Jersey Shore Rehab: Infection Control Failures - PA
Jersey Shore Skilled Nursing and Rehabilitation Center violated infection control protocols for a resident with MRSA — methicillin-resistant staphylococcus aureus — and draining wounds on both legs, according to a May inspection report. The facility knew the resident required enhanced barrier precautions but provided no gowns, gloves, or proper signage outside his room.
The violations occurred more than a year after federal regulators mandated enhanced barrier precautions for residents with chronic wounds or drug-resistant infections. The March 2024 directive from the Centers for Medicare and Medicaid Services required nursing homes to use protective equipment during "high-contact" activities like dressing changes, transfers, and wound care.
Employee 7, a nurse aide working in the resident's hallway, told inspectors on May 13 she had no idea why a precaution sign hung on the door. She wasn't aware the resident or his roommates required any special infection control measures.
"The sign may not have been removed from flu season," she said.
The wrong sign stayed up for months. Instead of enhanced barrier precaution warnings, the door displayed outdated "Droplet Precautions" signage from an earlier illness, requiring masks for respiratory protection rather than gowns and gloves for wound contact.
No protective equipment bins appeared outside the room. No disposal containers sat near the door. Staff entering to provide care had no way to follow the facility's own infection control policy.
The nursing home administrator confirmed on May 13 that neither the resident nor his roommates needed droplet precautions. The old sign should have been removed. But the resident did require enhanced barriers due to his MRSA history, she acknowledged.
Laboratory results from December 31 showed the resident's wound culture tested positive for the drug-resistant bacteria. His bilateral lower leg wounds continued draining, creating ongoing infection risks for anyone providing direct care.
Inspectors returned the next day to find the droplet precaution sign had been removed overnight. But no new signage appeared indicating enhanced barriers were needed. The resident wheeled himself out of his room in a wheelchair, bandages wrapped around his lower legs, with no protective warnings posted for staff or visitors.
The administrator admitted on May 14 that proper signage should have been changed immediately when the violation was identified the previous day. Enhanced barrier supplies should have been placed outside the room within hours.
By May 15, the facility finally added electronic medical record instructions indicating the resident required enhanced barrier precautions for draining wounds. The administrator and director of nursing confirmed the resident should have had proper signage and available protective equipment all along.
But the problems persisted. When inspectors made a final check on May 16, no enhanced barrier precaution signs appeared on the resident's door. No required protective equipment sat outside his room. Staff and visitors still had no warning that additional infection control measures were necessary before entering.
The facility's own policy required enhanced barrier precaution signs on patient doors when the protections were needed. Personal protective equipment was supposed to be "readily accessible and located outside the patient's room" for use during high-contact care activities.
The policy specified that protective equipment should be discarded in the room before exiting, followed by hand hygiene. But without gowns and gloves available outside the room, staff couldn't follow even basic infection prevention protocols.
Enhanced barrier precautions represent a middle ground between standard infection control and full contact isolation. The federal directive aimed to prevent transmission of drug-resistant organisms that have become increasingly common in nursing homes while avoiding the social isolation that comes with full quarantine measures.
High-contact activities requiring protection include dressing residents, bathing, transferring between bed and wheelchair, providing hygiene assistance, changing linens or adult briefs, wound care, and device maintenance. Each of these activities could potentially spread MRSA from infected wounds to staff hands and clothing.
MRSA infections can cause serious complications in nursing home residents, who often have compromised immune systems and multiple chronic conditions. The bacteria resist treatment with methicillin and related antibiotics, making infections harder to cure and more likely to spread between residents.
The inspection found the facility failed to implement appropriate enhanced barrier precautions for one of 24 residents reviewed. But the single violation revealed systemic problems with infection control oversight and staff training that potentially affected care for other residents with similar conditions.
Three days passed between the initial identification of missing protective equipment and the final inspection check, yet the facility never managed to post correct signage or provide required supplies outside the resident's room. The administrator and director of nursing acknowledged the violations but couldn't implement basic corrections within 72 hours.
The resident continued living in his shared room with bandaged, draining wounds while staff remained unaware of infection risks and lacked protective equipment for safe care delivery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jersey Shore Skilled Nursing and Rehabilitation Ce from 2025-05-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
JERSEY SHORE SKILLED NURSING AND REHABILITATION CE in JERSEY SHORE, PA was cited for violations during a health inspection on May 16, 2025.
The facility knew the resident required enhanced barrier precautions but provided no gowns, gloves, or proper signage outside his room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.