Inspection Reports for
Atlantic Coast Rehab & Health
485 River Ave, Lakewood, NJ, 08701
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
130 residents
Based on a May 2024 inspection.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS and related components, and describing their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 18, 2025
Visit Reason
The inspection was conducted due to complaints NJ 168136, 171968, and 176439, to investigate allegations and assess compliance with federal and state regulations for long term care facilities.
Complaint Details
The visit was complaint-related with complaints NJ 168136, 171968, and 176439. The facility was found not in substantial compliance with multiple regulatory requirements, and deficiencies were substantiated based on observations, interviews, and record reviews.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, with deficiencies cited related to resident rights, comprehensive care plans, bowel/bladder incontinence, pharmacy services, infection prevention and control, life safety code violations, and other regulatory requirements. Deficiencies were substantiated through observations, interviews, and record reviews.
Deficiencies (9)
Facility failed to ensure a resident was transported in a dignified manner, violating resident rights.
Facility failed to develop and implement comprehensive person-centered care plans for residents.
Facility failed to provide appropriate treatment and care for residents with bowel/bladder incontinence and catheter care.
Facility failed to establish a system of records for controlled drugs and maintain accurate medication administration records.
Facility failed to maintain food safety and sanitation standards in food storage and preparation areas.
Facility failed to maintain proper disposal of garbage and refuse, resulting in unsanitary conditions.
Facility failed to maintain resident records in a complete, accurate, and confidential manner.
Facility failed to comply with infection prevention and control program requirements, including PPE use and staff education.
Facility failed to maintain life safety code compliance, including exit signage and corridor door functionality.
Report Facts
Census: 140
Licensed Capacity: 160
Sample Size: 31
Certified Nurse Aides: 17
Certified Nurse Aides Required: 18
Residents Affected by Exit Sign Deficiency: 60
Residents Affected by Corridor Door Deficiency: 50
Inspection Report
Routine
Census: 130
Deficiencies: 0
Date: May 13, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 124
Deficiencies: 7
Date: Jan 11, 2023
Visit Reason
The facility underwent a standard routine survey to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including Medicaid/Medicare coverage notices, catheter care, drug regimen monitoring, food safety, garbage disposal, infection control, and staffing ratios. Deficiencies were cited in multiple areas including failure to issue required beneficiary notices, improper catheter management, inadequate monitoring of medication administration, unsafe dishwashing practices, unsanitary garbage disposal areas, and insufficient hand hygiene by staff.
Deficiencies (7)
Failure to issue required Medicaid/Medicare beneficiary notices to Resident #118.
Failure to maintain catheter below bladder level, improper positioning, and failure to maintain resident dignity for Resident #177.
Failure to adequately monitor antibiotic administration resulting in 28 doses given instead of 30 for Resident #45.
Failure to handle potentially hazardous foods and maintain dish machine sanitation and temperature logs properly.
Failure to keep garbage container area free of garbage and debris.
Failure to perform adequate handwashing by nurse during medication administration.
Failure to maintain required minimum direct care staff to resident ratios and failure to obtain medical exemption forms for employees declining influenza vaccination.
Report Facts
Census: 124
Deficient CNA staffing shifts: 5
CNA staffing shortfall: 1
Medication doses administered: 28
Medication doses prescribed: 30
Dish machine sanitizer chlorine level: 50
Dish machine wash temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in catheter care deficiency for Resident #177 |
| Director of Social Services | Director of Social Services | Named in Medicaid/Medicare beneficiary notice deficiency |
| Director of Admissions | Director of Admissions | Named in Medicaid/Medicare beneficiary notice deficiency |
| Registered Nurse #2 | Registered Nurse | Named in hand hygiene deficiency during medication administration |
| Infection Preventionist Licensed Practical Nurse | Infection Preventionist Licensed Practical Nurse | Named in hand hygiene and influenza vaccination deficiencies |
| Food Service Director | Food Service Director | Named in dishwashing and food safety deficiencies |
| Regional Food Service Director | Regional Food Service Director | Named in dishwashing and food safety deficiencies |
| Director of Nursing | Director of Nursing | Named in staffing and infection control deficiencies |
| Director of Human Resources | Director of Human Resources | Named in staffing deficiencies |
| Staffing Coordinator | Staffing Coordinator | Named in staffing deficiencies |
Inspection Report
Life Safety
Census: 127
Capacity: 127
Deficiencies: 7
Date: Jan 10, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 01/10/23 to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not to be in compliance with several life safety code requirements including exit door locking mechanisms, fire alarm system installation and testing, sprinkler system installation, corridor door latching, and evacuation plan deficiencies. Multiple deficiencies had the potential to affect residents but no immediate negative impact was identified.
