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 Shore Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and communication deficits experienced an unwitnessed fall and complained of left leg pain while found on the floor partially supported by a chair. An LPN documented no visible injury, noted repeated refusals of pain medication, assisted the resident to bed, and did not return to reassess, later stating they needed to complete a med pass and did not inform the physician of the pain complaint, assuming it was due to chronic arthritis. Neurological flow sheets for the post-fall period contained multiple blanks and incomplete entries for level of consciousness, movement, and staff initials. The DON confirmed that required post-injury monitoring, pain assessment, and direct provider notification were not carried out as expected under facility policies, and the resident was later sent to the hospital for evaluation of left hip pain and a femur fracture.
A cognitively intact resident with falls and muscle weakness was discharged to the community without an effective discharge plan documented. The record showed only a VNA referral and medication instructions, with no clear documentation of DME or other community referrals. The resident reported being taken by Uber to a hotel, unable to pay the check-in fee, and falling outside before calling 911, while staff stated rehab was not notified and no discharge evaluation was completed.
Surveyors found that the facility failed to provide a safe, clean, and homelike environment, with widespread issues such as peeling paint and wallpaper, broken and soiled furniture, stained toilets, and unclean AC units across all nursing units. Staff and residents confirmed that these problems were ongoing and not consistently reported or addressed, despite previous citations and a plan of correction.
Surveyors identified widespread deficiencies in the facility's environment, including peeling paint, broken furniture, soiled floors, stained toilets, and damaged shower areas. Staff and residents confirmed that these issues were ongoing and not consistently reported or addressed, despite previous citations and a plan of correction. Facility leadership acknowledged awareness of the problems, but documentation did not show that repairs or replacements had been completed.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as dirty floors, broken furniture, and unsanitary conditions observed across multiple units. Staff interviews revealed a lack of communication and follow-through on maintenance and housekeeping concerns, with the Maintenance Director confirming that issues should be addressed within 24 hours. Despite acknowledgment of the poor conditions by the DON and LNHA, no concrete plans for improvement were provided.
The facility failed to properly store potentially hazardous foods and maintain kitchen equipment in a sanitary manner. Opened boxes of raviolis and chicken breasts were found unsealed and unlabeled in the freezer, and the steam table contained murky water with food particles. Additionally, cutting boards were deeply pitted and discolored. The FSD acknowledged these issues, and the LNHA and DON were informed but provided no further information.
The facility failed to properly label and store medications and medical supplies, as observed on two medication carts and in a storage room. Expired medications were found, and supplies were improperly stored under a sink, posing infection control risks. Staff confirmed the deficiencies.
The facility failed to provide a dignified dining experience for residents by serving beverages in disposable plastic cups, as observed in one dining room. The LNHA and DON did not refute this concern, and the facility's meal assistance policy did not address the use of non-disposable dinnerware, leading to a deficiency in promoting dignity and respect.
A resident requested a lock for their closet to prevent theft, but the facility failed to install the necessary hardware despite the request being documented. The resident, who was cognitively intact and independent, experienced instances of their closet being found open. Interviews revealed that the facility's policy required residents or families to provide padlocks, while the facility provided hardware, but the lock was not installed.
An LPN failed to secure a medication cart during administration, leaving it unlocked and out of sight while attending to a resident. This action violated the facility's policy, which mandates that medication carts be locked when not in direct view. The incident was confirmed by the LPN/Unit Manager and acknowledged by the facility's administration.
A facility failed to obtain a physician's order for oxygen tubing care and did not develop a comprehensive care plan for a resident receiving oxygen therapy. The resident, with moderate cognitive impairment and multiple medical conditions, had an oxygen concentrator with improperly placed tubing. The physician's order for oxygen administration was present, but there was no order for tubing changes, and these changes were not documented in the EMR. The facility's policy lacked guidelines for oxygen tubing care, and the resident's care plan did not address respiratory care.
The facility failed to ensure proper accountability of narcotic shift count logs on two medication carts. On one cart, a pre-signed outgoing nurse signature was found, while on another, multiple missing signatures were identified for various shifts. The DON and IP confirmed that narcotics should be counted and signed by both incoming and outgoing nurses at shift changes, as per the facility's policy.
The facility failed to properly dispose of garbage and maintain the grounds, leading to potential rodent and pest issues. Observations included construction debris, litter, and numerous cigarette butts scattered across the grounds. The LNHA acknowledged the problem, and interviews revealed that the MD and HD were unaware of their responsibilities for grounds maintenance until recently.
