Shore Pointe Care Center

Inspectors wroteBased on interviews, record reviews, and review of pertinent facility documentation, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 2 of 29 residents (Resident #22 and #51) reviewed for accurately coding the MDS according to the Resident Assessment Instrument (RAI - used to assess and care plan residents). The deficient practice was evidenced by the following: 1. On 5/28/26 at 10:51 AM, during initial tour, Resident #22 was observed in their room in their bed. Resident #22 stated they were a smoker, and they could smoke up to five times a day at (9am, 11am, 1pm, 3pm, and 6pm). They further stated that the facility holds onto their cigarettes until it was time to smoke. [...]

Inspectors wroteBased on observation, interviews, record review and facility documents, it was determined that the facility failed to timely revise individual comprehensive care plans (ICCP) for 2 of 29 residents (Resident #2 and #15) reviewed for ICCP.This deficient practice was evidenced as follows: 1. On 5/29/2026 at 10:10 AM, the surveyor observed Resident #2 with their eyes closed in the room, in a reclining chair. The surveyor reviewed the electronic medical record (EMR) for Resident #2. A review of the admission Record (AR-an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a Physician's Order for continuous oxygen (O2) in accordance with professional standards of practice for 1 of 1 residents, (Resident #112), reviewed for respiratory care. 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 observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to ensure professional standards of nursing practice were followed by a.) clarifying a physician's order to accurately document the dosage calculation prior to administering a medication, (Vitamin B 12), for one (1) of seven (7) residents, (unsampled Resident #19), b.) ensuring observation of the administration of a medication (Polyethylene Glycol 3350) to one (1) of seven (7) residents, (unsampled Resident #89), and c.) accurately documenting medication administration for two (2) of seven (7) residents, (unsampled Resident #89 and Resident # 95). The deficient practices were identified for one (1) of three (3) nurses observed during the medication administration observation. The deficient practices were evidenced by the following: Reference: [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure infection control practices were implemented by performing appropriate hand washing technique to prevent the spread of infection in accordance with accepted national standards and Centers for Disease Control and Prevention (CDC) guidelines, during the medication administration observation for one (1) of three (3) nurses observed while administering medications to four (4) residents, (Unsampled Residents #19, #50, #89 and Resident #95). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interviews, and a review of medical records and pertinent facility documents on 11/12/25, it was determined that the facility failed to provide adequate supervision to a severely cognitively impaired resident (Resident #2) with a known history of wandering behaviors, who eloped from the facility on 10/29/25. The deficient practice was identified for 1 of 5 residents reviewed for elopement (Resident #2). During the survey, a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 483.25 (d)(2) F 689, as the facility failed to provide adequate supervision to a severely cognitively impaired resident (Resident #2) with a known history of wandering behaviors who eloped from the facility on 10/29/2025. Registered Nurse (RN) #1 who was assigned to Resident #2 last observed the resident at approximately 4:45 p.m. on 10/29/2025. [...]

Inspectors wroteBased on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to prevent unintended insidious (gradual but with harmful effects) weight loss of 31.5 pounds (lbs.) in one year from 1/3/24 through 1/1/25, and significant weight losses to include a 14 lb./10.5% loss in 6 months from 4/2/24 through 9/2/24; a 15 lb./11.2% loss in 6 months from 5/5/24 through 10/1/24; a 6.5 lb./5.6% loss in 1 month from 11/1/24 through 12/3/24; and an additional 4 lb. loss from 12/3/24 through 1/1/25; which was also a 16.5 lb./13.4% loss in 6 months from 8/1/24 through 1/1/25. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's Registered Dietitian (RD) reviewed and approved the menus (American and Korean) for nutritional adequacy and in accordance with nationally accredited standards, and b.) residents received care planned and physician ordered fortified foods for 3 of 3 residents (Resident's #41, 71 and 118) reviewed for food. The deficient practice was evidenced by the following: 1. On 1/2/25 at 9:46 AM, two surveyors toured the kitchen with the Food Service Director (FSD), the Regional RD and the Assistant Licensed Nursing Home Administrator (ALNHA). At that time, the FSD stated that the facility followed a three-week cycle menu (a menu prepared in advance which was repeated after three weeks). [...]

Inspectors wroteBased on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was dedicated solely to the infection prevention and control program (IPCP) from 8/9/24 and ongoing. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the residents' environment and living areas in a sanitary and homelike manner. This deficient practice was identified for 2 of 6 residents (Resident #90 and Resident #125) having lunch in the East Unit Sunshine Room in wheelchairs or recliners and 1 of 2 residents (Resident #124) utilizing overbed tables. This deficient practice was evidenced by the following: 1. On 1/02/25 at 11:10 AM, the surveyor observed Resident #90 out of bed, in a recliner in the Sunshine Room. A bead [NAME] activity center was noted on an overbed table in front of the resident. The resident was noted with closed eyes. No distress was noted. On 1/06/25 at 12:07 PM, the surveyor observed facility staff sitting next to Resident #90 in the Sunshine Room providing verbal cues/assisting as needed with lunch. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report and initiate an investigation for an injury of unknown origin in accordance with their abuse and neglect policy until surveyor inquiry. This deficient practice was identified for one (1) of one (1) resident reviewed for abuse (Resident #47), and was evidenced by the following: On 1/2/25 at 10:44 AM, the surveyor observed Resident #47 in bed. The resident had a line down the bridge of their nose with a reddish/brown colored marking and a dried scab. The surveyor attempted to interview the resident but the resident was not responding to the surveyor. On 1/3/25 at 9:00 AM, the Director of Nursing (DON) provided the surveyor with two investigations for Resident #47 from August 2024 and October 2024. [...]

