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 Pointe Care Center during CMS and state inspections, most recent first.
A severely cognitively impaired resident with a history of wandering eloped from the facility without staff knowledge. The resident was last seen by nursing staff, and a search was initiated after the resident was found missing. Despite existing policies, only wandering risk assessments were performed, and the resident was not placed on frequent monitoring. Staff were unsure how the resident exited, and there was no clear protocol for increased supervision for exit-seeking behavior, resulting in the resident being found by police in a nearby town.
A facility failed to maintain a resident's nutritional and hydration status, resulting in significant weight loss over six months. The resident's dietary preferences were not adequately addressed, and the facility relied on infrequent family visits for nutritional support. Staff did not consistently monitor or record the resident's intake of prescribed supplements, and there was a lack of suitable dietary interventions.
The facility failed to ensure menus were reviewed for nutritional adequacy, leading to discrepancies in dietary care for residents. Menus were not signed by a qualified nutrition professional, and residents received meals that did not match their preferences or physician's orders. The dietitian admitted to a lack of a formal follow-up system to ensure dietary changes were implemented.
The facility failed to ensure the Infection Preventionist (IP) was dedicated solely to the Infection Prevention and Control Program, as the IP was also acting in another role and spent limited time on IP duties. Despite the IP's assurance of up-to-date infection control measures, the facility did not comply with the requirement for a full-time IP dedicated solely to infection prevention and control.
The facility did not maintain clear exit discharges, as ice and snow were observed on pathways at multiple exits, including those by the employee entrance, Kitchen, and Room 105. Staff confirmed awareness of the need for snow and ice removal, affecting all 131 residents.
The facility failed to maintain its sprinkler system per NFPA 25 standards, affecting all 131 residents. Ice buildup was found on a sprinkler head in the freezer, and a missing escutcheon plate was noted in the dishwashing room. The facility lacked documentation for weekly inspections of the dry sprinkler system gauges.
The facility was found to have unsealed penetrations in smoke barriers, including gaps and overcuts in various locations such as near the Dining Room, Room 210, the Korean Office, the Break Room, and the Beauty Salon. This repeat deficiency, previously cited in a past survey, was confirmed by a facility representative who was unaware of the issue, potentially affecting all 131 residents.
The facility failed to maintain smoke barrier doors, affecting 42 residents. A door in the corridor by Room 104 did not close properly due to rubbing the floor, and a door between Rooms 210 and 211 lacked a self-closing device. Staff were unaware of these issues before the survey.
The facility failed to provide documentation of the annual tests and inspections of fire door assemblies as required by NFPA 80. During a record review, it was found that the documentation was missing from the Life Safety Code Survey Binder. Despite requests at various points, the documentation was not provided, and a staff member confirmed the inability to locate it. This deficiency had the potential to affect all 131 residents.
The facility failed to provide documentation of testing and performance data for electrical receptacles at patient bed locations, as required by NFPA 99. This deficiency could potentially affect all 131 residents, as the facility has a mix of hospital-grade and non-hospital-grade receptacles in resident rooms. An interview confirmed the facility's inability to locate the missing documentation.
The facility failed to maintain its generator according to NFPA 110 standards, as it could not provide documentation of the annual fuel quality test for the diesel generator. This deficiency, confirmed during an interview, had the potential to affect all 131 residents, as the generator is crucial for emergency power.
The facility failed to maintain a sanitary environment, as observed with a resident's recliner and another's wheelchair having dried substances, and an overbed table with brownish spots. Despite a cleaning schedule, these items remained uncleaned, indicating lapses in maintaining a homelike environment.
A facility failed to report and investigate a condition involving a resident until prompted by a surveyor. CNAs noticed the condition but did not report it, assuming it was known. The facility's policies required immediate reporting of such incidents, but there was a lapse in communication. The resident's medical records showed no assessment of the condition until after the surveyor's inquiry.
A registered nurse in an LTC facility borrowed medication from another resident's supply for a resident due to unavailability in the medication cart. The nurse did not follow the protocol of contacting the pharmacy or physician for guidance. Interviews revealed a lack of clarity regarding the policy on borrowing medications, although staff were instructed not to engage in this practice.
A facility failed to maintain a medication error rate below 5%, as observed during a medication pass where a nurse administered the wrong dose of a medication to a resident. The error was identified when the nurse applied a medication patch with incorrect strength to two sites on the resident. Despite inservice training on medication administration, the facility's policy did not ensure the correct dosage was administered.
The facility failed to ensure staff wore appropriate PPE for residents on Enhanced Barrier Precautions, as observed during rounds on two units. In one case, a staff member checked a resident's condition without a gown, despite signage indicating its necessity. In another instance, a staff member performed care without a gown, later claiming she had stepped out to retrieve an item. Both residents required Enhanced Barrier Precautions due to their diagnoses, highlighting non-compliance with infection control policies.
The facility failed to notify CMS and obtain authorization for a name change from "Gateway Care Center" to "Shore Point Care Center." The surveyor observed the incorrect name on the facility's signage and business cards. Facility representatives admitted the name change was for marketing purposes and had not been reported to CMS or the New Jersey Department of Health. The facility decided to revert to the original name.
