Inspection Reports for Barnegat Rehabilitation And Nursing Center
859 West Bay Ave, NJ, 08005
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Inspection Report
Complaint Investigation
Census: 99
Capacity: 116
Deficiencies: 4
Nov 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00168114 and NJ0017439, to determine compliance with 42 CFR Part 483 for long term care facilities.
Findings
The facility was found not in substantial compliance with requirements, with deficiencies cited related to accident hazards, pharmacy services, infection prevention and control, and staffing ratios. The facility failed to maintain a safe environment free of accident hazards and adequate supervision, failed to establish accurate controlled drug records, and failed to maintain minimum staffing ratios as mandated by the State of New Jersey.
Complaint Details
The complaint investigation was based on complaints NJ00168114 and NJ0017439. The facility was found not in substantial compliance with requirements. The complaint was substantiated as deficiencies were cited in accident hazards, pharmacy services, infection control, and staffing.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure resident environment was free of accident hazards and residents received adequate supervision and assistance devices to prevent accidents. | SS=D |
| Facility failed to establish a system of records for controlled drugs in sufficient detail to enable accurate reconciliation for 2 out of 3 medication carts inspected. | SS=D |
| Facility failed to maintain an infection prevention and control program including appropriate use of gowns and hand hygiene. | SS=D |
| Facility failed to maintain minimum direct care staff to resident ratios as mandated by the State of New Jersey for multiple weeks. | — |
Report Facts
Census: 99
Total Capacity: 116
Medication carts with deficiencies: 2
Weeks deficient in CNA staffing: 7
Residents affected by kitchen fire alarm deficiency: 99
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Apr 2, 2024
Visit Reason
The inspection was conducted based on complaint NJ172387 to investigate staffing ratio compliance at Barnegat Rehabilitation and Nursing Center.
Findings
The facility was found deficient in meeting required staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts and deficient in total staff on 1 of 14 overnight shifts during the review period. No residents were affected during the dates reviewed. The facility submitted a plan of correction to address staffing shortages.
Complaint Details
Complaint #: NJ172387. The complaint was substantiated with findings of deficient staffing ratios as per New Jersey minimum staffing requirements effective 02/01/2021. The facility failed to meet CNA staffing requirements on multiple days in March 2024.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts. |
Report Facts
Census: 97
Deficient CNA staffing days: 14
Deficient total staff overnight shifts: 1
Required CNAs on 03/17/24: 12
Actual CNAs on 03/17/24: 7
Required CNAs on 03/18/24: 11
Actual CNAs on 03/18/24: 9
Required CNAs on 03/19/24: 11
Actual CNAs on 03/19/24: 10
Required CNAs on 03/20/24: 11
Actual CNAs on 03/20/24: 9
Required CNAs on 03/21/24: 11
Actual CNAs on 03/21/24: 10
Required CNAs on 03/22/24: 12
Actual CNAs on 03/22/24: 10
Required CNAs on 03/23/24: 12
Actual CNAs on 03/23/24: 8
Required CNAs on 03/24/24: 12
Actual CNAs on 03/24/24: 10
Required total staff on 03/24/24 overnight: 7
Actual total staff on 03/24/24 overnight: 6
Required CNAs on 03/25/24: 12
Actual CNAs on 03/25/24: 8
Required CNAs on 03/26/24: 12
Actual CNAs on 03/26/24: 11
Required CNAs on 03/27/24: 12
Actual CNAs on 03/27/24: 9
Required CNAs on 03/28/24: 12
Actual CNAs on 03/28/24: 10
Required CNAs on 03/29/24: 12
Actual CNAs on 03/29/24: 7
Required CNAs on 03/30/24: 12
Actual CNAs on 03/30/24: 8
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 0
Dec 14, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Re-Inspection
Census: 97
Capacity: 116
Deficiencies: 11
Aug 8, 2023
Visit Reason
Recertification survey and complaint investigation with follow-up to verify correction of cited deficiencies.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including care plan timing and revision, professional standards of care, medication administration, accident hazards, incontinence care, psychotropic medication use, food safety, infection control, universal transfer form retention, staffing ratios, and life safety code compliance. Follow-up inspections verified corrections for all cited deficiencies.
