Inspection Reports for
Hampton Ridge Healthcare And Rehabilitation

94 Stevens Road, Toms River, NJ, 08755

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 4.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

10% better than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

16 12 8 4 0
2020
2021
2022
2023
2024
2025

Occupancy

Latest occupancy rate 91% occupied

Based on a October 2024 inspection.

Occupancy rate over time

70% 77% 84% 91% 98% 105% Dec 2020 Jan 2021 May 2021 Jul 2023 Oct 2024

Notice

Deficiencies: 0 Date: Nov 20, 2025

Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS regarding the use and disclosure of their medical information and their rights related to this information.

Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.

Report Facts
Effective date: 2011

Employees mentioned
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for questions about the notice

Inspection Report

Plan of Correction
Deficiencies: 1 Date: Oct 22, 2024

Visit Reason
The inspection was conducted to identify deficiencies related to the development and implementation of comprehensive care plans for residents, specifically focusing on Resident #5's care plan regarding indwelling catheter care.

Findings
The facility failed to develop and implement a care plan that meets the medical needs identified on the comprehensive assessment for Resident #5, specifically lacking documentation and interventions related to indwelling catheter care. Interviews with nursing staff and the Director of Nursing confirmed that such a care plan focus area should have been present.

Deficiencies (1)
Failed to develop and implement a complete care plan that meets the resident's needs, specifically lacking focus on indwelling catheter care for Resident #5.
Report Facts
Residents reviewed for comprehensive care plans: 35 Residents affected: 1

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN) #1Interviewed regarding care plan requirements for indwelling catheter
Licensed Practical Nurse (LPN) #3Interviewed regarding care plan requirements for indwelling catheter
Director of Nursing (DON)Interviewed regarding care plan requirements for indwelling catheter

Inspection Report

Annual Inspection
Census: 185 Capacity: 204 Deficiencies: 9 Date: Oct 22, 2024

Visit Reason
The inspection was a Recertification Survey combined with a Complaint Investigation to determine compliance with federal and state regulations for long term care facilities.

Complaint Details
Complaint numbers 154169, 161945, 170013, 172361, 172537, 1769295 were investigated. The complaint related to staffing deficiencies and care plan issues were substantiated as evidenced by deficient practices found during the survey.
Findings
The facility was found to have multiple deficiencies including failure to develop and implement comprehensive care plans, inadequate staffing ratios, fire safety code violations, and issues with emergency preparedness and physical environment maintenance. Corrective actions were planned and some deficiencies were corrected by the revisit date.

Deficiencies (9)
Failure to develop and implement a comprehensive person-centered care plan for residents.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Failure to provide two-hour fire resistance-rated elements and assemblies for fire separation doors in accordance with NFPA 101.
Failure to ensure quarterly local fire inspections and certificates of compliance were documented.
Failure to maintain operational night lights in resident rooms.
Failure to maintain stable level walking surfaces at exit discharge points.
Failure to ensure hazardous areas were protected with self-closing fire doors.
Failure to ensure bathroom exhaust fans were maintained in operational condition.
Failure to ensure emergency power supply (EPS) was tested and maintained according to NFPA standards.
Report Facts
Census: 185 Total Capacity: 204 Deficiencies cited: 9 Staffing ratios: 1 Staffing ratios: 1 Staffing ratios: 1

Employees mentioned
NameTitleContext
Director of NursingDirector of Nursing (DON)Interviewed regarding staffing levels and care plan compliance.
Maintenance DirectorMaintenance DirectorInterviewed regarding fire safety inspections, emergency preparedness, and physical environment deficiencies.
AdministratorFacility AdministratorInformed of deficiencies and participated in interviews regarding emergency preparedness and fire safety.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Jul 27, 2023

Visit Reason
The inspection was conducted in response to Complaint #NJ153752 regarding the facility's failure to develop and implement a comprehensive, person-centered care plan that honored a resident's preference not to be cared for by male aides.

Complaint Details
Complaint #NJ153752 was substantiated based on interviews and record reviews indicating the facility did not honor Resident #211's preference to avoid care from male aides, resulting in a male CNA providing care despite the care plan.
Findings
The facility failed to ensure that Resident #211's care plan was fully implemented to prevent male aides from providing care, despite the resident's documented preference. Interviews and record reviews revealed that a male CNA provided care to the resident contrary to the care plan, and the facility's CNA Assignment Sheets did not consistently reflect the resident's preference.

