Atrium at Navesink Harbor, the

Inspectors wroteBased on observation and interview it was determined the the facility failed to ensure that the Dietary staff had the appropriate skill sets and competencies to ensure a) staff maintained a sanitary dietary environment, b) a process was in place to ensure recipes were followed to ensure nutrition adequacy of fortified foods, and appropriate physician ordered diets were provided to residents, c) cooking temperatures were consistently monitored, d) staff were competent in utilizing food temperature measuring devices, e) infection control practices were consistently implemented with glove use and hand hygiene, and f) foods were appropriately labeled, dated and discarded by use by dates. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to ensure a process was in place to ensure a) modified texture foods were prepared utilizing standardized recipes to ensure adequate nutritional content and appropriate modified food texture, b) appropriate portions were provided for all texture modified foods and c) ensure all foods were served at appropriate temperatures. The deficient practice was observed during a meal observation and affected 6 of 6 residents who received puree diets and 4 of 4 residents who received mechanical soft diets, and was evidenced by the following: On 02/18/26 at 12:14 PM, the surveyor observed the meal service in the 3rd floor food service pantry and observed the following: A person was observed in the pantry with their hair not fully covered and one side was hanging outside of the hair net. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure a) all food was appropriately stored and food temperatures were monitored in a manner to prevent foodborne illness, b) all kitchen equipment and the environment in the main kitchen and remote service kitchen was maintained in a clean and sanitary manner, c) staff practiced hand hygiene and restrained their hair appropriately. This deficient practice affected all residents and increased the potential for the development of food borne illness, the potential from contamination from foreign substances and was evidenced by the following: On 02/18/26 at 8:24 AM, the surveyor toured the kitchen with the Executive Chef (EC), the Director of Dining Services (DDS) and observed the following: -The EC exited the refrigerated walk- in box and did not have all his facial hair covered. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure that garbage was properly contained in dumpsters and ensure cardboard was properly disposed of and the garbage area was maintained in a clean and sanitary manner to prevent the harborage and feeding of pests. The deficient practice affected all residents who resided at the facility and was evidenced by the following: On 2/18/26 at 8:54 AM, during the initial tour of the kitchen with the Executive Chef (EC), the surveyor observed an alcove area prior to the exit from the kitchen toward the dumpster area. The area had cardboard boxes strewn about and were piled up on the floor, and were against the walls. The cardboard boxes were also covering a black bin that appeared to have broken down cardboard boxes inside. [...]

Inspectors wroteBased on observations, interview and document review it was determined that the facility failed identify and include the staff competencies and skill sets that were necessary to provide the level and types of care needed for the resident population which included the contracted food service department. The deficient practice affected all residents who resided at the facility and was identified by the following: On 2/18/26, the facility provided the survey team with a copy of the Facility Assessment (FA). A review of the document revealed the following: Staff training/education and competencies: Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to self-identify areas of concerns and develop comprehensive data driven Quality Assurance Performance Improvement plans to address sanitation, pest management, garbage disposal, appropriate meal preparation and meal service, and also failed to self-identify concerns related to timely implementation of wound care recommendations and clarification of wound care orders. The deficient practice affected all residents who resided in the facility and was evidenced by the following: Refer to : F550, F686, F802, F804, F805, F812, F925 On 02/25/26 at 8:48 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) about the Quality Assurance Performance Improvement (QAPI) process and what the current active QAPI plans included. [...]

Inspectors wroteBased on interview and review of pertinent facility provided documentation, it was determined that the facility failed to ensure that the Infection Preventionist (IP) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance for one (1) of one (1) employee reviewed for IP.Refer to: F882: An IP must have obtained specialized IPC training beyond initial professional training or education prior to assuming the role. Training can occur through more than one course, but the IP must provide evidence of training through a certificate(s) of completion or equivalent documentation. CMS recommends specialized training include the following topics: [...]

Inspectors wroteBased on observation, interview and review of pertinent documents it was determined that the facility failed to ensure an effective pest management program was in effect to control flies in the kitchen. The deficient practice affected all residents who resided in the facility and was evidenced by the following: On 2/18/26 during a kitchen tour conducted by the surveyor that began on 8:24 AM, with the Executive Chef (EC),and the Director of Dining Services (DDS), the surveyor observed small black flies sporadically in the kitchen, and observed black flies were on the front and side of the white microware oven in the area where the ice cream freezer was located. The EC stated the flies were due to a leak in a pipe that had a crack. On 02/19/26 at 9:53 AM, the surveyor interviewed the Director of Facility Management (DFM) who was responsible for maintenance, housekeeping and security. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently treat residents in a dignified manner. This deficient practice was identified during the meal observation for three 4 of eight 8 residents (Resident #5, Resident #18, Resident #22, Resident #24) observed during breakfast and lunch on 2 of 2 resident units and was evidenced by the following. 1. On 02/18/26 at 8:30 AM, the surveyor toured the 300 Unit and observed the meal delivery system. Some residents were observed eating in their rooms while other residents were at the nursing station waiting for assistance with the breakfast meal. The surveyor observed Resident #24 in bed with the breakfast tray positioned on the bedside table. The surveyor observed that Resident #24 was eating with their bare hands. [...]

