Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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.
A cook repeatedly handled trash, raw fish, spices, and kitchen equipment with the same gloves and at times with bare hands without washing hands or changing gloves between tasks. The cook discarded items in the trash, touched the faucet and bin lids, and continued preparing raw fish and tilapia while using the same gloves. The IP and FSD stated staff must wash hands before and after glove use and change gloves after each task, and facility policy required hand hygiene and food prep practices that avoid contamination.
Failure to Follow EBP During Resident Care: A CNA entered a room with an EBP sign and performed multiple tasks using bare hands without gloves or a gown, including handling linens, touching a bedside table, bagging clothing, and changing trash. In a separate observation, an LPN provided wound care to a resident with a chronic wound and MDRO history without wearing a gown, despite the room’s EBP signage and PPE availability.
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.
A resident self-administered prescribed eye drops without an assessment, IDT determination, physician order, or care plan intervention. During med pass, the resident told an LPN they kept the drops in their drawer and gave them to themselves, and the LPN confirmed this. Record review showed diagnoses including alcohol abuse with withdrawal delirium, ADHD, and PTSD, but no authorization for self-administration, no care plan intervention, and no completed Medication Self-Administration Safety Screen. The LPN Unit Manager and DON both stated that self-medication required assessment, IDT review, and a physician order.
Survey Binder Missing Life Safety Code Deficiencies: The facility failed to ensure that the most recent survey results were readily accessible to residents and the public. During a lobby tour, the surveyor observed the State Survey Binder but did not find any Life Safety Code CMS-2567s from prior surveys, and the LNHA later acknowledged the issue before stating the document was now included in the binder.
A resident with generalized anxiety disorder and unspecified dementia was observed walking the halls and speaking incoherently to themselves. The resident had a BIMS score of 1/15, and an order for Lorazepam PRN for anxiety was written for 90 days without documented clinical rationale in the EMR. The DON stated the physician’s assessment should indicate the need for the extended duration, and the facility policy limited PRN psychotropic orders to 14 days unless the prescriber documented the reason for extension.
An MDS assessment was completed using only an LPN’s admission evaluation, without RN clinical verification before the RN signed the MDS. A resident with a central venous access device, sutures still present at the site, and diagnoses including osteomyelitis and MSSA infection was receiving IV oxacillin for an epidural abscess. The MDS Coordinator RN stated she used the LPN’s assessment for the MDS, and the DON said the RN could sign based on that initial assessment.
A resident with dementia, bipolar disorder, a history of falls, and severely impaired cognition had multiple documented falls, but the EMR showed no RN assessments for those events. The fall-risk care plan was initiated and managed by LPNs, was not updated to reflect the repeated falls, and the DON stated that LPN unit managers formulated the fall care plans and interventions.
Failure to maintain right hand ROM with ordered splint use: A resident with a right hand contracture was observed with flexed fingers and little movement, and no splint was seen during multiple observations. The EMR showed an active order for a resting hand splint up to 8 hours daily as tolerated, but the TAR and notes did not consistently reflect refusals, the care plan had not been updated since 2024, and OT discharge instructions said to remain consistent with the splint schedule. An LPN stated the resident had refused the splint and later said she did not realize it was not being done.
A resident with dementia, Alzheimer's disease, and a history of elopement had a wander guard in place, but after hospital readmission the orders were not fully reinstated and monitoring was inconsistent. The chart showed an order for placement checks, but no order for function checks, and the resident was omitted from the March checklist with no documentation of placement or function checks. The LPNUM acknowledged the orders were not reinstated after readmission, and the DON stated that wander guards require orders for both placement and function checks.
A resident with an indwelling catheter and diagnoses including UTI and urinary retention was observed with the drainage bag in direct contact with the floor while seated in a wheelchair. The resident also had an order for urine output and infection monitoring every shift, but the TAR contained multiple blank entries for urine output documentation over several months. The DON acknowledged that absent urine output could indicate a health concern, and the facility policy required catheter tubing and drainage bags to be kept off the floor.
A resident with CHF, dementia, and hospice care had a nasal cannula and nebulizer mask left exposed to air instead of being stored in a bag. Surveyors also found no physician order for oxygen, and the UM and DON both confirmed that oxygen requires an order and is treated as a medication.
A resident with ESRD and a prescribed 1000 mL fluid restriction did not have corresponding MAR monitoring orders after readmission, and intake was not documented as required. Surveyors observed the resident in bed with a cup nearby, while the ADON and an LPN Unit Manager confirmed the fluid restriction should have been tracked and signed off each shift in the MAR.