Complaint Details
Complaint NJ164925 related to failure to maintain required minimum direct care staffing ratios.
Severity Breakdown
SS=D: 4
SS=E: 4
SS=G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to revise care plan timely for a resident with medication changes. | SS=D |
| Failed to provide care and services meeting professional standards including medication errors and lab communication failures. | SS=D |
| Failed to ensure adequate supervision and assistance devices to prevent accidents for a resident requiring mechanical lift transfers. | SS=G |
| Failed to maintain incontinence devices properly preventing contamination and infection risk. | SS=E |
| Failed to limit psychotropic medication PRN orders to 14 days and document clinical rationale and monitoring. | SS=D |
| Failed to handle and store food safely including improper dating, wet nesting of pans, and unsanitary conditions in refrigerators and walk-in freezer. | SS=E |
| Failed to follow infection prevention and control practices including inadequate handwashing and failure to wear gloves during eye drop administration. | SS=D |
| Failed to maintain copies of New Jersey Universal Transfer Forms in resident medical records for transfers. | — |
| Failed to provide emergency illumination automatically along means of egress in second floor dining room. | SS=E |
| Failed to ensure fire-rated doors to hazardous areas were self-closing and properly sealed. | SS=E |
| Failed to maintain required minimum direct care staff to resident ratios on multiple day and overnight shifts. | — |
Report Facts
Census: 97
Total Capacity: 116
Deficiency counts: 11
Staffing ratios: 6
Staffing ratios: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to medication administration errors and infection control deficiencies. |
| LPN #2 | Licensed Practical Nurse | Named in findings related to medication administration errors and infection control deficiencies. |
| CNA #1 | Certified Nursing Assistant | Named in accident supervision deficiency related to mechanical lift use. |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding care plan, medication, infection control, and staffing deficiencies. |
| Maintenance Director | Maintenance Director | Named in findings related to life safety code deficiencies for emergency lighting and fire door closure. |
| Staffing Coordinator | Staffing Coordinator | Named in interview regarding staffing ratio compliance. |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
May 23, 2023
Visit Reason
The inspection was conducted based on complaint #NJ00164050 to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to deficiencies in care plan timing and revision, and failure to ensure a resident environment free of accident hazards and adequate supervision to prevent accidents. The facility failed to update care plans timely and follow their policy, and failed to consistently implement interventions to ensure resident safety.
Complaint Details
Complaint #NJ00164050 was substantiated based on interviews and medical record reviews indicating failure to update care plans timely and failure to implement interventions to prevent accidents for sampled residents.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Care Plan Timing and Revision - failure to update and/or initiate care plan interventions timely for a resident and failure to follow policy for care plans. | SS=D |
| Free of Accident Hazards/Supervision/Devices - failure to ensure resident environment free of accident hazards and adequate supervision to prevent accidents. | — |
Report Facts
Sample Size: 3
Deficiencies cited: 2
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 5
Sep 16, 2022
Visit Reason
Complaint investigation based on allegations of failure to notify resident's physician and family of changes, failure to update care plans, failure to obtain physician orders before treatments, failure to provide adequate ADL care, and staffing deficiencies.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to notify physicians and families of changes, failure to update care plans timely, failure to obtain and follow physician orders for treatments, failure to provide adequate ADL care and documentation, and failure to maintain required staffing ratios.