The facility failed to meet New Jersey's staffing ratios for CNAs across multiple shifts and did not enforce mask-wearing for employees with medical exemptions from the influenza vaccine. Observations and interviews revealed consistent understaffing and non-compliance with mask policies, indicating lapses in regulatory adherence.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A severely cognitively impaired resident with a history of wandering behaviors eloped from the facility without staff knowledge. The resident, diagnosed with unspecified dementia, mood disturbance, anxiety, and Alzheimer's disease, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The resident was last observed by a registered nurse at approximately 4:45 p.m., and was discovered missing by their assigned certified nurse aide at around 5:05 p.m. Despite a search initiated by staff and the activation of a Code Gray (elopement/missing person code), the resident was not found within the facility. The local police later contacted the facility, having found the resident in a nearby town approximately three miles away, and returned the resident to the facility. The facility's policy required systematic monitoring and management of residents at risk for elopement or unsafe wandering, including identification, assessment, and implementation of interventions to reduce risks. However, interviews with staff and review of facility documents revealed that only wandering risk assessments were conducted, not elopement risk assessments. The care plan for the resident included interventions for wandering and elopement risk, but staff did not place the resident on 15-minute checks, as they were not considered exit-seeking. The Director of Nursing and the Licensed Nursing Home Administrator both stated that the facility did not perform elopement risk assessments, only wandering risk assessments, and that the care plan may have mischaracterized the resident's risk. Staff statements indicated that the resident was known to wander and pace the unit, but there was no clear protocol for increased supervision or monitoring for exit-seeking behavior. The facility was unable to determine how the resident exited the building, as all doors were reported to be locked. The receptionist did not observe the resident leaving through the front entrance, and dietary and housekeeping staff did not recall seeing the resident exit. The lack of adequate supervision and failure to properly assess and monitor for elopement risk led to the resident's unsupervised departure from the facility.
Removal Plan
- All residents were visually checked to be sure they were safe and all staff facility wide were informed to check all residents to ensure safety.
- A complete head count of residents was conducted, and all other residents were accounted for.
- Audit to review the residents at risk of elopement assessments was conducted.
- Full house audit for residents at risk for elopement with review and revision of the care plans was conducted. This included implementation of interventions consistent with the residents' needs, goals and care plans to reflect current risk of elopement.
- The residents were monitored when noted in the common areas such as dayroom, dining rooms, and attending activities.
- The facility has now increased the monitoring to Q 15-minute monitoring Q shift.
- Staff were re-educated on the Elopement Policy and Procedure.
- At risk residents for elopement are identified with a discreet visual indicator listed under special instructions in the residents EMR (Electronic Medical Records).
- Elopement binders located on each unit and front entrance were reviewed and revised with the resident's profile picture in color.
- All exits, windows, and keypads were checked and functioning.
- Keypad codes were changed.
- Facility added monitoring rounds every 15 minutes for identified high-risk residents to maintain safety.
- Audit monitoring tool sheets will be completed by direct care staff and completion reviewed by the DON/Designee.
- Facility implemented a new protocol for Family/Vendors/Visitors to sign in upon entering and sign out prior to exiting the facility.
- Director of Maintenance conducted a full house audit of the keypad doors and windows noted secured, and functioning.
- The facility Director of Maintenance, Director of Housekeeping, and the Administrator will maintain the keypad codes.
- Director of Maintenance will revise the schedule for changing keypad codes, making changes more frequent to monthly to the exit doors located at the end of the units.
- Visitor Communication Signage is located at the vestibule alerting visitors and staff to monitor the surroundings prior to entering the lobby to ensure the safety of the residents.
- Facility Educator provided mandatory re-education for staff (nursing, direct care, dietary, housekeeping, maintenance, and department heads) on elopement prevention, supervision, and emergency response.
- Ongoing training will be provided with any staff on all shifts or vacations prior to the start of the next schedule shift.
- Facility Educator will continue to incorporate the Elopement prevention training into new hire orientation and annual education.
- Facility Educator provided mandatory training on the new implementation of identifying residents at risk for elopement under special instructions in the residents EMR (Electronic Medical Records).
- Facility Administrator conducted QAPI Ad Hoc (Quality Assurance and Performance Improvement) meeting with the Interdisciplinary Team to review the residents at risk for elopement care plans, interventions and elopement assessments.
- Quarterly elopement drills will be conducted to reinforce emergency response.
- Monthly review of elopement risk assessments by the interdisciplinary team will be conducted and revised as needed.
- A QAPI (Quality Assurance and Performance Improvement) has been initiated to report on the above monitoring and auditing procedures.
- Results of the audits and findings, if any, will be presented to the monthly QAPI (Quality Assurance and Performance Improvement) meeting for review and revised as deemed appropriate.
- Monitoring/Auditing and reporting will continue for a minimum of three months.
