisciplinary Care Plan should have been updated to reflect the resident’s oxygen therapy needs.
Pain Medication Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure a pain management regimen was followed in accordance with physician orders for a resident admitted with diagnoses including arthritis and low back pain. The resident’s annual MDS dated 12/02/2025 indicated a BIMS score of 11 out of 15, showing moderate cognitive impairment, and Section J noted that the resident had a pain assessment completed and received routine pain medication. During observations on 12/15/2025 and 12/16/2025, the resident stated feeling good and reported that pain medication was being received and that pain was controlled. Physician orders dated 05/26/2025 included hydrocodone-acetaminophen 5-325 mg every 4 hours as needed for moderate pain, tramadol 50 mg every 6 hours as needed for mild pain, and acetaminophen 325 mg, two tablets every 6 hours as needed for pain, with pain levels tied to specific numeric ranges. Review of the November and December 2025 MAR showed tramadol and acetaminophen were administered for pain ratings of four and five, and the hydrocodone-acetaminophen order was not administered according to the physician order. The RN and LPN Unit Manager both acknowledged that pain medication had been given outside the ordered parameters.
Late Administration of Ordered IV Antibiotic
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with prescriber orders when it did not administer an IV antibiotic within the required timeframe for one resident. The resident had diagnoses including acute osteomyelitis of the left ankle and foot, bacteremia, and an MRSA infection. A physician order dated 12/2/2025 directed Daptomycin IV 430 mg once daily at 18:00 for osteomyelitis. The facility’s Medication Audit Report showed that the 18:00 Daptomycin dose was administered outside the facility’s one-hour medication window on multiple occasions, including at 20:26, 20:01, 19:51, and 21:14 on different dates. During interview, the UMRN stated the antibiotic should be given at 6:00 PM with a one-hour window before and after, and that if a medication is late more than once, the nurse should notify the doctor and Infectious Disease to request a schedule change. The UMRN confirmed there was no indication in the progress notes that the physician had been contacted regarding the late administrations. The DON stated that medications should be given within their administration times, defined as one hour before and one hour after the scheduled time.
Unsafe Medication Storage and Unauthorized Bedside Medications
Penalty
Summary
The facility failed to ensure that medications and medical supplies were stored safely, securely, and in accordance with professional standards. For Resident #38, who had diagnoses including a left femur fracture, COPD, and acute respiratory failure with hypoxia, the record showed an order for Albuterol Sulfate HFA inhalation aerosol solution, 2 puffs every 6 hours as needed for wheezing, and a care plan focused on mitigating respiratory complications and infections. However, the resident’s electronic medical record contained no physician’s order for self-administration of medications and no care plan for self-administration. During observation, the surveyor found an inhaler and a nasal spray on the resident’s bedside table, and the resident stated she had brought the medications from home and was allowed to have them. The surveyor also found 3 hypodermoclysis kits with an expiration date of 10/01/2025 in the third-floor medication storage room. An LPN stated the expired items should not have been in the room and removed them for disposal. The DON stated that expired items should not be kept in medication rooms. The facility’s policy stated that medications not self-administered by residents are to be stored in an appropriate and safe medication storage area, and the policy on administering medications stated that residents may self-administer only if the attending physician and interdisciplinary care planning team determine they can do so safely. The facility did not provide a policy related to the expired supplies.
RN License and Compact Residency Rule Noncompliance
Penalty
Summary
The facility failed to ensure that 1 of 24 RNs maintained a valid license or multistate privilege to practice in New Jersey in accordance with the Nurse Licensure Compact 60-day residency rule. Record review showed that RN #1 was hired on 8/14/2025, and her employee file contained a New Jersey driver’s license issued on 01/17/2025 listing a primary residential address in New Jersey. Her employment application, signed on 07/21/2025, also listed a primary residential address in New Jersey. The licensure documentation in the file showed a Florida multistate RN license issued on 4/21/2025 with an expiration date of 4/30/2027, and the address on that license was another New Jersey residential address different from the one on her driver’s license. The report cited NLC rule 402.2, which requires a multistate licensee who changes primary state of residence to another party state to apply for a multistate license in the new party state within 60 days. Based on the documentation reviewed, RN #1 had established primary residency in New Jersey as of 01/17/2025 but continued to practice under a Florida multistate license beyond the 60-day requirement. During interview, the HR Manager stated RN #1 was a per-diem employee and there was no knowledge of any address change, and confirmed the residential address on file was in New Jersey with no Florida address found in the paper file. The DON confirmed RN #1 was an active employee and was scheduled to work in the facility.
