Inspection Reports for Jersey Shore Post Acute Rehabilitation And Nursing
101 Walnut Street, NJ, 07753
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Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform covered components and individuals about the privacy practices related to medical information, including how information may be used, disclosed, and the rights of individuals under these practices.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of the department to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 105
Deficiencies: 9
Mar 5, 2025
Visit Reason
A Recertification Survey was conducted from 2/27/25 to 3/5/25 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by Complaint #NJ177301.
Findings
Deficiencies were cited related to failure to develop and implement comprehensive care plans, failure to maintain required minimum direct care staff-to-resident ratios, life safety code violations including exit discharge and sprinkler system deficiencies, and medication administration errors. Corrective actions and plans of correction were provided with compliance dates of April 11, 2025.
Complaint Details
Complaint #NJ177301 triggered the survey. The complaint involved issues with care planning, staffing ratios, and medication administration. The complaint was substantiated as deficiencies were cited in these areas.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan including measurable objectives and timeframes for Resident #46. | SS=D |
| Failure to meet professional standards in medication administration and secure medication carts. | SS=E |
| Failure to maintain minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | — |
| Exit discharge did not maintain a stable level walking surface, posing a trip hazard. | SS=F |
| Exit signage was not properly marked or visible in accordance with NFPA 101 standards. | SS=F |
| Sprinkler heads and escutcheons were missing or not properly oriented in multiple locations. | SS=F |
| Corridor doors did not maintain required clearance between door bottom and floor covering. | SS=D |
| Subdivision of building spaces - smoke barrier doors did not close properly, leaving minimum clearance gaps. | SS=F |
| Medication cart was left unlocked with medications unattended. | — |
Report Facts
Census: 88
Total licensed beds: 105
Deficiencies cited: 9
Compliance date: Apr 11, 2025
Staffing ratios: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to in-service training on individualized comprehensive care plans and medication administration |
| Nurse Supervisors | Nurse Supervisors | In-serviced by Director of Nursing on care plan and medication cart procedures |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing schedules and use of agency staff |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 1
Feb 7, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers during the period 02/05/24 to 02/07/24.
Findings
The facility was found to be in substantial compliance with federal long term care requirements but was not in compliance with New Jersey state licensure standards due to failure to meet minimum staffing ratios for certified nurse aides (CNAs) on day shifts for 14 of 14 days reviewed.
Complaint Details
The complaint survey involved multiple complaint numbers and found the facility failed to meet minimum staffing requirements as mandated by New Jersey law, affecting all residents. The facility was required to submit a plan of correction with a completion date of 03/04/2024.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios met the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 14 of 14 days, specifically not meeting the minimum CNA to resident ratio on day shifts. |
Report Facts
Survey Census: 94
Sample Size: 27
Deficiencies cited: 1
Staffing ratios: 8
Staffing ratios: 9
Staffing ratios: 10
Staffing ratios: 12
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 10
Feb 7, 2023
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 including failure to activate emergency response for a full-code resident resulting in death, failure to report alleged neglect to the NJ Department of Health, failure to meet professional standards in communication and medication administration, failure to provide timely physician visits, medication administration errors, and infection control deficiencies.
