Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southern Ocean Center during CMS and state inspections, most recent first.
A deficiency was identified when a resident’s weight record showed a 16.5‑pound loss in one day without evidence of required re‑weighing or follow‑up, despite staff stating that significant changes should trigger re‑checks and nutrition/physician notification. Another resident’s MAR contained a blank entry for an oxycodone dose, even though an LPN and the UM stated that medications must be documented in real time and all required MAR documentation completed. In addition, three nurses documented a third resident’s Nursing Advanced Skilled Evaluations by clicking the wrong option under the Nutrition section, incorrectly attesting that specific oral intake and hydration criteria were met, contrary to facility policies requiring clear, factual, and accurate documentation.
Staff failed to follow the facility’s Enhanced Barrier Precautions policy by not consistently wearing required PPE, specifically gowns and gloves, during high-contact care activities for multiple residents on EBP. Observations showed a lab technician performing lab work without PPE, a therapist transporting a resident in the room without PPE while other staff wore gowns, a staff member using a Hoyer lift for a resident with only gloves and no gown, and another staff member providing in-bed care with gloves but no gown. Care plans for these residents required gown and glove use for high-contact tasks, and interviews with a CNA, an LPN, and the DON confirmed that staff were expected to wear appropriate PPE when entering EBP rooms or providing direct care, indicating a discrepancy between expected practice and actual staff behavior.
Expired unopened whole milk was found in the walk-in refrigerator during a kitchen tour. The DD stated the milk would be discarded and acknowledged that expired milk could cause illness. The facility policy stated that the manufacturer's expiration date is the use-by date for unopened items.
During an active COVID-19 outbreak, staff failed to follow PPE requirements for residents on droplet precautions and enhanced barrier precautions, including use of proper eye protection and gowns during high-contact tube feeding care. Surveyors also observed clean linen dragging on the floor in the hallway and residents in the dining room being given alcohol-free wipes instead of alcohol-based hand sanitizer before meals.
A resident with moderate cognitive impairment and multiple medical conditions was verbally abused by a housekeeper, who made humiliating comments about the resident's toileting habits. The housekeeper admitted to making these remarks both in the hallway and directly to the resident, causing the resident emotional distress and refusal to participate in therapy. The facility's investigation confirmed the incident as an isolated case, with no other residents reporting similar mistreatment.
A resident expired, but the facility did not complete or transmit the required MDS death in facility tracking record. During record review, the surveyor found no tracking record for the resident’s death, and the MDS Coordinator confirmed it had not been completed or sent as required.
A resident with complex medical needs did not receive ordered medications and required lab work as prescribed, and there was no documentation that physicians were notified of missed doses or unavailable results. Nursing staff and the DON confirmed that the expected process of physician notification and documentation was not followed, and medical providers were unaware of the missed treatments.
The facility failed to maintain accurate accountability of controlled substances, including not promptly recording the removal of drugs, not signing Shift Count forms, and not completing DEA-222 forms correctly. These deficiencies were observed in medication carts and the automated medication dispensing system, with staff admitting to lapses in procedure.
A resident was transferred to the hospital without written notification being provided to the resident or their representative. The facility's practice was to notify by phone and document in Progress Notes, but this did not comply with the policy requiring written notification.
A facility failed to complete a significant change assessment within 14 days after a resident elected hospice services, resulting in a delay of 49 days. The delay was attributed to staffing issues, as confirmed by the CCRC and DON.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter, as the catheter drainage bag was repeatedly observed in contact with the floor or bed wheels. Documentation of emptying the catheter drainage bag was also incomplete, and staff confirmed that the bag should not be on the floor due to infection control concerns.
The facility failed to ensure sufficient nursing staff on a 24-hour basis, leading to missed showers for residents. Multiple instances of inadequate CNA staffing were documented across several weeks, with the number of CNAs consistently falling short of the required levels. Interviews with CNAs and the DON confirmed the staffing issues, and reviews of bathing task lists showed missed showers for several residents.
A facility failed to adhere to proper infection control practices during wound care for a resident with a pressure ulcer. The LPN did not meet the required 20 seconds of hand lathering as per the facility's policy, performing hand hygiene for 19, 9, and 12 seconds instead. The Director of Nursing confirmed the 20-second requirement.