Deficiencies (7)
Exit doors were equipped with latches or locks requiring special knowledge or tools to open from the egress side, lacking delay egress, affecting five exit doors.
Failure to complete smoke detection sensitivity test for all 110 photo electric smoke detectors.
Five smoke detectors were installed less than 36 inches from air supply diffusers.
Sprinkler coverage was not provided under a staircase landing in the therapy area.
Three corridor doors did not latch properly or had impediments to closing, potentially allowing passage of smoke.
Fire alarm system testing and maintenance deficiencies including lack of smoke detection sensitivity testing and improper placement of smoke detectors.
Evacuation and relocation plan did not include procedures for moving residents beyond the smoke compartment affected by fire to an unaffected smoke compartment.
Report Facts
Residents potentially affected: 20
Residents potentially affected: 127
Residents potentially affected: 12
Residents potentially affected: 2
Number of photo electric smoke detectors: 110
Number of smoke detectors improperly placed: 5
Total beds: 127
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 1
Date: Apr 27, 2022
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations of abuse involving Resident #2 at Atlantic Coast Rehab & Health.
Complaint Details
The complaint investigation found substantiated abuse involving CNA #1 hitting Resident #2. The incident was reported to the New Jersey Department of Health, Police, Ombudsman, and Nursing Board. CNA #1 was terminated and had received prior training on abuse policies.
Findings
The facility failed to implement its abuse policy for one resident, resulting in a staff-to-resident abuse incident involving a Certified Nursing Assistant (CNA #1). The CNA was terminated following an investigation that included video surveillance and interviews. The facility provided re-education to staff and implemented monthly resident interviews to monitor care concerns.
Deficiencies (1)
Failure to implement abuse/neglect policies and procedures for Resident #2 during an abuse investigation.
Report Facts
Census: 124
Sample Size: 3
Correction Completion Date: May 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in abuse incident and terminated from employment |
| Director of Nursing | Reported abuse incident and provided re-education to staff | |
| Administrator | Verified abuse incident and notification to Nursing Board | |
| Director of Social Services | Conducts monthly resident interviews and reports findings |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Date: Jul 16, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145479 and NJ143244.
Complaint Details
Complaint numbers NJ145479 and NJ143244 were investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 10
Inspection Report
Routine
Census: 124
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 2
Date: Dec 11, 2020
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to pharmacy services including failure to ensure medications were received and administered as prescribed, and infection prevention and control practices during wound treatments were not properly followed.
Deficiencies (2)
Facility failed to ensure medications were received and administered as prescribed by the physician, evidenced by a medication running out without proper reorder and documentation.
Facility failed to minimize the potential spread of infection to residents during wound treatments, including failure to perform hand hygiene at appropriate times.
Report Facts
Census: 116
Sample size: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed administering medications and wound treatment; involved in medication reorder deficiency | |
| Subacute Unit Manager/Registered Nurse #1 (UM/RN #1) | Interviewed regarding medication ordering process | |
| Crest Unit Manager/Registered Nurse #2 (UM/RN #2) | Interviewed regarding medication reorder and documentation | |
| Director of Nursing (DON) | Interviewed regarding medication reorder and infection control expectations | |
| Assistant Director of Nursing (ADON) | Assisted with wound treatment observation |
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 11, 2020
Visit Reason
The inspection was conducted to assess the facility's compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
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