Southern Ocean Center

Inspectors wroteBased on interviews, medical record reviews and reviews of other pertinent facility documentation on 3/2/26 and 3/3/26, it was determined the facility failed to ensure that medical records for residents were accurate as evidenced by a.) an inaccurate weight being entered for a Resident #5 b.) the Licensed Practical Nurse (LPN) who did not sign out the Medical Administration Record (MAR) after administering (Resident #8) and c.) nurses clicking the wrong button under Nutrition while documenting their skilled evaluations for a Resident #4. This resulted in inaccurate medical records and failure to identify potential medication, weight, and documentation errors. This deficient practice was identified for 3 of 10 residents reviewed for resident records (Resident #4, Resident #5 and Resident #8), and was evidenced by the following:A. [...]

Inspectors wroteBased on observations, interviews, medical record review, and review of other pertinent facility documentation on 3/2/26 and 3/3/26, it was determined that the facility failed to ensure staff properly wore the appropriate personal protective equipment (PPE) when providing care for patients on Enhanced Barrier Precautions (EBP) for four residents (Resident #1, Resident #7, Resident #9 and Resident #10). The facility also failed to follow its policy titled IC 308 Enhanced Barrier Precautions. This deficient practice was identified for 4 of 10 residents reviewed for infection prevention and was evidenced by the following:According to Resident #1's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: [...]

Inspectors wroteThis deficient practice was evidenced by the following: On [DATE], from 08:47 AM to 09:39 AM, during the kitchen tour, the surveyor, accompanied by the Dietary Director (DD), observed three gallons of unopened whole milk in the walk-in refrigerator. The manufacturer's expiration date on the milk was [DATE]. On [DATE] at 8:47 AM, during an interview with the surveyor, the Dietary Director (DD) stated that the expired milk would be discarded, and that expired milk could cause illness. A review of the undated facility policy titled, Use By Dating Guidelines, revealed that .The manufactures' expiration date, when available, is the use by for unopened items. N.J.A.C 8:39-17.2 (g)

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices during a COVID-19 outbreak, specifically the a.) use of Personal Protective Equipment (PPE) for 2 unsampled residents (Resident #46 and Resident #105) and 1 resident (Resident #3) reviewed for tube feeding on transmission-based precautions, b.) handling of clean linen during transport in the nursing unit on COVID-19 outbreak, and c.) hand hygiene for residents in the dining room, 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 evidenced by the following:Reference: [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to implement their abuse policies and procedures by ensuring a resident (Resident #104) was free from verbal abuse. This deficient practice was identified for 1 of 1 resident reviewed for abuse (Resident #104) and was evidenced by the following:A review of the admission Record (admission summary) indicated that Resident # 104 was admitted to the facility with the diagnoses which included but was not limited to Parkinson's disease, atrial fibrillation, depression and diabetes mellites (DM). The annual Minimum Data Set (MDS), an assessment tool used to facilitate a resident's care dated 5/29/25, indicated that Resident #104 scored a 11/15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set death in facility tracking record in accordance with federal guidelines. This deficient practice was identified for 1 of 1 resident reviewed for resident assessment (Resident #17). This deficient practice was evidenced by:On [DATE], at 9:47 AM the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The surveyor reviewed Resident #17's electronic medical record. The record revealed that the resident expired on [DATE]. The electronic health record reflected that there was no death in facility tracking record completed for the resident's death date of [DATE]. On [DATE] at 12:30 PM, the surveyor interviewed the MDS Coordinator. [...]

