Jersey Shore Center

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure that all interdisciplinary team members (IDT) participated in quarterly care conferences for four of 28 sample residents (Resident (R) 36, R83, R101, and R225). This failure had the potential for the residents to have unmet care needs.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one resident (Resident (R) 57) observed out of a total sample of 28 residents had an assessment and an order for self-administration of medications. These failures placed R57 at risk for medication errors, medication adverse effects, or misappropriation of medications.

Inspectors wroteBased on observation, interview, record review, and policies, the facility failed to protect the resident's right to be free from sexual abuse by a resident for one of 28 sample residents (Resident (R) 89). Failure to identify risk factors and intervene to prevent an incident involving inappropriate sexual contact directly increased the risk R89 and other residents could experience abuse.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure an abuse investigation of inappropriate touching was documented for one of 28 sample residents (Resident (R) 89). Failure to ensure a thorough investigation of the incident increased the risk that other residents may have experienced a similar incident, or the incident had a negative impact on their sense of well-being.

Inspectors wroteBased on observation, interview, record review, and facility policy, the facility failed to ensure that one of three residents (Resident (R) 91) who used supplemental oxygen out of 28 sample residents had equipment kept in a clean and sanitary condition. Failure to ensure the oxygen lines were changed weekly and ensure the filter was clean increased the risk the resident could develop a respiratory infection.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were monitored for psychotropic medications for two of six residents (Resident (R) 91 and R102) reviewed for unnecessary medications out of a total sample of 28 residents. This failure had the potential to lead to unwarranted medication side effects or improperly treated symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) and hand hygiene were consistently implemented for two of 28 sample residents (Resident (R) 43 and R87). Failure to ensure the facility staff completed hand hygiene after handling clothing and linens, and implement EBP as directed placed these and other residents at risk for infections.

Inspectors wroteComplaint #'s NJ00172207, NJ00173028 and NJ00180815 Based on observation, interview, staffing assignment review, and record review, the facility failed to ensure there was adequate staffing to ensure the provision of resident care for two of 20 sampled residents (Resident (R) 9 and R2). This failure had the potential to affect resident care for all residents at the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to document resident grievances regarding care and staffing and failed to provide a resolution to the concerns for two of 22 residents (Resident (R) 2 and R9) reviewed for grievances. This had the potential to cause concerns and grievances to be unresolved.

Inspectors wroteComplaint #'s NJ00172207, NJ00173028 and NJ00180815 Based on interviews, record reviews, and facility policy review, the facility failed to provide showers as scheduled for one of three residents (Resident (R) 9) reviewed for activities of daily living (ADLs) out of a total sample of 20. R9, who was dependent on staff for ADLs, was not assisted with showers twice weekly as scheduled and consistent with the resident's choices. This failure had the potential to affect the resident's psychosocial wellbeing and quality of life.

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to obtain weekly weights as ordered for a resident with a significant weight loss since December of 2022. This deficient practice was identified for 1 of 4 residents (Resident #30) reviewed for nutrition and was evidenced by the following: On 2/14/23 at 10:55 AM, the surveyor observed Resident #30 in his/her room with the breakfast tray on an over bed table. The surveyor observed on the tray an empty cup of juice and the rest of the tray was untouched. At that time, the Licensed Practical Nurse (LPN) informed the surveyor that Resident #30 eats slowly and requested staff leave the tray at the bedside. The LPN confirmed the resident only drank the juice. The surveyor reviewed the medical record for Resident #30. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to maintain medication carts free from debris which included loose, unmarked, and unwrapped medications. This deficient practice was identified for 3 of 4 medication carts (Ocean low-side, Seashore high-side, Seashore low-side) on 2 of 3 nursing units (Ocean and Seaside) and the evidence was as follows: On [DATE] at 11:10 AM, in the presence of Licensed Practical Nurse (LPN #1), the surveyor inspected the Ocean nursing unit's low-side medication cart and observed in the second drawer, where the multiple-use medication blister packs were stored, one loose pink tablet which was unwrapped and unmarked. At this time, the surveyor interviewed LPN #1 who stated she was unsure what the medication was and removed the medication from the cart for destruction. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store, label, and date potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; c.) maintain storage areas in a sanitary manner; d.) maintain kitchen equipment to prevent microbial growth; and e.) air dry kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 2/14/23 at 9:19 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: 1. In the walk-in refrigerator, one opened quart of whole liquid eggs labeled 2/1/23 and 2/16/23. The FSD indicated the 2/1/23 was the opened date and the 2/16/23 was the discard date. The package indicated best results use within three days of opening. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 13 out of 14 day shifts reviewed during a two-week period prior to survey and for 4 of 4 day shifts observed on 2 of 3 nursing units (Seashore and Ocean) observed during survey.