CPAP Equipment Left Open to Air
Penalty
Summary
Staff failed to ensure that respiratory equipment was stored in a manner that prevented contamination for one resident who used CPAP equipment. During the initial tour on 12/16/2025, the surveyor observed the resident’s CPAP mask laying on the nightstand open to air. The resident’s admission record showed diagnoses including Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. The resident’s MAR included a physician’s order for a new patient bedside bag weekly for CPAP. During interviews, an LPN stated that respiratory equipment should be stored in a labeled plastic bag when not in use for proper infection control. The infection preventionist stated that tubing and masks should be stored in a bag when not in use, should be changed weekly, and should not be stored open to air on top of the nightstand. A facility policy titled Cleaning and Disinfection of BiPAP/CPAP devices Between Residents stated that clean BiPAP/CPAP devices should be stored in an area where there is low risk of contamination between uses.
Failure to Prevent Accident Hazard During Wheelchair Transport
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) pushed a resident in a wheelchair without using leg rests, resulting in the resident's legs becoming trapped underneath the wheelchair. The resident, who had diagnoses of Parkinson's Disease and Alzheimer's Disease and was non-ambulatory, complained of pain after the incident. The CNA did not report the incident to nursing staff, despite the resident expressing discomfort. The resident was later found to have a swollen and bruised left leg, and subsequent medical evaluation revealed a complex comminuted fracture of the distal femur, requiring surgical intervention. The resident's care plan indicated a self-care performance deficit related to cognitive impairment and impaired balance, with interventions to encourage participation in activities of daily living and a note that the resident was non-ambulatory. The incident occurred when the CNA, who was aware that the resident typically self-propelled the wheelchair, chose not to use the leg rests while pushing the resident. The CNA acknowledged that the resident said "ouch" during the transfer but did not inform the nurse, as the resident stated they were okay. Other staff members were not made aware of the incident at the time, and the change in the resident's condition was only noticed later during routine care. Interviews with facility staff, including the assistant director of nursing (ADON), director of nursing (DON), and other CNAs and nurses, confirmed that the use of leg rests is expected when propelling residents in wheelchairs to prevent accidents. The facility did not have a specific policy on wheelchair safety beyond a general falls risk management policy. The lack of immediate reporting and assessment following the incident contributed to a delay in identifying the injury and providing appropriate care.
Failure to Provide COVID-19 Vaccine Education and Offer Vaccination
Penalty
Summary
The facility failed to provide educational materials regarding the COVID-19 vaccine to residents and/or their representatives, preventing them from making informed decisions about vaccination. Interviews with the Infection Preventionist (IP), Medical Director, and Director of Nursing (DON) confirmed that no residents had been offered or administered the COVID-19 vaccine due to the lack of current educational materials for the 2025-2026 year. The IP stated that only outdated materials were available and had not reached out to the facility's pharmacy or local health department to obtain updated information. The Medical Director was unaware of the issue and emphasized the importance of providing educational materials for informed consent. The DON indicated that while vaccination status is checked on admission, residents must receive education materials to make an informed choice. The Health Department confirmed that the facility had not requested educational materials, and the facility's policy required that residents be provided with the most current vaccine information statement (VIS) before vaccine administration. The policy also specified that education regarding benefits, risks, and potential side effects must be given prior to offering the vaccine. As a result of these actions and inactions, none of the 145 residents, who are considered a vulnerable population, were offered or given the COVID-19 vaccine, and their vaccination status was not properly documented in accordance with policy and regulatory requirements.
Failure to Maintain Accountability for Controlled Substances
Penalty
Summary
Nurses at the facility failed to properly complete narcotic medication counts and maintain accountability for controlled substances for three out of four sampled residents. Facility policy required that controlled substances be counted and documented by two licensed nurses at each shift change, with specific procedures for liquid narcotics and storage. However, documentation and interviews revealed that nurses did not consistently count or document narcotics as required, and in some cases, signed off on counts they did not actually perform. For one resident with an order for lorazepam, discrepancies were found in the medication count, with a 2.5 ml deficit noted and no documentation of administration for the missing amount. Statements from LPNs indicated that the refrigerated lorazepam was not always counted during shift changes, and one LPN admitted to not completing the count due to time constraints and habitually delaying documentation. Another resident with an order for tramadol had a missing medication card, and the nurse involved admitted to signing out the medication for one resident but administering it to another, as well as not knowing the whereabouts of the missing card. For a third resident, hydrocodone was reportedly destroyed by a nurse after the order was discontinued, but this was done without a witness and the medication card was not located. Interviews with the Director of Nursing confirmed that nurses did not follow policy regarding narcotic counts and documentation, and that some staff signed off on counts they did not actually perform. The investigation determined that narcotics were diverted by a nurse, and that other staff failed to properly verify and document controlled substance counts as required by facility policy and regulations.