Complaint Details
Complaint # NJ149711, NJ156927. The facility was not in substantial compliance based on complaint visit findings related to notification failures, care plan deficiencies, treatment orders, ADL care, and staffing.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to notify resident's physician and family of new wounds and medication changes. | SS=D |
| Failure to update care plan timely when resident developed a new condition. | SS=D |
| Failure to obtain physician's order before administering treatment and failure to maintain accurate medical record documentation. | SS=D |
| Failure to provide adequate ADL care and documentation for dependent residents. | SS=D |
| Failure to maintain required staffing ratios for Certified Nursing Assistants (CNAs) on multiple shifts. | — |
Report Facts
Census: 96
Deficiency count: 5
Staffing ratios: 11
Staffing shortfalls: 6
Inspection Report
Routine
Census: 93
Deficiencies: 0
Aug 23, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations as it relates to the implementation of CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 9
COVID+ in-house: 13
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Jul 15, 2021
Visit Reason
The inspection was conducted based on complaints NJ137305 and NJ141673 to determine compliance with regulatory requirements.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ137305 and NJ141673 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 9
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 9
Jun 22, 2021
Visit Reason
Complaint investigation to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance overall but had multiple deficiencies including failure to maintain a clean and sanitary environment, inaccurate resident assessments, incomplete comprehensive care plans, improper catheter care, failure to provide ordered water flushes for tube feeding, failure to follow respiratory care orders, food safety violations, inadequate staffing ratios, and infection prevention and control issues.
Complaint Details
Complaint # NJ 00145779. The facility was found in substantial compliance overall but deficiencies were cited related to the complaint.
Severity Breakdown
SS=D: 5
SS=E: 3
SS=B: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to maintain a clean and sanitary environment including stained oxygen concentrators, dirty privacy curtains, walls with dried debris, and unclean feeding pumps. | SS=D |
| Failure to accurately assess resident status in Minimum Data Set (MDS) for alarms and safety devices. | SS=B |
| Failure to develop and implement comprehensive care plans addressing oxygen use for residents. | SS=D |
| Failure to ensure proper catheter care; catheter was observed in contact with the floor and not secured. | SS=D |
| Failure to provide ordered water flushes for residents with gastrostomy tubes, risking hydration and nutrition. | SS=E |
| Failure to follow physician orders for respiratory care including timely changes of oxygen tubing. | SS=D |
| Failure to procure, store, prepare, and serve food in a sanitary manner including unclean refrigerators, exposed food, improper plate storage, and inadequate hand hygiene by food service staff. | SS=E |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law. | SS=E |
| Failure to perform proper hand hygiene during wound care and improper storage of bedpans leading to potential infection transmission. | SS=D |
Report Facts
Census: 78
Deficiency count: 9
Staff to resident ratio: 19
Staff to resident ratio: 15
Staff to resident ratio: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in infection control finding for failure to perform hand hygiene during wound care. |
| LPNUM #2 | Licensed Practical Nurse Unit Manager | Named in respiratory care and food safety findings. |
| CNA #2 | Certified Nursing Assistant | Named in food safety and feeding findings. |
| Director of Nursing | Director of Nursing | Named in staffing and care plan findings. |
| Administrator | Facility Administrator | Named in staffing findings. |
| Infection Preventionist | Infection Preventionist | Named in infection control findings and staff education. |
Inspection Report
Life Safety
Deficiencies: 3
Jun 14, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 06/14/2021 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to be in noncompliance with Life Safety Code requirements, including deficiencies in fire alarm system maintenance, corridor door smoke resistance, and emergency electrical system testing. Specific issues included missing protection grills on smoke detectors, a resident room door obstructed from closing properly, and lack of documented certification that the emergency generator transfers power within 10 seconds.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Two of 14 smoke detectors were missing center protection grills, compromising the fire alarm system. | SS=D |
| One corridor door was obstructed by a gold door hanging bracket preventing proper closure and latching, restricting smoke containment. | SS=D |
| The emergency electrical system generator lacked documented certification that it transfers power within the required 10 seconds during monthly tests. | SS=E |
Report Facts
Smoke detectors inspected: 14
Doors observed: 30
Generator load tests reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed findings of missing smoke detector grills and door obstruction; involved in generator testing and corrective actions | |
| Administrator | Notified of findings at Life Safety Code exit conference and reviewed corrective actions |
Inspection Report
Routine
Census: 68
Deficiencies: 0
Jan 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 76
Deficiencies: 0
Dec 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Notice
Deficiencies: 0
Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices to inform individuals about how their medical information may be used and disclosed by NJDHSS and to describe their rights related to their health information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and NJDHSS's legal duties and policies regarding privacy.
Report Facts
Effective date: Apr 15, 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
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