Atlantic Coast Rehab & Health

Inspectors wroteBased on interviews, record reviews and a review of pertinent facility documentation, it was determined that the facility failed to a) ensure that a resident was protected from alleged abuse by a Certified Nursing Assistant (CNA) #1, and b) failed to implement facility's abuse policy when they became aware of an allegation that CNA #1 pushed the resident knocking them to the floor on 12/11/25. According to an undated document titled reference 12/11/25, which the facility provided to the surveyor, on 12/12/25, the facility administration reviewed video footage and statements from CNA #1 and LPN #1; and after the review, the Interdisciplinary Team (IDT) agreed to obtain formal statements about the incident from both Residents #1 and #2. The document stated that LPN #1 was alerted by the noise coming from Resident #2's room and went to the room, where she saw Resident #1 grabbing CNA #1. [...]

Inspectors wroteBased on interviews, medical record reviews, and review of pertinent facility documents on 3/5/26 and 3/11/26, it was determined that the facility failed to report to the New Jersey Department of Health an allegation of physical abuse that occurred on 12/11/25, after the resident notified staff that a Certified Nursing Assistant pushed them and knocked them down. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1). Findings Include:According to the admission Record (AR), Resident #1 was admitted to the facility with diagnose that included but were not limited to Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder. According to the comprehensive Minimum Data Set (MDS), an assessment tool, dated 2/6/26, Resident #1 had a Brief Interview Mental Status score of 15 out of 15, indicated that the resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice by not storing nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) and Bilevel positive airway pressure device (BiPap- a breathing device that helps a person breathe easier) equipment in bags which resulted in environmental exposure for 3 of 5 residents reviewed for oxygen use (Resident #22, 34, 89) . The deficient practice was evidenced by the following: 1. Upon initial tour of the facility on 2/10/2025 at 10:20 AM, surveyor #1 observed a nebulizer mask standing upright on a nebulizer machine located to the right of Resident #89 on the bedside table. The nebulizer mask was not bagged and exposed to the environment. [...]

Inspectors wroteBased on observation, interview, and pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 02/10/2025 from 09:17 AM until 10:15 AM, the surveyor observed the following in the kitchen in the presence of the Prep [NAME] (PC) then the Regional Food Service Director (RFSD): 1. In refrigerator #1 on the bottom right shelf there were shelled eggs in a carton that were out of the cardboard box. The PC stated the eggs should be stored in the original container. 2. On a storage shelf, souffle cups were opened and exposed to air. The RFSD stated the cups should be covered. 3. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a resident was transported from one area of the unit to another in a dignified manner for 1 of 29 sampled residents, (Resident #109). This deficient practice was evidenced by the following: On 02/10/2025 at 10:39 AM, the surveyor observed the Certified Nursing Assistant (CNA) transport a resident (Resident #109) backwards in his/her geriatric chair from the resident hallway to the nurse station. According to the admission Record Resident #109 was admitted to the facility with diagnoses including but not limited to: dementia and muscle weakness. A review of the most recent Minimum Data Set (MDS) an assessment tool used to facilitate care dated 12/20/24, revealed that Resident #109 had long and short-term memory deficits. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified furnished services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for a resident that required nebulized medications (liquid medicine that turns into a mist that can be easily inhaled) and a leg brace for 2 of 28 residents reviewed for care planning (Resident # 89 and 96). This deficient practice was evidenced by the following: 1. Upon initial tour of the facility on 2/10/2025 at 10:20 AM, surveyor #1 observed a nebulizer mask standing upright on a nebulizer machine located to the right of Resident #89 on the bedside table. The nebulizer mask was not bagged and exposed to the environment. Resident #89 was asleep and did not respond to surveyor #1's prompting. [...]