Inaccurate Clinical Documentation for Weights, MAR, and Skilled Nursing Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records in accordance with its own policies and accepted professional standards. For one resident, weight documentation showed a drop from 166.5 pounds on 11/28/25 to 150 pounds on 11/29/25. Staff interviews revealed that CNAs are responsible for obtaining weights and are expected to reweigh residents if there is more than a 2‑pound change and notify the nurse for significant changes. The PACU Unit Manager stated that a 15‑pound weight loss should prompt notification of the physician and nutrition, and the nutritionist reported that a 15‑pound loss typically triggers a weight alert and re‑weigh request. When shown the weight entries, the Unit Manager stated she was unsure what happened and believed it was probably an error, and the DON acknowledged that the facility’s weight policy, which requires re‑weighing if a weight is not as expected, was not followed and that the 11/29/25 weight was likely a mistake. A second component of the deficiency involved incomplete medication administration documentation for another resident. Review of the February 2026 MAR showed a blank entry for an oxycodone dose on 2/14/26. An LPN stated that medications are to be signed out on the MAR in real time as they are administered, and the PACU Unit Manager stated she expects all staff to complete required documentation, including MARs. The DON stated that staff are well educated and trained in documentation and facility policies, yet the MAR review showed that the oxycodone entry was not signed out as required, resulting in an inaccurate medication record. The third component involved inaccurate nursing documentation in the Nursing Advanced Skilled Evaluations for another resident. Review of these evaluations showed that three nurses clicked the wrong button under the Nutrition section, creating documentation errors. The LPN interviewed confirmed that this documentation serves as an attestation for a daily head‑to‑toe assessment. The PACU Unit Manager and the DON both confirmed that a new assessment is expected each shift and that staff must pay attention to what they document because it is their attestation. The surveyor pointed out that under Nutrition, nurses were selecting “met” for an item asking if the resident was taking nutrition and hydration orally, had no complaints of thirst, no signs or symptoms of a swallowing disorder, and moist mucous membranes, and the DON acknowledged the error and stated she could see how this could be confusing for staff. The surveyor also noted that three nurses made this documentation error while other nurses did not, despite facility policies requiring documentation to be factual, objective, clear, pertinent, and accurate.
Failure to Follow Enhanced Barrier Precautions and PPE Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff properly used personal protective equipment (PPE) in accordance with its Enhanced Barrier Precautions (EBP) policy for four residents on EBP. The facility’s policy IC308 required the use of gown and gloves during high-contact resident care activities to reduce the risk of transmission of multi-drug resistant organisms. Care plans for several residents specified that staff were to use gown and gloves for activities such as dressing, bathing, transferring, providing hygiene, changing linens and briefs, device care, and wound care. Despite this, surveyors observed multiple instances where staff did not wear the required PPE while providing care or handling equipment in rooms of residents on EBP. Resident #1, who was cognitively intact and admitted with conditions including a periprosthetic fracture and presence of a left artificial hip joint, had a care plan intervention directing staff to use gown and gloves for high-contact activities. On one observation, a therapist transported this resident to therapy while in the resident’s room without any PPE, even as other staff in the room, including the Unit Manager and a CNA, were wearing yellow gowns. Resident #7, also cognitively intact and admitted with right hip bursitis and osteoarthritis, had a care plan intervention stating that PPE should be changed before caring for another resident. A lab technician was observed in this resident’s room finishing lab work without any PPE. Resident #9, with moderately impaired cognition and diagnoses including nutritional anemia, Alzheimer’s disease, and rheumatoid arthritis, had a care plan requiring gown and gloves for high-contact activities. A staff member in scrubs was observed exiting this resident’s room with a Hoyer lift and later using the Hoyer lift for the resident while wearing only gloves and no gown. Resident #10, cognitively intact and admitted with acute cystitis with hematuria, malignant neoplasm of the prostate, and peripheral vascular disease, also had a care plan requiring gown and gloves for high-contact activities. Another staff member was observed providing care to this resident in bed while wearing gloves but no gown. Interviews with a CNA, an LPN, and the DON confirmed that residents on EBP have signs outside their doors and that staff were expected to wear appropriate PPE, including gown and gloves, when entering rooms or providing direct care, which was inconsistent with the observed practices.
Expired Milk Found in Walk-In Refrigerator
Penalty
Summary
Food was not stored in accordance with professional standards when three gallons of unopened whole milk were observed in the walk-in refrigerator with a manufacturer's expiration date that had passed. During the kitchen tour, the surveyor and the Dietary Director observed the milk, and the Dietary Director stated that the expired milk would be discarded and that expired milk could cause illness. A review of the facility's undated policy, Use By Dating Guidelines, stated that the manufacturer's expiration date, when available, is the use by date for unopened items.
