Shore Gardens Rehabilitation and Nursing Center

Inspectors wroteComplaint #3007960Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident (Resident #144), who was dependent on staff for transfers, was safely and properly transferred with two staff members via a mechanical lift. On 5/4/26, the resident was transferred by one staff member from their bed to a shower chair, which resulted in the resident sustaining a left upper extremity humeral fracture (a fracture of the left upper arm). This deficient practice was identified for 1 of 6 residents (Resident #144) reviewed for accidents and was evidenced by the following: On 6/23/26 at 9:00 AM, the surveyor requested from the Licensed Nursing Home Administrator (LHNA) a copy of the Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) for Resident #144. [...]

Inspectors wroteComplaint #: 374226Based on interviews, review of medical records, and review of other pertinent facility documents on 12/30/2025, it was determined that the facility failed to ensure that residents received care and services necessary to attain or maintain the highest practicable physical well-being, in accordance with professional standards of practice, by failing to properly assess, acknowledge pain, monitor, notify provider, and implement appropriate interventions for an identified unwitnessed fall and femur fracture. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1), as 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: [...]

Inspectors wroteNJ# 184886Based on interview and review of pertinent facility documentation on 8/19/25 and 8/20/25, it was determined that the facility failed to develop and implement an effective discharge (d/c) planning process that focused on the resident's discharge goals to return to the community. The deficient practice was identified for 1 of 3 residents (Resident # 6), reviewed for community discharge. The deficient practice was evidenced by the following:During a tour on 8/20/25 at 9:30AM, Resident #6 was observed sitting up in bed watching television. On 8/20/25 at 9:40AM, Surveyor interviewed Resident #6 in the presence of their family member. Resident #6 stated that on their day of discharge, he/she was told that an Uber was going to pick them up and transport them to a local hotel. [...]

Inspectors wroteREPEAT DEFICIENCY Complaint #: NJ185836; NJ186066 Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility was maintained to provide the residents with a safe, clean, comfortable and homelike environment. This deficient practice was identified on 3 of 3 nursing units, and was evidenced by the following: On 5/8/25 from 9:40 AM to 10:40 AM, the surveyor toured the Second-floor nursing unit and observed the following: 1. In Resident room [ROOM NUMBER], the wall paper was peeling off the wall behind the door. 2. [...]

Inspectors wroteComplaint #: NJ185836, NJ186066 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's Quality of Life - Homelike Environment policy and procedures to ensure the safety and well-being of all residents by providing a safe, clean, comfortable, and homelike environment. This deficient practice was identified for 3 of 3 nursing units, and was evidenced by the following: [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation it was determined that the facility failed to provide a safe, clean and comfortable homelike setting. This deficient practice was identified for 3 of 3 units, and was evidenced by the following: 1. On 2/5/25 at 9:00 AM, the surveyor entered the facility and observed the lobby floor to be dirty with scuff marks and discolored tiles. The elevator floors were also observed to be dirty and discolored and the walls of elevators were observed to be soiled. On 2/5/25 at 9:15 AM, during initial tour of the Third-floor nursing unit, the surveyor observed the following environmental issues: In Resident room [ROOM NUMBER]-A, the floor was observed to be soiled and sticky with liquid spills on the floor. The unsampled resident's trash was overflowing and there was trash on the floor under the bed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 2/5/25 at 9:26 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In the walk-in freezer, one opened box of raviolis and one opened box of chicken breasts in the manufacturer's box. Both products were in bags that were not sealed closed exposing the contents to air with ice crystals. Neither products were labeled with an opened or use by dates. The FSD was unable to say when the packages were opened. 2. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a) label opened multidose medication; b) properly dispose of expired medications; and c) properly store medical supplies. This deficient practice was observed on 2 of 3 medication carts and 1 of 2 medication storage rooms reviewed for medication storage and labeling, and was evidenced by the following: On 2/10/25 at 11:11 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #1), observed the following on the Third-floor high side nursing unit's medication cart: Fourteen individual, single use vials of ipratropium bromide/albuterol sulfate inhalation solution (a medication used to treat lung disease) 0.5 milligrams (mg) /3 mg per 3 milliliter (ml) in an opened foil pouch with a hand-written opened date of 1/2/24. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote dignity and respect of the residents. This deficient practice was observed in 1 of 3 dining rooms on 2/13/25, and was evidenced by the following: On 2/13/25 at 12:16 PM, the surveyor observed the lunch meal on the Third-floor nursing unit in the dayroom/dining room. On each of the 14 residents, the staff served the cold beverages composed of milk and cranberry juice in disposable plastic cups. During an interview with the survey team on 2/14/25 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) did not refute the identified concerns for dignity in using disposable plastic cups for the memory care residents. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the medication cart was secured during medication administration in accordance with professional standards of clinical practice. This deficient practice was identified for 1 of 4 residents observed during medication administration (Resident #89), and 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to a) obtain physician's orders for care of oxygen tubing and b) develop a comprehensive care plan for a resident receiving oxygen therapy. This deficient practice was identified in 1 of 4 residents reviewed for oxygen (Resident #95), and was evidenced by the following: On 2/5/25 at 12:07 PM, during the initial tour of the facility, the surveyor observed an oxygen concentrator (a device that enriches air with oxygen by removing nitrogen) in Resident #95's room with nasal oxygen tubing (small flexible tube with two prongs that delivers oxygen into the nose) connected. The tubing went from the oxygen concentrator onto the resident's bed, under the pillow, and hung off the opposite side of the bed. [...]

