Inspection Reports for Manahawkin Health and Rehabilitation Center
NJ, 08050
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
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 NJDHSS 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: 106
Deficiencies: 2
Oct 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00175433 and NJ00178356 to assess compliance with federal and state regulations regarding laboratory services and staffing ratios.
Findings
The facility was found not in substantial compliance due to failure to notify the ordering physician of laboratory results for one resident and deficiencies in meeting minimum staffing ratios for certified nurse aides during multiple shifts.
Complaint Details
Complaint numbers NJ00175433 and NJ00178356 triggered the investigation. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify the ordering physician of laboratory results for Resident #3 as required by policy and regulation. | Level D |
| Failure to maintain required minimum staffing ratios for certified nurse aides on multiple day and evening shifts during the complaint period. | — |
Report Facts
Census: 106
Sample Size: 3
Deficient CNA staffing days: 7
Deficient CNA staffing days: 20
Deficient CNA staffing days: 2
Deficient CNA staffing days: 1
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 2
Jun 27, 2024
Visit Reason
The inspection was conducted based on complaints NJ172232, NJ173948, and NJ174987 to investigate compliance with professional standards and staffing requirements.
Findings
The facility was found not in substantial compliance due to failure to follow standards of clinical practice for documenting medication administration in the electronic Medication Administration Record (EMAR) for one resident, and failure to meet required staffing ratios on multiple shifts. Plans of correction were submitted with completion dates.
Complaint Details
Complaint numbers NJ172232, NJ173948, and NJ174987 triggered the visit. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow standards of clinical practice for documenting medication administration in the electronic Medication Administration Record (EMAR) for Resident #3. | SS=D |
| Failure to ensure staffing ratios were met for 8 of 14 day shifts and 1 of 14 overnight shifts reviewed. | — |
Report Facts
Census: 111
Deficiencies cited: 2
Staffing shortfalls: 8
Staffing shortfalls: 1
Completion date for medication documentation correction: Aug 12, 2024
Completion date for staffing training: Jul 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Interviewed regarding medication administration responsibilities and EMAR documentation. |
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 0
Oct 21, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 116
Deficiencies: 19
Sep 20, 2023
Visit Reason
Routine standard survey to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including emergency preparedness, resident rights, Medicaid/Medicare coverage notices, safe environment, restraint use, care planning, ADL care, mobility, accident prevention, nurse aide training, menu compliance, food safety, infection control, and QAPI program implementation. Deficiencies were cited in these areas with corrective actions planned.
Severity Breakdown
Level F: 7
Level E: 3
Level D: 4
Deficiencies (19)
| Description | Severity |
|---|---|
| Emergency Preparedness Plan was not reviewed and updated annually as required. | Level F |
| Residents' dining experience did not promote dignity and respect; residents were not served meals simultaneously at the same table and improper feeding practices were observed. | Level D |
| Facility failed to inform Medicaid-eligible resident of potential financial liability and appeal rights. | Level D |
| Facility failed to ensure a safe, clean, comfortable, and homelike environment in dining rooms; food remained on trays throughout meals. | Level E |
| Facility failed to identify use of physical restraints (merry walker with seat belt) for two residents and failed to have appropriate orders and care plans. | Level E |
| Facility failed to complete criminal background and reference checks prior to employment for multiple employees. | — |
| Facility failed to implement care plan for nail care for a resident with specific diagnosis requiring licensed nurse care. | Level D |
| Facility failed to provide necessary personal hygiene care for a resident with specific diagnosis requiring licensed nurse care. | Level D |
| Facility failed to consistently provide services to treat and prevent decline in range of motion and mobility for a resident; failed to have physician orders and care plan for assistive device use. | Level D |
| Facility failed to follow fall prevention interventions and ensure a resident who sustained a fall was followed by a physician. | Level E |
| Facility failed to follow planned menu and notify residents in advance of menu changes; failed to post menu in accessible areas. | Level E |
| Facility failed to maintain kitchen sanitation including uncovered food items, undated food, uncovered meat slicer, and lack of monitoring of personal refrigerators. | Level F |
| Facility failed to implement an effective, comprehensive, data-driven QAPI program and failed to provide documentation of ongoing QAPI activities. | Level F |
| Facility failed to ensure Certified Nursing Assistants received annual performance reviews. | Level D |
| Facility failed to ensure Certified Nursing Assistants received required 12 hours of annual in-service training including dementia training. | Level F |
| Facility failed to ensure new employees completed health history and received physical examination within required timeframe. | Level F |
| Facility failed to ensure new employees received required two-step Mantoux tuberculin skin test. | Level F |