Infection Control Failures During COVID-19 Outbreak
Penalty
Summary
The facility failed to follow infection control practices during an active COVID-19 outbreak involving residents on droplet precautions and a resident on enhanced barrier precautions. On 9/3/2025, a nurse practice educator/RN entered the room of a resident with COVID-19 wearing an N95 mask, eyeglasses without side covers, a gown, and gloves, then left the room with the door open while assisting the resident to a wheelchair. The resident had diagnoses including COVID-19 and dementia, a BIMS score of 7 indicating severely impaired cognition, required moderate assistance for transfers, and had an active order and care plan for droplet precautions. The infection preventionist and DON later stated that staff inside rooms of residents with COVID-19 were expected to wear an N95 mask, gown, gloves, and protective eye gear such as a face shield or goggles, and that eyeglasses without closed sides were not appropriate eye protection. The facility also failed to follow its own transmission-based precaution practices for another resident with COVID-19 and for a resident on enhanced barrier precautions for tube feeding. A licensed practical nurse entered the room of a resident with COVID-19 wearing an N95 mask, gown, gloves, and eyeglasses without side covers, then later continued wearing the same eyeglasses while performing medication administration in the nursing unit. In a separate observation, a registered nurse/unit manager entered the room of a resident with COVID-19 wearing an N95 mask, gown, and gloves but without eye protection. The resident had diagnoses including COVID-19, metabolic encephalopathy, and COPD, with an active order for droplet precautions and a care plan focused on respiratory risk. For the resident on enhanced barrier precautions, an LPN administered a water flush and bolus tube feeding while wearing an N95 mask and gloves but no gown, even though the doorway signage for enhanced barrier precautions indicated gown and glove use for high-contact direct care, including feeding tube care. That resident had a gastrostomy status, an active feeding tube order, and a care plan calling for enhanced barrier precautions. The facility also failed to maintain proper handling of clean linen and resident hand hygiene practices. A surveyor observed a housekeeping cart with a tied plastic bag containing clean-looking washcloths touching the hallway floor while a housekeeper wheeled the cart and dragged the bag along the hallway. The infection preventionist and DON stated that clean linen should not touch the floor. In the dining room, the infection preventionist provided residents with alcohol-free moist towelettes for hand hygiene before lunch and stated she was not sure whether they contained alcohol but believed they were sufficient. The LHNA later stated that staff should ensure residents use alcohol-based hand sanitizer before meals, and clarified that wipes were intended for cleaning hands and faces after messy foods. The facility policy stated that when hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for hand hygiene.
Verbal Abuse of Resident by Housekeeper
Penalty
Summary
A resident with a history of Parkinson's disease, atrial fibrillation, depression, and diabetes mellitus, and who had moderate cognitive impairment, was subjected to verbal abuse by a housekeeper. The incident occurred when the housekeeper made derogatory and humiliating comments to the resident regarding the resident's toileting habits, including statements about feces being on and around the toilet. The resident reported feeling emotionally upset and humiliated by the comments, which were also overheard by the resident. The facility's investigation revealed that the housekeeper admitted to making the inappropriate remarks both in the hallway and directly to the resident. The incident was reported by the resident to a physical therapist, who noted the resident's emotional distress and refusal to attend therapy due to the humiliation experienced. The facility's records confirmed that the housekeeper had received prior training on abuse policies and procedures, and a background check had been conducted at the time of hire. The facility's abuse prohibition policy defines verbal abuse as the use of disparaging or derogatory language within hearing distance of residents. The surveyor's review of documentation and interviews with staff and other residents confirmed that the incident was isolated to this resident, with no other residents reporting similar mistreatment by the housekeeper.
Failure to Complete and Transmit Death in Facility Tracking Record
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set death in facility tracking record for Resident #17 in accordance with federal guidelines. The resident expired on [DATE], but the electronic health record showed that no death in facility tracking record had been completed for the resident’s death date. During review of the facility assessment task and the resident’s electronic medical record, the surveyor identified that the required tracking record was missing. When interviewed, the MDS Coordinator confirmed that the death in facility tracking record had not been completed or transmitted for Resident #17 and stated that it should have been completed and transmitted by [DATE]. The report also states that the facility must electronically transmit the MDS within 14 days of the assessment being completed.
