Barnegat Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation during food preparation in a safe and consistent manner designed to prevent food borne illness by cross contamination. This deficient practice was evidenced by the following:On 3/27/2026 at 10:18 AM, during a follow-up visit to the kitchen, the surveyor observed [NAME] #1 on the preparation (prep) table wearing disposable latex gloves with a hair cover. The surveyor observed the cook pull a plastic tape from a blue box on the table, go to the large grey trash bin, lifted the lid of the bin with their gloved right hand, threw the plastic tape in the trash bin, and returned the lid of the bin. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documents, it was determined that the facility failed to appropriate infection control practices specifically by failing to use personal protective equipment upon entering rooms that required it when performing patient care for 2 of 8 residents reviewed under enhanced barrier precautions (EBP) (Resident #10, #101). The deficient practice was evidenced by the following: On 03/26/2026 at 9:31 AM while touring the first floor, while outside of Resident # 10's room, the surveyor observed an orange sign outside the room door that revealed a stop sign symbol and the words, Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. [...]

Inspectors wroteBased on observation, interview, record review, and facility provided documentation, the facility failed to ensure that a resident did not self administer medication without an assessment, interdisciplinary care team meeting determination, a physician's order, or care plan intervention for 1 of 3 residents (Resident #28) reviewed for the Medication Administration task. This deficient practice was evidenced by the following:During observation of medication administration on 03/27/2026 at 9:33 AM, Resident #28 told Licensed Practical Nurse (LPN) #1 that they had already administered their eye drops. Resident #28 stated, I have them in my drawer; I do it myself. When the LPN asked, You give yourself the eye drops? the resident confirmed. The surveyor then asked the LPN whether Resident #28 self medicated their eye drops, and the LPN stated, Yes. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the results of the most recent survey were readily accessible to residents and the public. The deficient practice was evidenced by the following:On 03/26/2026 at 09:52 AM during the initial tour, the surveyor observed the State Survey Binder located in the lobby of the facility. At that time, the surveyor did not observe any Life Safety Code Statement of Deficiencies (CMS-2567) from previous surveys within the binder. On 03/31/2026 at 12:00 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) replied I will check after the surveyor asked if there is a reason the Survey Binder does not include any Life Safety Code Statements of Deficiencies. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 of 2 units (First and Second Floor). This was evidenced by: On 03/26/2026 at 10:06 AM, Surveyor #1 observed the first-floor shower room. In the first shower stall, on the bottom left corner, Surveyor #1 observed black discoloration and several chipped tiles. During an interview on 03/30/2026 at 11:15 AM, the Assisitant Director of Nursing (ADON) stated that housekeeping was responsible for the major cleaning of the shower room. Surveyor #1 and the ADON reviewed the shower room together. The ADON acknowledged that the shower tiles need attention. During the initial tour on 03/26/2026 at 9:26 AM, the surveyor observed room [ROOM NUMBER]A. At that time, the surveyor observed that the wallpaper was ripped behind the bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility did not ensure a residents medication regimen was free from unnecessary psychotropic medications. Specifically, a psychotropic medication ordered for an extended duration lacked documented clinical rationale in the resident's record. The deficient practice was identified for 1 of 5 residents (Resident #41) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 03/26/2026 at 12:43 PM, the surveyor observed Resident #41 walking the facility halls speaking incoherently to themselves. A review of the Electronic Medical Record (EMR) under Diagnoses revealed that Resident #41 was diagnosed with but not limited to generalized anxiety disorder and unspecified dementia (a decline of cognitive function). [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate by relying solely on an initial assessment performed by a Licensed Practical Nurse (LPN) without further RN clinical verification for 1 of 1 resident (Resident # 36) reviewed for assessment accuracy. 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, review of medical records and other facility documentation, it was determined that the facility failed to ensure that nursing assessments for falls were completed by a Registered Nurse (RN) and fall care plans were formulated and evaluated for effectiveness by an RN, in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents (Resident #10) reviewed for accidents. 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, review of medical records and other pertinent facility documentation, it was determined that the facility failed to ensure that appropriate incontinence care was provided for a resident who was dependent on staff for toileting hygiene and incontinence care. This deficient practice was identified for 1 out of 3 residents (Resident #70) reviewed for bladder and bowel incontinence. The deficient practice was evidenced by the following:On 3/26/2026 at 9:40 AM, during the initial tour of the facility, the surveyor observed a malodorous smell on the first-floor unit hallway across the room of Resident #70. The surveyor observed Certified Nursing Assistant #1 (CNA #1) 1 enter Resident #70's room. On 3/26/2026 at 9:56 AM, the surveyor observed the door to the resident's room open. From the hallway, the surveyor observed CNA #1 fixing Resident #70's hair. [...]