Inspectors wroteBased on interview and document review, it was determined that the facility failed to have a system in place to ensure a) prior to hire, all employees were pre-screened to ensure that they had not been found guilty in a court of law of abuse, neglect, or misappropriation, or had findings entered into the state nurse aide registry or against a professional license, and b) a process was in place to maintain documentation to confirm an appropriate pre-screening had occurred for all contracted facility employees which included dietary. The deficient practice was identified for 3 of 56 employee files reviewed that were provided by the facility. The evidence was as follows:A review of facility policy Hiring Policy: Employment Application & Pre-Employment Checks, revised April 2025 included:Policy: [Facility Name], Inc. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure dependent residents were provided with routine and appropriate nail care in a timely manner. This deficient practice was identified for 1 of 2 resident reviewed for Activities of Daily Living Care (Residents #18) and was evidenced by the following: On 02/18/2026 at 8:25 AM, the surveyor observed Resident #18, seated in a recliner chair adjacent to the nursing, their breakfast tray was on the bedside table. The surveyor observed the resident's nails long, jagged and discolored with a black substance underneath the fingernails. The resident was unable to answer the surveyor's inquiries when asked if they would like their nails to be trimmed and cleaned. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a system was in place to ensure wound treatment recommendations were clarified and implemented in a timely manner. This deficient practice was identified for one (1) of three (3) residents reviewed for pressure ulcers (Resident #1), who had a wound treatment recommended by the Wound Consultant (WC) on 1/13/26, which was implemented on 1/21/26 (7 days later) and the dose was not clarified by the physician until 2/19/26 (38 days later). The deficient practice was evidenced by the following:On 2/18/26 at 12:16 PM, the surveyor observed Resident #1 in the seated in a recliner in the dining room and was being assisted with the meal by facility staff. On 2/19/26 at 8:57 AM, the surveyor observed Resident #1 sleeping in bed. [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to have a system in place to ensure a) weights were consistently and accurately monitored and verified a weight loss and implemented interventions in response to a significant weight loss, and b) staff implemented identified nutritional interventions appropriately and consistently. The deficient practice was identified for 2 of 2 residents reviewed for nutrition, who sustained significant unplanned weight loss (Resident #1 lost 9.53% in 10 days (from 12/17/25 to 12/27/25) and Resident #5 who had a 14 % weight loss x 6 months). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to assure the nursing staff had the competency and skills sets to provide nursing care to two sampled residents to provide appropriate wound care and ensure nursing staff were competent in a process to verify physician recommendations and clarify orders for wound care. The deficient practice was evidenced for 2 of 3 residents reviewed for wound care (Resident #1 and Resident #3) and was evidenced by the following: a. On 1/13/26 [untimed], WC #2's documented, on a Consultation form, New Findings and Recommended Treatment: measurements 13.5 [cm] x 8.5[cm] x 2[cm]; and wound was debrided. the wound was debrided; Cleanse wound with Vashe, apply Santyl to slough, pack with Dakin's (sodium hypochlorite; modified bleach used as an antiseptic to clean and treat infected wounds or ulcers; [...]

Inspectors wroteBased on observation, interview, record review and document review it was determined that the facility failed to ensure a system was in place to ensure that a resident who required a mechanically altered diet, received appropriate meal items. The deficient practice was identified for 1 of 3 Residents reviewed for nutrition (Resident #5) and who required a mechanical soft diet and had the potential to affect all residents who required a mechanical soft diet. The deficient practice was evidenced by the following: On 2/19/26 at 8:48 AM, the surveyor interviewed the Registered Dietitian (RD) about Resident #5's weight loss. The RD stated that the resident has had weight loss, has become increasingly confused, and she has added interventions in response to the weight loss. On 2/19/26 at 2:30 PM, the surveyor reviewed the electronic medical record for Resident #5 which revealed the following: [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documentation, it was determined that the facility failed to maintain proper infection control practices for a) hand hygiene and establishing a clean field during a wound treatment b) hand hygiene during resident meal service one (1) of two (2) nurses who administered medications to one (1) of four (4) residents during the medication administration observation, to limit the potential of spreading infection. The deficient practice was evidenced by the following: Reference: According to Centers for Disease Control and Prevention, Guideline for Disinfection and Sterilization in Healthcare Facilities, dated 11/28/23, included that: Semicritical items contact mucous membranes or non-intact skin. This category included respiratory therapy. These medical devices should be free from all microorganisms. a. [...]