Inspectors wroteComplaints: NJ00176578, NJ00181499, NJ00184013, NJ00184932 Based on interviews, record review, and review of other pertinent facility documents on 06/04/2025 and 06/06/2025, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, by failing to ensure that; a.) medications were administered according to Physician orders (POs), b.) bloodwork was obtained and faxed according to POs, and c.) Physicians were notified that medications were not administered or available. This deficient practice was identified for 1 out of 3 residents reviewed for quality of care (Resident #5). This 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, and review of other facility documentation, it was determined that the facility failed to: a) promptly record the removal of a controlled drug from inventory b) maintain accurate accountability of controlled substances within the medication administration carts c) maintain accurate accountability of all controlled medications within the automated medication dispensing system d) accurately document and complete DEA (Drug Enforcement Agency)-222 forms. This deficient practice was identified in 2 of 4 medication carts on 2 of 3 nursing units and for 12 of 12 DEA-22 forms reviewed. This deficient practice was evidenced by the following: 1. On [DATE] at 12:14 PM, the surveyor inspected the Low Hall Garden Unit medication cart with Registered Nurse (RN) #1. [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify the resident and or resident representative in writing of the reason for transfer or discharge to the hospital for 1 of 3 residents (Resident #108) reviewed for hospitalization. This deficient practice was evidenced by the following: During the initial tour of the facility on 04/24/24 at 11:08 AM, the surveyor observed Resident #108 lying in bed awake. The resident was unable to be interviewed at that time due to a language barrier. Review of Resident #108's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to complete a significant change assessment within 14 days after a resident elected hospice services using the Resident Assessment Instrument (RAI) process. This deficient practice was identified for 1 of 2 residents (Resident #24) reviewed for hospice and end of life care. This deficient practice was evidenced by the following: On 04/24/24 at 9:48 AM during the initial tour of the facility, the surveyor observed Resident #24 lying in bed asleep. The resident was accompanied by the hospice aide who provided personal care to the resident at the time of the observation. Review of Resident #24's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included, but were not limited to: [...]

Inspectors wroteBased on observations, interview, record review, and pertinent facility documents it was determined that the facility failed to provide appropriate treatment and care, based upon current standards of practice and the resident's comprehensive care plan specifically not securing a urinary catheter drainage bag properly resulting in the bag making contact with the floor. The deficient practice was identified for 1 of 3 (Resident # 15) investigated for Urinary Catheter. The deficient practice was evidenced by the following: A review of Resident # 15's admission Minimum Data Set (MDS; an assessment tool) dated 04/08/2024 revealed that he/she had an indwelling catheter (tube inserted into the bladder to assist in the flow of urine). [...]

Inspectors wroteNJ Complaint #159967, #159711, #169655, #170197, Based on interview, review of the Nurse Staffing Report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: On 04/29/24 at 10:30 AM, the surveyor held a Resident Council meeting with six residents in attendance. During the Resident Council meeting the surveyor asked all residents in attendance if they received showers, or assistance with showers. Four of the six residents in attendance told the surveyor that showers were not offered twice weekly (Resident #21, #84. #94, and #122). All were aware of their shower day schedule but stated they do not always receive them because of staffing issues. 1. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to use appropriate infection control practices, specifically failing to adhere to the minimum time to lather hands during hand hygiene when providing wound care. The deficient practice was observed during wound care for 1 of 2 residents (Residents # 59) investigated for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 59's Quarterly Minimum Data Set (MDS; an assessment tool) dated 01/22/2024 revealed that he/she had wounds. A review of Resident # 59's Electronic Medical Record (EMR) revealed under Orders to Cleanse Right heel with wound cleanser. Pat dry. Apply hydrogel fluffed gauze. Cover with ABD, wrap with kling [gauze-style bandage] every day shift for open wound for 14 Days AND as needed. [...]

Inspectors wroteBased on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for the pneumococcal vaccination for 1 (Resident #4) of 5 residents whose MDS assessments were reviewed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to maintain documentation of eligibility and consent to receive or refusal of the pneumococcal vaccination upon admittance into the facility for 1 (Resident #4) of 5 residents reviewed for immunizations.