Deficient Food Handling and Storage Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by a surveyor. During an inspection of the kitchen, several issues were identified. In the walk-in refrigerator, raw fish was found wrapped in plastic wrap with a use-by date that had already passed. Similarly, in the walk-in freezer, a bag of frozen pork and three bags of frozen corned beef were discovered, all with expired use-by dates. Additionally, in the prep refrigerator, there were 11 salad plates on two trays and two pitchers of iced tea, all without labels or dates. The Regional Food Service Director acknowledged these oversights and removed the items. The facility's policy on food receiving and storage, revised in November 2022, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. However, the facility did not adhere to these guidelines, as evidenced by the expired and unlabeled food items found during the survey. The Licensed Nursing Home Administrator confirmed that food past its use-by date should not be present in the freezer or refrigerator.
Failure to Document Skin Cancer on MDS
Penalty
Summary
The facility failed to accurately document and transmit a resident's diagnosis of skin cancer on the Minimum Data Set (MDS), an essential assessment tool for resident care. This deficiency was identified for one resident who had been diagnosed with skin cancer and had visible lesions on their face. Despite the resident's known diagnosis and the presence of skin cancer lesions for three years, the MDS inaccurately recorded the absence of open lesions other than ulcers, rashes, or cuts. This discrepancy was noted in multiple MDS assessments, where the resident's skin cancer lesions were not documented, despite being observed and recorded in weekly skin checks. The MDS Coordinator, responsible for ensuring the accuracy and completeness of resident assessments, acknowledged that the skin cancer should have been documented on the MDS. The coordinator typically gathered resident information from progress notes, staff, medication and treatment records, and skin checks. However, the failure to accurately reflect the resident's condition on the MDS indicates a lapse in the assessment process. The facility's administrative team was informed of the concern but did not provide additional information regarding the resident's MDS inaccuracies.
Failure to Transmit MDS Assessment for Deceased Resident
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) assessment for a resident who died in the facility. The resident, who had been admitted with diagnoses including hypertension and atherosclerotic heart disease, was found nonresponsive in their wheelchair and later pronounced dead. Despite the resident's death, the MDS assessment, which is required to be completed and transmitted within seven days of assessment, was not conducted or submitted. During an interview, the MDS Coordinator acknowledged the oversight, confirming that the assessment should have been completed and transmitted in a timely manner. The facility's policy, revised in October 2023, mandates that resident assessments be conducted and submitted according to federal and state guidelines. However, the facility did not provide any additional information or justification for the failure to comply with these requirements.
Failure to Document and Care Plan for Resident's Leg Splint
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident's positioning needs, specifically regarding the use of a leg splint. The deficiency was identified when a surveyor observed the resident in a wheelchair with a leg splint on multiple occasions, but there was no physician's order or care plan intervention for the splint in the resident's electronic medical record. The resident had a history of cerebral vascular accident and hemiplegia affecting the left side, which necessitated the use of the splint. However, the care plan did not initially include any focus or intervention for the splint, and the physician's order for its use was only added after the surveyor's review. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that the resident chose to wear the splint from a prior hospital admission, but there was no immediate documentation or care planning upon the resident's arrival at the facility. The facility's policy required that a comprehensive, person-centered care plan be developed within a specific timeframe and that any range of motion devices be included in the care plan with specific physician orders. The lack of timely documentation and care planning for the resident's leg splint constituted a failure to meet professional standards of practice.
Improper Catheter Care and Documentation Lapses
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, as evidenced by improper handling and documentation practices. The urinary catheter drainage bag was observed in contact with the floor and unsecured to the bed frame, contrary to the facility's policy and standard infection control practices. This observation was made during a surveyor's tour of the unit, highlighting a lapse in maintaining hygiene and safety standards for catheter care. Additionally, the facility did not document the resident's urinary outputs as ordered by the physician. The Treatment Administration Record (TAR) showed multiple instances where urinary output measurements were not recorded, despite the resident having a physician's order to measure and document urinary outputs every shift. This lack of documentation was confirmed during an interview with the Director of Nursing, who acknowledged that a blank TAR does not indicate that the order was administered. These deficiencies were identified for a resident diagnosed with muscle wasting, atrophy, and a urinary tract infection.