A facility failed to follow proper infection control practices during medication administration. An LPN was observed handling medication tablets with bare hands without performing hand hygiene or wearing gloves. Interviews with other staff revealed inconsistencies in understanding and implementing proper procedures for medication handling, highlighting a lack of adherence to the facility's hand hygiene policy.
A facility failed to investigate an allegation of resident-to-resident sexual abuse involving two cognitively impaired residents. The incident was reported by a family member who found one resident partially undressed. The LNHA forwarded the grievance to the SW, but no investigation was initiated, and key staff were not informed. Interviews revealed a lack of awareness and communication about the incident, and facility policies on abuse prevention and investigation were not followed.
A facility failed to address a grievance regarding alleged resident-to-resident sexual abuse. A family member reported finding a resident in a compromised state with another resident, but the grievance was not properly investigated. The Social Worker did not involve key staff or complete the grievance process as per policy, leading to a deficiency.
A facility failed to investigate an allegation of resident-to-resident sexual abuse properly. A resident was found partially undressed and distressed by a family member, who reported the incident. The LNHA did not read the complaint immediately and only forwarded it to the SW, who did not conduct a comprehensive investigation. The facility's policies on abuse prevention and grievance handling were not followed, highlighting lapses in management and oversight.
Failure to Adequately Assess, Monitor, and Communicate After Unwitnessed Fall With Pain Complaint
Penalty
Summary
The deficiency involves the facility’s failure to properly assess, acknowledge, monitor, and communicate about pain, and to implement appropriate interventions following an unwitnessed fall with a resulting femur fracture for one resident. The resident had dementia and was documented on the MDS as rarely or never understood, with long- and short-term memory problems. On the evening of 4/2/25, an LPN found the resident on the floor in their room, with the upper body leaning halfway on a chair. The resident could not give an accurate statement but complained of left leg pain. The LPN’s assessment documented no visible injury, no swelling, redness, or signs of trauma, and noted that the resident was offered pain medication but refused it three times before being assisted to bed. The LPN later stated in interview that the resident complained of leg pain, was able to take a couple of steps to the bed, and that the LPN did not return to check on the resident after the initial assessment because the resident did not require pain medication and the LPN needed to complete a medication pass. The LPN reported calling and leaving a message for the physician and calling the family, but did not inform the physician that the resident was complaining of pain, explaining that the resident always complained of leg pain from arthritis. There was no progress note identified from the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts documenting the fall beyond the late entry note, and the care plan later reflected that the resident was sent to the hospital for evaluation of left hip pain after the unwitnessed fall. Review of the neurological flow sheet from the time of the fall through the following morning showed multiple incomplete entries. The resident’s level of consciousness was not completed for several time points overnight, with only a notation of sleep, and movement entries were missing or marked as refused, including a blank entry at 3:00 a.m. The initials section was left blank for multiple time slots on the evening and overnight shifts. The DON stated that after an injury the nurse should monitor a resident according to the neurological flow sheet and complete pain monitoring for 48 hours, that no blanks should be present on the neurological flow sheet, and that the LPN should have spoken directly to the provider and explained that the resident was in pain rather than just leaving a message. Facility policies required immediate practitioner notification by phone when a fall results in significant injury or condition change, observation and documentation of delayed complications for approximately 48 hours, and documentation of pain and related signs and symptoms, as well as prompt initiation and documentation of accident/incident investigations and care plan review when desired outcomes are not met.
