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: 141
Capacity: 149
Deficiencies: 8
Feb 14, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including multiple complaints numbered 169551, 169664, 171379, 172311, 175440, 175662, 177276, 177818, 181054, 181847, 182524, and 182687.
Findings
Deficiencies were cited related to resident rights, dignity, safe environment, professional standards, medication administration, respiratory care, pharmacy services, infection control, food safety, garbage disposal, and life safety code violations. The facility failed to maintain adequate staffing, safe environment, proper medication cart security, and compliance with fire safety requirements.
Complaint Details
The visit was complaint-related with multiple complaint numbers listed. The complaints involved issues such as resident rights, dignity, personal property, safe environment, medication administration, respiratory care, and staffing deficiencies. The complaints were substantiated as evidenced by the cited deficiencies.
Severity Breakdown
Level D: 6
Level F: 1
Level E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Residents were served cold beverages in disposable plastic cups in the dining room, which did not promote dignity and respect. | Level D |
| Facility failed to ensure resident rights to personal property and dignity, including failure to provide locks on closet doors and proper notification of maintenance requests. | Level D |
| Facility failed to provide a safe, clean, comfortable, and homelike environment, including dirty floors, broken furniture, and poor housekeeping. | Level F |
| Facility failed to meet professional standards for medication administration, including unsecured medication cart and failure to lock medication cart during administration. | Level D |
| Facility failed to obtain physician's orders and develop comprehensive care plans for residents receiving respiratory care. | Level D |
| Facility failed to provide routine and emergency drugs and biologics, including proper labeling, storage, and disposal of medications. | Level D |
| Facility failed to maintain a safe environment, including fire safety code violations such as failure to maintain fire barriers and elevator emergency communication. | Level E |
| Facility failed to maintain adequate staffing levels as mandated by state regulations. | Level D |
Report Facts
Census: 141
Total Capacity: 149
Complaint Numbers: 12
Deficiency Counts: 8
CNA Staffing Deficiencies: 7
CNA Staffing Deficiencies: 2
Elevators: 3
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 2
Nov 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on allegations related to failure to investigate grievances and allegations of abuse, neglect, exploitation, or misappropriation at Shore Gardens Rehabilitation and Nursing Center.
Findings
The facility was found not in substantial compliance with federal requirements due to failure to investigate grievances and allegations of abuse and neglect. The investigation was unable to substantiate the allegations, but deficiencies were identified related to grievance handling, investigation processes, and administration oversight. Corrective actions and plans were implemented but the facility failed to meet all requirements at the time of the visit.
Complaint Details
The complaint investigation was based on allegations NJ00179177 and NJ00179069 regarding failure to investigate grievances and allegations of abuse and neglect. The facility was unable to substantiate the allegations but was found deficient in grievance investigation and administration oversight.
Severity Breakdown
SS=J: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to investigate and address grievances and allegations of abuse, neglect, exploitation, or misappropriation. | SS=J |
| Failure to ensure staffing ratios met minimum requirements. | SS=D |
Report Facts
Census: 143
Sample Size: 7
Deficient CNA staffing days: 8
Minimum CNA staffing required: 18
Actual CNA staffing: 16
Inspection Report
Annual Inspection
Census: 138
Capacity: 149
Deficiencies: 21
May 11, 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 related to resident rights, reporting of alleged violations, medication administration, respiratory care, dialysis coordination, physician visits, social services, food safety and preferences, infection prevention and control, and life safety code violations including emergency lighting, hazardous area enclosure, sprinkler system maintenance, corridor door integrity, smoking regulations, electrical systems maintenance, and gas equipment storage.
Complaint Details
Complaint investigations NJ #147719, NJ 150149, NJ 150832, NJ 151124, NJ 151993 were included in the survey. Substantiation status is not explicitly stated.