Failure to Maintain Resident's Nutritional and Hydration Status
Penalty
Summary
The facility failed to maintain the nutritional and hydration status of a resident, as evidenced by the lack of appropriate interventions and monitoring. The resident experienced significant weight loss over a period of six months, which was not adequately addressed by the facility's staff. Despite the resident's preferences and dietary needs being known, the facility did not provide suitable alternatives or ensure the resident received the necessary nutrition and hydration. Observations revealed that the resident often had untouched meals and supplements, and there were instances where no lunch tray was provided. The facility relied on the resident's family to bring in preferred foods during their infrequent visits, which was not a reliable intervention. The staff failed to consistently monitor and record the resident's intake of physician-prescribed supplements, and there was no evidence of weekly monitoring of the resident's nutritional status. Interviews with staff indicated a lack of awareness and action regarding the resident's nutritional needs. The staff did not implement or document necessary interventions, such as offering suitable substitutes or adjusting the resident's diet to meet their preferences and needs. The facility's policies on weight management and nutritional procedures were not followed, leading to the resident's continued weight loss and inadequate nutritional support.
Plan Of Correction
Element 1 Resident #67's diet was liberalized to regular. [R]NJ Exec Order 26.4b1 was increased from three times a day to four times a day. The physician added an [R]NJ Ex Order 26.4(b)(1) and provided [R]NJ Ex Order 26.4(b)(1) that the resident enjoys based on their [R]EXOT preferences and enjoyment of a [R]. Element 2 [R]NJ Ex Order 26.4(b)(1) All residents have the potential to be affected by this deficiency. Element 3 The facility has hired an experienced Dietician with extensive knowledge in the management of residents with weight loss. Additionally, a Weight Loss audit is being conducted to review newly identified significant weight losses (5% weight loss in 30 days, or 10% weight loss in 180 days) in order to remain in compliance with F692. This audit began on 1/27/2025 and is reviewing all residents in the facility. The results of the audit indicated one newly identified weight loss in the month of January. Element 4 To maintain and monitor ongoing compliance, the Weight Loss audit is being conducted by the Dietician or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Menu Review and Nutritional Adequacy Deficiencies
Penalty
Summary
The facility failed to ensure that menus were reviewed and approved for nutritional adequacy in accordance with nationally accredited standards. During a kitchen tour, it was revealed that the facility followed a three-week cycle menu, but the menus provided were not signed or dated by a qualified nutrition professional to confirm their adequacy. Additionally, the facility's dietitian was unaware of who developed or reviewed the menus, indicating a lack of oversight and accountability in the menu planning process. The surveyors found discrepancies in the dietary care provided to three residents. For instance, one resident's care plan included a physician's order for a specific dietary supplement twice a day, but this was not reflected in the resident's dietary records or meal tickets. Similarly, another resident's preferences and physician's orders were not accurately documented or followed, leading to inconsistencies in the meals served. These issues were compounded by the dietitian's admission that there was no formal system to ensure that dietary recommendations and updates were implemented. Interviews with residents and staff further highlighted the deficiencies. Residents reported receiving meals that did not match their documented preferences, and the dietitian acknowledged the lack of a formal follow-up system to verify that dietary changes were executed. The facility's electronic medical record system was supposed to link with the food service software to automatically update dietary information, but manual errors and communication breakdowns persisted, resulting in unmet nutritional needs and preferences for the residents.
Plan Of Correction
Element 1 This deficiency was corrected by having the NJ Ex Order 26.4(b)(1) and NJ Ex Order 26.4 Menus reviewed and approved by a Licensed Dietitian. Additionally, a Food Preference audit was performed to ensure that all resident food preferences were included in the facilities meal ticket system, and that the residents received meals based on their food preferences. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Food Preference audit was performed on 1/27/2025 to ensure all residents' food preferences were included in the facilities meal ticket system, and that the residents received meals based on their food preferences. During the audits, seven residents expressed additional food preferences, which were immediately added to the meal ticket system. Additionally, the food preference audit will continue to ensure that the facility remains in compliance with F803. Element 4 To maintain and monitor ongoing compliance, a Food Preference audit is being conducted by the dietitian or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Inadequate Dedication of Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was dedicated solely to the Infection Prevention and Control Program (IPCP) as required by regulations. The IP, who was also acting in another role, indicated that she spent only an hour to an hour and a half each day on her IP duties, with the majority of her time spent on other responsibilities. This was contrary to the requirement that facilities with 100 or more beds must hire a full-time employee in the infection prevention role with no other responsibilities. The surveyor's interviews revealed that the IP position was part-time and temporary, and there was uncertainty about whether the allocated hours were sufficient for the role. Despite the IP's assurance that infection control measures were up to date, the facility did not comply with the directive to have a full-time IP dedicated solely to infection prevention and control, as evidenced by the job description and position action form provided by the facility.