Incomplete Community Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process focused on a resident’s goal to return to the community. Resident #6 was cognitively intact with a BIMS score of 13 out of 15 and was independent with ADLs, with supervision or touch assist for transfers and ambulation. The resident had diagnoses including repeated falls and muscle weakness. Documentation showed the resident had previously received notice of Medicare non-coverage and appeal information, and later had an OT discharge summary that listed discharge recommendations including home health services, safety equipment, and 24-hour care. For the 3/26/25 discharge, the record showed a physician order for discharge, a social services note stating the social worker spoke with the resident about the discharge plan, and an interdisciplinary discharge summary that only reflected a referral for visiting nursing services. There was no documentation that durable medical equipment was ordered or that other community referrals were made. Another social services note stated the resident was discharged to the community with a reconciled medication list, instructions to contact the PCP, and transport with belongings, but there was no other documentation describing the discharge plan or the resident’s community placement. During interview, the resident stated that an Uber took them to a local hotel, where they were told they had to pay $50 to check in; because they had no money, they left, fell outside, and called 911. The resident said they were readmitted the next day and denied requesting to leave or receiving prior notice of the discharge. Staff interviews reflected that the rehab department was not notified, so no discharge evaluation was completed, and the DOR stated she would have requested a rollator if notified. The DSS and Administrator stated the resident wanted to leave and that the facility could not force the resident to stay, but neither could recall whether the discharge had been discussed in interdisciplinary meetings, and there was no documentation of discussion about the resident’s discharge location or understanding of the plan.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents across all three nursing units. Observations included widespread issues such as peeling wallpaper and paint, cracked and stained ceiling tiles, broken or missing furniture parts, stained and soiled floors, and malfunctioning or dirty air conditioning units. Bathrooms were found with cracked tiles, stained or rusted toilet bowls, missing or damaged grab bars, and peeling paint. Common areas, such as dayrooms and shower rooms, also exhibited soiled and damaged furniture, missing grout, and rusted fixtures. These conditions were confirmed by both staff and residents, with some residents reporting that broken furniture and soiled conditions had persisted for extended periods without resolution. Staff interviews revealed a lack of consistent reporting and follow-up on maintenance issues. While a computerized work order system was in place, several staff members admitted to being aware of broken or damaged items but did not always submit maintenance requests. Housekeeping staff reported daily cleaning routines, but surveyors observed persistent soiling and debris, particularly in and around AC units and on furniture. Maintenance staff acknowledged that many of the environmental issues predated their employment and that repairs were often limited to what was immediately visible or reported. The Environmental Service Director and other staff confirmed that some cleaning and maintenance tasks, such as cleaning AC units and replacing filters, were not consistently performed as required. The facility had previously been cited for similar deficiencies and had submitted a plan of correction, which included staff education and regular audits of resident rooms and common areas. However, during the current survey, many of the same issues remained unaddressed, and staff acknowledged that corrective actions had not been fully implemented. Facility leadership, including the LNHA, confirmed awareness of the ongoing environmental concerns and acknowledged the poor condition of resident rooms, bathrooms, and common areas during the survey tour.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility's Licensed Nursing Home Administrator (LNHA) failed to ensure the implementation of the facility's Quality of Life - Homelike Environment policy and procedures, resulting in a failure to provide a safe, clean, comfortable, and homelike environment for residents. During a survey, multiple deficiencies were observed across all three nursing units, including resident rooms with peeling wallpaper and paint, broken or damaged furniture, soiled and stained floors, stained toilet bowls, grab bars coming off the walls, holes in walls, missing trim, and discolored ceiling tiles. In addition, shower rooms were found with rusted fixtures, damaged shower curtains, broken soap holders, and missing grout. These conditions were confirmed by both staff and residents, with some residents reporting that issues such as broken furniture and soiled areas had persisted for extended periods without resolution. Staff interviews revealed a lack of consistent reporting and follow-up on maintenance issues. While some staff were aware of the process for submitting maintenance requests through a computerized work order system, not all concerns identified by the surveyor were present in the system. Housekeeping and maintenance staff stated that cleaning and maintenance tasks were performed regularly, but acknowledged that certain issues, such as rust stains in toilets and soiled air conditioning units, had not been adequately addressed. The Environmental Service Director and other staff confirmed the presence of these deficiencies during the surveyor's walkthroughs. The LNHA and other facility leadership acknowledged awareness of the environmental issues and confirmed that many of the problems identified by the surveyor were known to them. Despite previous citations for similar deficiencies and a plan of correction that included regular audits and cleaning protocols, the survey found that many of the same issues persisted. Documentation provided by the facility, such as a quote and a check for new furniture, did not demonstrate that corrective actions had been completed, and there was no evidence that the necessary repairs or replacements had been made at the time of the survey.