Inspection Reports for
Oakland Rehabilitation And Healthcare Center
20 Breakneck Road, Oakland, NJ, 07436
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
188% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
93% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, 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, circumstances under which health information may be used or disclosed, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Annual Inspection
Census: 199
Deficiencies: 30
Date: May 30, 2025
Visit Reason
A Recertification Survey was conducted at Oakland Rehabilitation & Healthcare Center from 5/22/25 through 5/30/25 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint NJ#172385 and NJ#177038 triggered the recertification survey. The complaint involved allegations of non-certified nursing aides providing independent resident care without required training and certification, inadequate staffing, privacy violations, medication errors, and infection control issues.
Findings
The survey identified multiple deficiencies including Immediate Jeopardy related to non-certified nursing aides providing independent resident care without required training and certification, failure to maintain adequate staffing ratios, privacy violations during resident care, failure to notify physicians of medication refusals, environmental cleanliness issues, inaccurate resident assessments, medication administration errors, and life safety code violations including improper door locks and missing smoke detectors.
Deficiencies (30)
Non-certified Nursing Assistant (NA#1) provided independent resident care without completing required training and certification, working past 120 days without certification, constituting Immediate Jeopardy.
Failure to maintain minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 25 of 28 day shifts and 1 of 7 overnight shifts.
Failure to ensure privacy and dignity for residents during care, including open doors and lack of privacy curtains during medication administration and personal care.
Failure to notify resident's physician of medication refusals for 1 resident.
Failure to maintain a safe, clean, and homelike environment including dirty vents, brownish ceiling discoloration, broken basins, and improperly stored meal trays.
Inaccurate Minimum Data Set (MDS) assessment for 1 resident, failing to reflect a fall with injury.
Failure to complete and monitor bowel and bladder patterning for 1 resident with incontinence.
Failure to follow physician's orders for nutritional supplements and weekly weights for 1 resident.
Insufficient nursing staff to provide timely and appropriate care for 1 resident, resulting in delayed incontinent care.
Failure to ensure non-certified nursing aides were enrolled in state-approved training and competency evaluation program and did not work past 120 days without certification.
Failure to maintain accurate and complete records of receipt of controlled substances on DEA 222 forms.
Failure to identify and act on medication regimen irregularities including sequencing of PRN medications and matching diagnosis for certain medications.
Failure to properly store medications; eight unidentified loose tablets/capsules found in medication cart.
Failure to implement facility policies and procedures related to hiring, training, and assignment of nurse aides, resulting in non-certified aides providing independent care.
Facility assessment failed to include non-certified nursing aides as part of staffing guidelines and contingency plans for staffing shortages.
Failure to maintain accurate and accessible resident assignment sheets for nursing staff.
Failure to follow appropriate infection control practices including use of enhanced barrier precautions and PPE for resident with wound and MDRO.
Resident call bell pull stations in shower rooms were not functioning properly.
Delayed egress locking devices on exit doors did not function properly and doors were equipped with thumb turn locks, violating life safety code.
Stairwell doors and smoke barrier doors were not equipped with positive latching hardware or self-closing devices as required.
Directional exit signage was missing in corridors where direction of travel to nearest exit was not apparent.
Hazardous areas such as clean linen rooms, storage rooms, laundry folding room, and soiled linen rooms were not equipped with self-closing or positive latching doors as required.
Smoke detection was not provided in open spaces adjacent to corridors including family room and vending area, and in elevator machine rooms.
Sprinkler system was missing coverage in data room, storage closet, and had missing sprinkler cover in rehab gym restroom; expired gauge on antifreeze loop.
Elevators were not inspected and tested in accordance with regulatory requirements; smoke detectors missing in elevator machine rooms.
Fire door assemblies were not inspected and tested annually as required by NFPA 80.
Emergency generator lead acid battery monthly testing of electrolyte specific gravity was not conducted.
Newly hired employee did not complete required physical examination within two weeks prior to employment.
Newly hired employee did not complete required two-step Mantoux tuberculin skin test upon hire.
Facility failed to analyze and document emergency preparedness drill responses and revise emergency plan accordingly.