| Facility failed to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey for multiple day shifts. | — |
| Facility failed to ensure all staff completed mandated LGBTQI+ training as required by state law. | — |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in feeding and dining deficiencies |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in feeding and dining deficiencies |
| Unit Manager/Licensed Practical Nurse #2 | Unit Manager/Licensed Practical Nurse | Named in feeding and dining deficiencies |
| Licensed Nursing Home Administrator | Administrator | Named in emergency preparedness and staffing deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including restraint, staffing, QAPI |
| Director of Maintenance | Director of Maintenance | Named in emergency preparedness deficiency |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in in-service training deficiency |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Named in in-service training deficiency |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Named in in-service training deficiency |
| Human Resources Director | Human Resources Director | Named in background check and staffing deficiencies |
| Food Service Director | Food Service Director | Named in menu and food safety deficiencies |
| Staff Development Nurse | Staff Development Nurse | Named in in-service training deficiency |
| Certified Nursing Assistant #52 | Resident | Named in food safety deficiency related to personal refrigerator |
| Certified Nursing Assistant #79 | Resident | Named in restraint and accident prevention deficiencies |
| Certified Nursing Assistant #167 | Resident | Named in accident prevention deficiency |
| Certified Nursing Assistant #101 | Resident | Named in care planning and ADL care deficiencies |
Inspection Report
Life Safety
Deficiencies: 14
Sep 20, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 9/15/23 and 9/18/23 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code for an existing health care occupancy.
Findings
The facility was found noncompliant with multiple Life Safety Code requirements including delayed egress door features, hazardous area door enclosures, cooking facility protections, fire alarm sensitivity testing, sprinkler system maintenance, portable fire extinguisher inspections, corridor door smoke resistance, HVAC ventilation, elevator emergency communication, smoking area safety, electrical receptacle testing, emergency power system certification, power cord and extension cord usage, and oxygen cylinder storage.
Severity Breakdown
SS=F: 11
SS=E: 3
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure 15-second delayed egress feature on exit doors functioned and proper signage was missing on 6 egress doors. | SS=F |
| Failed to ensure fire-rated doors to hazardous areas were self-closing, labeled, and separated by smoke resisting partitions; 10 of 15 hazardous storage room doors deficient. | SS=F |
| Failed to ensure kitchen ansul system inspection tags were inspected monthly and smoke detector was installed less than 20 ft from cooktop/range. | SS=E |
| Failed to ensure smoke detection sensitivity testing was completed in accordance with NFPA 72. | SS=F |
| Failed to maintain sprinkler system in optimal condition; sprinkler heads dirty and ceiling tiles missing. | SS=E |
| Failed to perform and document monthly visual examination of fire extinguishers; 2 of 15 fire extinguishers deficient. | SS=E |
| Failed to ensure corridor doors resist passage of smoke; 19 of 60 resident room doors observed with issues. | SS=F |
| Failed to ensure resident bathroom ventilation systems and PTAC units were maintained and operating properly; 7 of 50 bathroom vents and 6 of 30 PTAC units deficient. | SS=E |
| Failed to maintain elevator emergency communication for 2 of 2 passenger elevators tested. | SS=F |
| Failed to maintain smoking areas properly; cigarette butts dumped in combustible trash cans and non-smoking areas. | SS=F |
| Failed to functionally test electrical receptacles in resident rooms annually for grounding, polarity, and blade tension; 60 of 60 rooms deficient. | SS=F |
| Failed to certify which systems were on the emergency generator and ensure capability to supply service within 10 seconds. | SS=F |
| Failed to prohibit use of extension cords and power strips beyond temporary installation; multiple instances of daisy chaining and improper use observed. | SS=F |
| Failed to store portable oxygen cylinders properly secured against tipping, rupture, and damage; 3 of 6 cylinders unsecured. | SS=F |
Report Facts
Egress doors with delayed egress feature: 6
Hazardous storage room doors deficient: 10
Fire extinguishers deficient: 2
Resident room doors deficient: 19
Resident bathroom vents deficient: 7
PTAC units deficient: 6
Resident rooms with non-hospital grade outlets: 60
Portable oxygen cylinders unsecured: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to delayed egress doors, hazardous area doors, fire alarm testing, sprinkler maintenance, fire extinguisher inspections, corridor doors, HVAC, elevator communication, smoking area, electrical testing, emergency power, power cord usage, and oxygen cylinder storage | |
| Regional Plant Operations Director | Present during observations and interviews confirming multiple deficiencies | |
| Dietary Director | Interviewed regarding kitchen smoke detector deficiency |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 3
Nov 15, 2022
Visit Reason
The inspection was conducted based on a complaint visit (Complaint#: NJ159383) to determine compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to develop and implement a baseline care plan for a resident, failure to transcribe a Physician's Order for treatment, and failure to consistently complete documentation of Activities of Daily Living (ADLs) care tasks. These deficiencies were identified for 1 of 3 residents reviewed.