Inspectors wroteBased on observations, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide treatment and care, based upon current standards of practice specifically by having a urinary catheter drainage bag in contact with the floor, not documenting urinary outputs, and not providing a privacy bag for 2 of 3 residents (Resident # 89, 100) reviewed for Urinary Catheters. The deficient practice was evidenced by the following: On 02/10/2025 at 10:43 AM during the initial tour, Surveyor # 1 observed Resident # 100 in bed. At that time, Surveyor # 1 observed a catheter drainage bag in contact with the floor. A review of Resident # 100's Order Summary located in the Electronic Medical Record (EMR) revealed an order to, Monitor and document [trade name] catheter output every shift. If no output in 8 hours notify MD every shift. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications for 1 out of 3 medication carts inspected under the Medication Storage Task. This deficient practice was evidenced by the following: On 02/12/2025 at 11:39AM in the presence of the Registered Nurse (RN)# 1, the surveyor inspected the medication cart on the subacute high side cart for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed 15 Oxycodone-Acetaminophen (a narcotic medication used to treat pain) in the blister pack in the narcotic box, but the Controlled Drug Sheet (CDS) documented 16 were left. [...]

Inspectors wroteBased on observation, interview, and facility provided documentation, it was determined that the facility failed to ensure all medical supplies were stored in accordance with professional standards by having expired supplies in 1 of 2 medication storage rooms inspected. This deficient practice was evidenced by the following: On [DATE] at 11:13 AM the surveyor in the presence of a Licensed Practical Nurse (LPN)# 1, observed the following in the subacute medication storage room: 1. 6 unopened boxes of probe covers with an expiration date of [DATE]. 2. 2 opened boxes of colostomy bags with an expiration date of 01/2025. 3. 1 unopened box of paper medical tape with an expiration date of 12/2024. During an interview on [DATE] at 11:13 AM with the surveyor LPN #1 said there should not be any expired medical supplies in the storage room and she removed the items. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a sanitary environment by failing to a.) keep the garbage container area free of debris and b.) have a closed cover over the opening the garbage container. This deficient practice was evidenced by the following: On 02/11/25 at 01:09 PM, the surveyor observed the outside garbage area. There were wooden pallets, broken orange plastic pieces, a recliner chair with a rolled-up carpet on top of it, a geriatric chair, a medical glove, a gray container labeled trash, and a commode. These items were not in a container and were in proximity of vehicles. The surveyor observed a green garbage container filled with cardboard boxes. The garbage container was opened on one side exposing the cardboard boxes inside. On 02/12/25 at 11:27 AM, the surveyor observed the garbage area again. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain a complete and readily accessible medical records. This deficient practice was identified for 1 of 29 residents reviewed, Resident #70 and was evidenced by the following: On 02/10/2025 at 11:20 AM, the surveyor observed Resident #70 in bed. Resident #70 states he/she feels great. The surveyor reviewed Resident #70's electronic health record and observed a Physician Order dated 1/29/25: hospice evaluation and treat. There was no other documentation in the electronic health record including the care plans and progress notes regarding hospice. Further review of the medical record revealed the resident was admitted to the facility with diagnoses which included dementia and malnutrition. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically by not following proper technique with personal protective equipment (PPE) on 1 of 3 units observed. The deficient practice was evidenced by the following: On 02/10/2025 at 9:53 AM during initial tour of the facility the surveyor observed a certified nursing assistant (CNA) walk out of resident # 58's room, down the hall to the soiled utility room and back wearing a gown and gloves. The resident's room had an enhanced barrier precautions (a infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use) sign on the door. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/9/2023 from 10:04 AM to 11:37 AM, the surveyor, accompanied by the Food Serviced Director (FSD) and Regional Food Service Director (RFSD) observed the following in the kitchen: 1. The surveyor entered the kitchen on 1/9/2023 to observe the dish machine in operation after the breakfast meal. The surveyor observed (3) dietary staff actively washing dishes upon entering the kitchen. The surveyor asked the FSD to provide a copy of the dish machine temperature log for the surveyor to review. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a) maintain an indwelling urinary catheter drainage bag off the floor to prevent the spread of infection, b) failed to position the catheter tubing and bag below bladder level and c) failed to maintain resident dignity when the catheter drainage bag was visible from the hallway. This deficient practice was identified for 1 of 3 residents (Resident #177) reviewed for indwelling urinary catheters and was evidenced by the following: During the initial tour of the unit on 1/3/2023 at 11:14 AM, Resident # 177 was observed lying in bed with the head of the bed elevated and pillow under both knees. The Foley bag was observed lying on the floor with urine in the bag, uncovered and visible from the hallway. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to adequately monitor the use of an antibiotic by administering 28 doses instead of the prescribed 30 doses. The deficient practice was identified for 1 of 2 residents (Resident #45) reviewed for Antibiotics. The deficient practice was evidenced by the following: A review of Resident #45's physician orders located in the electronic medical record (EMR), revealed that he/she was prescribed Augmentin Suspension 250-62.5 milligrams (mg)/5 milliliters (ml) (an antibiotic) for cough and congestion to be given three times a day for ten days. The Augmentin Suspension was to begin being administered on December 25, 2022 at 2:00 PM. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following On 1/3/2023 between 9:34 AM and 10:30 AM, the surveyor, accompanied by the Dietary Aide (DA) observed the following in the designated facility garbage area: 1. The area directly behind the facility trash compactor was littered with trash, which included rubber gloves, plastic wrappers, cardboard boxes, plastic spoons, empty milk containers, paper, and other unidentifiable objects. On interview the DA stated, We clean the area when they come to pick the dumpster up. We share it with housekeeping. It gets picked up once a week on Wednesday. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to perform adequate handwashing to prevent the spread of infection as well as failed to follow their own Hand Hygiene policy. This deficient practice was identified for 1 of 2 nurses observed during medication administration. This deficient practice was evidenced by the following: On 1/5/2023 at 8:05 AM, the surveyor observed Registered Nurse (RN #2) administer an injectable medication to an unsampled resident. At 8:11 AM, the surveyor observed RN #2 enter the resident's bathroom. At that time, RN #2 turned on the faucet, wet hands her hands, applied soap, lathered outside the stream of water for 7 seconds, rinsed her hands, dried her hands, and turned off the faucet. RN #2 did not use alcohol-based hand sanitizer. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the required beneficiary notices for 1 of 3 residents reviewed for Beneficiary Protection Notification, (Resident # 118). This deficient practice was evidenced by the following: On 1/5/2023 at 10:09 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #118. The SNFBPNR indicated Resident # 118 last covered Medicare day was 10/31/2022 and Resident # 118 remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #118. There was no documentation to indicate why the form was not given to Resident #118. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that medications were received and administered as prescribed by the physician. This deficient practice was identified for 1 of 2 nurses observed during medication administration on 1 of 2 units (Crest Unit) and was evidenced by the following: On 12/03/2020 at 9:20 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #59. The LPN prepared the medications for Resident #59 and realized the resident's Buspar 5 mg tablet ordered three times daily for anxiety was unavailable. The LPN reviewed the resident's Medication Administration Record (MAR) and told the surveyor that the resident's Buspar medication ran out on 11/29/2020 and that was the last day the resident received the Buspar. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to minimize the potential spread of infection to residents during wound treatments for 1 of 2 nurses observed during wound treatment observations on 1 of 2 units (Manor Unit). This deficient practice was evidenced by the following: 1. On 12/04/2020 at 11:00 AM, the surveyor observed the Licensed Practical Nurse (LPN), with the assistance of the Assistant Director of Nursing (ADON), complete the bilateral heel wound dressing changes for Resident #39. The surveyor observed the LPN provide privacy, perform hand hygiene and don gloves. The ADON assisted the LPN to remove the resident's right sock, exposing the heel. The LPN stated that the dressing came off during AM care. The LPN then cleansed the wound, applied the treatment to the wound and dressed the wound as ordered. [...]