Report Facts
Census: 199
Sample Size: 35
Deficiency cited day shifts: 25
Deficiency cited overnight shifts: 1
Non-certified NA shifts worked: 68
Nursing Assistant to Resident ratio required: 8
Nursing Assistant to Resident ratio observed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA#1 | Nursing Assistant in Training | Named in Immediate Jeopardy finding for working independently without certification |
| NA#2 | Nursing Assistant in Training | Named in finding for working without passing written CNA test or receiving CNA license |
| RN #1 | Registered Nurse | Interviewed about medication administration and documentation |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication administration and drug interaction awareness |
| Staff #1 | Life Enrichment Staff | Named in finding for delayed physical examination after hire |
| Staff Development Coordinator/Educator | Interviewed about new hire physicals and nurse aide training | |
| Licensed Nursing Home Administrator | Interviewed about nurse aide hiring and training policies | |
| Regional Director of Clinical Services | Interviewed about nurse aide hiring and training policies | |
| Regional Director of Operations | Interviewed about nurse aide hiring and training policies | |
| Maintenance Director | Named in findings related to fire safety, sprinkler system, smoke detectors, and emergency generator maintenance |
Inspection Report
Routine
Census: 199
Deficiencies: 17
Date: May 30, 2025
Visit Reason
Routine state inspection of Oakland Rehabilitation and Healthcare Center to assess compliance with healthcare regulations including resident care, medication management, staffing, environment, and infection control.
Complaint Details
Complaint #172385 regarding failure to maintain accurate and accessible medical records.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, failure to notify physicians of condition changes, unsafe and unclean environment, inaccurate resident assessments, inadequate bladder and bowel care, failure to monitor nutrition and weights, insufficient nursing staff, untrained nursing aides working independently, incomplete medication documentation, improper medication storage, failure of consultant pharmacist to identify medication irregularities, failure to follow medication parameters, failure to follow infection control precautions, incomplete medical records, and non-functioning call bell systems.
Deficiencies (17)
Failure to treat residents with dignity and respect by not providing privacy during medication administration.
Failure to notify resident's physician of change in condition for a resident refusing medication.
Failure to provide a safe, clean, and homelike environment including dusty vents, broken basins, and unclean areas.
Failure to accurately reflect resident status in Minimum Data Set (MDS) assessment.
Failure to ensure bladder patterning was completed and monitored according to resident's assessment and facility policy.
Failure to ensure adequate nutrition monitoring and weight documentation for a resident at risk for nutritional problems.
Failure to provide sufficient nursing staff to meet residents' needs and timely incontinence care.
Failure to ensure nursing aides were trained and certified prior to independent resident care assignments.
Failure to provide pharmaceutical services ensuring accurate documentation of receipt of controlled substances.
Consultant pharmacist failed to identify medication irregularities during medication regimen review for multiple residents.
Failure to follow physician's order for medication with parameters and failure to document vital signs prior to administration.
Failure to properly store medications; unidentified loose pills found in medication cart.
Failure of Licensed Nursing Home Administrator to ensure staff compliance with policies regarding nursing aide training and certification.
Facility-wide assessment failed to include non-certified nursing aides in staffing guidelines and contingency plans.
Failure to maintain accurate and accessible medical records; missing CNA assignment sheets for requested dates and shifts.
Failure to follow infection prevention and control practices; hospice aide failed to wear gown when required by Enhanced Barrier Precautions.
Failure to ensure working call bell system in resident shower and bathing areas; multiple call bell pull stations not functioning.
Report Facts
Residents affected: 38
Residents affected: 199
Nursing Aides: 3
Nursing Aide shifts worked without certification: 68
Call bell pull stations not functioning: 4
Residents affected: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA#1 | Nursing Assistant in Training | Worked independently without certification and completed training late |
| NA#2 | Nursing Assistant in Training | Worked without CNA license and failed written test |
| LNHA | Licensed Nursing Home Administrator | Failed to ensure proper hiring and training of nursing aides |
| DON | Director of Nursing | Responsible for nursing staff oversight and medication management |
| CP | Consultant Pharmacist | Failed to identify medication irregularities during medication regimen review |
| LPN#1 | Licensed Practical Nurse | Interviewed about medication administration parameters |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Interviewed about Enhanced Barrier Precautions and staffing |
| Hospice CNA | Certified Nursing Aide | Failed to follow Enhanced Barrier Precautions by not wearing gown |
| MD | Maintenance Director | Tested call bell pull stations and identified non-functioning devices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2025
Visit Reason
The inspection was conducted based on Complaint #172385 regarding the facility's failure to maintain accurate and easily accessible medical records.