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.
Unsafe glove use and food handling during kitchen prep
Penalty
Summary
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. During observation in the kitchen, a cook wearing disposable latex gloves and a hair cover handled a trash bin, discarded items, touched the faucet handle, moved raw frozen fish fillets from blue boxes to a tray, and returned to food preparation without washing hands or changing gloves. The cook also handled a bottle of red jam, discarded it in the trash, replaced the lid with bare hands, put on new gloves without washing hands, and continued handling raw fish fillets and placing them in the oven while using the same gloves. The surveyor further observed the cook continue food preparation while wearing the same gloves, including taking spice bottles from the rack, mixing powdered spices with ground tilapia in a metal bowl, ladling the mixture into a deep pan, covering the pan with plastic wrap, handling liquid lemon and aluminum foil, and placing the tray in the oven. The cook also moved the trash bin to the dish machine area while holding raw fish fillets and the bin handles, discarded the fish and gloves in the trash, replaced the lid with bare hands, and put on another pair of gloves without washing hands. The Infection Preventionist stated that staff should always wash hands before wearing gloves and change gloves after each task, and the Food Service Director stated that dietary staff are expected to wash hands before and after using gloves and change gloves after every task. Facility policies stated that hand hygiene is the final step after removing PPE, gloves do not replace hand washing, and food preparation must avoid contamination by potentially harmful physical, biological, and chemical contamination.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to use appropriate infection control practices for residents on Enhanced Barrier Precautions (EBP). While touring the first floor, a surveyor observed a CNA inside a room with an EBP sign posted outside the door stating that staff must clean their hands and wear gloves and a gown for high-contact resident care activities. The CNA was not wearing a gown or gloves and was observed using bare hands to pick up linens from the floor, placing them in a clear plastic bag, touching the resident bedside table with bare hands, bagging clothing by reaching in and out of the nightstand drawers, and changing the trash bag on the resident’s side of the room. The CNA later stated she was only asking the residents if they wanted showers and denied providing care or not wearing gloves. The Assistant DON stated that if staff are picking something up off the floor, they should have gloves to do so. Resident #10’s care plan identified EBP related to a history of ESBL U/A. The facility also failed to follow EBP during wound care for another resident. A surveyor observed an LPN provide wound care to a resident with an EBP sign on the door that directed staff to wear gloves and a gown for wound care. The LPN entered the room without a gown and did not wear one during the wound care procedure. After the observation, the LPN stated she should have worn a gown. The resident had diagnoses including staphylococcal arthritis of the left hip and had physician orders for EBP related to a wound, including daily and evening irrigation of the left distal hip wound with acetic acid, packing with silver alginate, and covering with a super absorbent dressing. The resident’s care plan also identified EBP related to a history of MDRO and a chronic wound, and the Infection Preventionist confirmed that a gown should have been worn during the wound care.
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.
Unapproved Self-Administration of Eye Drops
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medication without an assessment, interdisciplinary care team determination, physician order, or care plan intervention. During medication administration observation, the resident told the LPN that they had already given themselves their eye drops and stated that the drops were kept in their drawer and that they administered them independently. When asked, the LPN confirmed that the resident self-administered the eye drops. Record review showed the resident had diagnoses including Alcohol Abuse with Withdrawal Delirium, Attention Deficit Hyperactivity Disorder, and Post-Traumatic Stress Disorder. The physician’s order for Refresh Celluvisc Ophthalmic Gel 1% directed one drop in both eyes twice daily for dry eyes, but there was no order authorizing self-administration. The care plan contained no focus, goal, or intervention related to self-administration, and the EMR had no Medication Self-Administration Safety Screen completed before the observation. The LPN Unit Manager stated that self-medication required an assessment, an IDT meeting, and a physician order, and that no residents on the unit were approved to self-medicate. The DON also stated that residents may self-administer medications only after evaluation by therapy and the IDT, with a physician order and care plan intervention in place.
Survey Binder Missing Life Safety Code Deficiencies
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were readily accessible to residents and the public. During an initial tour of the lobby, the surveyor observed the State Survey Binder but did not find any Life Safety Code Statement of Deficiencies (CMS-2567) from previous surveys within the binder. When asked about the absence of the Life Safety Code Statements of Deficiencies, the LNHA replied, "I will check." On a later interview, the LNHA stated that the Life Safety Code Statement of Deficiencies was now included in the Survey Binder.