Failure to Administer Medications and Notify Physicians per Orders
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including acute myeloblastic leukemia, anemia, chronic kidney disease, and severely impaired cognition, did not receive treatment and care in accordance with physician orders and professional standards of practice. The resident had specific orders for medications such as Epoetin Alfa and Venclexta, as well as regular bloodwork and communication of lab results to the oncologist. Documentation revealed that several doses of these medications were not administered as ordered, and required bloodwork and faxing of results were not completed on multiple occasions. The medication administration records showed missing documentation for certain doses, with codes indicating that the medications were not given. Progress notes from nursing staff indicated that medications were on order but did not confirm administration or provide evidence that the physician was notified of missed doses or unavailable medications. Similarly, there was no documentation that the physician was notified when lab results were not obtained or faxed as required. Interviews with nursing staff and the DON confirmed that the expected process was to notify the physician and document such notifications, but this was not done in these instances. Further interviews with the resident's medical providers, including the medical director and oncologist, confirmed that they were not notified of missed medication doses or unavailable lab results, contrary to their expectations and facility policy. The facility's job descriptions and policies also required prompt notification of physicians regarding missed medications, abnormal labs, or changes in condition, but these procedures were not followed or documented for the resident in question.
Controlled Substance Accountability Deficiencies
Penalty
Summary
The facility failed to promptly record the removal of a controlled drug from inventory, maintain accurate accountability of controlled substances within the medication administration carts, maintain accurate accountability of all controlled medications within the automated medication dispensing system, and accurately document and complete DEA-222 forms. During an inspection of the Low Hall Garden Unit medication cart, a registered nurse admitted to not signing out Oxycodone 5 mg tablets when removed from the cart, resulting in an inaccurate count. The nurse stated she felt nervous and forgot to sign it out during a medication pass. The Director of Nursing (DON) confirmed that controlled medications must be signed out immediately to ensure accurate counts and prevent discrepancies. In another instance, the surveyor found that the Shift Count form for the Post Acute Unit (PACU) medication cart #3 was not signed by the outgoing nurse, which is required to ensure both nurses agree on the controlled medication count. The Licensed Practical Nurse (LPN) and the Registered Nurse/Unit Manager (RN/UM) confirmed that both nurses must sign the form to maintain accountability. The DON stated that failure to sign the Shift Count form could result in a write-up, emphasizing the importance of accurate narcotic counts. Additionally, the automated medication dispensing system in the PACU was not routinely signed to indicate that the controlled medication count was completed daily. The RN/UM and DON acknowledged that the count should be done every morning and signed by the assigned nurse. Furthermore, the review of DEA-222 forms revealed that 12 out of 12 forms did not have Part 5 filled in by the purchaser, as required. The DON admitted to not being trained to complete this section and had copied the previous DON's method. The Pharmacist in Charge confirmed the requirement to fill out Part 5 on the DEA-222 forms.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to notify the resident and the resident's representative in writing of the reason for transfer or discharge to the hospital. This deficiency was identified during a survey when it was observed that a resident was transferred to the hospital without written notification being provided to the resident or their representative. The resident, who had diagnoses including age-related debility, muscle wasting, and obstructive and reflux uropathy, was sent to the hospital following abnormal lab results. The facility's documentation showed that a phone call was made to the resident's son, but there was no evidence of written notification in the resident's electronic health record. Interviews with the Social Services Director and the Director of Nursing revealed that the facility's practice was to notify the resident and their family by phone and document the transfer in the Progress Notes, but not to provide written notification. The facility's policy on Discharge and Transfer required written notification to the resident and their representative prior to transfer or discharge, but this was not followed. The Director of Nursing admitted that the nurses had not been providing written notifications, citing that residents were often too sick and families sometimes reacted negatively. This failure to provide written notification was a violation of the facility's policy and regulatory requirements.
Failure to Complete Timely Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days after a resident elected hospice services, as required by the Resident Assessment Instrument (RAI) process. This deficiency was identified for a resident who was admitted with Alzheimer's disease and later received hospice care due to end-stage dementia. The resident's Minimum Data Set (MDS) assessment, which should have been completed within 14 days of the hospice start date, was not finalized until 49 days later. The assessment was initiated on 11/16/23 but was not completed until 01/04/24, well beyond the required timeframe. The Certified Clinical Reimbursement Coordinator (CCRC) acknowledged the delay, attributing it to being the sole worker in the building after a co-worker retired. The Director of Nursing (DON) also confirmed that the significant change MDS assessment was delayed. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual both mandate timely completion of the MDS, which was not adhered to in this case.
