Southern Ocean Center

In the surveyor’s words

From the most serious findings on record at Southern Ocean Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 8, 2025

  This 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)

• No harm, potential for more than minimal, widespreadF809Apr 6, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 6, 2022

  Based 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. […]

• No harm, potential for more than minimal, patternF880Sep 8, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF755May 2, 2024

  Based 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. […]