Complaint Details
Complaint #172385 was investigated and substantiated by observations, interviews, and record reviews showing incomplete and inaccessible CNA assignment sheets for requested dates.
Findings
The facility failed to provide complete Certified Nurse Assistant (CNA) unit assignment sheets for requested dates, with missing records for multiple units and shifts, indicating that medical records were not accessible as required.
Deficiencies (1)
Failure to maintain medical records that were accurate and easily accessible, specifically incomplete CNA assignment sheets for multiple units and shifts.
Report Facts
Dates of requested CNA assignment sheets: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Requested CNA assignment sheets during the survey | |
| Licensed Nursing Home Administrator (LNHA) | Provided incomplete CNA assignment sheets and confirmed missing records | |
| Regional Director of Operations (RDO) | Present during provision of CNA assignment sheets | |
| Regional Director of Clinical Services (RDoCS) | Present during provision of CNA assignment sheets |
Inspection Report
Complaint Investigation
Census: 194
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00185128.
Complaint Details
Complaint #: NJ00185128. The facility was found in substantial compliance based on this complaint visit.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Census: 194
Inspection Report
Complaint Investigation
Census: 200
Deficiencies: 4
Date: Jan 29, 2025
Visit Reason
A Complaint Survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers. The survey was conducted from 01/27/25 to 01/29/25 to investigate allegations of abuse, neglect, and failure to report injuries.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, and failure to report injuries timely. The facility failed to ensure residents were free from abuse and failed to report alleged violations within required timeframes. Staff education and Quality Assurance Performance Improvement plans were implemented.
Findings
The facility was found not in substantial compliance with requirements for long term care facilities. Deficiencies included failure to ensure residents were free from abuse, neglect, and exploitation, failure to report alleged violations timely, and failure to maintain adequate staffing ratios. Staff education and corrective actions were planned and implemented.
Deficiencies (4)
Failure to ensure five residents were free from abuse, neglect, and exploitation.
Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment within required timeframes.
Failure to have an effective antibiotic stewardship program.
Failure to ensure staffing ratios were met for 8 weeks of day shifts and overnight shifts.
Report Facts
Survey Census: 200
Sample Size: 32
Deficiency counts: 4
Staffing ratios deficient weeks: 8
Residents affected by staffing deficiency: 7
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 29, 2025
Visit Reason
The inspection was conducted due to allegations of abuse and failure to properly report and investigate suspected abuse incidents involving multiple residents at the facility.
Complaint Details
The complaint investigation focused on allegations of physical abuse involving residents R1, R5, R13, R14, and R32. The investigation found failures in abuse prevention, reporting, and investigation processes. The abuse was substantiated with findings of bruises and altercations among residents and staff. The facility failed to report some incidents timely to the State Survey Agency and did not suspend alleged perpetrators during investigations.
Findings
The facility failed to protect residents from physical abuse, failed to timely report suspected abuse to the State Survey Agency, and failed to conduct thorough investigations into abuse allegations. Additionally, the facility did not have an effective antibiotic stewardship program as the Infection Preventionist did not complete an infection screening evaluation for a resident treated for a urinary tract infection.
Deficiencies (4)
Failed to ensure five residents reviewed for abuse were free from physical abuse, increasing risk of further abuse.
Failed to timely report suspected abuse of two residents to the State Survey Agency.
Failed to respond appropriately and conduct thorough investigations into allegations of abuse for two residents.
Failed to implement an effective antibiotic stewardship program; infection screening evaluation was not completed for one resident treated for UTI.