Severity Breakdown
SS=E: 6
SS=F: 6
SS=D: 7
: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Facility failed to obtain consent from a resident representative prior to administering a treatment for Resident #134. | SS=D |
| Facility failed to report an allegation of abuse to the New Jersey Department of Health for Resident #193. | SS=E |
| Facility failed to investigate an allegation of abuse for Resident #193. | SS=E |
| Facility failed to document medication administration according to standards of practice for Resident #109 and failed to follow physician's order for Resident #69. | SS=D |
| Facility failed to ensure respiratory care equipment was set at proper parameters for Resident #13. | SS=D |
| Facility failed to provide snack bag and coordinate medication administration times with scheduled dialysis days for Resident #48. | SS=E |
| Facility physician failed to have a face to face visit for Resident #192 after admission and did not return. | SS=D |
| Facility failed to provide medically-related social services for Resident #134 who had no representative or legal guardian. | SS=D |
| Facility failed to ensure meals were served at safe and appetizing temperatures on the third floor during lunch meal service. | SS=D |
| Facility failed to ensure resident food preferences were honored for Resident #85. | SS=D |
| Facility failed to store and label potentially hazardous foods properly, sanitize cookware, and maintain sanitation to prevent food borne illness. | SS=F |
| Facility failed to maintain proper infection control practices during laboratory specimen collection, medication administration, linen storage, and kitchen staff practices. | SS=E |
| Facility failed to maintain required minimum direct care staff-to-shift ratios for 21 of 28 day shifts reviewed. | — |
| Facility failed to provide battery back-up emergency light above the electric fire pump transfer switch independent of building electrical system and emergency generator. | SS=E |
| Facility failed to provide fire barrier with two hour fire resistance rating in hazardous areas (boiler room) as required. | SS=D |
| Facility failed to annually inspect private property fire hydrants, maintain fire pump in optimal condition, and document monthly fire pump testing. | SS=F |
| Facility failed to ensure corridor doors resisted passage of smoke and were properly latched and closed in 31 of 50 resident room doors observed. | SS=F |
| Facility failed to maintain smoking areas in accordance with NFPA 101, with cigarette butts and no metal container with self-closing cover devices for ashtrays. | SS=F |
| Facility failed to functionally test electrical receptacles in resident rooms annually for grounding, polarity, and blade tension. | SS=F |
| Facility failed to ensure electrical equipment wiring was safe; three bug lights had modified spliced plugs not permitted by code. | SS=F |
| Facility failed to prohibit combustible storage within 5 feet of quantities of oxygen exceeding 300 cubic feet. | SS=E |
Report Facts
Deficient CNA staffing day shifts: 21
Certified beds: 149
Current census: 138
Resident rooms with compromised doors: 31
Portable oxygen cylinders stored improperly: 41
Resident rooms observed for electrical receptacles: 50
Resident room doors observed: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and infection control findings. |
| LPN #3 | Licensed Practical Nurse | Reported allegation of abuse to supervisor and ADON. |
| LPN #5 | Licensed Practical Nurse Unit Manager | Interviewed about consent and resident rights. |
| LPN #6 | Licensed Practical Nurse | Informed dietary aide about infection control. |
| LPN #7 | Licensed Practical Nurse | Observed administering medication without proper documentation. |
| LPN #8 | Licensed Practical Nurse | Interviewed about resident rights and consent. |
| LPN #9 | Licensed Practical Nurse | Interviewed about dialysis medication administration and snack bags. |
| LPN #10 | Licensed Practical Nurse | Interviewed about dialysis snack bags and medication timing. |
| LPN UM #1 | Licensed Practical Nurse Unit Manager | Interviewed about consent and abuse reporting. |
| LPN UM #2 | Licensed Practical Nurse Unit Manager | Interviewed about medication orders and food preferences. |
| LPN UM #3 | Licensed Practical Nurse Unit Manager | Sent fax to attending physician. |
| LPN UM #5 | Licensed Practical Nurse Unit Manager | Interviewed about consent and resident rights. |
| LPN UM #6 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN UM #8 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN UM #9 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN UM #10 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN UM #11 | Licensed Practical Nurse Unit Manager | Wrote telephone order. |
| LPN/UM #2 | Licensed Practical Nurse Unit Manager | Interviewed about infection control and medication administration. |
| LPN/UM #3 | Licensed Practical Nurse Unit Manager | Sent fax to attending physician. |
