Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barnegat Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a clean, sanitary, and homelike environment on both floors, including black discoloration and chipped tiles in a first-floor shower stall, ripped wallpaper behind a bed in one room, and a gap with black vegetative substance between an AC/heater unit and drywall in another room. On the second floor, surveyors observed cracked tiles, a clump of hair in a shower room corner, a black substance on the shower floor, and a bathroom sink with cracked, peeling caulk and a gap between the sink and wall. The ADON acknowledged the need for attention to the shower tiles and stated housekeeping handled major shower room cleaning, while the LNHA reported that maintenance and an ambassador team tour the facility daily to promote a homelike environment, consistent with the facility’s Homelike Environment policy requiring a clean, sanitary, and orderly setting.
A resident with severe cognitive impairment, frequent bowel and bladder incontinence, and a history of sacral pressure injury and CHF requiring furosemide was not provided timely incontinence care despite needing maximal assistance with toileting hygiene. Surveyors twice observed strong urine odors in and around the resident’s room, a wet mattress without a sheet, and a soaked incontinence brief with a disposable bed liner underneath, while the resident reported not being changed since the previous morning. Review of POC documentation showed multiple shifts with no recorded bladder incontinence care, even though the care plan identified the need for toileting assistance and facility policy and the DON’s expectations required regular incontinence checks and scheduled toileting.
A resident receiving continuous IV oxacillin via a right internal jugular central line for osteomyelitis and MSSA infection had an Admission/readmission Evaluation and care plan focuses for central line and IV antibiotic therapy completed and initiated by an LPN. Interviews revealed that LPNs routinely conducted initial head-to-toe assessments, completed admission evaluations, and initiated baseline care plans for new admissions without clear RN oversight, while the DON confirmed that LPNs were directed to perform these initial evaluations and start care plans, contrary to state scope-of-practice requirements and the facility’s own LPN job descriptions.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with a history of falls did not have the prescribed bilateral floor mats properly placed, as one mat was consistently folded against the wall. Despite the care plan and facility policy emphasizing fall prevention, observations showed non-compliance with the safety measures, as confirmed by the DON.
The facility failed to maintain accurate records for controlled drugs, with discrepancies found in the counts of Xanax and Oxycontin during a surveyor's inspection. An LPN on the second floor forgot to sign out Xanax after administration, while another LPN on the first floor thought she had signed out Oxycontin. The DON confirmed that narcotics should be signed out in the CDS upon administration.
A facility staff member failed to wear a gown during wound care for a resident with a pressure ulcer, despite enhanced barrier precautions being in place. The resident had been on these precautions due to a central line and the wound, as indicated by a sign on the door. The infection preventionist confirmed the need for gown use, aligning with the facility's policy.
Failure to Maintain Clean, Sanitary, and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility did not maintain a clean, sanitary, and homelike environment on both the first and second floors. On the first-floor shower room, a surveyor observed black discoloration and several chipped tiles in the bottom left corner of the first shower stall. During the initial tour of resident rooms, the surveyor observed in one room that the wallpaper was ripped behind the bed. In another room, the surveyor observed a gap between the air conditioner/heater unit and the drywall above, with a black vegetative substance present within the gap. The Assistant Director of Nursing, when touring the first-floor shower room with the surveyor, acknowledged that the shower tiles needed attention and stated that housekeeping was responsible for major cleaning of the shower room. On the second floor, the surveyor observed in the shower room cracked tiles, a clump of hair in the corner, and a black substance around the middle shower floor. During subsequent rounds, the surveyor observed that the sink in the bathroom of another room had caulk that was cracked and peeling, with a gap between the wall and the sink. In an interview with the survey team, the Licensed Nursing Home Administrator stated that maintenance and an ambassador team tour the facility daily and that they try to be diligent in treating the facility as they would their own homes and to ensure a homelike environment. A review of the facility’s Homelike Environment policy showed that staff and management are expected to maximize characteristics of a personalized, homelike setting, including maintaining a clean, sanitary, and orderly environment.
Failure to Provide Timely and Appropriate Incontinence Care for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate incontinence care and toileting hygiene to a resident who was dependent on staff for these activities of daily living. During an initial tour, a surveyor detected a strong urine odor in the hallway near the resident’s room and later observed a CNA exiting the room after fixing the resident’s hair. Upon entering the room, the surveyor noted a strong urine odor, a dark blue mattress without a bed sheet that was wet and strongly smelled of urine, and the resident in a wheelchair stating they had last been changed the previous morning. The CNA assignment sheet showed that the CNA was responsible for 16 residents on that shift. On a subsequent incontinence tour, the resident was observed in bed with a blue incontinence brief that was soaked with urine in both the front and back, with a malodorous urine smell when the brief was exposed, and a blue disposable bed liner underneath. The resident again stated that the last time they were changed was the previous morning, although their buttocks skin was not red at the time of observation. The resident’s medical record showed diagnoses including pressure-induced deep tissue damage of the sacral region, cerebrovascular disease, and congestive heart failure, with a recent comprehensive MDS indicating severely impaired cognition, frequent bowel and bladder incontinence, and a need for maximal assistance with toileting hygiene. The resident also had an active order for furosemide for congestive heart failure. Review of Point-of-Care documentation for March showed multiple day, evening, and night shifts with no documented bladder incontinence care for the resident. The care plan identified a problem that the resident required assistance for toileting related to a recent cerebrovascular accident. The DON stated that staff were expected to check residents for incontinence every two hours, and both the staffing coordinator and DON acknowledged awareness of the state’s minimum direct care staffing ratio of 1 CNA to 8 residents on day shift. Facility policy on urinary incontinence required staff to provide scheduled toileting, prompted voiding, or other interventions based on assessment, but the observations and documentation review showed that such care was not consistently provided to this resident.
