Inspection Reports for
Big Oak Rehabilitation And Healthcare Center
849 Big Oak Road, Pittsgrove, NJ, 08318
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
84 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, including how their medical information may be used and disclosed, and their rights related to this 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 the department's legal duties and responsibilities regarding privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ00184848, NJ00184907, and NJ184927 during the survey dates of 04/23/2025 and 04/24/2025.
Complaint Details
Complaint numbers NJ00184848, NJ00184907, and NJ184927 were investigated. The facility was found compliant overall, but the nurse staffing deficiency was noted. No residents were negatively affected by the deficient practice as there was always oversight by an RN in the facility.
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. However, a deficiency was identified related to mandatory nurse staffing where the facility failed to ensure a Registered Nurse worked 7 days a week for at least 8 consecutive hours for 8 days over 3 weeks reviewed.
Deficiencies (1)
Failure to ensure a Registered Nurse worked 7 days a week for at least 8 consecutive hours for 8 days of the 3 weeks reviewed.
Report Facts
Census: 84
Sample Size: 5
Days without RN staffing: 8
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 13
Date: Sep 7, 2023
Visit Reason
Complaint investigations were conducted related to multiple complaint numbers. The facility was surveyed for compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
Complaint investigations were conducted for complaint numbers NJ 160885, NJ 160875, NJ 161663, NJ 163965, NJ 164120, NJ 164276, NJ 165154, NJ 165680, NJ 166441.
Findings
The facility was found not in substantial compliance with requirements. Deficiencies were cited related to reasonable accommodations for residents, baseline care plans, accident hazards and supervision, respiratory care, dialysis medication scheduling, drug regimen review, infection prevention and control, staffing ratios, employee health records, and life safety code violations including egress doors, sprinkler system installation, and portable fire extinguishers.
Deficiencies (13)
Facility failed to ensure residents' call devices were within reach, affecting 2 of 5 residents.
Facility failed to develop and implement baseline care plans within 48 hours of admission for residents.
Facility failed to follow policies for investigating and reporting accidents and failed to ensure adequate supervision and interventions for residents at risk of accidents.
Facility failed to follow professional standards by providing respiratory care equipment without physician's order for 1 of 3 residents reviewed.
Facility failed to ensure medication administration times were adjusted to accommodate resident dialysis schedules for 1 of 1 resident reviewed.
Facility failed to address consultant pharmacist recommendations in a timely manner for 4 of 5 residents reviewed for unnecessary medications.
Facility failed to use appropriate precautions to disinfect and store respiratory equipment to prevent infection risk for 3 residents reviewed.
Facility failed to maintain required minimum direct care staff to resident ratios as mandated by New Jersey for multiple weeks in 2023.
Facility failed to ensure new employees completed health history and physical examination within required timeframe for 6 of 10 employees reviewed.
Facility failed to ensure new employees received Mantoux tuberculin skin test upon hire for 8 of 10 employees reviewed.
Facility failed to provide two of ten designated exit discharge doors in the means of egress readily accessible and free of obstructions or impediments.
Facility failed to properly install sprinklers and failed to provide fire sprinkler coverage to all areas of the facility.
Facility failed to perform monthly examination for 3 of 20 portable fire extinguishers as required by NFPA standards.
Report Facts
Census: 73
Deficient CNA staffing days: 10
Deficient CNA staffing days: 4
Deficient CNA staffing days: 12
Number of portable fire extinguishers inspected: 20
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Date: Jul 28, 2023
Visit Reason
The inspection was conducted based on complaint NJ165382 to investigate concerns related to pharmacy services, medication administration, infection prevention and control, and staffing ratios at Eagleview Health & Rehabilitation.
Complaint Details
Complaint NJ165382 was substantiated. The facility was not in substantial compliance with 42 CFR Part 483, Subpart B, based on the complaint visit. Deficiencies were identified related to pharmacy services, medication administration, infection prevention and control, and staffing ratios.
Findings
The facility was found not in substantial compliance with federal and state regulations due to deficiencies in pharmacy services, medication administration practices, infection prevention and control, and staffing ratios. Deficient practices were identified for specific residents and corrective actions were initiated by the facility.
Deficiencies (3)
Failure to maintain professional standards of practice in medication administration, including not following cautionary instructions for a medication administered to Resident #5.
Failure to establish and maintain an infection prevention and control program, including failure to maintain infection control practices when administering insulin and failure to follow facility policy titled 'Insulin Administration.'
Failure to ensure staffing ratios met the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 15 of 28 day shifts.
Report Facts
Census: 70
Sample Size: 10
Staffing Deficiency Counts: 11
Staffing Deficiency Counts: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed administering medications to Resident #5 and involved in deficient medication administration practice |
| LPN #1 | Licensed Practical Nurse | Observed administering medications to Resident #4 and involved in deficient infection control practice |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication administration and infection control practices; provided in-service training |
| LPN/IP | Licensed Practical Nurse/Infection Preventionist | Provided interview statements regarding infection control practices and medication administration |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: May 22, 2023
Visit Reason
The inspection was conducted based on complaint NJ00163657 regarding failure to maintain adequate supervision and transcription of physician orders related to resident safety and care plans.
Complaint Details
Complaint NJ00163657 was substantiated. The facility failed to transcribe physician orders and implement care plan interventions for two residents, and failed to maintain minimum staffing ratios on 15 of 28 day shifts.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to transcribe physician orders and implement care plan interventions for two residents, and failure to maintain required staffing ratios on multiple day shifts.