Severity Breakdown
Immediate Jeopardy: 1
SS=E: 3
SS=J: 1
SS=D: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to activate emergency response system by calling 911 and initiating CPR for a full-code resident found unresponsive, resulting in death. | Immediate Jeopardy |
| Failure to report an allegation of staff to resident neglect to the New Jersey Department of Health within required timeframes. | SS=E |
| Failure to communicate hospice treatment recommendations to physician and failure to follow medication administration hold parameters. | SS=D |
| Failure to provide basic life support including CPR to a resident requiring emergency care prior to arrival of emergency personnel. | SS=J |
| Failure to assess, educate, obtain physician order, and care plan for resident self-administration of oxygen and respiratory inhalers; inaccurate documentation of administration. | SS=E |
| Failure to ensure physician visits at least every 30 days for residents; missing documentation of visits. | SS=E |
| Medication administration error rate of 7.14%, exceeding 5% threshold. | SS=D |
| Failure to maintain proper infection control practices including disinfecting equipment between residents and hand hygiene after touching surgical masks. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey. | — |
| Failure to notify Clearing House Coordinator of terminated nurse due to incompetence resulting in resident death. | — |
Report Facts
CNA staffing shortfall: 6
Medication administration opportunities: 28
Medication administration errors: 2
Medication administration error rate: 7.14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Failed to initiate CPR and call 911 for full-code resident resulting in death; terminated for incompetence | |
| Director of Nursing (DON) | Interviewed regarding emergency response failure, medication administration, and physician visit deficiencies | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding emergency response failure and staffing | |
| Medical Director (MD) | Interviewed regarding emergency response and physician visit requirements | |
| Infection Preventionist/LPN (IP/LPN) | Interviewed regarding infection control practices and emergency response | |
| Food Service Director (FSD) | Observed failing to perform hand hygiene after touching surgical mask | |
| Licensed Practical Nurse (LPN #1) | Observed medication administration errors and failure to disinfect equipment | |
| Licensed Practical Nurse (LPN #2) | Interviewed about disinfecting practices and medication cart equipment |
Inspection Report
Annual Inspection
Census: 71
Capacity: 71
Deficiencies: 2
Feb 7, 2023
Visit Reason
An annual Life Safety Code Survey and Emergency Preparedness Survey were conducted to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found to be in compliance with Emergency Preparedness requirements but not in compliance with Life Safety Code requirements. Deficiencies included improper installation of 10 photoelectric smoke detectors too close to air supply registers and unprotected penetrations in smoke barriers, potentially affecting all 71 residents and 38 residents respectively.
Severity Breakdown
SS=F: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| 10 of 190 photoelectric smoke detectors were installed less than 36 inches from supply registers of forced air heating or cooling systems, violating NFPA 72 standards. | SS=F |
| Penetrations in smoke/fire barrier walls were not properly sealed, including large holes and pipes passing through barriers, violating NFPA 101 Life Safety Code. | SS=E |
Report Facts
Number of photoelectric smoke detectors: 190
Number of smoke detectors improperly installed: 10
Number of residents potentially affected by smoke detector deficiency: 71
Number of residents potentially affected by smoke barrier deficiency: 38
Facility total licensed capacity: 71
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Nov 4, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ147747, NJ147578, and NJ146257.
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.
Complaint Details
Complaint numbers NJ147747, NJ147578, and NJ146257 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 7
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 0
Mar 9, 2021
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements for long term care facilities. No deficiencies were cited in the report.
Report Facts
Sample size: 15
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Jan 28, 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 testing of residents and staff.
Findings
The facility failed to test staff for COVID-19 at the required frequency based on the COVID-19 Activity Level Index (CALI) Weekly Report, testing staff only once per week instead of twice per week when the regional positivity rate was above 10%.
Complaint Details
The complaint investigation found that the facility did not comply with required COVID-19 testing frequency for staff as mandated by New Jersey Department of Health Executive Directive No. 20-026 and CDC guidelines. The deficiency was substantiated based on interviews and review of testing records for three staff members.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to test staff for COVID-19 at the frequency required by the COVID-19 Activity Level Index Weekly Report. | SS=F |
Report Facts
Census: 54
Regional COVID-19 Positivity Rate: 11.15
Testing Frequency: 1
Testing Frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON)/Infection Preventionist (IP) | Interviewed regarding staff COVID-19 testing frequency and facility testing schedule | |
| Director of Nursing (DON) | Involved in implementing bi-weekly testing schedule and staff in-service | |
| Regional Nurse Consultant | Completed in-service with IP/ADON and DON regarding COVID-19 staff testing frequency |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Jan 7, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health based on complaints NJ 142169 and NJ 142172 to assess compliance with infection control regulations.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations due to failure to utilize appropriate personal protective equipment (PPE) by staff, specifically improper use of N95 respirators. The facility was in substantial compliance with other long term care requirements based on this complaint visit.
Complaint Details
Complaint # NJ 142169, NJ 142172. The facility was found in substantial compliance with 42 CFR part 483, subpart B, for long term care facilities based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to utilize appropriate personal protective equipment (PPE) to prevent the potential spread of infection, including improper use of N95 respirators by staff. | SS=D |
Report Facts
Sample size: 5
Deficiency completion date: Jan 26, 2021
Revisit date: Jan 19, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding PPE requirements and facility policy | |
| Infection Preventionist | Conducted counseling and education on proper N95 mask use; conducted audits | |
| Director of Nursing (DON) | Participated in walking rounds and audits to ensure compliance with PPE policy | |
| Licensed Practical Nurse (LPN) | Observed wearing multiple masks improperly; interviewed about mask use |
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