Unnecessary Psychotropic Medication Order Lacked Documented Rationale
Penalty
Summary
A deficiency was identified for failure to ensure a resident’s medication regimen was free from unnecessary psychotropic medications. During observation, Resident #41 was seen walking the facility halls and speaking incoherently to themselves. Record review showed diagnoses including generalized anxiety disorder and unspecified dementia, and the MDS dated 03/11/2026 documented a BIMS score of 1 out of 15, indicating severely impaired cognition. The resident’s physician orders included Lorazepam oral concentrate 2 mg/mL, started 03/03/2026, with instructions to give 0.25 mL by mouth every 6 hours as needed for anxiety for 90 days, noted as hospice. Review of the EMR did not reveal documented rationale for the extended 90-day PRN order. During interview, the DON stated the physician’s assessment should indicate the need for the extended duration of use. The facility policy stated PRN psychotropic medication orders are limited to 14 days unless the prescriber documents the rationale for extending use and includes the duration.
Inaccurate MDS Assessment Based on LPN Admission Evaluation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate for one resident because the assessment was based solely on an initial admission/readmission evaluation completed by an LPN, without further RN clinical verification before the MDS was signed. The resident was observed with a subclavian access device identified as a central venous access device and stated there were still sutures underneath. The resident’s record showed diagnoses including encounter for other orthopedic aftercare, osteomyelitis of the lumbar vertebrae, and methicillin susceptible staphylococcus aureus infection. The physician’s orders included oxacillin sodium intravenous solution, 12 grams IV daily for MSSA epidural abscess through 03/29/2026, administered in normal saline over 24 hours. The admission/readmission evaluation in the electronic record was completed by an LPN, and the MDS section Z audit showed the MDS Coordinator RN’s signature verifying completion. During interview, the MDS Coordinator RN stated the LPN does the admission assessment and she uses that information for the MDS, and the DON stated the RN could sign based on an LPN initial assessment. The facility policy stated the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments.
RN Oversight Missing for Fall Assessments and Care Planning
Penalty
Summary
The facility failed to ensure that nursing assessments for falls were completed by an RN and that fall care plans were formulated and evaluated for effectiveness by an RN for Resident #10. The resident was admitted with diagnoses including dementia, history of falling, and bipolar disorder, and the most current quarterly MDS dated 1/16/2026 showed severely impaired cognition and multiple falls since admission. The surveyor reviewed the EMR and found nursing progress notes documenting falls on 5/29/2025, 7/27/2025, 8/2/2025, 8/21/2025, 11/1/2025, 12/3/2025, 12/9/2025, 1/9/2026, 1/17/2026, 1/26/2026, 2/4/2026, and 2/9/2026, with no documented RN assessments for those events. The resident’s ICCP included a fall-risk focus initiated by an LPN/UM on 5/23/2025, but the focus and goal were not updated to reflect the resident’s multiple falls. The fall interventions also did not include any RN involvement corresponding to the documented falls. During interviews, an LPN/UM stated that LPNs complete initial assessments and initiate care plans for newly admitted residents, another LPN/UM stated they did not think only RNs can assess new admissions and formulate care plans, and the DON stated that LPNs can assess falls and that the unit managers, who are both LPNs, formulate fall care plans and add goals and interventions after meeting as a team.
Failure to Maintain Right Hand ROM With Ordered Splint Use
Penalty
Summary
The facility failed to ensure that a resident with a documented right hand contracture received services to prevent further decreased ROM after therapy discharge. Resident #25 was admitted with diagnoses including contracture of the right hand, right foot drop, and dementia, and the most recent MDS reflected intact cognition. On observation, the resident’s right fingers were flexed with little movement, the right palm was dry under the nails, and no device for the right hand was seen in the room. The resident stated that staff do not put anything on the right hand, and the surveyor did not observe a right-hand splint during multiple observations in the room, dining room, hallway, and wheelchair. The EMR showed an active order for a right resting hand splint as tolerated every day and evening shift, to be worn up to 8 hours a day as tolerated, with documentation of tolerance and refusals. The March 2026 TAR showed the splint as administered on day shift on 3/26/2026 and 3/27/2026, but progress notes did not document refusal. The care plan for right hand splint use had not been updated since 2024, and OT discharge recommendations stated to remain consistent with the splint wearing schedule of 8 hours a day as tolerated. During interview, the primary nurse stated the resident had refused the splint and later said she did not realize it was not being done, while the DON stated that a check mark in the TAR meant the order was administered and refusals should be marked differently.
