Inspection Reports for
Southern Ocean Center

The facility was found deficient in completing and transmitting Minimum Data Set death tracking records, storing and discarding expired food products, and implementing proper infection control practices including PPE use, linen handling, and resident hand hygiene during a COVID-19 outbreak. Deficiencies were noted in staff use of eye protection, gown use during high-contact care, clean linen handling, and use of alcohol-based hand sanitizers for residents.

The complaint was substantiated as the housekeeper admitted to verbally abusing Resident #104. The facility reported the incident to the Department of Health and conducted a full investigation including interviews with other residents and staff.

The facility failed to prevent verbal abuse by a housekeeper who made derogatory comments to Resident #104 about toileting. The housekeeper admitted to the abuse, was terminated immediately, and the facility provided the resident with 1:1 emotional support. Interviews with other residents found no additional abuse.

The investigation was complaint-driven based on four complaints (NJ00176578, NJ00181499, NJ00184013, NJ00184932). The findings confirmed deficiencies related to medication administration and lab result handling for Resident #5. The complaint was substantiated with minimal harm or potential for harm.

The facility failed to ensure that Resident #5 received medications and lab tests as ordered, failed to document medication administration or physician notification when medications were not given or labs not obtained, and failed to notify physicians of these issues. This deficient practice was identified with minimal harm potential affecting a few residents.

Complaint #: NJ173739, NJ175403. The facility failed to meet minimum staffing ratios as mandated by New Jersey law during the complaint period from 06/23/2024 to 07/06/2024.

The facility was found in compliance with COVID-19 infection control regulations but was not in compliance with New Jersey staffing ratio requirements, failing to meet minimum CNA staffing ratios on multiple day, evening, and overnight shifts during the two-week complaint period.

The survey included complaint investigations for complaints #159232, 159474, 159711, 159967, 160488, 165676, 165838, 169655, 169813, 170197. Deficiencies were substantiated related to notification of transfer, assessment after significant change, staffing, and medication management.

Deficiencies were cited related to notice requirements before transfer/discharge, comprehensive assessment after significant change, bowel/bladder incontinence care, sufficient nursing staff, pharmacy services, infection prevention and control, and life safety code compliance. The facility failed to meet several regulatory requirements impacting resident care and safety.

The investigation was triggered by complaints alleging insufficient nursing staff and failure to provide scheduled showers. The complaints were substantiated with evidence of CNA staffing deficiencies on multiple shifts and missed resident showers documented in bathing task lists.

The facility was found deficient in providing sufficient nursing staff on a 24-hour basis, with documented CNA staffing shortages on numerous day and evening shifts over multiple weeks. Several residents reported not receiving scheduled showers twice weekly due to staffing issues, and bathing task lists confirmed missed showers. The Director of Nursing acknowledged the staffing shortfalls.

The investigation was triggered by complaints related to hospital transfer notification failures, delayed hospice assessments, catheter care issues, staffing shortages affecting resident care, medication management errors, and infection control lapses.

The facility was found deficient in timely notification of hospital transfers, delayed completion of significant change assessments for hospice residents, improper urinary catheter care, insufficient nursing staff leading to missed showers, inaccurate controlled substance management including documentation and counts, and inadequate hand hygiene during wound care.

The facility was found to be in noncompliance with several Life Safety Code requirements including inadequate fire barrier enclosure of the boiler room, unprotected low voltage wiring under seven feet, and failure to conduct annual inspections of fire doors. These deficiencies had the potential to affect all 102 residents.

The facility failed to accurately code the MDS assessment for pneumococcal vaccination for one resident and failed to maintain proper documentation of eligibility, consent, or refusal of the pneumococcal vaccine upon admission for the same resident. Interviews and record reviews confirmed lack of supporting documentation for vaccine offers prior to the survey date.

Deficiencies were cited related to resident rights, self-determination, request/refusal of treatment, reporting of alleged violations, investigation of alleged violations, care plan timing and revision, services meeting professional standards, nutritive value and food temperature, frequency of meals and snacks, food procurement and sanitation, dialysis care, sufficient nursing staff, influenza and pneumococcal immunizations, COVID-19 testing and vaccination of staff.

The facility was found noncompliant with emergency lighting requirements and hazardous area enclosures. Specifically, a battery backup emergency light was missing above one of two emergency generator transfer switches, and fire-rated doors to hazardous areas were not self-closing and properly separated by smoke-resisting partitions, posing fire and smoke risks.

The facility was found deficient in multiple areas including failure to ensure resident dignity related to urinary catheter privacy covers, failure to honor resident bathing requests, incomplete advance directive documentation, failure to report and investigate an abuse allegation, incomplete care plan updates for pressure ulcers and accidents, failure to maintain emergency cart security, failure to investigate unsafe smoking incidents, failure to provide oxygen per physician orders and maintain oxygen equipment properly, inconsistent offering of evening snacks, unsanitary kitchen conditions, incomplete COVID-19 staff testing and vaccination tracking, and failure to offer pneumococcal vaccine to a resident.

Complaint # NJ148246, NJ148369 triggered the inspection. The facility was found not in substantial compliance based on these complaints. The infection control deficiency was substantiated and corrected by 10/28/2021.

The facility was found not in substantial compliance due to failure to prevent the spread of infection, specifically by failing to keep soiled linens and a soiled brief off the floor. The facility was otherwise found compliant with COVID-19 infection control regulations. A follow-up revisit on 10/28/2021 confirmed correction of the cited deficiency.