Plan Of Correction
Element 1 Upon identification of the issue regarding the employee covering Infection Prevention (IP) and Unit Manager duties, the employee's role and responsibilities were reviewed. A formal assessment was completed to ensure the employee was properly supported in these dual roles and was provided with the necessary training and resources. The facility transitioned a current staff nurse to the dedicated Unit Manager position effective 1/27/2025, and the employee covering these roles was transitioned back to their original full-time duties as the dedicated Infection Preventionist with no other responsibilities. Element 2 All residents have the potential to be affected. Element 3 The facility has established a more structured planning protocol to ensure continuity of care and leadership in all key roles, including Infection Preventionist and Unit Manager. A permanent, qualified Infection Preventionist and Unit Manager have been appointed immediately to ensure clear leadership and responsibility in these areas. Element 4 The facilities leadership (Administrator and Director of Nursing) will meet with the Infection Preventionist and Unit Manager monthly for continued support in their roles and will be reassessed to ensure they are meeting the requirements of their positions.
Failure to Maintain Clear Exit Discharges
Penalty
Summary
The facility failed to maintain means of egress free of obstructions as required by NFPA 101 Life Safety Code (2012 Edition), Section 7.1. Observations made on January 7, 2025, revealed ice and snow buildup on the pathways from the building to the public way at multiple designated exit discharges, including those located by the employee entrance and 200 Hall, the Kitchen, and Room 105. During interviews conducted at the time of the observations, the staff confirmed the findings and acknowledged awareness that the snow and ice on the sidewalks needed to be removed. This deficiency had the potential to affect all 131 residents of the facility.
Plan Of Correction
Element 1 This deficiency was corrected by shoveling the snow and salting all exit discharge pathways from the building to the public way. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Snow/Ice audit is being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K271. This audit will be completed by making rounds around the facility. Element 4 The Snow/Ice audit is being monitored by the Administrator or designee weekly for four weeks, then every other week for four weeks, and then monthly for one month. If the facility experiences any snow or icy conditions, the audit will be performed on that day, as well as the following day to ensure safe conditions. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for three months to the Quality Assurance Performance Improvement team for review and action as necessary.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, which had the potential to affect all 131 residents. During an observation, ice buildup was found on the deflector of a sprinkler head inside the walk-in freezer. The facility was aware of this issue prior to the survey. Additionally, in the dishwashing room closet, the escutcheon plate was missing from a sprinkler, a fact also known to the facility before the survey. Further review of the facility's sprinkler system records revealed a lack of documentation for weekly inspections of the gauges for the dry sprinkler system. During an interview, the facility confirmed the absence of these records and acknowledged their inability to provide documentation of the weekly inspections during the survey.
Plan Of Correction
Element 1 This deficiency was corrected by removing the ice build up on the sprinkler head deflector located inside the walk-in freezer, replacing the escutcheon plate on the sprinkler head located in the dishwashing room closet, and performed weekly inspections of the gauges for the dry sprinkler system. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Sprinkler Head audit and Dry Sprinkler System Gauge audit are being conducted by the Maintenance Director or designee to ensure that the facility remains in compliance with K353. This audit is being completed by making rounds within the facility to ensure they are being completed. Element 4 The Sprinkler Head audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. The Dry Sprinkler System Gauge audit will be performed weekly on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Unsealed Smoke Barriers in Facility
Penalty
Summary
The facility failed to ensure that penetrations in smoke barriers were adequately sealed, as required by the NFPA 101 Life Safety Code (2012 Edition) Section 8.5. During observations conducted on January 7, 2025, several unsealed gaps and overcuts were identified in various locations throughout the facility. These included a two-inch unsealed overcut around conduit penetrations near the Dining Room, a similar unsealed overcut around wire penetrations by Room 210, and a six-inch unsealed gap at the top of the wall in the Korean Office. Additional unsealed gaps were found in the Break Room and near the Beauty Salon. The deficiency was confirmed during an interview with a facility representative, who acknowledged the findings and admitted that the facility was unaware of the unsealed gaps and penetrations in the smoke barriers. This issue was a repeat deficiency, having been previously cited during the Life Safety Code Survey conducted on September 29, 2023. The unsealed penetrations in the smoke barriers had the potential to affect all 131 residents in the facility.
Plan Of Correction
Element 1 This deficiency was corrected by sealing all openings within the smoke barriers including: the two inch overcut around two conduit penetrations above the ceiling located in the corridor by the dining room, the two inch overcut around the blue wire penetrations above the ceiling located in the corridor by room 210, the six inch gap at the top of the wall above the ceiling located inside the Korean Office, the two inch gap at the top of the wall above the ceiling located inside the break room, and the four inch gap in the wall above the ceiling located in the corridor by the Beauty Salon. Element 2 All residents have the potential to be affected by this deficiency. Element 3 A Smoke Barrier audit is being conducted by the Maintenance Director to ensure that the facility remains in compliance with K372. This audit will be completed by making rounds within the facility to view the smoke barriers. Element 4 The Smoke Barrier audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Smoke Barrier Door Deficiencies
Penalty
Summary
The facility failed to maintain smoke barrier doors in accordance with NFPA 101 (Life Safety Code) 2012 Edition, Section 8.5, which had the potential to affect 42 residents. During an observation, a smoke barrier door located in the corridor by Room 104 did not close smoke tight when released from the magnetic hold open device, stopping halfway between the open and closed position. The facility staff confirmed the door was rubbing the floor and was unaware of this issue prior to the survey. Additionally, another observation revealed that a smoke door located in the bathroom between Rooms 210 and 211 lacked a self-closing device. The facility staff confirmed the absence of the self-closing device and stated they were unaware of this deficiency before the survey.
