Inspection Reports for
Barnegat Rehabilitation And Nursing Center

Complaint NJ182922 alleged physical abuse of Resident #4 by CNAs on 1/25/25. The allegation was substantiated as an Immediate Jeopardy (IJ) situation from 1/25/25 8:40 PM until 1/26/25 12:37 PM when reported. The IJ was Past Non-Compliance (PNC). The facility self-corrected by 1/30/25 with staff suspensions, terminations, education, resident assessment, and policy reinforcement.

The facility failed to protect Resident #4 and other residents from abuse by not immediately reporting and investigating the alleged physical abuse incident. The investigation concluded no intent to harm but found the facility initially non-compliant. The facility implemented corrective actions including suspension and termination of involved staff, staff education, resident assessment, and updated care plans.

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.

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.

The facility failed to establish an accurate system of records for controlled drugs, as discrepancies were found in the controlled drug sheets for 2 out of 3 medication carts inspected, indicating lapses in signing out narcotic medications.

The facility failed to ensure a resident's environment was free from accident hazards by not using bilateral floor mats as ordered for a high fall-risk resident. Additionally, staff failed to use appropriate infection control practices by not wearing a gown during wound care for a resident on Enhanced Barrier Precautions.

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.

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 NJ164925 related to failure to maintain required minimum direct care staffing ratios.

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.

The complaint investigation substantiated that Resident #299 fell from a mechanical lift due to a staff member operating the lift alone, contrary to facility policy requiring two staff members. The resident sustained serious injuries including a fractured femur, head laceration, and shoulder fracture.

The facility failed to ensure adequate supervision during the transfer of Resident #299 using a mechanical lift, resulting in the resident falling and sustaining a fractured femur, head laceration, and shoulder injury. The investigation included interviews, record reviews, and policy evaluations confirming the requirement of two staff members for safe mechanical lift operation.

The facility was found deficient in multiple areas including failure to revise care plans for residents on antibiotics, medication administration errors including administering medication outside prescribed parameters and improper handling of medications, failure to notify physicians of abnormal lab results, improper catheter care leading to infection risk, inadequate monitoring and documentation of psychotropic medication use, unsafe food handling and storage practices, and lapses in infection prevention practices such as insufficient handwashing and failure to wear gloves during eye drop administration.

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.

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 #NJ00164050 involved allegations that the facility failed to update care plans and follow policies for residents at risk for alcohol abuse, resulting in intoxication incidents. The complaint was substantiated with findings of inadequate care plan updates, failure to notify physicians and supervisors, and lack of incident reporting.

The facility failed to timely update care plans and consistently implement interventions for residents at risk of alcohol abuse, resulting in incidents of intoxication and inadequate supervision. The facility also failed to follow policies for incident reporting, investigation, and notification of changes in residents' conditions.

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.

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 # NJ 00145779. The facility was found in substantial compliance overall but deficiencies were cited related to the complaint.

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.

The facility was found deficient in maintaining a clean and sanitary environment, accurate resident assessments, comprehensive care plans for oxygen therapy, proper catheter care, feeding tube hydration, respiratory care, food safety and sanitation, staffing ratios below state minimums, and infection prevention practices including hand hygiene and proper bed pan storage.

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.