| LPN/UM #4 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN/UM #5 | Licensed Practical Nurse Unit Manager | Interviewed about consent and resident rights. |
| LPN/UM #6 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN/UM #7 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN/UM #8 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN/UM #9 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN/UM #10 | Licensed Practical Nurse Unit Manager | Interviewed about infection control. |
| LPN/UM #11 | Licensed Practical Nurse Unit Manager | Wrote telephone order. |
| ADON | Assistant Director of Nursing | Interviewed about infection control and consent. |
| DON | Director of Nursing | Interviewed about infection control, consent, and staffing. |
| Administrator | Facility Administrator | Interviewed about consent, infection control, staffing, and life safety findings. |
| FSD | Food Service Director | Interviewed about food safety and infection control. |
| IP | Infection Preventionist | Interviewed about infection control practices. |
| RD | Registered Dietitian | Interviewed about food preferences. |
| SW #1 | Social Worker | Interviewed about resident representative and psychosocial assessment. |
| LPN #4 | Licensed Practical Nurse | Interviewed about respiratory care. |
| LPN #5 | Licensed Practical Nurse | Interviewed about consent and resident rights. |
| LPN #3 | Licensed Practical Nurse | Reported abuse allegation to supervisor and ADON. |
| LPN #8 | Licensed Practical Nurse | Interviewed about resident rights and consent. |
| LPN #7 | Licensed Practical Nurse | Observed administering medication without proper documentation. |
| LPN #9 | Licensed Practical Nurse | Interviewed about dialysis medication administration and snack bags. |
| LPN #10 | Licensed Practical Nurse | Interviewed about dialysis snack bags and medication timing. |
| LPN #1 | Licensed Practical Nurse | Named in medication administration and infection control findings. |
| Dietary Aide #1 | Dietary Aide | Observed with hair outside hairnet. |
| Dietary Aide #2 | Dietary Aide | Observed handwashing and infection control practices. |
| Maintenance Director | Maintenance Director | Interviewed about life safety and infection control findings. |
Inspection Report
Routine
Census: 138
Capacity: 149
Deficiencies: 8
May 11, 2023
Visit Reason
Routine inspection of Shore Gardens Rehabilitation and Nursing Center to assess compliance with health and safety regulations including fire safety, electrical systems, and hazardous materials storage.
Findings
The facility was found deficient in multiple areas including emergency lighting, hazardous area enclosures, sprinkler system maintenance, corridor door integrity, smoking area maintenance, electrical receptacle testing, electrical equipment safety, and oxygen cylinder storage. Corrective actions were planned and subsequently verified as completed during a revisit.
Severity Breakdown
SS=E: 2
SS=D: 1
SS=F: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide battery back-up emergency light above the electric fire pump transfer switch. | SS=E |
| Failed to provide fire barrier with two hour fire resistance rating in hazardous areas. | SS=D |
| Failed to annually inspect private fire hydrants, maintain fire pump in optimal condition, and document monthly fire pump testing. | SS=F |
| Failed to ensure corridor doors resist passage of smoke; 31 of 50 resident room doors had issues such as loose hardware, holes, or did not latch properly. | SS=F |
| Failed to maintain smoking area properly; cigarette butts found outside designated ashtray areas and lack of metal container with self-closing cover for ashtray disposal. | SS=F |
| Failed to functionally test electrical receptacles in resident rooms annually for grounding, polarity, and blade tension. | SS=F |
| Electrical equipment wiring unsafe; 3 of 9 bug lights had modified spliced plugs not permitted by facility policy. | SS=F |
| Failed to prohibit combustible storage within 5 feet of oxygen cylinders exceeding 300 cubic feet; 41 cylinders stored within 3 feet of combustible cardboard boxes. | SS=E |
Report Facts
Deficiencies cited: 8
Resident census: 138
Total licensed capacity: 149
Number of oxygen cylinders stored improperly: 41
Number of resident room doors with deficiencies: 31
Number of bug lights with unsafe wiring: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed multiple findings including emergency lighting, fire barriers, sprinkler system issues, door deficiencies, smoking area maintenance, electrical testing, and oxygen storage. | |
| Administrator | Informed of all findings at Life Safety Code exit conference and involved in smoking area observation. |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Aug 2, 2021
Visit Reason
The inspection visit was conducted in response to complaint number 147093 to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint visit.
