Inspection Reports for
Big Oak Rehabilitation And Healthcare Center

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.

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.

Complaint #: NJ176956 regarding failure to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness.

The facility was found to have multiple sanitation issues including a dietary staff member placing food prep items in a designated handwashing sink, rust on metal shelving units in the walk-in refrigerator, buildup of black substance in the dish washing area, and chipped ceramic meal plates. Additionally, a resident's room was found to be in poor condition with soiled flooring, peeling paint, a rusty over bed table, and lack of personal effects, indicating failure to maintain a clean and homelike environment.

The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment, failure to report abuse allegations timely, failure to notify ombudsman of resident hospitalizations, incomplete care plans for anticoagulant use and hospice, lack of physician orders for blood glucose monitoring, improper medication storage, failure to provide adaptive dining equipment, poor kitchen sanitation, uncovered dumpsters with debris, missing attendance of the LNHA at a QAPI meeting, inadequate infection control practices including hand hygiene and lack of water management program for Legionella, inaccurate antibiotic stewardship documentation, incomplete immunization documentation and failure to offer updated vaccines, and unsafe medication storage room conditions.

The facility failed to ensure residents' call devices were within reach for 2 of 5 residents, and failed to follow policies for investigating and reporting accidents and incidents. Additionally, the facility did not ensure that residents with multiple falls had new or revised interventions to prevent subsequent falls or injuries. Several falls were documented without appropriate care plan updates or timely family notification.

The facility was found deficient in multiple areas including failure to ensure residents' call devices were within reach, failure to develop baseline care plans within 48 hours of admission, providing respiratory treatments without physician orders, failure to adjust medication times for dialysis patients, failure to address consultant pharmacist recommendations timely, and inadequate infection prevention and control practices related to respiratory equipment.

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.

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.

Complaint NJ165382 was substantiated with findings that the facility failed to maintain professional nursing standards and infection control practices during medication administration.

The facility failed to ensure proper medication administration practices, including not instructing a resident to rinse their mouth after steroid inhaler use and improper infection control during insulin administration. These deficiencies were identified through observations, interviews, and record reviews involving two residents and nursing staff.

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.

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.

Complaint NJ00163657 was substantiated based on interviews, medical record review, and facility document review conducted on 05/18/23 and 05/22/23, confirming failures in transcription and implementation of wander guard orders for two residents.

The facility failed to transcribe physician orders and implement care plan interventions for wander guards for Resident #1 and Resident #2, resulting in missing documentation of wander guard checks for placement, function, and skin integrity. The facility had recently transitioned to electronic medical records, which contributed to documentation gaps.

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.

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.

Complaint NJ160931 was substantiated with findings that the facility failed to meet required staffing ratios on multiple shifts, affecting all residents potentially.

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 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.

The facility failed to meet required staffing ratios for 17 of 42 shifts, with staff to resident ratios exceeding mandated limits on day, evening, and night shifts. Additionally, the facility failed to maintain two dryers free from lint accumulation, posing a potential safety hazard.

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.

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.

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.