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to consistently offer residents HS (hour of sleep) snacks. This deficient practice was identified for 5 of 5 residents (Resident #17, #23, #68, #44, and #25) during resident council meeting and was evidenced by the following: On 03/22/22 at 11:06 AM, the Surveyor conducted resident council meeting with five residents. During that time, the Surveyor inquired about HS snacks. All five residents commented that they do not always get offered bedtime snacks and that it would depend on the staff that evening. On 03/23/22 at 8:09 AM, the second floor Licensed Practical Nurse Unit Manager (LPN UM) stated that the process would be for the evening snacks to be delivered from the kitchen about 6:45 PM to 7 PM. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to maintain the kitchen in a clean and sanitary manner to limit the spread of infection and potential food borne illness by failing to ensure: a.) the environment and kitchen equipment was maintained in a manner to limit the potential for microbial growth and to prevent physical contaminants from entering the food, b.) staff practiced appropriate hand hygiene and restrained hair appropriately, c.) food items were maintained in a manner to ensure they were not used past their use by date, and d.) a process was in place to ensure bottled water was maintained in a manner to ensure the water was not used by a use by date. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on interview, medical record review, and review of facility documentation, it was determined that the facility failed to: a.) follow the facility policy for Activities of Daily Living (ADL's), and b.) ensure that a resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Specifically, the facility failed to identify and honor a resident's bathing request. This deficient practice was identified for 1 of 27 residents reviewed (Resident #50) and was evidenced by the following: On 03/17/22 at 9:50 AM, the Surveyor observed Resident #50 in bed with their eyes closed. On 03/17/22 at 12:19 PM, the Surveyor returned to Resident #50s room during the lunch meal, and observed a Friend of Resident #50 that was visiting at the bedside. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow the facility policy for Advance Directives to ensure a complete and updated Advance Directive was maintained in a resident's medical file, and b.) inform and offer educational material regarding Advance Directives. This deficient practice was identified for 1 of 1 resident (Resident #2) who was reviewed for Advance Directives. The deficient practice was evidenced by the following: On 03/17/22 at 9:43 AM, the Surveyor observed Resident #2 in their room with their spouse. Resident #2 spoke to the Surveyor and was confused at times. A review of Resident #2's medical records revealed the following: [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents, it was determined that the facility failed to: a.) administer oxygen per the physician order for 2 of 5 residents sampled for respiratory/oxygen (Resident #36 and Resident #17), b.) ensure that all oxygen supplies were changed, labeled and dated weekly for 4 of 5 residents sampled for respiratory/oxygen, and c.) post cautionary signage to indicate that oxygen therapy was in use for 4 of 5 residents reviewed for oxygen/respiratory (Resident #36, #17, # 63 and Resident #27). The deficient practice was evidenced by the following: 1. On 03/17/22 at 10:13 AM, the Surveyor observed Resident #36 resting in bed with eyes open wearing oxygen (O2) by way of nasal cannula (tubing used to deliver oxygen). [...]

Inspectors wroteBased on observation, interview, review of the medical record and other pertinent facility documentation, it was determined that the facility failed to: a.) consistently communicate information to the dialysis center by failing to document an assessment and pre-dialysis treatment, on the Hemodialysis Communication Record (HCR), per facility policy, for 22 of 35 scheduled dialysis treatments, b.) document an assessment, post dialysis treatment, on the HCR, per facility policy, for 33 of 35 scheduled dialysis treatments, c.) accurately monitor and account for the intake of all fluids administered for a resident with a physician ordered fluid restriction, d.) ensure a physician ordered medication that required additional fluid for administration would not exceed the fluid restriction, and was documented. [...]

Inspectors wroteBased on interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure: a.) a resident was offered a shower on scheduled shower days, and b.) that residents were consistently offered evening snacks. The deficient practice was evidenced by the following: Refer to F561 and F809 The facility failed to: a.) follow the facility policy for Activities of Daily Living (ADLs), and b.) ensure that a resident had the right to make choices about aspects of his/her life in the facility that were significant to the resident. Specifically, the facility failed to identify and honor a resident's bathing request. This deficient practice was identified for 1 of 27 residents reviewed (Resident #50). [...]

Inspectors wroteBased on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to develop a process to track and perform weekly: a.) COVID-19 testing for staff that did not receive a COVID-19 vaccination, and b.) COVID-19 testing for staff who were not up-to-date with all recommended COVID-19 vaccinations. This deficient practice was evidenced by the following: Reference: CMS QSO-20-38-NH dated revised 09/10/21, Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested. Facilities should use their community transmission level as the trigger for testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site:https://covid.cdc.gov/covid-data-tracker/#county-view. Table 2: [...]

Inspectors wroteBased on observation, interview, medical record review and review of other pertinent documentation, it was determined that the facility failed to ensure resident dignity by failing to ensure a urinary collection privacy cover was in place over the urinary catheter collection bags. This deficient practice was identified for 2 of 4 residents reviewed (Resident #54 & Resident #69) for urinary catheter use. The deficient practice was evidenced by the following: a.) On 03/17/22 at 9:40 AM, during a tour of the facility, the Surveyor observed Resident #54 seated in the Dining Room (DR) with three other residents. The catheter drainage bag was underneath the chair and had a visible amount of urine inside the bag and did not have a privacy cover. On 03/17/22 at 10:36 AM, the Surveyor observed Resident #54 attending an activity in the DR with other residents present. [...]