Complaint Details
Complaint#: NJ159383. The facility was not in substantial compliance based on this complaint visit.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop and implement a baseline care plan for a resident (Resident #1). | SS=D |
| Failed to transcribe a Physician's Order for treatment to the resident's medical record. | SS=D |
| Failed to consistently complete the Resident's Documentation Survey Report (DSR) for ADLs care tasks. | SS=D |
Report Facts
Census: 111
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Acknowledged failure to develop care plan and failure to transcribe physician orders. | |
| Director of Nursing (DON) | Confirmed deficiencies and described expectations for care plan and order transcription. | |
| Certified Nursing Assistant (CNA) | Provided information about documentation practices on DSR forms. |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Oct 17, 2022
Visit Reason
The inspection was conducted based on a complaint visit to assess compliance with professional standards of nursing practice and staffing requirements.
Findings
The facility failed to maintain the required minimum direct care staff to resident ratios for 13 of 14 day shifts reviewed, and failed to ensure a physician's order for therapy was carried out or an alternative medication was sought when a prescribed medication was unavailable for one resident.
Complaint Details
The complaint investigation found the facility was not in compliance with 42 CFR Part 483, Subpart B, based on failure to follow professional standards of nursing practice related to medication administration for Resident #3.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 13 of 14 nursing day shifts reviewed. | — |
| Failed to follow professional standards of practice by ensuring a physician's order for therapy was carried out or an alternative medication was sought when a prescribed medication was unavailable for one resident. | SS=D |
Report Facts
Deficient CNA staffing days: 13
Resident census: 109
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reviewed October eMAR and acknowledged medication was not given as ordered; provided inservice education to nurses on proper procedures. | |
| Licensed Practical Nurse (LPN) | Assigned to Resident #3 on day shift; acknowledged not administering medication and needing supervision. |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 1
Jan 14, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in infection prevention and control practices, specifically staff failing to wear required gowns when entering a resident's room under COVID-19 precautions. The facility provided re-education and in-service training to staff and implemented monthly rounds to ensure compliance.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to wear required personal protective equipment (gowns) when entering 1 of 8 resident rooms under COVID-19 precautions despite posted signage. | SS=D |
Report Facts
Census: 96
Deficiency completion date: Mar 4, 2022
Inspection Report
Routine
Census: 87
Deficiencies: 1
Jul 23, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing ratios as per new minimum staffing requirements.