Plan Of Correction
Element 1 This deficiency was corrected by preventing the door from rubbing against the floor in the corridor near room 104, allowing the smoke barrier door to fully close and latch. Additionally, a self-closing device was installed on the bathroom door between rooms 210 and 211. Element 2 This deficiency has the potential to affect forty-two residents on the East Wing. Element 3 A Smoke Barrier Door audit is being conducted by the Maintenance Director or designee to ensure the facility remains in compliance with K374. This audit will be completed by making rounds within the facility. Element 4 The Smoke Barrier Door audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Missing Documentation for Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation of the annual tests and inspections of the fire door assemblies as required by NFPA 80, Section 5.2. This deficiency was identified during a record review conducted on January 7, 2025, at 3:30 PM, where it was discovered that the documentation was missing from the facility's Life Safety Code Survey Binder. The surveyor requested this documentation at multiple points, including the entrance conference, during the record review, and at the exit conference, but it was not provided. During an interview at the same time, a staff member confirmed the finding and stated that the facility was unable to locate the missing documentation during the survey. This deficient practice had the potential to affect all 131 residents in the facility.
Plan Of Correction
Element 1 This deficiency was corrected by performing tests and inspections of the fire door assemblies. Element 2 All residents had the potential to be affected by this deficiency. Element 3 A Fire Door Assembly audit is being conducted by the Maintenance Director to ensure that the facility remains in compliance with K761. This audit is being completed by making rounds within the facility. Element 4 The Fire Door Assembly audit is being monitored by the Administrator or designee once a month for six months and then performed annually on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Document Electrical Receptacle Testing
Penalty
Summary
The facility failed to provide documentation of testing and performance data for electrical receptacles at patient bed locations, as required by NFPA 99 (2012), Section 6.3.4. This deficiency was identified during a review of the facility's Life Safety Code Survey documentation binder, where the necessary documentation was not available. The surveyor requested this documentation at multiple points, including the entrance conference, document review, and exit conference, but the facility was unable to produce it. The deficiency has the potential to affect all 131 residents in the facility, as the documentation pertains to both hospital-grade and non-hospital-grade receptacles in resident rooms. An interview with a facility representative confirmed the finding and revealed that the facility could not locate the missing documentation, indicating a lapse in maintaining required records for electrical system maintenance and testing.
Plan Of Correction
Element 1 This deficiency was corrected by conducting performance tests on the receptacles. Element 2 This deficiency has the potential to affect all residents. Element 3 A Receptacle audit was conducted by the Maintenance Director or designee to ensure the facility remains in compliance with K914. This audit is being completed by making rounds within the facility. Element 4 The Receptacle audit is being monitored by the Administrator or designee once a month for six months and then performed annually on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 Emergency Power and Standby Power Systems (2010 Edition), specifically Section 8.3.8. During a record review, it was discovered that the facility did not provide documentation of the annual fuel quality test for the diesel generator. This documentation was requested multiple times, including at the entrance conference, during the record review, and before the exit conference, but was not provided. An interview conducted on the same day confirmed the finding, with a staff member acknowledging the facility's inability to locate the missing documentation. This deficiency had the potential to affect all 131 residents in the facility, as the generator is a critical component of the facility's emergency power system.
Plan Of Correction
Element 1 This deficiency was corrected by performing the fuel quality test of the diesel generator. Element 2 This deficiency has the potential to affect all residents. Element 3 A Generator audit is being conducted by the Maintenance Director to ensure the facility remains in compliance with K918. This audit is being completed by reviewing the inspection book. Element 4 The Generator audit is being monitored by the Administrator or designee every three months for the next twelve months to ensure that this test is being performed annually. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for twelve months to the Quality Assurance Performance Improvement team for review and action as necessary.
Facility Fails to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by observations made by a surveyor. Resident #90 was observed in a recliner with dried brown substances on the sides of the chair on multiple occasions. Despite the presence of facility staff assisting the resident with lunch, the recliner remained uncleaned over several days. The resident's admission record and recent Minimum Data Set (MDS) indicated certain diagnoses, but specific details were redacted. Similarly, Resident #125 was observed in a wheelchair with dried brownish and white substances on the left wheel. The surveyor noted this during lunch assistance, and although a staff member acknowledged the issue and promised to notify housekeeping, the wheelchair remained uncleaned the following day. The resident's admission record and MDS also contained redacted information regarding diagnoses. Resident #124 was observed with an overbed table that had multiple dried brownish spots on the bottom. Despite a housekeeper's claim of a cleaning schedule, the table remained uncleaned. The facility's policy on wheelchair and recliner cleaning was reviewed, indicating a monthly cleaning schedule, but the actual practice seemed inconsistent. Interviews with staff revealed that cleaning was often adjusted based on immediate needs, but the observed deficiencies suggested lapses in maintaining a clean environment.