Deficiencies (1)
Failure to develop and implement a comprehensive, person-centered care plan that included interventions to ensure a resident's preference not to be cared for by male aides was honored.
Report Facts
Residents reviewed for care plan development: 37 Resident BIMS score: 12 Date of care plan entry: Mar 21, 2022 Date male CNA provided care: Apr 2, 2022

Employees mentioned
NameTitleContext
Assistant Director of NursingADONSigned Nurse's Note reviewing Resident #211's care plan and assisted in care plan development
Licensed Practical Nurse/Unit ManagerLPN/UMInterviewed regarding care plan updates and CNA assignments; demonstrated resident's Plan of Care Dashboard
Director of NursingDONProvided CNA Task History and explained CNA signatures indicating care rendered
AdministratorAdministratorInterviewed regarding male CNA providing care to Resident #211

Inspection Report

Annual Inspection
Deficiencies: 5 Date: Jul 27, 2023

Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to evaluate the facility's care and operational practices.

Complaint Details
Complaint #NJ153752 involved failure to develop and implement a comprehensive, person-centered care plan that included interventions to ensure a resident's preference not to be cared for by male aides was honored. The complaint was substantiated with findings for 1 of 37 residents reviewed.
Findings
The facility was found deficient in several areas including inaccurate completion of Minimum Data Set (MDS) assessments, failure to develop and implement a comprehensive person-centered care plan respecting resident preferences, failure to provide appropriate devices for range of motion, improper storage and monitoring of respiratory equipment, and improper medication storage and labeling practices.

Deficiencies (5)
Failure to accurately complete the Minimum Data Set (MDS) for 3 of 34 residents, including inaccurate documentation of oxygen use and tobacco use.
Failure to develop and implement a comprehensive, person-centered care plan that honored a resident's preference not to be cared for by male aides.
Failure to provide a device (left palm grip) to address contracture for 1 of 2 residents reviewed for range of motion.
Failure to properly store respiratory equipment to prevent contamination and failure to assess pulse oximetry as ordered for 1 of 2 residents reviewed for respiratory care.
Failure to properly store medications, maintain clean medication storage areas, and properly label opened multidose medications, observed in 3 of 4 medication carts.
Report Facts
Residents reviewed for MDS accuracy: 34 Residents reviewed for care plan development: 37 Residents reviewed for range of motion: 2 Residents reviewed for respiratory care: 2 Medication carts inspected: 4 Loose pills observed: 14 Pulse oximetry readings reviewed: 17

Employees mentioned
NameTitleContext
Minimum Data Set Coordinator (MDSC)Interviewed regarding MDS completion responsibilities and accuracy
Licensed Practical Nurse Unit Manager (LPN/UM)Interviewed about smoking resident and care plan implementation
Certified Nursing Assistant (CNA)Interviewed about honoring resident preference for no male aides
SecretaryInterviewed about CNA assignment sheet responsibilities
Assistant Director of Nursing (ADON)Interviewed about care plan review and male aide assignment
Director of Nursing (DON)Interviewed about care plan compliance, pulse oximetry monitoring, and medication storage
Licensed Practical Nurse (LPN) #1 and #2Interviewed about oxygen tubing storage
Licensed Practical Nurse 1, 2, and 3 (LPN1, LPN2, LPN3)Observed medication cart deficiencies

Inspection Report

Life Safety
Census: 167 Capacity: 204 Deficiencies: 2 Date: Jul 27, 2023

Visit Reason
The inspection was conducted to assess compliance with life safety code requirements, specifically focusing on exit discharge and illumination of means of egress.

Findings
The facility failed to maintain a level walking surface at one exit discharge and failed to provide emergency illumination that operates automatically along the means of egress in one occupied access area.

Deficiencies (2)
Exit discharge surface was not level and had a lifted concrete pad approximately 1 inch high, failing to provide a firm level walking surface free of obstructions.
Emergency illumination was not provided automatically along the means of egress; two wall switches shut off all six light fixtures in a resident day room, leaving the means of egress unlit.
Report Facts
Certified beds: 204 Census: 167 Deficiencies cited: 2

Employees mentioned
NameTitleContext
Maintenance DirectorPresent during observations and interviews related to deficiencies
Regional Plant Operations DirectorPresent during observations and interviews related to deficiencies

Inspection Report

Annual Inspection
Census: 167 Capacity: 204 Deficiencies: 8 Date: Jul 27, 2023

Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Complaint Details
Complaint # NJ00153752 triggered the recertification survey. The complaint involved issues with accuracy of assessments and care plan development.
Findings
Deficiencies were cited related to accuracy of assessments, development and implementation of comprehensive care plans, mobility, respiratory care, medication storage and labeling, staffing ratios, and life safety code violations including exit discharge and illumination of means of egress.