Inspectors wroteBased on observation, interview, review of medical record and other pertinent facility documentation, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased range of motion (ROM) after discharge from therapy. This deficient practice was identified for 1 of 1 resident (Resident #25) reviewed for position and mobility. This deficient practice was evidenced by the following: On 3/26/2026 at 10:07 AM, the surveyor observed Resident #25 in bed. The surveyor observed the resident's right fingers flexed with short nails visible. The surveyor asked the resident if they could open their right hand. [...]

Inspectors wroteBased on observation, interview, record review and review of facility provided information, it was determined that the facility failed to ensure that a resident at risk for elopement had complete and accurate physician orders and consistent monitoring of a wander guard device following readmission from the hospital. The deficient practice was identified for 1 of 1 Resident (Resident # 52) reviewed for elopement. This deficient practice was evident by the following:During the initial tour on 03/26/2026 at 10:23 AM, the surveyor observed Resident #52 in bed with a wander guard device (a device that may trigger an audible sound when the wearer passes through an exit doorway) on the right ankle. A review of Resident #52's admission Record showed diagnoses including dementia, major depressive disorder, and Alzheimer's disease. [...]

Inspectors wroteBased on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter (tube inserted in the bladder to drain urine) drainage bag was secured in a manner to prevent contamination and provide appropriate and sufficient services based upon current standards of practice and the resident's comprehensive care plan to document urinary output in the Treatment Administration Record (TAR). The deficient practice was identified for 1 of 1 resident (Resident # 3) investigated for Urinary Catheter or UTI.The deficient practice was evidenced by the following:On 03/27/2026 at 9:31 AM, the surveyor observed Resident #3 seated in a wheelchair in the dining room, the urinary drainage bag was observed below the resident's wheelchair in direct contact with the floor. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice specifically by leaving a nasal cannula out of a bag, exposed to air and not having a physician's order for oxygen administration. The deficient practice was identified for 1 of 1 (Resident # 12) residents reviewed for Respiratory Care. The deficient practice was evidenced by the following:On 03/26/2026 at 9:47 AM, during the initial tour, the surveyor observed Resident #12 in their room. [...]

Inspectors wroteBased on observation, interview, record review and review of facility provided information, it was determined that the facility failed to ensure that a resident (Resident #2) with a prescribed fluid restriction had monitoring orders in place and documented intake as required for 1 of 1 resident reviewed for dialysis. This deficient practice was evidenced by the following: On 03/27/2026 at 09:19 AM, the surveyor observed Resident #2 in bed with a cup on the bedside table. Resident #2 voiced no concerns at that time. A review of Resident #2's admission record revealed diagnoses including, but not limited to, End Stage Renal Disease (kidneys do not function properly). A review of the electronic medical record showed that Resident #2 was admitted to the hospital on [DATE] for hyperpotassemia (elevation of potassium in the blood) and was readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure Licensed Practical Nurse staff practiced within their professional scope of practice. The facility permitted Licensed Practical Nurses (LPNs) to independently conduct initial nursing assessments and initiate resident care plans without Registered Nurse (RN) coordination or oversight. The deficient practice was identified for 1 of 1 resident (Resident # 36) reviewed under the Competent and Sufficient Nursing Staff. 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 wroteComplaint #: NJ182922Based on interviews, medical record review, and review of other pertinent facility documents on 7/21/25, it was determined that the facility failed to implement their abuse policy by protecting Resident #4, as well as all residents from abuse, when on 1/25/25 at 8:40 PM, the Certified Nursing Aide (CNA #3) observed CNA #1 and CNA #2 physically abuse Resident #4 and CNA #3 did not report the incident until the next day, 1/26/25 at approximately 12:37 PM. On 1/25/25 at 8:40 PM, during the 3:00 PM to 11:00 PM shift (3-11), CNA #3 reported hearing screaming coming from Resident #4's room, and when she walked into the room, CNA #3 stated that she observed the resident sitting on their bed with CNA #1 trying to remove the resident's shirt and CNA #2 trying to put on a [NAME] coat (hospital gown). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation it was determined that the facility failed to ensure the resident's environment is free of accident hazards by failing to use bilateral floor mats as ordered. The deficient practice was identified for 1 of 5 residents (Resident # 31) reviewed under Accidents. The deficient practice was evidenced by the following: A review of Resident # 31's comprehensive Minimum Data Set, dated [DATE] revealed that Resident # 31 had a fall prior to admission. A review of Resident # 31's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Mats at the bedside while in bed every shift for safety. The order became active on 09/21/2024. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications for 2 out of 3 medication carts inspected. This deficient practice was evidenced by the following: On 10/30/2024 at 10:06 AM, in the presence of the Licensed Practical Nurse (LPN)# 1, the surveyor inspected the medication cart on the second floor labeled the high side cart for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed 8 Xanax (a narcotic medication used to treat anxiety) 5mg (milligram) in the blister pack in the narcotic box, but the Controlled Drug Sheet (CDS) documented 9 were left. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically by failing to wear a gown when providing wound care. The deficient practice was identified for 1 of 2 (Resident # 27) residents reviewed for Pressure Ulcer/Injury. The deficient practice was evidenced by the following: A review of Resident # 27's physician's orders located in the Electronic Medical Record (EMR) revealed that he/she was receiving Santyl External Ointment (topical ointment enzyme that breaks down collagen) applied to the left trochanter wound topically every day shift for healing. The order further revealed to cleanse with acetic acid 0.25%, pat dry, apply santyl, calcium alginate, and cover with a [clean dry dressing]. [...]