Incomplete Wander Guard Orders and Monitoring
Penalty
Summary
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 after readmission from the hospital. The resident had diagnoses including dementia, major depressive disorder, and Alzheimer's disease, and the care plan identified a risk for elopement with an intervention for the resident to wear a wander guard. During the initial tour, the resident was observed in bed with a wander guard on the right ankle. The physician order summary showed an order for the wander guard to the right ankle with checks for proper placement every shift, but there was no order to check the device for function. The prior MAR showed an earlier order for the wander guard to the left ankle with daily function checks. The EMR showed the resident had been sent to the hospital for seizure activity and later readmitted, and a progress note documented that the nurse practitioner instructed staff to continue the wander guard. However, the daily wander guard check book showed the resident was checked for placement throughout February 2026, and the resident was not listed on the March 2026 checklist, with no documentation of placement or function checks. The LPN Unit Manager stated the device is removed only when the resident is sent to the hospital and reapplied upon return, and acknowledged that the wander guard orders were not reinstated after readmission and that the resident should also have had an order to check function. The DON stated that residents with wander guards must have orders to check both placement and function.
Catheter Drainage Bag on Floor and Missing Urine Output Documentation
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling urinary catheter when the drainage bag was observed hanging below the wheelchair and in direct contact with the floor while the resident was seated in the dining room. During interview, a CNA stated that urinary drainage bags should be stored below the waist and should not touch the floor. The resident’s record showed diagnoses including urinary tract infection and retention of urine, and the quarterly MDS indicated the resident had an indwelling catheter. The resident also had a physician’s order to monitor urine output every shift and to monitor for signs and symptoms of infection every shift, along with a care plan focus for a suprapubic catheter related to obstructive uropathy. Review of the TAR showed multiple blank entries across December 2025 through March 2026 for the ordered urine output monitoring on various shifts. The DON stated that no urine output would indicate a health concern and that documenting urine output would indicate potential complications for residents with urinary catheters. The facility policy stated that catheter tubing and drainage bags should be kept off the floor.
Improper Storage of Respiratory Equipment and No Oxygen Order
Penalty
Summary
The facility failed to provide specialized respiratory care for Resident #12 by leaving a nasal cannula and nebulizer mask exposed to air rather than stored in a bag. During the initial tour, the surveyor observed the resident in the room with a nasal cannula resting on top of an oxygen concentrator and a nebulizer mask stored in the bedside table. A CNA stated that the oxygen tubing and nebulizer mask were not stored correctly and should be in a bag. Resident #12’s record showed diagnoses including chronic systolic congestive heart failure and dementia, and the order summary dated 3/26/2026 showed hospice care but no order for oxygen. When asked, the UM confirmed there was no oxygen order and stated that anything given to the resident must be based on a physician’s order. The DON also stated that oxygen should have a physician’s order and that oxygen is considered a medication and should be monitored and ordered by the physician.
Missing MAR Monitoring for Fluid-Restricted Resident
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis-related fluid restriction monitoring for a resident with End-Stage Renal Disease. Resident #2 had been admitted to the hospital for hyperpotassemia and then readmitted to the facility. On 03/27/2026, the surveyor observed the resident in bed with a cup on the bedside table, and the resident voiced no concerns at that time. A review of the record showed a prior 1000 mL fluid restriction order with shift-specific monitoring that had been discontinued on 03/16/2026. A new physician order dated 03/19/2026 specified a renal diet with a 1000 mL daily fluid restriction, but no corresponding monitoring order was entered into the MAR after the resident's readmission. The ADON stated the resident should have been monitored and that the monitoring should have been documented in the MAR, and the 2nd-floor LPN Unit Manager stated fluid restrictions must be documented on the MAR so staff can sign off each shift on the amount consumed. The facility policy titled Encouraging and Restricting Fluids directed staff to follow specific fluid intake instructions and record fluid intake in mLs.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 222 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 | ★★★★★ | 2 | 0 |
| Crystal Lake Healthcare And Rehabilitation | 9.8 mi | — | 25 | 1 |
| Tallwoods Care Center | 10.2 mi | ★★★★★ | 17 | 0 |
| Mystic Meadows Rehabilitation And Nursing Center | 11 mi | ★★★★★ | 24 | 0 |
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