Crystal Lake Healthcare And Rehabilitation
CRYSTAL LAKE HEALTHCARE AND REHABILITATION in BAYVILLE, NJ — inspection on April 29, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 4/3/25 revealed Staff reported she witnessed Resident #1 perform oral sex on Resident #2.
According to the facility's Summary of Investigation with an event date of 4/3/25 revealed under Summary, Staff knocked on the door and entered the room to complete her work assignment.
The staff member observed Resident #1 and #2 involved in a sexual act between each other.
The staff member exited the room and reported what she witnessed to the nurse.
The residents were immediately separated and placed on 1:1.
The residents expressed consent to their actions without anyone being taken advantage of by the other.
Abuse is unsubstantiated as both residents were consenting to their sexual action.
1.
According to the Admission Record (AR), Resident #1 was admitted to the facility in April 2021 with diagnoses which included but were not limited to: major depressive disorder, alcohol abuse, and toxic encephalopathy (a neurologic disorder caused by exposure to toxins).
According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 1/26/25, Resident #1 had a BIMS score of 3, which indicated the resident had severe cognitive impairment.
2.
According to the AR, Resident #2 was admitted to the facility in September 2020 with diagnoses which included but were not limited to: schizoaffective disorder (a mental health condition with hallucinations, delusions, and mood disorder symptoms), bipolar disorder, and major depressive disorder.
According to the Quarterly MDS, an assessment tool dated 2/21/25, Resident #2 had a BIMS score of 8, which indicated the resident's cognition was moderately impaired.
A review of Resident #2's care plan (CP) revealed under Focus, Resident #2 has an alteration in thought process related to cognitive loss associated with mental illness.
History of asking for pornography and fixating on females.
Under Interventions, Monitor for sexually inappropriate behaviors.
On 4/10/25 at 11:03 A.M., the surveyor interviewed the Licensed Practical Nurse (LPN#1), who stated that on 4/3/25 she was informed by the CSC that the HK walked into the room and witnessed both residents in a sexual act. LPN #1 stated she immediately reported the incident to the ADON and the LNHA. LPN #1 stated Resident #2 told me he had been involved with another guy before, but I never seen [sic] anything. LPN #1 further stated that even though both residents were able to make their own decisions, she did not know if they were able to have sex.
315125
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315125 B.
Wing 04/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721
According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 4/3/25 revealed Staff reported she witnessed Resident #1 perform oral sex on Resident #2.
315125
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315125 B.
Wing 04/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Lake Healthcare and Rehabilitation 395 Lakeside Blvd Bayville, NJ 08721