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment across multiple units, as evidenced by several observations made by the surveyor. On the initial tour, the surveyor noted dirty and discolored floors in the lobby and elevators. In resident rooms, there were issues such as soiled and sticky floors, overflowing trash, broken furniture, and missing or damaged fixtures. The Registered Nurse acknowledged awareness of these issues but admitted to not reporting them through the facility's computer system, which is used to notify housekeeping and maintenance departments. Interviews with various staff members, including the Housekeeping Director, Maintenance Assistant, and Licensed Practical Nurse, revealed a lack of communication and follow-through regarding maintenance and housekeeping concerns. The Maintenance Assistant and Housekeeping Director were unaware of specific issues until pointed out by the surveyor, and the Maintenance Director confirmed that maintenance issues should be addressed within 24 hours of receiving a work order. However, the system's effectiveness was questioned as several staff members reported that concerns were not always addressed promptly. Further observations included damaged walls and furniture in the dining room and resident rooms, as well as unsanitary conditions in the shower room. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the poor environmental conditions and mentioned discussions with corporate about replacing furniture, but no concrete plans were provided. The facility's policies on maintenance and housekeeping were not effectively implemented, leading to the observed deficiencies.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store potentially hazardous foods properly and maintain kitchen equipment in a sanitary manner, as observed by the surveyor. In the walk-in freezer, an opened box of raviolis and an opened box of chicken breasts were found in unsealed bags, exposing the contents to air and ice crystals. These items were not labeled with opened or use-by dates, and the Food Service Director (FSD) could not confirm when the packages were opened. Additionally, the steam table contained murky water with food particles, indicating it had not been drained and cleaned as required. The FSD admitted that the steam table water should be changed daily, but there were no work accountability logs to verify when it was last done. Furthermore, four plastic cutting boards were found to be deeply pitted and discolored, suggesting inadequate cleaning and maintenance. The FSD acknowledged that the freezer items should have been labeled and sealed, and that the cooking equipment should have been cleaned to prevent foodborne illness. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were informed of these issues but did not provide additional information. The facility's policies on sanitation and food storage were reviewed, revealing requirements for maintaining cleanliness and proper labeling, which were not adhered to in this instance.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as observed during a survey. On the Third-floor high side nursing unit's medication cart, fourteen individual, single-use vials of ipratropium bromide/albuterol sulfate inhalation solution were found in an opened foil pouch with a hand-written opened date of 1/2/24, despite the manufacturer's instructions indicating the medication should be used within two weeks of opening. Similarly, on the Second-floor low side nursing unit's medication cart, two boxes of the same medication were found with opened foil pouches, one dated 12/7 and the other undated, both exceeding the recommended usage period. The LPNs present confirmed the medications were expired and should have been discarded. Additionally, the Second-floor medication storage room contained improperly stored medical supplies and expired medications. Items such as sterile dressings, feeding tube irrigation sets, and nebulizer machines were stored in a cabinet under the sink, which was confirmed by the LPN/Unit Manager to be an unacceptable storage area due to infection control risks. Expired intravenous solutions were also found in the storage room. The Director of Nursing and the Infection Preventionist acknowledged the deficiencies, confirming that medications should be labeled with the date opened and discarded upon expiration, and that medical supplies should not be stored in areas that pose an infection control risk.
Deficiency in Resident Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents in one of the three dining rooms. On February 13, 2025, during the lunch meal on the third-floor nursing unit, 14 residents were served cold beverages in disposable plastic cups. This practice was observed by the surveyor and was not refuted by the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) during an interview on February 14, 2025. The facility's Assistance with Meals policy, revised in March 2022, emphasized meal assistance with attention to safety, comfort, and dignity but did not address the use of non-disposable dinnerware. This oversight led to a deficiency in promoting dignity and respect for the residents' dining experience.
Failure to Provide Lock for Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure that a resident was provided with a lock to prevent the loss or theft of personal items. This deficiency was identified for a resident who was cognitively intact and independent in activities of daily living. The resident had requested a lock for their closet door after being moved to a new room, as they experienced instances where their closet was found open in the morning. Despite the request being documented in the facility's work order system, the lock and necessary hardware were not installed on the closet door. Interviews with facility staff revealed that the Licensed Practical Nurse/Unit Manager was aware of the lock request and had notified maintenance through the TELS system. However, the facility's policy required the family or resident to provide the padlock, while the facility provided the hardware. The Maintenance Director confirmed that he was informed of such requests through the work order system. The Licensed Nursing Home Administrator stated that the facility did not provide locks for residents, indicating a gap in the process that led to the resident's request not being fulfilled.
Medication Cart Security Lapse During Administration
Penalty
Summary
The facility failed to ensure that the medication cart was secured during medication administration, which is a violation of professional standards of clinical practice. This deficiency was observed when an LPN left the medication cart unlocked and out of sight while administering medications to a resident. The incident occurred when the LPN parked the medication cart outside the resident's room, sanitized their hands, and prepared the medications, including oral medications and injectable insulin pens. The LPN then walked to the resident's bedside, leaving the cart unattended and unlocked, despite acknowledging that it should have been locked. The facility's policy on administering medications requires that the medication cart be kept closed and locked when out of sight of the medication nurse or aide. During an interview, the LPN/Unit Manager confirmed that nurses should always lock the cart and minimize the computer screen when stepping away. The surveyor discussed the findings with the Licensed Nursing Home Administrator and the Director of Nursing, who did not dispute the observations. The deficiency was identified for one of the four residents observed during medication administration.