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) a resident with an external catheter urinary collection system received shift and daily care in accordance with manufacturer's instructions including changing of the catheter every eight to twelve hours, daily maintenance of the system, and storage off the floor to prevent infection since January 2023 and b.) housekeeping staff were cleaning resident rooms from well to ill (COVID-19 positive) in accordance with facility policy and national guidance for infection control during a COVID-19 outbreak to mitigate the spread of the disease. This deficient practice was identified for 1 of 5 residents (Resident #22) reviewed for urinary catheters and 1 of 3 nursing units (Seashore) and was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident dependent on staff for care, including transferring to bed, received the services needed in a timely and dignified manner. This deficient practice was identified for 1 of 28 residents (Resident #129) reviewed for care and services and was evidenced by the following: On 2/14/23 at 11:10 AM, the surveyor observed Resident #129 in their room sitting in a wheelchair with a family member visiting. The resident stated they just returned from the rehabilitation gym and wanted to return to bed. The surveyor asked the resident how they communicated that with staff, and the resident responded you push the call bell, but it took staff a long time to answer the call bell. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, the facility failed to implement their abuse policy by reporting to the New Jersey Department of Health (NJDOH) an injury of unknown origin that was discovered on 9/27/22. This deficient practice was identified for 1 of 3 residents (Resident #36) reviewed for abuse and was evidenced by the following: On 2/14/23 at 11:16 AM, the surveyor observed Resident #36 in the dayroom in a wheelchair participating in group activities with other residents at a table. The resident's wheelchair seat was equipped with a pommel wedge (a device used for positioning and to help prevent forward sliding), and rear stabilizers (to help prevent tipping). The surveyor reviewed the medical record for Resident #36. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, the facility failed to implement their abuse policy by thoroughly investigating an injury of unknown origin to rule out abuse or neglect for a resident identified on 9/27/22. This deficient practice was identified for 1 of 3 residents (Resident #36) reviewed for abuse and was evidenced by the following: On 2/14/23 at 11:16 AM, the surveyor observed Resident #36 in the dayroom in a wheelchair participating in group activities with other residents at a table. The resident's wheelchair seat was equipped with a pommel wedge (a device used for positioning and to help prevent forward sliding), and rear stabilizers (to help prevent tipping). The surveyor reviewed the medical record for Resident #36. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure fall prevention interventions were implemented and monitored for a resident with a fall in the facility. This deficient practice was identified for 1 of 3 residents (Resident #38) reviewed for accidents and was evidenced by the following: On 2/14/23 at 11:08 AM, the surveyor observed Resident #38 sitting in their wheelchair in their room. The surveyor observed the resident stand up from their wheelchair and quickly sit back down when they noticed the surveyor at the door. The surveyor observed what appeared to be a chair alarm placed on the back of the resident's wheelchair, but they did not hear the alarm sound when the resident stood up. The surveyor with permission proceeded into the resident's room to interview them. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain a clean, comfortable, sanitary, homelike environment for 7 of 25 residents reviewed in the facility (Resident #47, #48, #63, #68, #71, #78 and #110) residing on 1 of 3 resident care units (Seashore unit). The evidence was as follows: 1. On 03/16/21 at 11:29 AM, Surveyor #1 observed Resident #63 sitting on his/her bed in their room. The resident stated that the housekeepers who worked on the unit did not clean his/her room appropriately and only used a dry mop to clean the floors. The resident stated that he/she was unhappy with the cleanliness of his/her bathroom and showed the surveyor the shared bathroom belonging to Resident #47 and Resident #63's room. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure: a.) a resident receiving hospice services had a specific individualized plan of care, and b.) subsequently ensure that plan of care was followed for the same resident receiving hospice services for end of life care. This deficient practice was identified for 1 of 2 residents reviewed for hospice services (Resident #120). The evidence was as follows: On 3/16/21 10:49 AM, the surveyor observed Resident #120 lying in bed. The surveyor attempted to interview the resident, but the resident did not respond to the surveyor. On 3/17/21 at 11:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she was familiar with Resident #120. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to identify and implement interventions to address resident concerns regarding housekeeping services through their Quality Assurance and Performance Improvement program (QAPI). This deficient practice was identified on 1 of 3 resident care units (Seashore) and during a review of the resident council meeting minutes for the months of December 2020, January 2021, and February 2021. The evidence was as follows: From 3/16/21 through 3/25/21, two surveyors observed on the Seashore Unit that several of the resident's rooms had soiled floors, bathrooms, curtains, a bedside table, and resident room floors that were sticky and had areas of peeling paint, and there was dust covering a resident's TV . [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure 2 of 5 facility staff reviewed (a Certified Nursing Aide and a Contracted Dietary Aide) were tested for COVID-19 twice a week in accordance with the New Jersey Department of Health Executive Directive 20-026, nationally accepted guidelines for infection prevention and control, and the facility's testing schedules related to the high COVID-19 county positivity rate. The evidence was as follows: According to the U.S. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to perform reference checks in accordance with their Abuse Prohibition Policy and Procedure. The deficient practice was identified during an Abuse Prevention review for 1 of 5 newly hired employees in the last four months (a Contracted Housekeeper). The evidence was as follows: On 3/24/21 at 9:00 AM, the surveyor reviewed the employee file for a contracted housekeeper, Employee #1 who was hired on 2/9/21. A review of Employee #1's Reference Form for Applicant Information indicated to please provide up to two professional references if available. The Reference Form for Applicant Information indicated that Employee #1 provided only one close family member as a professional reference, a parent. [...]