Report Facts
Residents reviewed for abuse: 32
Residents with abuse issues identified: 5
BIMS score: 3
Bruise size: 17
Bruise size: 15
Bruise size: 2
Antibiotic dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN7 | Licensed Practical Nurse | Reported bruise on R1's left arm and performed skin and pain assessment |
| CNA9 | Certified Nurse Aide | Observed and reported bruise on R1's left arm; assigned to R1 during incident |
| LPN6 | Licensed Practical Nurse | Nurse on duty during R5's injury incident; confirmed typical behavior and lack of knowledge of injury cause |
| ADON | Assistant Director of Nursing | Involved in reporting and investigation of abuse allegations; confirmed failures in reporting and investigation |
| Administrator | Facility Administrator | Oversaw investigation and reporting processes; acknowledged failures and initiated Quality Assurance Performance Improvement plan |
| CNA10 | Certified Nurse Aide | Present in room during R5's injury incident; denied abuse |
| CNA13 | Certified Nurse Aide | Observed resident-to-resident abuse incident involving R12 slapping R13 |
| Infection Preventionist | Infection Preventionist | Failed to complete infection screening evaluation for resident R11 |
| Director of Nursing | Director of Nursing | Conducted wound audits; acknowledged missed infection screening evaluation for R11 |
| Regional Clinical Nurse | Regional Clinical Nurse | Confirmed Infection Preventionist's responsibility for antibiotic stewardship |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
A project survey was conducted for the construction of a new wall in an existing dining room at Oakland Healthcare and Rehabilitation Center.
Findings
The facility was found to be in compliance with N.J.A.C 8:39-31.1 and NFPA 101:2012 Edition with no deficiencies noted.
Inspection Report
Routine
Census: 173
Deficiencies: 0
Date: Dec 11, 2023
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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 9
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
The inspection was conducted as a standard annual survey of Oakland Rehabilitation and Healthcare Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 188
Capacity: 188
Deficiencies: 17
Date: Mar 3, 2023
Visit Reason
A recertification survey was conducted to assess compliance with federal regulations and state standards for nursing home operations.
Findings
The facility was found to be in substantial compliance overall but had multiple deficiencies including failure to promote dignified dining, failure to accommodate resident preferences, incomplete advance directive documentation, inadequate discharge planning and summaries, failure to follow care plans for fall prevention, medication regimen review deficiencies, improper medication administration technique, unsanitary food storage, infection preventionist training delay, and multiple life safety code violations.
Deficiencies (17)
Failed to promote a dignified dining experience when staff served meals to residents seated at overbed tables in the hallway.
Failed to ensure one resident had the right to reside and receive services with reasonable accommodation of needs and preferences, including inappropriate unit placement without consent.
Failed to complete documentation of residents' wishes for treatment in Practitioner Orders for Life-Sustaining Treatment (POLST) for three residents.
Failed to provide a discharge plan and develop a discharge care plan for one resident reviewed for discharge.
Failed to ensure one resident had a discharge recapitulation of stay, medication reconciliation, and discharge plan of care.
Failed to ensure staff followed care planned interventions to prevent falls for one resident, resulting in harm.
Failed to ensure attending physician acted upon pharmacist recommendations for unnecessary medications for one resident.
Failed to ensure proper injection technique for insulin administration for one resident.
Failed to ensure kitchen unit pantry refrigerators were maintained in a sanitary manner and food items were properly labeled and dated.
Failed to ensure infection preventionist completed specialized training in infection prevention before assuming the position.
Failed to ensure one exit discharge was provided with a hard packed, all-weather travel surface.
Failed to ensure four stairway exit doors had two-hour fire resistance ratings.
Failed to ensure spaces open to corridors had smoke detection systems in four areas on two floors.
Failed to ensure one storage room was protected with automatic sprinkler system.
Failed to ensure two elevators were equipped with emergency in-car key operation and smoke detection in machine room and lobby.
Failed to ensure ashtrays of noncombustible material with safe design and metal containers with self-closing cover devices were provided and readily available in smoking areas.
Failed to meet minimum certified nursing assistant staffing ratios on 14 of 14 day shifts for two consecutive weeks.