Plan Of Correction
1/27/25 Element 1 It is the practice of the facility to ensure that all residents reside in a safe, clean, homelike environment. The deficiency was corrected by performing a facility wide sanitization audit of all resident care areas, including overbed tables, wheelchair and Geri chairs; all areas that were identified to be dirty were immediately cleaned. Element 2 All residents are potentially affected by this deficiency. Element 3 The systemic changes that were implemented to prevent this deficiency from occurring again include: increasing sanitization rounds on resident care areas and wheelchairs as part of the facilities Guardian Angel Program. The Guardian Angel program is a comprehensive auditing tool used to identify issues throughout the facility. This program was expanded to include all resident care areas, with special attention to wheelchairs, Geri chairs, and overbed tables, in order to remain in compliance with F584. Additionally, the Housekeeping Director and Administrator make daily rounds to ensure identified issues are corrected in a timely manner. Element 4 To maintain and monitor ongoing compliance, the Guardian Angel/Homelike Environment Audit is being conducted by all Department Heads once a week for two months, then once every other week for two months, and then monthly for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Report and Investigate Resident Condition
Penalty
Summary
The facility failed to report and initiate an investigation for a specific incident involving a resident, identified as Resident #47, until prompted by a surveyor's inquiry. The deficiency was identified when the surveyor observed Resident #47 in bed and attempted to interview them, but the resident was unresponsive. Subsequent interviews with Certified Nursing Assistants (CNAs) revealed that they had noticed a condition on the resident but did not report it, assuming it was already known by the staff. Further investigation showed that the facility had not conducted a proper investigation into the incident involving Resident #47, despite having policies in place that required immediate reporting of any suspected abuse, neglect, or injuries of unknown origin. The CNAs involved had received training on these policies, but there was a lapse in communication and reporting, as they did not inform the nursing staff about the resident's condition. The Licensed Practical Nurse (LPN) and other staff members were unaware of the issue until it was brought to their attention by the surveyor. The resident's medical records and individualized plan of care indicated that they required assistance with activities of daily living and had certain medical conditions. However, there was no documentation of an assessment being completed for the resident's condition until after the surveyor's inquiry. The facility's failure to adhere to its own policies and procedures for reporting and investigating incidents led to the deficiency being cited by the surveyor.
Plan Of Correction
Element 1 Upon discovering the NJ Exec Order 26.4b1 on resident #47, immediate steps were taken to assess the injury, ensure the residents' safety, and provide appropriate care (cleaning, applying any necessary treatment). The resident was closely monitored for any further changes in condition. The Ex was promptly documented on in the resident's medical chart. On the same day, an incident report was created to ensure a complete record of the event. An in-service was completed by the Assistant Director of Nursing for all nursing staff regarding notifying the nurse immediately of any skin alterations, as well as Abuse and Neglect policy and reporting. Element 2 The standard was not met for resident #47. All residents that are at risk for skin alterations have the potential to be affected by this deficient practice. Element 3 All nursing staff were re-educated on the facility's Abuse and Neglect policies and procedures for reporting injuries and incidents. In addition, they were re-educated on the facilities abuse reporting and prevention policy. Emphasis will be placed on the importance of documenting every skin alteration. Element 4 Incident audits have been conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance and to ensure all injuries are documented and reported appropriately. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Medication Borrowing from Another Resident's Supply
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by borrowing medication from another resident's supply. This deficiency was identified during a medication administration observation involving a registered nurse (RN#1) and Resident #122. RN#1 was observed administering medication to Resident #122 and admitted to borrowing the medication from another resident's supply because the required medication was not available in the medication cart for Resident #122. The surveyor reviewed the electronic medication administration record (EMAR) and confirmed that RN#1 had administered the borrowed medication without proper authorization. The nurse educator at the facility confirmed that nurses were not allowed to borrow medications from other residents and that the facility had a stock of over-the-counter medications available for residents with physician orders. Despite this, RN#1 did not follow the protocol of contacting the pharmacy or the physician for guidance when the medication was unavailable. Interviews with facility staff, including the nurse educator and other nursing staff, revealed a lack of clarity regarding the policy on borrowing medications. The nurse educator stated that borrowing medications could lead to medication errors and emphasized that nurses were instructed not to engage in this practice. However, there was no documented policy available at the time of the survey to reinforce this directive.