Improper Storage and Use of Oxygen Delivery System
Penalty
Summary
The facility failed to ensure the proper storage and use of a resident's oxygen delivery system, leading to a deficiency in respiratory care. The deficiency was identified for a resident with a history of Chronic Obstructive Pulmonary Disease (COPD), dementia, and pneumonia, who was observed using a portable oxygen tank with a nasal cannula (n/c) as an oxygen delivery system. On multiple occasions, the surveyor noted that the n/c was not stored in a protective container when not in use, leaving it exposed to the environment. Additionally, the oxygen concentration was set incorrectly at 0.5 L/minute instead of the prescribed 2 L/minute, as observed by the Registered Nurse Unit Manager (RN UM). The facility's policy on oxygen and nebulizer use, adopted in August 2021, specifies that the oxygen cannula and tubing should be kept in a plastic bag when not in use to prevent infection. However, the RN UM acknowledged that the n/c was not stored correctly and that the oxygen tank was set at the wrong concentration. Despite being informed of these observations, the facility did not provide any additional information or corrective actions to the surveyor. This oversight in following the facility's infection control policy and ensuring the correct oxygen concentration contributed to the identified deficiency.
Failure to Monitor and Document Resident Behaviors on Psychotropic Medications
Penalty
Summary
The facility failed to consistently monitor and document the behaviors of residents on psychotropic medications as per physician's orders and the resident-centered Care Plan. This deficiency was identified for two residents. For the first resident, the surveyor observed the resident in the day room, unresponsive to greetings, and later learned from the CNA that the resident often yelled at staff during care. The RN Unit Manager confirmed that behavior charting should be documented every shift, yet the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed multiple instances of incomplete documentation, with blank areas and unrecognized codes like 'NO' and 'X'. The resident's care plan included monitoring for changes in behavior every shift, with specific interventions for paranoia, delusions, and other symptoms. However, the TARs for several months showed numerous shifts where monitoring was not documented, and interventions were not recorded despite documented behaviors. The facility's policy on charting and documentation emphasized the importance of consistent and approved abbreviations, which was not adhered to in this case. For the second resident, similar issues were observed. The resident was noted to be easy to redirect when upset, yet the TARs revealed numerous shifts with incomplete behavior monitoring documentation. The facility's Director of Nursing and Assistant Director of Nursing acknowledged the documentation failures, noting that the use of 'X' and 'N' was not in accordance with the facility's approved codes. The facility's policies on behavioral assessment and monitoring were not followed, leading to a lack of proper documentation and communication regarding the residents' conditions and responses to care.
Failure to Monitor and Document Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor and document potential side effects of psychotropic medications for two residents, as per physician's orders and the resident-centered care plan. Resident #105 was observed unresponsive in the day room, and a review of their records showed multiple psychotropic medications prescribed for mood disorders and depression. Despite orders to monitor for side effects every shift, the Treatment Administration Records (TAR) revealed numerous shifts left blank and undocumented side effects, with an unexplained 'X' used in place of proper documentation. Similarly, Resident #117, who was observed interacting with a stuffed dog and being easily redirected by staff, was also on multiple psychotropic medications for anxiety and mood disorders. The TARs for this resident showed significant gaps in documentation, with many shifts left blank and the same unexplained 'X' used. The facility's policy on charting and documentation was not followed, as only approved abbreviations and symbols should be used, and the 'X' was not listed as an approved abbreviation. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the documentation was incomplete and not in accordance with the facility's policies. The ADON acknowledged that the 'X' indicated that monitoring was not done, which was contrary to the physician's orders and the facility's policy on behavior assessment and monitoring. This lack of proper documentation and monitoring could potentially impact the residents' care and safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 141 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Little Egg Harbor Tw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mystic Meadows Rehabilitation And Nursing Center | 3.4 mi | ★★★★★ | 24 | 0 |
| Manahawkin Health And Rehabilitation Center | 10.6 mi | ★★★★★ | 13 | 3 |
| Southern Ocean Center | 10.6 mi | ★★★★★ | 13 | 0 |
| Atlas Healthcare At Seashore Gardens | 10.9 mi | ★★★★★ | 0 | 0 |
| Health Center At Galloway, The | 11.1 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.