Report Facts
Survey Census: 188
Sample Size: 35
Deficiency Count: 16
CNA Staffing Deficit: 5
Resident Census: 180
Resident Census: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication administration technique deficiency |
| RN2 | Registered Nurse Unit Manager | Named in medication administration technique deficiency |
| Director of Nursing | Director of Nursing | Named in multiple findings including medication review and infection preventionist training |
| Consultant Pharmacist | Pharmacist | Named in medication regimen review deficiency |
| Maintenance Director | Maintenance Director | Named in multiple life safety code deficiencies |
| Regional Director of Plant Operations | Regional Director | Named in multiple life safety code deficiencies |
| Administrator | Facility Administrator | Named in food safety and smoking area deficiencies |
| Director of Social Services | Social Services Director | Named in advance directive and discharge planning deficiencies |
| Licensed Practical Nurse 4 | Unit Manager | Named in fall prevention deficiency |
| CNA1 | Certified Nursing Assistant | Named in fall prevention deficiency |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 3, 2023
Visit Reason
The inspection was a routine regulatory visit to assess compliance with healthcare facility regulations, including resident rights, care planning, medication management, infection control, and facility sanitation.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, inadequate accommodation of resident preferences, incomplete advance directive documentation, lack of discharge planning, failure to follow fall prevention care plans resulting in resident injury, failure to act on pharmacist medication recommendations, improper insulin injection technique, unsanitary kitchen conditions, and incomplete infection preventionist training.
Deficiencies (10)
Failed to promote a dignified dining experience when staff served meals to residents seated at overbed tables in the hallway for 15 of 55 residents on Unit 2E.
Failed to reasonably accommodate the needs and preferences of one resident readmitted to a locked dementia care unit against her wishes.
Failed to complete documentation of residents' wishes for treatment in Practitioner Orders for Life-Sustaining Treatment (POLST) for three residents.
Failed to provide a discharge plan and develop a discharge care plan for one resident reviewed for discharge.
Failed to ensure discharge summary, medication reconciliation, and discharge plan of care for one resident reviewed for closed records.
Failed to follow care planned interventions to prevent falls for one resident resulting in a right femur fracture after a fall from being turned in bed without assistance.
Failed to ensure attending physician acted upon pharmacist recommendations to discontinue duplicate calcium channel blockers for one resident.
Failed to ensure proper insulin injection technique was used for one resident, including priming the pen and holding needle in site for 10 seconds.
Failed to maintain kitchen in a sanitary manner; unit pantry refrigerators contained unlabeled food items and had grime and food residue inside.
Failed to ensure designated Infection Preventionist completed specialized infection prevention training before assuming the position.
Report Facts
Residents affected: 15
Residents affected: 35
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | Nurse Manager of Unit 2E | Confirmed meals served in hallway due to staffing |
| Director of Nursing | DON | Discussed resident placement and pharmacy recommendation process |
| Licensed Practical Nurse 3 | LPN | Admitted resident and commented on unit suitability |
| Registered Nurse Unit Manager | RN Unit Manager | Commented on resident behavior and unit appropriateness |
| Social Services Director | SSD | Discussed discharge planning and POLST documentation |
| Consultant Pharmacist | Recommended discontinuation of duplicate medications | |
| Licensed Practical Nurse 1 | LPN | Administered insulin pen without proper technique |
| Director of Nurse Education | Confirmed lack of insulin pen administration training | |
| Registered Nurse 2 | RN Unit Manager | Discussed insulin pen administration procedure |
| Certified Nursing Assistant 1 | CNA | Turned resident resulting in fall without assistance |
Inspection Report
Original Licensing
Census: 53
Deficiencies: 0
Date: Jan 20, 2023
Visit Reason
State Licensure Certification survey for a Dementia/Alzheimer's Unit at Oakland Rehabilitation and Healthcare Center.
Findings
The facility was found to be in compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically for Alzheimer's/Dementia programs. The facility is not authorized to advertise the certified dementia unit until final licensing approval is granted.
Inspection Report
Complaint Investigation
Census: 190
Deficiencies: 0
Date: Aug 31, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00147379, NJ00148303, NJ00150712, NJ00150920, and NJ00156573.