Plan Of Correction
Element 1 Upon identification of the error to resident #122 U.S. FOIA (b)(6), immediate corrective actions were implemented. The resident's condition was assessed for any adverse effects resulting from the NJ Exec Order 26.4b1 administration. The physician was notified and consulted to determine if any additional medical intervention was required. The physician initially provided a one-time order for the NJ Exec Order 26.4b1 that was applied. Additionally, the order was permanently revised to [R]. The nurse who administered the incorrect [R] was counseled and re-educated on the proper administration procedures for [R], including verifying the correct strength per the physician's order. A medication error form was completed right away, and she was successfully re-med passed by the Assistant Director of Nursing. All nurses were educated on the following: not to borrow any medications, NJ Exec Order 26.4b1 are over the counter and [R] is a prescription, and the right of medication pass (right patient, right drug, right dose, right dosage form, right route, right time). A follow-up monitoring plan was implemented to ensure the residents' comfort and safety were maintained and effective with the new order for [R]. A review of all residents receiving NJ Exec Order 26.4(b)(1) treatments, including NJ Exec Order 26.4b1, was conducted. An audit was completed ensuring all residents' [R] were in stock and had the appropriate dose in place. Element 2 All residents receiving topical analgesic treatments, including lidocaine patches, are at risk. Element 3 All nurses were educated on the proper procedure of medication administration by the Assistant Director of Nursing. RN#1 was med passed from the facility's pharmacy consultant with a 0% medication error rate on 1/24/25. A medication error form was completed right away for RN#1, and she was successfully re-med passed by the Assistant Director of Nursing. The Pharmacy consultant will continue to do their monthly unit inspections and medication passes. Element 4 Patch spot check audits will be conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance for residents who are receiving patches to ensure the right dosage was applied and available. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to ensure that all medications were administered without a medication error rate of 5% or more. During a morning medication administration observation, a surveyor observed three nurses administering medications to six residents. Out of 27 opportunities, two errors were observed, resulting in a medication administration error rate of 7.4%. The errors were identified for one resident, who was administered medications by one of the three nurses observed. The deficiency was evidenced when a Registered Nurse (RN#1) administered the wrong dose of a medication to a resident. The RN was observed applying a medication patch to two different sites on the resident, but the strength of the medication applied was not as ordered. The RN acknowledged the error after the surveyor pointed it out, and it was confirmed that the physician was contacted regarding the error. The facility's medication administration policy did not reflect procedures for ensuring the administration of the correct dosage. The surveyor's review of the resident's medical record revealed active physician orders for the medication to be applied to two different sites. The facility's staff, including the person responsible for nursing staff education, acknowledged the error and stated that the nurse should have contacted the physician if the correct medication was not available. The facility had provided inservice training on medication administration, but the error still occurred, indicating a lapse in following the correct medication pass procedures.
Plan Of Correction
Element 1 Upon identifying the error with the applied to Resident #122, immediate corrective actions were taken. The resident's condition was assessed to determine if any adverse effects occurred due to the incorrect patch. The physician was promptly notified and consulted to evaluate whether any further medical intervention was necessary. The physician initially issued a one-time order for the [R], which was applied. Following this, the order was permanently revised to the NJ Exec Order 26.4b1. The nurse who administered the incorrect patch was counseled and retrained on the proper procedures for administering lidocaine patches, including verifying the correct strength based on the physician's order. A medication error form was completed immediately, and the nurse was successfully re-med passed. Element 2 All residents receiving topical analgesic treatments, such as lidocaine patches, may be at risk. Element 3 Additionally, all nursing staff were educated on key points, including: not borrowing medications, the distinction between OTC 4% lidocaine patches and prescription 5% patches, and the rights of medication administration (right patient, right drug, right dose, right dosage form, right route, and right time) by the Assistant Director of Nursing. A follow-up monitoring plan was also implemented to ensure the residents' comfort and safety with the newly revised order for the 4% lidocaine patch. A comprehensive review of all residents receiving topical analgesic treatments, including lidocaine patches, was conducted. An audit was completed to ensure that all patches in stock were properly dosed and matched the physician's orders. Element 4 Patch spot check audits will be conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance that all medications are administered according to physician orders. All residents receiving patches will be verified to ensure the correct dosage was applied and is available. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing, and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for nine months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Adhere to PPE Protocols for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) as per the facility policy and acceptable standards of infection control practice. This deficiency was observed during rounds on two units, involving two unsampled residents. In the first instance, a staff member approached a resident lying in bed, donned gloves, and checked the resident's condition without wearing a gown, despite a sign indicating that both gloves and a gown were required for high-contact resident care activities. The staff member acknowledged the oversight when questioned by the surveyor. In the second instance, another staff member was observed performing care on a different resident without wearing a protective gown, although a sign indicated that a gown was required. The staff member later explained that she had stepped out of the room to retrieve an item and did not wear a gown upon returning to complete the care. The surveyor noted that there was no evidence of a discarded gown in the room's garbage can, suggesting non-compliance with the facility's policy. Both residents involved had diagnoses that necessitated the use of Enhanced Barrier Precautions, which include donning gowns and gloves during high-contact activities to prevent the transmission of multi-drug resistant organisms. The facility's policy clearly outlines the procedures for managing such infections, yet the staff failed to adhere to these guidelines, leading to the observed deficiencies.