Inspectors wroteREFER to F759 Based on observation, interview, and record review, it was determined that the facility failed to follow acceptable professional standards of clinical practice by borrowing a medication (Lidocaine 4% patch) from another resident's supply. The deficient practice was identified for one (1) of three (3) nurses observed during medication administration for one (1) of six (6) residents, (Resident #122). 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 wroteREFER to F658 Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 1/3/25, the surveyor observed three (3) nurses administer medications to six (6) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.4%. The deficient practices were identified for one (1) of six (6) residents, (Resident #122), that were administered medications by one (1) of three (3) nurses that were observed. The deficient practices were evidenced by the following: On 1/3/25 at 8:59 AM, during the morning medication administration pass, the surveyor observed Registered Nurse (RN#1) at the door of Resident #122's room with the medication cart. [...]

Inspectors wroteBased on observations, interviews, and record review it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP)(designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 2 of 3 unsampled residents (Resident #99 and #Resident #106) reviewed for EBP on 2 of 2 units (North Unit and East Unit) and was evidenced by the following: 1. On 1/03/25 at 07:58 AM, during incontinence rounds with the Acting Unit Manager / Infection Preventionist (UM/IP) on the North Unit, the surveyor observed the UM/IP approach unsampled Resident #99 who was lying in bed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. [...]

Inspectors wroteComplaint NJ #165453; 159439; 156933; 164687 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a clean, comfortable, homelike environment for the residents. This deficient practice was identified on 3 of 3 nursing units, (the 100, 200, and 300 units) and was evidenced by the following: On 09/21/23 at 12:54 PM, in room [ROOM NUMBER], the surveyor observed that the window in the resident's room had a portable air conditioning unit which had a piece of cardboard surrounding the cylinder that was positioned outside of the window. The cardboard was observed to be bent, exposing outside air. On 09/22/23 at 8:50 AM, on the 300 unit, the surveyor was standing in Resident #104 and Resident #149's room and observed a small black bug flying around the room. [...]

Inspectors wroteComplaint NJ#: 159439; 165453 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain an effective pest control program. This deficient practice was identified on 2 of 3 nursing units, (the 200 and the 300 unit), for 4 of 29 residents, (Resident #17, #64, #104 and #149), reviewed for concerns related to pests, and by 5 out of 6 alert and oriented residents during the Resident Council meeting. This deficient practice was evidenced by the following: On 09/21/23, the surveyor toured the 200 unit and observed dead insects on the floors in rooms [ROOM NUMBERS]. At 11:16 AM, on the 200 unit, the surveyor observed a fly on Resident #17's forehead. At that time, the resident stated that the facility had, quite a few flies. [...]

Inspectors wroteBased on observation, interviews, and review of medical record it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for a resident's personal preference to wear a specific urinary collection device (leg bag) during the day while the resident was out of bed. This deficient practice was identified for 1 of 29 residents reviewed, (Resident #25) and was evidenced by the following: On 09/21/23 at 11:19 AM, during tour the surveyor observed the resident sitting up in his/her wheelchair in their room. The resident was interviewed at this time and stated that he/she had an indwelling urinary catheter. The resident stated that he/she wore a leg bag (urine collection storage bag) during the day and a urinary drainage storage bag at night that hung on the resident's bedframe. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to complete an incident report, after a resident sustained an injury in the facility. This deficient practice was identified for 1 of 3 residents reviewed for skin issues (Resident #28), 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 wroteComplaint NJ: 165453, 163618 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to provide dependent residents with routine and appropriate incontinence care, specifically by applying double briefs. This deficient practice was identified for 1 of 6 residents observed for incontinence care, (Resident #71) and was evidenced by the following: On 09/27/2023 at 8:47 AM, the surveyor performed a care tour of the 200 unit with the Licensed Practical Nurse/Unit Manager (LPN/UM). At 08:55 AM, Resident # 71 gave permission to the surveyor and the LPN/UM to observe his/her adult brief. The surveyor observed that Resident #71 had two green colored briefs on. The briefs were dry. At that time the LPN/UM confirmed that Resident #71 had two briefs on and said, I am sorry. [...]

Inspectors wroteComplaint#: NJ157073 Based on interview, review of clinical records, and other pertinent facility documentation it was determined that the facility failed to provide timely treatment and care for a resident. This deficient practice was identified for 1 for 32 residents, (Resident #252) reviewed for quality of care and was evidenced by the following: According to the admission Record (AR), Resident #252 was admitted to the facility with the diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing) and benign prostatic hyperplasia (BPH - an enlarged prostate). [...]

Inspectors wroteComplaint NJ#: 164539; 165453 Based on observation, interview, record review, and review of facility documents it was determined that the facility failed to: a.) accurately document body check assessments, b.) obtain physician orders based on the recommendations of the wound care consultant in a timely manner, and c.) ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 2 of 4 residents (Resident #49 and #255) reviewed for pressure ulcers and was evidenced by the following: 1.) The surveyor reviewed Resident #255's closed Electronic Medical Record (EMR). According to the admission Record, Resident #255 had diagnoses which included, but were not limited to: multiple sclerosis (MS), pressure ulcer of sacral region stage 4, difficulty in walking, vascular dementia with behavioral disturbance, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to maintain ongoing complete communication notes between the facility and the dialysis center. This deficient practice was identified for 1 of 1 resident reviewed for dialysis, (Resident #110) and was evidenced by the following: On 09/26/23 at 09:45 AM, on the North wing 300 unit, Resident #110 was observed seated in a chair in the main dining room. The resident stated that before he/she went to dialysis (a treatment to remove waste and extra fluids from your blood when the kidneys are not able to) that the nurse checked his/her vital signs and that he/she would take the dialysis binder with them. [...]