Inspectors wroteBased on interview, record review, and document review, it was determined that the facility failed to issue the required Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) in the proper time frame for 2 of 3 residents (Resident #12, and Resident #46) reviewed for Beneficiary Protection Notification. This deficient practice was evidenced by the following:On 2/18/26 at 1:36 PM, the surveyor reviewed the facility provided list of residents who were discharged from Medicare covered Part A in the last six months and randomly chose three residents and requested the Beneficiary Notices from the Licensed Nursing Home Administrator (LNHA). On 2/21/26 at 1:55 PM, the surveyor reviewed the Beneficiary Notices provided which revealed the following: [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to identify medication irregularity from 1/13/26 to 2/19/26, during the monthly Medication Record Review (MRR) of the Consultant Pharmacist (CP) for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers. The deficient practice was evidenced by the following: On 2/18/26 at 12:16 PM, the surveyor observed Resident #1 in the dining room seated in a recliner with legs elevated and was fed by a facility staff. On 2/19/26 at 8:57 AM, the surveyor observed Resident #1 asleep on their back, unaroused by the surveyor's voice, head of the bed was elevated, and legs were covered with a blanket. The surveyor reviewed the medical record for Resident #1. [...]

Inspectors wroteBased on interview, record review, and document review, it was determined that the facility failed to have a current written agreement between the Medicare-certified hospice and the facility for 1 of 1 resident (Resident #28) reviewed for hospice/end of life care. The deficient practice was evidenced by the following:On 2/20/2026 at 9:23 AM, the surveyor observed and interviewed Resident #28 who was in their room. On 2/24/26 at 10:20 AM, the surveyor reviewed the resident's hard chart (paper chart) which revealed the following: The Face Sheet revealed the resident had diagnoses including but not limited to; arteriosclerotic heart disease (thickening and hardening of the arteries of the heart). The physician's orders included an order dated 10/27/25 for [name redacted #1] Hospice (H #1). A review of Resident #28's electronic medical record (EMR) revealed the following: [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) store food in a manner to prevent food-borne illness and, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: 1. On 09/17/24 at 7:30 AM, an initial brief tour of the kitchen was conducted in the presence of the Food Service Director (FSD), and the surveyor observed the following: - The large commercial food processor was stored on the metal table with the lid, and when the FSD lifted the lid the inside was wet. The FSD stated it should not have been left wet. - Various crumb type debris was observed on the bins which stored bulk flour and sugar. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain an Automated External Defibrillator (AED-equipment used for the purposes of immediate response for cardiac arrest) and other emergency items prior to their expiration date. This deficient practice was identified for 2 of 2 expired AED kits located on 2 of 2 resident units (2nd and 3rd floor), which contained expired defibrillator pads dated [DATE], and was evidenced by the following: On [DATE] at 11:01 AM, in the presence of the Licensed Practical Nurse (LPN), the surveyor observed an AED emergency response kit, mounted on the wall of the AED room on the Third floor. [...]

Inspectors wroteBased on interview, medical record review, and review of other pertinent facility documentation, it was determined the facility failed to consistently offer residents a pneumococcal vaccine. The deficient practice was identified for 2 of 5 residents (#2, #18) reviewed for immunizations and was evidenced by the following. Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 2/13/23, included the following. The CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown . 1. The surveyor reviewed Resident #12's immunization history on the hybrid (paper and electronic) medical record on 9/18/24. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to a.) maintain the dignity of an unsampled resident. This deficient practice was found with 1 of 2 Certified Nursing Aides (CNA) observed during a dining observation on the third floor, and b.) place a urine drainage collection bag in a privacy cover to ensure a resident's dignity for 1 of 2 residents (Resident #26) reviewed for urine catheters. The deficient practice was evidenced by the following: a.) On 9/17/24 at 12:40 PM, during a lunch meal dining observation on the 3rd floor in the main dining room, an unsampled resident asked the surveyor a question regarding wanting pineapple chunks with their meal. The CNA was next to the resident when the request was made, and the CNA did not say anything. The surveyor asked the CNA if she could help the resident with their request. [...]