Failure to Properly Secure Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with an indwelling urinary catheter. The resident's catheter drainage bag was observed multiple times in contact with the floor or the wheels of the bed, indicating that it was not properly secured. This was observed on several occasions by the surveyor, despite the resident's care plan specifying that the catheter should be kept off the floor. Additionally, the Treatment Administration Record (TAR) showed multiple instances where the required documentation of emptying the catheter drainage bag was left blank, suggesting that the care was either not provided or not documented as required. Interviews with facility staff, including a Certified Nurses Aide (CNA) and the Director of Nursing (DON), confirmed that the catheter drainage bag should not be in contact with the floor due to infection control concerns. The DON acknowledged that if the care is not documented, it is considered not done. The facility's own procedures and documentation standards also specify that the catheter drainage bag should be kept off the floor and that nursing care should be properly recorded in the medical record.
Inadequate Nursing Staff and Missed Showers
Penalty
Summary
The facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficiency was evidenced by multiple instances of inadequate Certified Nursing Assistant (CNA) staffing across several weeks, as documented in the Nurse Staffing Report. For example, during the week of 10/02/2022 to 10/08/2022, the facility was deficient in CNA staffing for residents on all seven day shifts, with the number of CNAs ranging from 6 to 10, while at least 14 were required. Similar deficiencies were noted in subsequent weeks, with the facility consistently failing to meet the required number of CNAs on both day and evening shifts across multiple months, including October, November, December, and January, as well as in the weeks leading up to the survey in April 2024. During a Resident Council meeting, four out of six residents reported that they did not receive showers twice weekly as scheduled due to staffing issues. The surveyor's review of the bathing task lists for several residents corroborated these claims. For instance, Resident #21's task list was blank for the first 22 days of April, indicating that care was not rendered, and the resident only received baths on four days. Similarly, Resident #94 received a bath on only six out of 30 days, and Resident #84 had only one documented shower for the entire month of April. Resident #122's task list showed missed showers on three scheduled days. Interviews with CNAs and the Director of Nursing (DON) further highlighted the staffing issues. CNA #1 confirmed that shower schedules were in the assignment book, but staffing shortages often prevented showers from being completed. CNA #3 mentioned that short staffing affected all shifts, leading to missed showers or the need to offer bed baths instead. The DON acknowledged the staffing deficiencies and stated that if care is not documented, it is considered not done. The facility's failure to meet the required staffing levels and provide scheduled showers as per residents' care plans constitutes a significant deficiency in ensuring adequate care for its residents.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to use appropriate infection control practices during wound care for a resident with a documented pressure ulcer on the right heel. The Licensed Practical Nurse (LPN) did not adhere to the minimum required time for lathering hands during hand hygiene. The surveyor observed the LPN performing hand hygiene for 19 seconds, 9 seconds, and 12 seconds during different stages of the wound care process, which is below the facility's policy requirement of 20 seconds of lathering. The LPN confirmed during an interview that she believed the lathering should be 20 seconds but did not adhere to this standard. The resident's medical records indicated that the wound care order was initiated on 04/25/2024, and the care plan noted the presence of a pressure ulcer on 04/24/2024. The Director of Nursing also confirmed that the lathering portion of hand hygiene should be 20 seconds. The facility's hand hygiene policy, revised on 05/01/23, specifies that hands should be lathered for 20 seconds covering all surfaces of the hands and fingers. The failure to adhere to this policy was observed and documented by the surveyor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 223 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Manahawkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manahawkin Health And Rehabilitation Center | 0 mi | ★★★★★ | 13 | 3 |
| Barnegat Rehabilitation And Nursing Center | 4.1 mi | ★★★★★ | 3 | 0 |
| Mystic Meadows Rehabilitation And Nursing Center | 7.2 mi | ★★★★★ | 24 | 0 |
| Seacrest Rehabilitation And Healthcare Center | 10.6 mi | ★★★★★ | 21 | 0 |
| Crystal Lake Healthcare And Rehabilitation | 14 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Southern Ocean Center.
100% money-back within 48 hours.
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.