Failure to Obtain Physician's Order and Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the care of oxygen tubing and did not develop a comprehensive care plan for a resident receiving oxygen therapy. During an initial tour, a surveyor observed an oxygen concentrator in a resident's room with nasal oxygen tubing improperly placed. The resident, who had moderate cognitive impairment and medical diagnoses including chronic obstructive pulmonary disease, heart failure, and kidney failure, informed the surveyor that they had removed the oxygen. The physician's order for oxygen administration was present, but there was no order for changing the nasal cannula tubing, and the tubing changes were not being documented in the Electronic Medical Record (EMR). The facility's policy on oxygen administration, last revised in 2010, did not include guidelines for the care of oxygen tubing. Additionally, the resident's comprehensive care plan lacked a focus area for respiratory care or oxygen. When questioned, the Director of Nursing confirmed that a care plan should be in place for any resident receiving oxygen therapy. This deficiency was identified in one of the four residents reviewed for oxygen therapy.
Narcotic Count Log Deficiency
Penalty
Summary
The facility failed to ensure the accountability of narcotic shift count logs, as observed by surveyors on two of three medication carts. On the third-floor high side nursing unit's medication cart, a pre-signed outgoing nurse signature was found for the shift-to-shift narcotic count for a specific shift. The LPN confirmed that the log was pre-signed and should have been signed in the presence of the incoming nurse after a narcotic count was completed. On the second-floor low side nursing unit's medication cart, multiple missing nurses' signatures were identified for various shifts throughout January 2025. The LPN confirmed that the incoming and outgoing nurses were supposed to count the narcotics together and sign the log at the time of shift change. The Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that medication cart narcotics were to be counted and immediately signed by the incoming and outgoing nurses at the time of shift change. They acknowledged that there should not have been any pre-signed spaces or blanks for previous shifts, and missing documentation indicated the count was not done. The facility's Controlled Substance policy, revised in November 2022, requires nursing staff to count controlled medication inventory at the end of each shift, with both the incoming and outgoing nurses making the count together and documenting any discrepancies.
Improper Garbage Disposal and Grounds Maintenance
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, leading to a potential rodent and pest problem. During a tour of the facility grounds and loading dock area, the surveyor observed construction debris, broken pallets, plastic wrap, Styrofoam panels, and paper litter scattered across the grassy side yard visible from the first-floor residents' windows. Additionally, numerous cigarette butts were found on the ground along the driveway and grassy area, with a cigarette receptacle lying on its side. Behind a short brick wall, more construction debris, metal benches, milk cartons, and tarps were found haphazardly thrown. Further observations behind a large blue storage trailer shed revealed orange milk crates, construction trash, soda cans, and gloves on the ground. Around the facility's three green trash dumpsters, gloves, soda cans, and cigarette butts were also present. The Licensed Nursing Home Administrator (LNHA) acknowledged the concern, stating it was unfair for residents to view such conditions and that the trash could lead to a rodent and pest problem. Interviews with the Maintenance Director (MD) and Housekeeping Director (HD) revealed that both were unaware of their responsibilities for grounds maintenance until recently. The facility's undated policies on grounds maintenance, food-related garbage and refuse disposal, and smoking were reviewed, indicating that maintenance should keep the grounds free of litter and that storage areas should be kept clear at all times.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to appropriate infection control practices during medication administration, as observed by a surveyor. Specifically, an LPN was seen preparing medications for a resident without performing hand hygiene or donning clean gloves. The LPN used their bare fingers to handle a vitamin tablet, which is against the recommended practices for infection control. When questioned, the LPN acknowledged the mistake and admitted that the contaminated tablet should have been discarded. Further interviews with other staff members, including another LPN and the LPN/Unit Manager, revealed inconsistencies in the understanding and implementation of proper procedures for obtaining medications from a bottle. The staff members provided varying responses regarding the use of gloves and hand hygiene, indicating a lack of uniformity in following the facility's hand hygiene policy. The facility's policy states that hand hygiene should be performed before and after handling medications, but this was not consistently practiced by the staff.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident sexual abuse involving two residents, one with severe cognitive impairment and the other with moderate cognitive impairment. The incident was reported by a family member of the alleged victim, who observed the two residents in a compromising situation. The family member's email described finding the alleged victim partially undressed and frazzled, with a staff member allegedly stating that such interactions were common and left unaddressed. The License Nursing Home Administrator (LNHA) received the grievance via email and forwarded it to the Social Worker (SW) with instructions to write a grievance. However, the SW did not initiate an investigation or follow the facility's policies on abuse reporting and investigation. The SW attempted to arrange an Interdisciplinary Care Team (IDCT) meeting to address the grievance but did not complete the grievance process or involve key staff members such as the Director of Nursing (DON) or the Unit Manager. Interviews with facility staff revealed a lack of awareness and communication regarding the alleged incident. The Unit Manager and Behavioral Monitoring Aide were unaware of any resident-to-resident sexual abuse, and the assigned CNA had never observed the two residents together. The facility's policies on abuse prevention and investigation were not followed, as the Administrator did not ensure a thorough investigation or keep the resident and family informed of the investigation's progress.