Inspectors wroteBased on interviews, review of facility policy, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to ensure a criminal background checks were completed prior to the start date of employment. This deficient practice was identified for 1 of 10 employee files reviewed (Employee #7) and was evidenced by the following: The surveyor reviewed ten employee files who had been hired since the last standard survey conducted on 7/7/23, which revealed the following incomplete pre-employment screening documents: Employee #7, Activities Aide, hired 5/13/24. The background check revealed a report date of 5/17/24. A review of the employee's position description, signed on 5/13/24, revealed a job summary to provide therapeutic activity programs to the residents. Essential Functions, as follows but not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure a urinary drainage collection bag and drainage tubing were not in direct contact with the floor to prevent potential contamination. This deficient practice was identified for 1 of 2 residents (Resident #26) reviewed for urinary catheter use and was evidenced by the following: A review of the facility provided policy, Indwelling Urinary Catheter Insertion/Maintenance (Male/Female) revised 01/29/24, included but was not limited to; 5. Both the drainage tubing and bag must be kept from touching the floor. On 09/17/2024 at 7:41 AM, the surveyor observed Resident #26 lying in bed with part of the urinary drainage tube and urinary drainage bag lying in direct contact with the floor. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who received pain management: a.) had a comprehensive patient-centered care plan for pain, and b.) the pain management physician recommendation was acted upon in a timely manner. This deficient practice was identified for 1 of 1 resident, reviewed for pain management (Resident #15) and was evidenced by the following: On 9/17/24 at 7:43 AM, a surveyor observed Resident #15 in bed who complained of pain. The resident stated that the pain medication would be administered after breakfast. On 9/17/24 at 11:11 AM, a surveyor observed the resident in the rehabilitation room. At that time, during an interview with the surveyor, the Physical Therapist (PT) stated that they would provide a hot pad for the resident's back pain. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to appropriately administer medications used to manage low blood pressure in accordance with physician orders. The deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications (Resident #15) and was evidenced by the following: On 9/17/24 at 7:43 AM, a surveyor observed Resident #15 in bed who complained of pain. The resident stated that the pain medication would be administered after breakfast. On 9/17/24 at 11:11 AM, a surveyor observed the resident in the rehabilitation room. At that time, during an interview with the surveyor, the Physical Therapist (PT). The surveyor then interviewed the Registered Nurse/Charge Nurse who informed the surveyor that they charted the resident's pain by exception. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to identify and address a significant weight loss of 5.5 pounds (lbs.) which was 5.4% in 20 days from admission on [DATE] through 6/5/23 and an additional 0.7 lb. loss from 6/5/23 through 7/1/23. The facility failed to: a.) consistently ascertain and monitor weekly weights for 4 weeks after admission and implement weekly weights for 4 weeks after a significant weight loss occurred, b.) obtain a re-weight to verify a significant weight loss, c.) implement a comprehensive admission nutritional assessment and care plan in a timely manner, d.) consistently record and monitor meal consumption, and e.) ensure a recommended nutritional supplement was prescribed and provided to the resident prior to surveyor inquiry. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to complete a fall investigation for 1 of 2 residents (Resident #1) reviewed for falls. This deficient practice was evidenced by the following: On 6/29/23 at 9:59 AM, the surveyor observed Resident #1 ambulating with a walker with a staff member. On that same day at 10:03 AM, the surveyor observed the resident seated a table with another resident. The resident had a wander guard to the left ankle. The surveyor reviewed the medical record for Resident #1. Review of the face sheet (an admission summary) indicated that the resident was admitted to the facility on [DATE], with diagnoses which included but not limited to dementia with behavioral disturbances, paroxysmal atrial fibrillation, Alzheimer's disease and repeated falls. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to develop a person-centered baseline care plan for a resident within 48 hours of admission. This deficient practice was identified for 1 of 15 residents reviewed for person-centered baseline care plans (Resident #8) and was evidenced by the following: The evidence was as follows: On 6/28/23 at 10:55 AM, two surveyors observed Resident #8 in a wheelchair on the third activity room. This resident was noted to require assistance at meals. The surveyor reviewed the medical record for Resident # 8. Review of the resident's Face Sheet (an admission record) reflected the resident was admitted on [DATE], with diagnoses that included but were not limited to; Alzheimer's disease, oropharyngeal dysphagia (difficulty swallowing) and hypothyroidism. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the physician a.) addressed a significant weight loss of 5.5 pounds (lbs.) which was 5.4% in 20 days from admission on [DATE] through 6/5/23, b.) monitored weekly weights, and c.) implemented nutritional interventions in a timely manner for 1 of 4 residents (Resident #8) reviewed for nutrition. The deficient practice was evidenced by the following: On 6/28/23 at 10:55 AM, two surveyors observed Resident #8 in a wheelchair on the third activity room. This resident was noted to require assistance at meals. On 7/07/23 at 8:40 AM, the surveyor observed the resident in bed with the head of the bed elevated. The resident's eyes were opened, and he/she smiled, appeared to be missing his/her top two teeth. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 9 (nine) residents (Resident #9) observed during the medication observation pass. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]