Inspectors wroteBased on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic shift count logs were completed in accordance with professional standards of practice. This deficient practice was identified on 2 of 3 medication carts, and was evidenced by the following: On 2/10/25 at 11:11 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #1), observed the Third-floor high side nursing unit's medication cart. A review of the medication cart's narcotic logbook revealed a pre-signed outgoing nurse signature for the shift-to-shift narcotic count Narcotic Bingo Card Count Sheet for the 2/10/25 3:00 PM- 11:00 PM shift. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to dispose of garbage and refuse properly to prevent rodents and pests. This deficient practice was evidenced by the following: On 2/5/25 at 9:32 AM, the surveyor toured the facility grounds and loading dock area with the Food Service Director (FSD). The surveyor observed the following. 1. The grassy side yard, which the First-floor residents looked at from their windows, was filled with construction debris, pallets that were broken and thrown around, plastic wrap in the trees, Styrofoam panels, and paper litter in the tree line that ran along neighborhood fences. 2. Along the black top driveway and grassy area, there were cigarette butts (too numerous to count) thrown on the ground. There was a cigarette receptacle lying on its side in the grass. 3. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to use appropriate infection control practices during medication administration to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was identified for 1 of 4 residents observed during medication administration (Resident #96), and was evidenced by the following: Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; [...]

Inspectors wroteComplaint #: NJ 182687 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was provided a lock to prevent loss/theft of items. This deficient practice was identified for 1 of 28 residents reviewed for resident rights (Resident #132), and was evidenced by the following: A review of the admission Face Sheet revealed that Resident #132 was admitted to the facility with diagnoses that included but were not limited to: anxiety disorder, emphysema, and tracheostomy (a tube placed in a surgical hole through the neck to the windpipe). A review of the Minimum Data Sheet (MDS), an assessment tool, revealed the resident was cognitively intact and was independent for activities of daily living (ADL). [...]

Inspectors wroteC#: NJ00179177, NJ00179069 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 11/11/2024, 11/12/2024, and 11/22/2024, it was determined that the facility failed to investigate an allegation of Resident-to-Resident sexual abuse between two residents, a cognitively impaired resident (Resident #1), who wanders and requires frequent monitoring and Resident #4, who has moderate cognitive impairment. On 9/24/2024 at 8:35 p.m., the License Nursing Home Administrator (LNHA) received a grievance by email written by Resident #1's family member, which included an alleged allegation of sexual interaction between Resident #1 and Resident #4. The LNHA forwarded the email to the Social Worker (SW) with instructions to write a Grievance. However, the grievance was not addressed, and an investigation was never initiated into the allegation. [...]

Inspectors wroteC#: NJ00179177, NJ 00179069 Based on interviews, record review, and review of other pertinent facility documents on 11/11/2024, 11/12/2024, and 11/22/2024, it was determined that the facility failed to implement its policy titled Grievance Policy and Procedure and the Social Worker Job description after a resident family member made an allegation of sexual abuse. This deficient practice was identified for 1 of 7 residents, Resident #1, and was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted on [DATE] with diagnoses that included but were not limited to Altered Mental Status, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. [...]

