Inspection Reports for
United Methodist Communities At The Shores
2201 Bay Avenue, Ocean City, NJ, 08226
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
47% occupied
Based on a September 2021 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 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 explains 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
Routine
Deficiencies: 4
Date: Aug 29, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pre-admission screening, baseline care planning, comprehensive care planning, and catheter care.
Findings
The facility was found deficient in multiple areas including failure to conduct a new PASRR level one assessment after a resident received a new mental illness diagnosis, failure to develop and implement a baseline care plan within 48 hours of admission including necessary medication information, failure to develop and implement a complete care plan addressing all resident needs for those with indwelling urinary catheters, and failure to ensure proper catheter drainage bag care to prevent contamination.
Deficiencies (4)
Failed to conduct a new PASRR level one assessment after a resident received a new mental illness diagnosis.
Failed to develop and implement a baseline care plan within 48 hours of admission including necessary medication information such as anticoagulants.
Failed to develop and implement a complete care plan that meets all the resident's needs related to indwelling urinary catheters.
Failed to ensure that an indwelling urinary catheter drainage bag was secured to prevent contamination and was not resting on the floor.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Timeframe for baseline care plan: 48
Timeframe for baseline care plan: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding PASRR policy and catheter care | |
| Register Nurse/Unit Manager (RN/UM #1) | Interviewed regarding baseline care plan requirements and medication inclusion | |
| Regional Registered Nurse | Interviewed regarding baseline care plan timeframe and anticoagulant inclusion | |
| Registered Nurse (RN) | Interviewed regarding care plans for residents with indwelling urinary catheters | |
| Registered Nurse Mentor (RNM) | Interviewed regarding proper catheter drainage bag care |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 20, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care, including resident assessments, care planning, medication administration, kitchen sanitation, and staff education.
Findings
The facility was found deficient in multiple areas including failure to issue proper Medicare beneficiary notices, inaccurate resident assessments, incomplete care plans, medication administration errors exceeding 5%, inconsistent offering of evening snacks, poor kitchen sanitation, and inadequate annual education for at least one certified nursing assistant.
Deficiencies (8)
Failed to issue proper Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents reviewed.
Failed to accurately complete the Minimum Data Set (MDS) assessment for 2 of 17 residents reviewed.
Failed to develop and implement a comprehensive person-centered care plan addressing skin disorder and use of bilateral heel protectors for Resident #21.
Failed to maintain professional nursing standards by not obtaining a physician's order for bilateral heel protectors for Resident #21.
Medication administration error rate of 7.69% observed during medication pass, exceeding the 5% threshold.
Failed to consistently offer nighttime snacks to all residents on a nightly basis.
Failed to maintain kitchen sanitation including expired and unlabeled food items, exposed food, dust and mold accumulation, improper storage of equipment and food items, and inadequate cleaning schedules.
Failed to ensure 1 of 5 Certified Nursing Assistants received the required 12 hours of annual education.
Report Facts
Residents reviewed for Beneficiary Protection Notification: 3
Residents reviewed for MDS accuracy: 17
Residents observed for medication errors: 5
Medication administration opportunities: 26
Medication administration error rate: 7.69
Residents affected by inconsistent snack offering: 4
CNA annual education hours completed: 10.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication administration error findings |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding application of bilateral heel protectors |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding application of bilateral heel protectors and snack distribution |
| Director of Nursing | DON | Interviewed regarding care planning, pressure ulcer prevention, and medication administration expectations |
| Nursing Staff Educator | NSE | Interviewed regarding CNA education compliance |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding staff education compliance |
| Executive Chef | EC | Interviewed and observed during kitchen sanitation inspection |
| General Manager | GM | Interviewed and observed during kitchen sanitation inspection |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 20, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, specifically focusing on the accuracy of resident assessments using the Minimum Data Set (MDS).
Findings
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for 2 of 17 residents reviewed, resulting in incorrect coding of falls and injuries. The deficiencies were related to inaccurate reporting of falls and their associated injuries in resident records.
Deficiencies (2)
Failure to accurately complete the Minimum Data Set (MDS) for Resident #29, including omission of a fall in the assessment.
Failure to accurately complete the Minimum Data Set (MDS) for Resident #101, including incorrect coding of falls and injuries.
Report Facts
Residents reviewed: 17
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding inaccuracies in MDS coding for residents |
Inspection Report
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a standard survey to assess the facility's compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 17, 2023
Visit Reason
The inspection was conducted based on a complaint regarding failure to file a formal grievance and follow grievance policy, inaccurate admission assessment, failure to develop a comprehensive care plan, and failure to provide appropriate incontinence care for Resident #1.
Complaint Details
Complaint NJ159493 involved failure to file a grievance, inaccurate admission assessment, lack of care plan for incontinence and wounds, and failure to provide/document incontinence care for Resident #1. The complaint was substantiated based on interviews, record reviews, and policy evaluations.
Findings
The facility failed to file a formal grievance after a family complaint, inaccurately completed the admission assessment, failed to develop a comprehensive care plan for urinary incontinence and lacerations, and failed to consistently provide and document incontinence care for Resident #1. These deficiencies were supported by interviews, medical record reviews, and policy reviews.
Deficiencies (4)
Failed to file a formal grievance and follow grievance policy after receiving a family complaint.