Removal Plan
- Initiating an investigation related to the grievance/allegation of the resident to resident sexual abuse.
- Completing an assessment related to any signs and symptoms of psycho-social concerns.
- Initiating in-services for the SW and all staff on the facility's policy on Abuse and Neglect, Investigating and Reporting, the Abuse Prevention Program Policy, and the Grievance Policy and Procedure.
- Auditing of incidents and accident reports and grievances to ensure there were not any additional unresolved investigative allegations of abuse, abuse, and neglect identified.
Failure to Address Grievance of Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Grievance Policy and Procedure and the Social Worker Job description after a family member of a resident made an allegation of sexual abuse. The incident involved two residents, one with severely impaired cognition and the other with moderate cognitive impairment. The family member reported finding the resident in a compromised state with another resident in the room, and a staff member allegedly stated that such incidents were known but not addressed. The grievance was initially reported via email to the Licensed Nursing Home Administrator (LNHA), who forwarded it to the Social Worker (SW) for investigation. However, the SW did not conduct a comprehensive investigation or involve key personnel such as the Director of Nursing (DON), unit manager, or other nurses. The SW suggested an Interdisciplinary Care Team (IDCT) meeting to address the grievance, but the family member could not attend. The grievance process was not completed as per the facility's policy, and the IDCT did not review the complaint in a timely manner. Interviews with various staff members, including the Unit Manager, Behavioral Monitoring Aide, and Certified Nursing Assistant, revealed a lack of awareness of any resident-to-resident sexual abuse. The facility's policy requires prompt investigation and resolution of grievances, but this was not adhered to in this case. The Director of Nursing was unaware of the grievance, and the LNHA expected a full investigation, which was not carried out, leading to the deficiency.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility's administration failed to conduct a thorough and complete investigation into an allegation of resident-to-resident sexual abuse, as required by their policies. This deficiency was identified during a survey conducted on specific dates in November 2024. The incident involved two residents, one of whom was found in a compromised state by a family member. The family member reported the incident via email, describing how they found their relative partially undressed and distressed, with another resident quickly leaving the room. The family member also mentioned that a staff member had previously observed similar incidents but did not intervene. The facility's policies on abuse prevention, grievance handling, and investigation were not followed. The Licensed Nursing Home Administrator (LNHA) received the complaint but did not read it immediately and only forwarded it to the Social Worker (SW) the following day. The SW, upon receiving the email, attempted to investigate by speaking with Certified Nursing Assistants (CNAs) but did not engage with other key personnel such as nurses, the Director of Nursing (DON), the Unit Manager, or the Administrator. This lack of comprehensive investigation and communication among staff members contributed to the failure to address the serious allegation appropriately. The facility's policies clearly outline the responsibilities of the administration in investigating allegations of abuse, ensuring resident safety, and maintaining open communication with residents and their families. However, these procedures were not adequately implemented in this case. The Administrator's job description emphasizes the importance of directing the facility's functions in compliance with regulations to ensure quality care, which was not achieved in this instance. The failure to follow established protocols and ensure a thorough investigation highlights significant lapses in the facility's management and oversight of resident safety and rights.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 401 citations issued within 25 miles in the last 12 months — including the 20 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Toms River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Green Acres | 1.5 mi | ★★★★★ | 0 | 0 |
| Harrogate Village | 2 mi | ★★★★★ | 15 | 0 |
| Hampton Ridge Healthcare And Rehabilitation | 2 mi | ★★★★★ | 9 | 0 |
| Childrens Specialized Hospital Toms River | 2 mi | ★★★★★ | 0 | 0 |
| Leisure Chateau Rehabilitation | 2.2 mi | ★★★★★ | 15 | 0 |
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