Findings
The facility failed to meet the required staffing ratios for Certified Nursing Assistants (CNAs) on 49 of 57 shifts reviewed, with deficiencies noted across day, evening, and night shifts. Interviews with staff and administration confirmed awareness of the staffing shortfalls. The facility policy did not document required CNA staffing ratios.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 49 of 57 shifts reviewed, violating minimum staffing requirements. |
Report Facts
Shifts with deficient staffing ratios: 49
Day shifts not meeting minimum ratio: 16
Evening shifts not meeting minimum ratio: 14
Night shifts not meeting minimum ratio: 19
Resident census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Temporary Nursing Assistant (TNA #2) | Temporary Nursing Assistant | Interviewed on 7/21/21 regarding resident assignments and staffing. |
| Director of Nursing | Director of Nursing | Interviewed on 7/21/21 acknowledging awareness of staffing regulations and deficiencies. |
| Facility Director | Facility Director | Interviewed on 7/21/21 acknowledging awareness of staffing regulations and deficiencies. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed on 7/21/21 acknowledging awareness of staffing requirements and daily review of staffing. |
Inspection Report
Life Safety
Deficiencies: 4
Jul 19, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health 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 for existing health care occupancy.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including improperly secured electrical outlet boxes exposing live wires, inadequate ventilation in 32 of 64 resident bathrooms, unsafe disposal of smoking refuse with over 100 cigarette butts found outside designated areas, and failure to certify that the emergency generator transfers power within the required 10-second timeframe.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Surface mounted 4-outlet electrical box in a resident room was not attached to the wall, exposing live electrical wires. | SS=D |
| Ventilation in 32 of 64 resident room bathrooms did not function adequately as required by NFPA 90A. | SS=E |
| More than 100 cigarette butts were found outside the designated smoking area, indicating failure to ensure safe disposal of smoking refuse. | SS=D |
| Facility failed to certify that the emergency generator transfers power to the building within the required 10 seconds as per NFPA 110 and NFPA 99. | SS=D |
Report Facts
Resident bathrooms with ventilation issues: 32
Cigarette butts found outside designated smoking area: 100
Generator load test dates missing certification: 13
Generator load test dates missing certification: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to findings on electrical outlet, ventilation, generator testing, and corrective actions | |
| Regional Plant Operations Director | Named in relation to findings on electrical outlet, ventilation, smoking refuse, generator testing, and corrective actions | |
| Administrator | Named in relation to findings on ventilation and generator testing corrective actions | |
| Housekeeping Director | Named in relation to smoking refuse removal and corrective actions | |
| Corporate Environmental Director | Named in relation to counseling Maintenance and Housekeeping Directors on deficiencies |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 1
May 13, 2021
Visit Reason
The inspection was conducted based on Complaint # NJ 140226 to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to maintain complete, accurate, and readily accessible medical records for 1 of 4 residents reviewed (Resident #3). Missing documentation included physician progress notes, nursing progress notes, and physician's order form results. The medical record was misfiled due to insufficient staff education.
Complaint Details
Complaint # NJ 140226 was substantiated as the facility was found not in substantial compliance with medical record maintenance requirements.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain complete, accurate, and readily accessible medical records for Resident #3, including missing physician progress notes, nursing progress notes, and physician's order form results. | SS=D |
Report Facts
Sample size: 4
Audit period: 30
Review frequency: 3
Review duration: 60
Quality Measure Meeting review period: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Involved in locating missing medical records, conducting in-service training, and reviewing medical records | |
| Facility Director | Involved in locating missing medical records, conducting in-service training, and reviewing medical records | |
| Assistant Director of Nurses | Conducted in-service training with Director of Nursing |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Jan 12, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ142179.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint # NJ142179 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 2
Dec 22, 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 and COVID-19 related practices.
Findings
The facility failed to follow appropriate infection control practices to prevent the spread of infection, including failure to post appropriate Transmission-Based Precaution signs and failure to report a positive COVID-19 case to the local health department as required by Executive Directive No. 20-013.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow appropriate infection control practices and post Transmission-Based Precaution signs outside rooms/cohort areas for residents under investigation for COVID-19. | SS=E |
| Failure to adhere to Executive Directive No. 20-013 by failing to report a positive COVID-19 case to the local health department. | SS=E |
Report Facts
Census: 93
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Behavior Monitor Assistant | Observed entering TBP unit without proper PPE | |
| Licensed Practical Nurse | LPN | Observed Behavior Monitor Assistant entering TBP unit without proper PPE and stated PPE requirements |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Stated PPE expectations and lack of signage on TBP unit |
| Director of Nursing | DON | Interviewed regarding positive COVID-19 case reporting and infection control practices |
| Regional Corporate Clinical Coordinator | RCCC | Provided information about TBP unit and infection control practices |
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