Inspectors wroteBased on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to maintain an indwelling urinary catheter in a manner that would limit the potential to cause a Urinary Tract Infection (UTI) for 3 of 3 residents reviewed for indwelling urinary catheters (Resident #199, #79, and #20). This deficient practice was evidenced by the following: On 07/25/2023 at 10:23 AM, during the initial tour of the facility, the Surveyor #1 observed Resident #199 lying in bed. Surveyor #1 observed Resident #199's catheter bag suspended from bed frame and no privacy bag/cover was in place. Urine was visible, however Resident #199's catheter drainage bag was obscured from view on this observation due to their privacy curtain preventing observation from the common hallway outside the room. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 07/25/2023 from 9:15 to 9:41 AM, the surveyor, accompanied by the Account Manager (AM), observed the following in the kitchen: 1. In the walk-in refrigerator a plastic pan on top of a wheeled cart contained sliced pears. The pan was covered with plastic wrap and dated 7/21. The AM removed the pears to the trash. 2. During the observation of the walk-in freezer it was noted that the walk-in floor was covered with unidentified debris and ice chunks. When interviewed the AM stated that the freezer is on the cleaning schedule and is generally cleaned on delivery day. 3. [...]

Inspectors wroteBased on interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to revise a care plan for a resident who transitioned from intravenous antibiotics to oral antibiotics. This deficient practice was identified for 1 of 25 sampled residents, (Resident # 69) and was evidenced by the following: A review of the admission Record revealed Resident #69 was admitted to the facility with diagnoses including but not limited to: Right Hip Replacement and Methicillin Susceptible Staphylococcus Aureus Infection (MSSA) (is an infection caused by a type of bacteria commonly found on the skin). A review of the admission Minimum Data Set, an assessment tool used to facilitate resident care dated 04/12/2023, revealed a Brief Interview for Mental Status of 15/15 indicating Resident #69 was cognitively intact. [...]

Inspectors wrote2. According to the admission Record, Resident # 28 was admitted to the facility with diagnoses including but not limited to: Hypothyroidism (means that the thyroid gland can't make enough thyroid hormone to keep the body running normally). A review of the Consultant Pharmacist (CP) report dated 05/10/2023 revealed a note to the physician to Consider ordering TSH- last noted 7/22 in medical record. A handwritten note indicated TSH ordered 5-15-22. A review of the lab results for the TSH dated 05/15/2023 revealed Results 0.04 with a Ref (reference range) 0.3-4.2 A review of the progress notes dated 05/15/2023 through 05/31/2023 did not include documentation that the physician was notified of the abnormal lab results. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to A.) limit the timeframe for a PRN (as needed) psychotropic medication, which was not an antipsychotic medication, to 14 days, unless a longer timeframe was deemed appropriate by the attending physician or the prescribing practitioner and B.) provide a clinical reason or a clinically pertinent rationale for administering a PRN (as needed) psychotropic medication and failed to monitor and accurately document the resident's response to the medication. The deficient practice was identified for 2 of 5 residents (residents #47, #66) reviewed for Unnecessary Medications. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observations, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to implement appropriate infection prevention and control practices during medication administration specifically by a staff member lathering with soap and water for less than twenty seconds and by a staff member administering eye drops to a resident without wearing gloves. The deficient practices were identified for 2 of 2 nurses during the Medication Administration task. On 07/26/2023 at 8:20 AM, during medication administration, the surveyor observed Licensed Practical Nurse (LPN #1) finish administering medications to a resident. At 8:27 AM, the surveyor observed LPN #1 enter the bathroom in the residents room with the door open. [...]