Inspectors wroteC#:NJ 00179177, NJ 00179069 Based on interviews, Medical Record (MR) review, and review of pertinent facility documentation on 11/11/2024, 11/12/2024 and 11/11/2024, it was determined that the facility's Administration failed to ensure a thorough and complete investigation was completed for an allegation of Resident-to-Resident sexual abuse and follow its Abuse and Neglect, Investigating and Reporting, the Abuse Prevention Program Policy, the Grievance Policy and Procedure, and the Administrator's Job Description. This deficient practice was identified for 2 of 7 residents (Resident #1 and Resident #4) and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted on [DATE] with diagnoses which included but were not limited to: Altered Mental Status, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. [...]

Inspectors wroteBased on observation, interview, and policy review it was determined that the facility failed to a.) store and label potentially hazardous foods in a manner to prevent food borne illness, b.) failed to sanitize and air-dry cookware in a manner to prevent microbial growth, and c.) maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 04/26/23 at 10:00 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. Dietary Aide #1 was observed with hair hanging outside of her hair net by each ear. The surveyor asked the FSD about the observation and the expectation of hair restraint use. [...]

Inspectors wroteREPEAT DEFICIENCY Complaint # NJ 150832 Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) for 1 of 2 residents (Resident #193) reviewed for abuse. This deficient practice was evidenced by the following: According to the admission Face Sheet, Resident #193 had diagnoses which included, but were not limited to, dementia and Alzheimer's Disease. Review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/15/21, included the resident had a Brief Interview for Mental Status score of 12, which indicated the resident's cognition was moderately impaired. [...]

Inspectors wroteREPEAT DEFICIENCY Complaint # NJ 150832 Based on interview, record review, and review of facility documents, it was determined that the facility failed to investigate an allegation of abuse for 1 of 2 residents (Resident #193) reviewed for abuse. This deficient practice was evidenced by the following: According to the admission Face Sheet, Resident #193 had diagnoses which included, but were not limited to, dementia and Alzheimer's Disease. Review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/15/2021, included the resident had a Brief Interview for Mental Status score of 12, which indicated the resident's cognition was moderately impaired. [...]

Inspectors wroteBased on observations, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to: a.) provide a snack bag to send with the resident on scheduled dialysis (the clinical purification of blood, as a substitute for normal kidney function) days and b.) coordinate medication administration times with scheduled dialysis days. This deficient practice was identified for 1 of 1 resident (Resident #48) reviewed for dialysis and was evidenced by the following: On 04/28/23 at 12:23 PM, the surveyor observed Resident #48 lying in bed awake. When interviewed, the resident stated that he/she went to dialysis every Tuesday, Thursday and Saturday at 5:30 AM. [...]

Inspectors wrote3.) On 05/05/23 at 8:20 AM, the surveyor accompanied the Environmental Service Director (ESD) to a storage area the facility referred to as the nursery where additional linens were stored. The Administrator joined and entered the storage area with the surveyor and the ESD. At that time, the surveyor observed six cardboard boxes directly on the floor. One box contained sealed paper towels, two boxes contained resident clothing, and three sealed boxes contained linen. The ESD Services stated the boxes should be off the floor and on pallets so they could clean the area underneath. During an interview with the surveyor on 05/05/23 at 11:29 AM, the IP stated storage of the boxes should not be directly on the floor in case the boxes get wet or dirty. Review of an undated policy titled, Receipt and Storage of Supplies and Equipment, included but was not limited to; [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to obtain consent from a resident representative prior to administering a Pneumococcal vaccination for 1 of 5 residents (Resident #134) reviewed for immunizations. This deficient practice was evidenced by the following: On 05/01/23 at 9:39 AM, the surveyor observed Resident #134 sitting in the day room during a music activity. According to the admission Face Sheet, Resident #134 had diagnoses which included, but were not to, dementia and metabolic encephalopathy. Further review of the admission Face Sheet indicated the resident's son as the only next of kin and emergency contact. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to a.) document medication administered according to standards of practice for 1 of 3 residents (Resident #109), and b.) follow a physician's order as written for 1 of 5 residents (Resident # 69) reviewed for medications. 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: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that a resident received supplemental oxygen as prescribed by the physician for 1 of 1 resident (Resident #13) reviewed for respiratory care. The deficient practice was evidenced by the following: On 04/26/23 at 10:22 AM, the surveyor observed Resident #13 in bed wearing a nasal cannula (a device used to deliver supplemental oxygen). The surveyor observed that the nasal cannula was connected to an oxygen concentrator that was set to 3 liters per minute (LPM) of oxygen. On 05/01/23 at 09:57 AM, the surveyor observed Resident #13 lying in bed with their eyes closed. The surveyor observed that the resident was wearing the nasal cannula and that the oxygen concentrator was set to 3 LPM. [...]