Plan Of Correction
Element 1 Upon discovering the breach in [R], the employees involved were immediately removed from direct care duties and counseled on the proper use of personal protective equipment (PPE) required for residents on NJ Ex Order 26.4(b)(1). On 1/3/25, all staff were retrained by the Assistant Director of Nursing on the facility's protocols regarding the appropriate use of PPE, including gloves and gowns when entering rooms of residents on enhanced barrier precautions. Element 2 All residents on Enhanced Barrier Precautions have the potential to be affected. Element 3 All staff underwent immediate re-education on the facility's enhanced barrier precaution protocols, emphasizing the importance of wearing gowns and gloves when caring for residents on enhanced barrier precautions. Staff were also re-educated on how to identify which residents need these precautions; all re-education was conducted by the Assistant Director of Nursing. Element 4 Enhanced Barrier Precaution spot check audits are being conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance with PPE protocols for residents on enhanced barrier precautions. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Failure to Notify CMS of Facility Name Change
Penalty
Summary
The facility failed to notify the Centers for Medicare & Medicaid Services (CMS) and obtain authorization for a change in the facility's name, as required by 42 CFR 424.516. The surveyor discovered this deficiency during a review of the facility's website and physical signage, which displayed the name "Shore Point Care Center" instead of the CMS-licensed name "Gateway Care Center." This discrepancy was confirmed upon arrival at the facility, where the surveyor observed the incorrect name on the building and on business cards provided by facility representatives. During interviews, facility representatives acknowledged that the facility had been operating under the name "Shore Point Care Center" for nearly three years, and they claimed that the state licensing department was aware of this. However, the facility was unable to provide documentation showing that the New Jersey Department of Health Division of Certificate of Need & Licensing or CMS had been notified of the name change. The facility's license, issued by the New Jersey Department of Health, still listed the name as "Gateway Care Center." Further investigation revealed that the facility had not completed the necessary CMS form 855B to report the name change. The facility representatives admitted that the name change was intended for marketing purposes and had not been formally processed with the appropriate regulatory bodies. As a result, the facility decided to revert to operating under the name "Gateway Care Center" and planned to change the signage back to reflect the licensed name.
Plan Of Correction
Element 1 This deficiency was corrected by revising the name listed on facility documents back to Gateway Care Center. Element 2 All residents have the potential to be affected by this deficiency. Element 3 Facility understands that in order to operate under a different name, the Department of Health Division of Certificate of Need must be notified, and the form 855B to CMS must be completed. Element 4 To maintain and monitor ongoing compliance, the Administrator will conduct a Facility Name audit to ensure documents are listed as Gateway Care Center. The Facility Name audit will be conducted by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Staffing and Mask-Wearing Deficiencies
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. This deficiency was observed over multiple periods, including specific weeks in October 2023, June to July 2024, and December 2024. During these times, the facility consistently had fewer Certified Nurse Aides (CNAs) than required for the day shifts, and there were also deficiencies in total staff numbers for evening and overnight shifts. Interviews with the Human Resources director and the Director of Nursing revealed attempts to meet staffing ratios through bonuses and agency staff, but these efforts were not always successful. Additionally, the facility did not ensure that employees with medical exemptions from the influenza vaccine wore surgical or procedural masks when in direct contact with patients and in common areas, as required by New Jersey law. The surveyor observed that two employees, a dietary employee and an activity employee, were not wearing masks despite having medical exemptions from the influenza vaccine. Interviews with these employees indicated a lack of awareness or enforcement of the mask-wearing requirement. The facility's policy on influenza vaccination did not address the use of masks for employees with medical exemptions. The Director of Nursing was unaware of the requirement for these employees to wear masks, which contributed to the deficiency. The facility's failure to comply with staffing ratios and mask-wearing requirements for exempt employees highlights significant lapses in adhering to state regulations designed to ensure resident safety and care quality.
Plan Of Correction
Element 1 It is the practice of the facility to ensure that the minimum direct care staff-to-shift ratios are in compliance with the mandate from the State of New Jersey. The deficiency is being corrected by offering bonuses and overtime to staff to cover openings/callouts in the schedule, offering openings/callouts to staffing agencies, utilizing job search engines (Apploi) to expand the view of job postings, and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, all staff members who are Medically Exempt from receiving the Flu Vaccine were immediately informed they must wear a surgical mask while within the facility, and given masks to wear. Element 2 All residents are affected by this deficiency. Element 3 The deficiency is being corrected by offering bonuses and overtime, utilizing staffing agencies, utilizing job search engines (Apploi), and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, a Staffing Audit is being conducted by the Staffing Coordinator to ensure the facility remains in compliance with S560. Staff were also educated that they must wear a mask while in the facility if they are Medically Exempt from receiving the Flu Vaccine; a Mask Audit is being conducted by the Infection Preventionist to ensure the facility remains in compliance. Element 4 To maintain and monitor ongoing compliance, the Staffing Audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Additionally, the Mask Audit is being monitored by the Director of Nursing or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
What surveyors are citing around you — mapped
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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 483 citations issued within 25 miles in the last 12 months — including the 17 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 Eatontown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jersey Shore Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Redbank Center For Rehabilitation And Healing | 3.3 mi | ★★★★★ | 0 | 0 |
| Complete Care At Shrewsbury Llc | 3.8 mi | ★★★★★ | 15 | 0 |
| Complete Care At Monmouth, Llc | 3.9 mi | ★★★★★ | 0 | 0 |
| Atrium At Navesink Harbor, The | 4.1 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.