LPNs Performed Initial Assessments and Initiated Care Plans Without RN Oversight
Penalty
Summary
The deficiency involves the facility’s failure to ensure that LPN staff practiced within their professional scope of practice as defined by the New Jersey Nurse Practice Act and facility job descriptions. Surveyors determined that LPNs were independently conducting initial nursing assessments and initiating baseline care plans for newly admitted residents without RN coordination or oversight. The New Jersey statutes cited in the report distinguish RN practice, which includes diagnosing and treating human responses and formulating plans of care, from LPN practice, which is limited to providing supportive and restorative care and reinforcing teaching under the direction of an RN or physician. For Resident #36, who was observed with an IV infusion in place, record review showed that the Admission/readmission Evaluation dated 02/28/2026 was completed by an LPN. The resident’s EMR documented diagnoses including encounter for other orthopedic aftercare, osteomyelitis of the lumbar vertebra, and MSSA infection, with a physician’s order for continuous IV oxacillin 12 g in 500 mL normal saline at 21 mL/hour over 24 hours via a right internal jugular central line. The care plan contained a focus for a right internal jugular central line secondary to infection/antibiotic therapy and a focus for IV antibiotic therapy via the right internal jugular line related to MSSA epidural abscess, both initiated and created on 02/28/2026 by an LPN. Interviews with staff confirmed that LPNs routinely performed initial assessments and initiated care plans for new admissions. One LPN unit manager stated that after completing the admission assessment, she verified medications with the prescriber, reviewed hospital records, and initiated care plans, and that other LPNs also performed initial assessments and started care plans, including head-to-toe assessments. Another LPN unit manager reported that she and other nurses, including LPNs, completed the Admission/readmission Evaluation and Baseline Care Plan, and she was unsure whether a designated RN oversaw this work, only assuming the DON reviewed them. The DON acknowledged that LPNs perform initial resident evaluations and initiate baseline care plans, explaining that they were directed to do so, despite facility job descriptions indicating that LPNs provide care under RN supervision and implement, rather than independently formulate, plans of care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Prescribed Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by not adhering to the prescribed use of bilateral floor mats. The deficiency was identified for one resident who had a history of falls prior to admission. The resident's comprehensive Minimum Data Set indicated a fall risk, and the care plan included an intervention for bilateral mats next to the bed for safety. However, during multiple observations by the surveyor, it was noted that only one mat was consistently placed on the floor, while the other was folded and placed against the wall, contrary to the prescribed safety measures. Interviews with the resident and the Director of Nursing (DON) revealed that the resident had experienced multiple falls at home before admission, and the DON acknowledged the improper placement of the mats. The facility's policy on managing falls and fall risk emphasized implementing a resident-centered fall prevention plan, but the failure to use the bilateral mats as ordered demonstrated a lapse in following this policy. The resident's diagnosis included repeated falls, highlighting the importance of adhering to the prescribed safety interventions.
Controlled Drug Recordkeeping Deficiency
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs, as evidenced by discrepancies found during a surveyor's inspection of medication carts. On the second floor, a medication cart labeled the high side cart was inspected, revealing a discrepancy in the count of Xanax 5mg tablets. The blister pack contained 8 tablets, while the Controlled Drug Sheet (CDS) documented 9 remaining. The Licensed Practical Nurse (LPN) present admitted to forgetting to sign out the medication after administration. Similarly, on the first floor, another medication cart labeled low side cart 2 was inspected, showing a discrepancy in the count of Oxycontin 60mg tablets. The blister pack contained 38 tablets, but the CDS documented 39 remaining. The LPN responsible acknowledged that she thought she had signed the CDS after administering the medication. The Director of Nursing confirmed that narcotics should be signed out in the CDS upon administration to maintain accurate records, as per the facility's policy on controlled substances.
Failure to Use Appropriate Infection Control Practices During Wound Care
Penalty
Summary
The facility staff failed to adhere to appropriate infection control practices by not wearing a gown during wound care for a resident with a pressure ulcer on the left hip. The resident was receiving Santyl External Ointment for the wound, and the physician's orders specified the use of enhanced barrier precautions, including wearing gloves and a gown for high-contact activities such as wound care. Despite an orange sign on the resident's door indicating the need for enhanced barrier precautions, the registered nurse (RN) providing care did not wear a gown during the procedure. The infection preventionist confirmed that the resident had been on enhanced barrier precautions since August 2024 due to the presence of a central line and the wound. The facility's policy on enhanced barrier precautions, dated April 2024, indicated that these precautions are necessary for residents with wounds or indwelling medical devices. The RN acknowledged missing the sign and not wearing a gown, and the infection preventionist confirmed that a gown should have been worn during the wound care.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Barnegat
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manahawkin Health And Rehabilitation Center | 4.1 mi | ★★★★★ | 13 | 3 |
| Southern Ocean Center | 4.1 mi | ★★★★★ | 13 | 0 |
| Crystal Lake Healthcare And Rehabilitation | 9.8 mi | — | 1 | 0 |
| Tallwoods Care Center | 10.2 mi | ★★★★★ | 17 | 0 |
| Mystic Meadows Rehabilitation And Nursing Center | 11 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.