Inspectors wroteComplaint #: NJ 151993 Based on interviews and review of the closed medical record, it was determined that the facility physician failed to have a face to face visit for a resident who was transferred to the hospital on [DATE] and did not return. This deficient practice was identified for 1 of 4 residents (Resident #192) reviewed for hospitalization. This deficient practiced was evidenced by the following: Review of Resident #192's Face Sheet revealed that the resident was admitted to the facility in January of 2021 with diagnosis which included but were not limited to: COVID-19, acute renal (kidney) failure and anxiety disorder. Review Resident #192's admission Minimum Data Set (MDS), an assessment tool dated 01/14/21, revealed that the resident's memory was described as OK and the resident had no memory impairment. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that facility failed to provide social services for a resident with severe cognitive impairment. This deficient practice was identified for 1 of 5 vulnerable residents (Resident #134) reviewed and was evidenced by the following: On 05/01/23 at 9:39 AM, the surveyor observed Resident #134 sitting in the day room during a music activity. According to the admission Face Sheet, Resident #134 had diagnoses which included, but were not to, dementia and metabolic encephalopathy. Further review of the admission Face Sheet indicated the resident's son as the only next of kin (NOK) and emergency contact. [...]

Inspectors wroteComplaint #NJ 150149 Based on observation, interview and review of pertinent facility documentation it was determined that the facility failed to ensure meals were served at safe and appetizing temperatures. This deficient practice was on one (1) of three (3) nursing units (the third floor), during the lunch meal service on 5/3/23 and was evidenced by the following: On 5/3/23 at 10:30 AM, the surveyor conducted a Resident Council Meeting with five (5) alert and oriented residents in which 5 of 5 residents (Resident #29, #40, #89, #90, and #91) at the meeting stated that the food was cold. They stated that the food was cold and old, and they never have received a hot piece of pizza or a burger. The residents further stated that the trays were on open food carts. [...]

Inspectors wroteComplaint #NJ 147719, Complaint #NJ 150149 Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident's dietary preferences were honored for 1 of 4 residents reviewed for food concerns (Resident #85) This deficient practice was evidenced by the following: On 05/03/23 at 1:31 PM, during lunch mealtime, the surveyor observed Resident #85 sitting at the bedside. Resident #85 was alert, oriented, and able to make needs known. A lunch tray was on the resident's bedside table. Resident #85 stated they could not eat what was on the lunch tray. Resident #85 removed the insulated dome and the plate contained sloppy joe which had sauce and peas and carrots. Resident #85 stated they had preferences listed on the meal ticket and always received something they shouldn't. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff to resident abuse that occurred on 3/20/21. The deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #26) and was evidenced by the following: On 3/23/21 at 11:03 AM, the surveyor interviewed a Resident Advocate who stated that Resident #26 was involved in a verbal altercation with an Agency Nurse on Saturday (3/20/21). The Resident Advocate noted that the police were called to the facility regarding this incident by Resident #26. The Resident Advocate stated that the Nursing Supervisor/Registered Nurse (NS/RN) informed the nurse to leave the facility and not return. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to investigate an allegation of staff to resident abuse that occurred on 3/20/21. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #26) and was evidenced by the following: On 3/23/21 at 11:03 AM, the surveyor interviewed a Resident Advocate who stated that Resident #26 had a verbal altercation with an Agency Nurse on Saturday (3/20/21). The Resident Advocate noted that the police were called to the facility regarding this incident by Resident #26. The Resident Advocate stated that the Agency Nurse had to leave the facility and was told to not return, so the Nursing Supervisor/Registered Nurse (NS/RN) had to care for her assigned residents. The Resident Advocate was unsure of the nurse's name because she was an Agency staff member. [...]

Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documentation, it was determined the facility staff members failed to a.) don (apply) Personal Protective Equipment (PPE) to enter the rooms of residents on Transmission-based precautions (TBP); and, b.) maintain appropriate infection control practices regarding a housekeeping cart. This deficient practice was identified for 3 of 52 (Resident #59, #27 and #29) for Persons Under Investigation (PUI) / non-ill unit and, 1 of 2 active nursing units (Second Floor). The deficient practice was evidenced by the following: 1) On 3/24/21 at 1:24 PM, the surveyor observed Resident #59's room on PUI hall. Resident #59's room was observed with a stop see nurse sign - on Transmission Based Precautions, and how to don and doff (remove) PPE sign; [...]