Failed to accurately complete an admission assessment reflecting the resident's status, including urinary continence and wound care.
Failed to initiate a comprehensive person-centered care plan for urinary incontinence and lacerations.
Failed to provide evidence that incontinence care was consistently provided and documented.
Report Facts
Residents affected: 1
Dates of review: 3
Admission evaluation date: Oct 25, 2022
Care Plan date: Oct 26, 2022
Physician admission note date: Oct 26, 2022
ADL documentation gaps: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Former Social Worker | Interviewed regarding grievance filing and documentation for Resident #1. | |
| Nurse Mentor / Registered Nurse (NMRN) | Completed admission assessment for Resident #1 and involved in grievance discussion. | |
| Director of Nursing (DON) | Interviewed multiple times regarding grievance, admission assessment, care plan, and incontinence care documentation. | |
| Certified Nursing Assistant (CNA) | Provided statements and interviews regarding incontinence care and documentation for Resident #1. | |
| Licensed Practical Nurse (LPN #1) | Provided statements about incontinence care for Resident #1. | |
| Licensed Practical Nurse (LPN #2) | Provided statements about responding to resident call light and care needs. |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 5, 2021
Visit Reason
The inspection was conducted to evaluate compliance with pharmaceutical services and food safety standards at the nursing home, including medication management and food handling practices.
Findings
The facility failed to detect and remove expired medications from the automated pharmacy dispensing unit, and failed to maintain proper sanitation and food safety practices in the kitchen, including lack of soap at handwashing sinks, improper food storage, and failure to label and date food items.
Deficiencies (2)
Failed to detect and remove expired medication in the automated pharmacy dispensing unit.
Failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness.
Report Facts
Expired Nitrofurantoin capsules: 8
Expired Levofloxacin tablets: 6
Expired Phenytoin capsules: 6
Expired Atropine Sulfate bottle: 1
Expired Cefpodoxime tablets: 10
Expired Potassium Chloride tablets: 5
Expired Warfarin 1 mg tablets: 16
Expired Warfarin 3 mg tablets: 9
Expired Warfarin 4 mg tablets: 10
Inspection duration: 52
Leftover cooked sausage date: 4
Shelf life for excess prepared foods: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Acknowledged presence of expired medications and responsibility for checking medication in APDU | |
| Licensed Practical Nurse (LPN) | Acknowledged presence of expired medications and discussed checking frequency of APDU stock | |
| Director of Nursing (DON) | Responsible for checking medication expiration dates and removing expired medications from APDU | |
| Licensed Nursing Home Administrator (LNHA) | Present during interview confirming expired medication removal responsibility | |
| Dining Director (DD) | Observed kitchen sanitation issues and food handling deficiencies | |
| Executive Director (ED) | Observed kitchen sanitation issues, removed expired food items, and provided statements on food safety |
Inspection Report
Census: 120
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
Phase 3/Final Phase of the Renovation Project: An off-site approval with Attestation of Compliance for cosmetic upgrades of the first floor and second floor areas including dining rooms, conference areas, town hall, existing library, wellness waiting room, activities, salon, and rest rooms. No construction was involved.
Findings
The facility was in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs based on this initial survey visit.
Report Facts
Sample Size: 0
Inspection Report
Routine
Census: 114
Deficiencies: 6
Date: Jul 16, 2021
Visit Reason
Standard Survey of 250 residential units to assess compliance with New Jersey Administrative Code 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs.
Findings
The facility was found not in substantial compliance with all standards, with deficiencies including failure to conspicuously post required hotline numbers, improper food refrigeration temperatures, inadequate sanitizing solution concentration, unlabeled and undated cooked food storage, lack of mechanical ventilation in some resident bathrooms, and failure to maintain hot water temperatures within required range.
Deficiencies (6)
Failure to post the New Jersey Department of Health Hotline and Ombudsman phone numbers conspicuously to residents and visitors.
Refrigerated foods not maintained at 41 degrees Fahrenheit or below in one refrigerator ('Continental 2').
Sanitizing solution concentration in manual pot-washing sink was below acceptable range.
Cooked food stored in refrigerator in cognitive care unit was unlabeled and undated.
Mechanical ventilation not provided or not functioning in 7 of 15 resident bathrooms without windows.
Hot water temperature for bathing and handwashing was below required minimum of 105 degrees Fahrenheit in 4 sampled rooms.
Report Facts
Census: 114
Refrigerator temperature: 55
Refrigerator temperature: 48
Refrigerator temperature: 45
Number of resident bathrooms without functioning mechanical ventilation: 7
Number of sampled rooms with hot water below 105°F: 4
Hot water temperatures: 102.8
Hot water temperatures: 100.8
Hot water temperatures: 103.2
Hot water temperatures: 101.8
Days water temperature below 105°F at recirculating pump: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Building Services | Director of Building Services | Interviewed regarding posting of hotline numbers and ventilation issues. |
| Dining Director | Dining Director | Interviewed and observed regarding refrigerator temperatures and sanitizing solution concentration. |
| Executive Chef | Executive Chef | Interviewed regarding refrigerator temperatures and sanitizing system malfunction. |
| Medical Technician | Medical Technician | Confirmed storage date of cooked sausage in refrigerator. |
Viewing
Loading inspection reports...