Deficiencies (2)
Failure to transcribe physician orders and implement care plan interventions for residents, resulting in inadequate supervision and accident hazards.
Failure to maintain required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on multiple day shifts.
Report Facts
Census: 64
Sample size: 3
Day shifts with staffing deficiency: 15
CNA staffing shortfalls: 8
CNA staffing shortfalls: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding resident care and physician order documentation |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding resident care and physician order documentation |
| Director of Nursing | DON | Provided information on resident care, order transcription, and staffing |
| License Nursing Home Administrator | LNHA | Present during follow-up interviews and involved in staffing discussions |
| Vice President of Clinical | Present during follow-up interviews | |
| Senior Director of Plant Operations | Present during follow-up interviews | |
| Regional Director of Operations | RDO | Provided information on EMR transition and staffing |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
The inspection was conducted in response to complaint NJ160931 to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint NJ160931 was substantiated with findings that the facility failed to meet required staffing ratios on multiple shifts, affecting all residents potentially.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements, failing to meet minimum staff-to-resident ratios for 14 of 14 day shifts and 11 of 14 evening shifts. The facility was deficient in CNA staffing for 5 of 14 day shifts.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey.
Report Facts
Sample size: 71
Day shifts deficient: 14
Evening shifts deficient: 11
CNA staffing deficiency days: 5
Residents on 01/22/2023: 77
CNA staff on 01/22/2023: 8
Required CNA staff on 01/22/2023: 10
Residents on 01/23/2023: 77
CNA staff on 01/23/2023: 6
Required CNA staff on 01/23/2023: 10
Residents on 01/29/2023: 75
CNA staff on 01/29/2023: 7
Required CNA staff on 01/29/2023: 9
Residents on 01/31/2023: 75
CNA staff on 01/31/2023: 8
Required CNA staff on 01/31/2023: 9
Residents on 02/03/2023: 75
CNA staff on 02/03/2023: 8
Required CNA staff on 02/03/2023: 9
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 2
Date: Jul 2, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to meet staffing ratios for 17 of 42 shifts, and failure to maintain two dryers free from lint, posing potential risk to residents.
Deficiencies (2)
Facility failed to ensure staffing ratios were met for 17 of 42 shifts, violating New Jersey minimum staffing requirements.
Facility failed to maintain 2 of 2 dryers completely free from lint, creating a fire hazard.
Report Facts
Census: 63
Shifts with staffing ratio deficiencies: 17
Staffing ratios posted: 9
Staffing ratios posted: 11.1
Staffing ratios posted: 12.6
Staffing ratios posted: 21
Lint accumulation thickness: 0.125
Preventive maintenance cleaning frequency: 5
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Date: May 27, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145511 and NJ143208 regarding failure to notify responsible parties and physicians of residents' changes in condition.
Complaint Details
Complaint Intake #NJ143208 identified failure to notify the responsible party and attending physician of Resident #1's change in condition, including initiation and increase of treatment. The deficiency affected 1 of 3 residents reviewed.
Findings
The facility was found not in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities due to failure to notify the responsible party and attending physician of a resident's significant change in condition, affecting 1 of 3 residents reviewed. The facility lacked documentation of notification regarding changes in treatment and condition for Resident #1.
Deficiencies (1)
Failure to notify the responsible party and attending physician of a resident's change in condition, including use of new treatments and increased care needs.
Report Facts
Census: 64
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding notification practices and documentation for Resident #1 |
| RN #1 | Registered Nurse | Documented Resident #1's condition and treatment changes |
| Director of Nurses (DON) | Director of Nursing | Interviewed and verified lack of documentation for family and physician notification |
Inspection Report
Routine
Census: 57
Deficiencies: 0
Date: Jan 29, 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 and recommended practices for 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.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ139972 and NJ140025.
Complaint Details
Complaint #: NJ139972 and NJ140025. The facility was found compliant based on this complaint survey.
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.
Report Facts
Sample Size: 5
Inspection Report
Abbreviated Survey
Census: 13
Deficiencies: 1
Date: Jan 6, 2021
Visit Reason
The inspection was a COVID-19 focused infection control survey conducted to assess the facility's compliance with emergency back-up supply requirements for personal protective equipment (PPE) as mandated by the New Jersey Department of Health Executive Directive 20-026.
Findings
The facility failed to maintain a two-month emergency back-up supply of PPE, specifically gowns, and did not calculate PPE par levels based on the highest use during a COVID-19 surge. The facility had only 800 gowns in stock, sufficient for approximately 10 days, which is inadequate for the required two-month supply. PPE inventory logs and accountability were lacking, and the facility had not updated burn rate calculations since early in the pandemic.
Deficiencies (1)
Failure to ensure a two-month emergency back-up supply of personal protective equipment (PPE) and failure to identify a par level for PPE using a burn rate based on highest use during COVID-19 surge.
Report Facts
Residents on transmission-based precautions: 13
Gowns in stock: 800
Gown burn rate per day: 78
Days supply of gowns: 10.25
Gown orders: 10
Gown orders: 500
Gown orders: 40
Gown orders: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Interviewed regarding PPE supply, burn rate calculation, and inventory accountability. |
| Assistant Director of Nursing/Infection Preventionist | ADON/IP | Interviewed regarding PPE supply and inventory. |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding facility operation and PPE supply. |
| Director of Environmental Services | DES | Responsible for PPE inventory count and stock. |
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