Inspectors wroteBased on interview, review of clinical records and other pertinent facility documentation, it was determined that the facility failed to report an allegation of abuse to the state survey agency, Department of Health (DOH). This was identified for 1 of 1 resident reviewed for abuse (Resident #51) and was evidenced by the following: On 03/18/22 at 8:55 AM, the Surveyor interviewed Resident #51 who stated that he/she remembered reporting a complaint about a Certified Nursing Assistant (CNA) to the human resources manager (HRM). The resident that stated that he/she reported that the CNA did not provide care to him anymore or since he/she reported it to the administration. The resident stated that the CNA was rude and was talking about him/her in the hallway loudly enough so that he/she could hear him/her. [...]

Inspectors wroteBased on interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to follow the facility Abuse Prohibition policy by failing to thoroughly investigate an allegation of abuse. This deficient practice was identified for 1 of 1 resident reviewed for abuse (Resident #51) and was evidenced by the following: On 03/17/22 at 9:49 AM, during the tour the surveyor observed Resident #51 in his/her room in bed who stated that there were nurses and Certified Nursing Assistants (CNAs) in the facility that were mean. Resident #51 stated that last Saturday he/she requested the CNA to change him/her because he/she had a bowel movement (BM). Resident #51 stated that the CNA assigned to his/her care did not change him/her for four hours and he/she was left sitting in BM. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to update and revise resident Care Plans (CP) to include interventions for: a.) 1 of 3 residents reviewed for pressure ulcers (Resident #11), and b.) 1 of 4 resident reviewed for accidents (Resident #17). This deficient practice and was evidenced by the following: a.) On 03/17/22 at 10:05AM, during the initial tour the Surveyor interviewed Resident #11 in his/her room who stated that he/she did not remember when he/she developed the wound to the right heel. The Surveyor reviewed the clinical record which revealed the following information: The admission Record revealed that Resident #11 was admitted to the facility with diagnoses that included, but were not limited to, venous insufficiency and cellulitis. [...]

Inspectors wroteBased on interview, and review of pertinent facility documentation it was determined that the facility failed to follow standards of practice by failing to accurately document a locked emergency cart. This deficient practice was identified on 2 of 3 units (1st floor subacute unit and 2nd floor long term care unit) and was evidenced by the following: Reference: New Jersey Statutes, 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 other facility documents, it was determined that the facility failed to investigate an incident of unsafe smoking. This deficient practice was identified for 1 of 5 residents reviewed for accidents (Resident #17) and was evidenced by the following: On 03/17/22 at 10:13 AM, the Surveyor observed Resident #36 resting in bed with his/her eyes open. The Surveyor observed the resident had oxygen (O2) infusing by way of a nasal cannula (tubing used to deliver oxygen, flexible tube that is placed under the nose) that was connected to an oxygen concentrator (an electronic device that removes nitrogen from room air and increases the oxygen concentration). On 03/17/22 at 12:41 PM, the Surveyor observed Resident #17 self-propelling in a wheelchair in the hallway. [...]

Inspectors wroteBased on observation, interview, and document review it was determined that the facility failed to provide foods at the appropriate hot and cold temperatures on 1 of 2 units, and for 1 of 3 Residents reviewed for food (Resident #57). The deficient practice was evidenced by the following: On 03/17/22 at 10:40 AM, Surveyor #1 conducted an interview with Resident #57. The resident stated that the food sat on the trays, there was no temperature control for the food, and the food was cold at times. The Surveyor reviewed the 02/24/22 Resident Council Minutes. Complaints for Food Committee revealed: Food is extremely cold- Not using plate warmers. On 03/22/22 at 12:04 PM, the Surveyor observed the tray-line in progress. At that time, the Surveyor reviewed the lunch meal food temperature log as identified by the Cook. [...]

Inspectors wroteBased on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a pneumococcal vaccine. This deficient practice was evidenced for 1 of 7 residents reviewed for immunizations (Resident # 50). The deficient practice was evidenced by the following: On 03/25/22, the Surveyor reviewed Resident #50's medical record. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to: a.) develop and implement a policy to track and securely document the COVID-19 vaccination status for all staff, and b.) ensure all staff were vaccinated for COVID-19. The deficient practice was evidenced by the following: Reference: Centers for Medicare and Medicaid Services (CMS) QSO-22-07 ALL, dated 12/28/21, included the following: Within 30 days after issuance of this memorandum 2, if a facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; [...]