Complaint Details
Complaint number 147093 was investigated and the facility was found compliant.
Report Facts
Complaint number: 147093
Sample size: 3
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 4
Apr 5, 2021
Visit Reason
The inspection was conducted as a recertification survey with complaints, including allegations of staff to resident abuse and failure to report and investigate such allegations.
Findings
The facility was found not in compliance with requirements related to reporting and investigating alleged abuse, maintaining accurate medical records, and infection prevention and control practices. Specific deficiencies included failure to timely report an abuse allegation, failure to investigate the abuse allegation, incomplete and inaccurate medical records for a resident, and failure of staff to properly don PPE and maintain infection control protocols.
Complaint Details
Complaint numbers NJ14516, NJ142594, NJ144335 involved allegations of staff to resident abuse, failure to report and investigate abuse, and infection control issues. The abuse allegation involved Resident #26 and an Agency Nurse. The facility failed to report the incident timely and did not complete an investigation until prompted by surveyors. Police reports corroborated the resident's statements. Infection control deficiencies involved failure to don PPE for residents on transmission-based precautions and improper housekeeping cart storage.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report an allegation of staff to resident abuse to the New Jersey Department of Health in a timely manner. | SS=D |
| Failure to investigate an allegation of staff to resident abuse thoroughly and timely. | SS=D |
| Failure to maintain an accurate, complete, and accessible medical record for a resident, including discrepancies in bowel elimination records. | SS=D |
| Failure of staff to don appropriate Personal Protective Equipment (PPE) when entering rooms of residents on transmission-based precautions and improper handling of housekeeping carts. | SS=D |
Report Facts
Census: 100
Sample size: 37
Dates: Mar 20, 2021
Dates: Mar 29, 2021
Dates: Apr 5, 2021
Dates: Jun 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #26 | Resident | Involved in abuse allegation with Agency Nurse. |
| Licensed Nursing Home Administrator (LNHA) | Administrator | Reported abuse incident to NJDOH and responsible for investigations. |
| Director of Nursing (DON) | Director of Nursing | Briefed on abuse incident and confirmed it should have been investigated. |
| Nursing Supervisor/Registered Nurse (NS/RN) | Nurse | Informed Agency Nurse to leave facility and corroborated resident's abuse report. |
| Certified Nursing Assistant (CNA#1) | CNA | Observed failing to don PPE when entering isolation room. |
| Certified Nursing Assistant (CNA#2) | CNA | Observed failing to don PPE when entering isolation room. |
| Temporary Nursing Assistant (TNA#1) | TNA | Observed failing to don PPE when entering isolation room. |
| Temporary Nursing Assistant (TNA#2) | TNA | Observed failing to don PPE when entering isolation room. |
| Housekeeper #1 | Housekeeper | Observed bringing housekeeping cart into resident room. |
| Housekeeping Director | Director of Housekeeping | Provided counseling and reviewed housekeeping cart policy. |
| Regional Director/Infection Preventionist | Regional Director/LPN | Provided infection control guidance and policy. |
Inspection Report
Life Safety
Deficiencies: 1
Mar 23, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code requirements, specifically focusing on the maintenance and condition of portable fire extinguishers in the facility.
Findings
The facility was found not in substantial compliance with the Life Safety Code due to failure to maintain portable fire extinguishers in proper working condition. Specifically, 12 of 15 fire extinguishers were red-tagged for not having the required 6-year hydrostatic test performed, posing a significant fire safety risk.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain portable fire extinguishers in proper working condition; 12 of 15 extinguishers were red-tagged for missing required 6-year hydrostatic test. | SS=E |
Report Facts
Number of portable fire extinguishers non-compliant: 12
Total portable fire extinguishers observed: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during inspection and interview regarding fire extinguisher deficiencies. | |
| Administrator | Provided documentation and was notified of deficiencies at exit conference. | |
| Corporate Maintenance Director | Conducted in-service training with Maintenance staff and Administrator on fire extinguisher safety. |
Inspection Report
Routine
Census: 107
Deficiencies: 0
Jan 27, 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 recommended COVID-19 practices.
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
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