Deficiencies (8)
Facility failed to accurately complete Minimum Data Set (MDS) assessments for 3 residents.
Facility failed to develop and implement a comprehensive, person-centered care plan honoring resident preferences for 1 resident.
Facility failed to provide device to prevent decrease in range of motion for 1 resident.
Facility failed to store respiratory equipment properly and assess resident respiratory care for 1 resident.
Facility failed to properly store medications, maintain clean medication storage areas, and label opened multidose medications.
Facility failed to maintain required minimum direct care staff-to-resident ratios for multiple weeks in 2022 and 2023.
Facility failed to provide and maintain a level walking surface free of obstructions at an exit discharge.
Facility failed to provide emergency illumination that operates automatically along means of egress in a resident day room.
Report Facts
Census: 167 Total Capacity: 204 Deficiencies cited: 7 Staffing ratios: 7

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN1)Observed medication storage deficiencies
Licensed Practical Nurse (LPN2)Observed medication storage deficiencies and confirmed unlabeled eye drop bottle
Licensed Practical Nurse (LPN3)Observed medication storage deficiencies
Director of Nursing (DON)Interviewed regarding staffing and medication storage policies
Maintenance Director (MD)Interviewed regarding exit discharge and illumination deficiencies
Regional Plant Operations Director (RPOD)Interviewed regarding exit discharge and illumination deficiencies
Staffing CoordinatorInterviewed regarding staffing levels

Inspection Report

Routine
Census: 163 Deficiencies: 0 Date: May 4, 2022

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.

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

Deficiencies: 0 Date: May 27, 2021

Visit Reason
The document is a statement of deficiencies and plan of correction for Hampton Ridge Healthcare and Rehabilitation, related to a regulatory survey completed on May 27, 2021.

Findings
No health deficiencies were found during the survey.

Inspection Report

Life Safety
Deficiencies: 1 Date: May 27, 2021

Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations on 05/25/21 and 05/26/21 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code.

Findings
The facility was found to be in noncompliance with Life Safety Code requirements due to failure to maintain all parts of the automatic sprinkler system in optimal condition, specifically corrosion and paint on sprinkler heads at the main entrance overhang.

Deficiencies (1)
Five sprinkler heads at the main entrance overhang showed signs of green coating of oxidation/corrosion; two of these had paint on the spray head.
Report Facts
Date sprinkler system last checked: Date not provided in the report Deficiency citation date: Apr 22, 2021 Number of sprinkler heads observed with corrosion: 5 Number of sprinkler heads observed with paint: 2 Scheduled replacement date for corroded sprinkler heads: Jul 7, 2021

Employees mentioned
NameTitleContext
Maintenance DirectorInterviewed and acknowledged sprinkler head corrosion and paint
Regional Plant Operations DirectorInterviewed and acknowledged sprinkler head corrosion and paint

Inspection Report

Routine
Census: 173 Deficiencies: 0 Date: May 27, 2021

Visit Reason
A standard routine survey was conducted including a COVID-19 Focused Infection Control Survey by the New Jersey Department of Health.

Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities and in compliance with infection control regulations related to COVID-19.

Report Facts
Sample size: 43

Inspection Report

Routine
Census: 168 Deficiencies: 0 Date: Feb 24, 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.

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: 3

Inspection Report

Routine
Census: 169 Deficiencies: 0 Date: Jan 29, 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.

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

Abbreviated Survey
Census: 176 Deficiencies: 1 Date: Jan 4, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.

Findings
The facility failed to follow proper infection control procedures including improper donning and doffing of PPE and inadequate hand hygiene between resident contacts on the SMART Unit. Observations showed staff inconsistently changing gowns and gloves between residents and lapses in hand hygiene during meal tray delivery and resident care.

Deficiencies (1)
Failure to don and doff proper personal protective equipment for residents on transmission-based precautions and failure to perform hand hygiene between resident contacts on the SMART Unit.
Report Facts
Census: 176 Sample size: 7 Completion date for plan of correction: 2021 Transmission based precautions duration: 14

Employees mentioned
NameTitleContext
CNA #1Certified Nursing AssistantObserved delivering meals in full PPE and interviewed regarding PPE use
CNA #2Certified Nursing AssistantObserved delivering meals without proper PPE and hand hygiene; interviewed about PPE practices
CNA #3Certified Nursing AssistantObserved delivering meals and assisting residents; interviewed about PPE practices
CNA #4Certified Nursing AssistantObserved delivering meals and removing trays without proper PPE or hand hygiene
Infection PreventionistInterviewed regarding infection control policies and observations
AdministratorInterviewed regarding infection control procedures
Director of NursingInterviewed regarding infection control procedures

Inspection Report

Routine
Census: 166 Deficiencies: 0 Date: Dec 7, 2020

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 related to COVID-19.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.

Report Facts
Sample size: 3

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