Complaint Details
The survey was complaint-driven with multiple complaint numbers listed. The facility was found compliant, indicating no substantiated deficiencies.
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: 6
Inspection Report
Abbreviated Survey
Census: 175
Deficiencies: 0
Date: Nov 4, 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 has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 174
Deficiencies: 0
Date: Jul 26, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Deficiencies: 1
Date: Mar 26, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with maintaining complete and readily accessible medical records, specifically regarding hospice care documentation for Resident #116.
Findings
The facility failed to maintain complete hospice nurse visit notes in the resident's medical records from October 30, 2020, through March 2021. Despite multiple attempts to locate the notes, including discussions with hospice staff and facility personnel, the weekly hospice visit notes were missing, indicating a deficiency in medical record keeping.
Deficiencies (1)
Failure to maintain complete and readily accessible medical records, specifically missing hospice nurse visit notes for Resident #116 from October 30, 2020, through March 2021.
Report Facts
Residents reviewed: 32
Hospice nurse visit notes missing timeframe: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Informed surveyor about resident condition and hospice visit notes | |
| Director of Nursing (DON) | Confirmed expectation of weekly hospice visit notes and followed up with hospice company | |
| Director of Risk Management | Present during discussion about missing hospice notes | |
| Licensed Nursing Home Administrator (LNHA) | Met with surveyors regarding concerns about missing hospice notes | |
| Regional Nurse | Discussed concerns and facility policies regarding hospice notes | |
| Regional Director of Operations (RDO) | Participated in discussion about missing hospice notes | |
| Hospice Liaison (HL) | Removed some documents from hospice binder and communicated about missing notes |
Inspection Report
Annual Inspection
Census: 160
Deficiencies: 1
Date: Mar 26, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility failed to maintain complete and readily accessible medical records for 1 of 32 residents reviewed (Resident #116). Specifically, weekly nurse visit notes were missing from the resident's medical record, despite requirements and agreements to maintain complete documentation.
Deficiencies (1)
Failure to maintain complete and readily accessible medical records, specifically missing weekly nurse visit notes for Resident #116.
Report Facts
Residents reviewed: 32
Closed records: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager | LPN/UM | Informed surveyor about Resident #116 and missing nurse visit notes |
| Director of Nursing | DON | Confirmed missing nurse visit notes and followed up with Clinical Manager and medical record staff |
| Licensed Nursing Home Administrator | LNHA | Met with surveyors to discuss concerns about missing documentation |
| Regional Nurse | Discussed concerns about missing nurse visit notes and facility staff instructions | |
| Regional Director of Operations | RDO | Participated in discussion with surveyors about documentation concerns |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 26, 2021
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following a survey of Oakland Rehabilitation and Healthcare Center.
Findings
The facility is in substantial compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types and is in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Abbreviated Survey
Census: 163
Deficiencies: 2
Date: Dec 30, 2020
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 related to COVID-19.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene among staff in a Person Under Investigation (PUI) unit, increasing risk of COVID-19 transmission.
Deficiencies (2)
Failure to use required Personal Protective Equipment (PPE) for 2 of 2 staff observed donning and doffing in a PUI unit.
Failure to practice appropriate hand hygiene for 1 of 5 staff in accordance with CDC guidelines.
Report Facts
Census: 163
Sample size: 5
COVID-19 positive cases: 6
COVID-19 positive staff: 1
Handwashing duration: 42
Weekly audits: 4
Staff audited weekly: 10
Monthly audits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided information about COVID-19 positive cases and facility policies; acknowledged deficiencies | |
| Licensed Nursing Home Administrator (LNHA) | Present during observations and meetings with surveyors | |
| Registered Nurse/Regional (RN/R) | Provided information about unit division and PPE policies | |
| Certified Nursing Aide (CNA) | Observed donning PPE and providing care to PUI resident | |
| Housekeeper (HK) | Observed failing to properly use PPE and hand hygiene; received training and suspension |
Inspection Report
Complaint Investigation
Census: 157
Deficiencies: 0
Date: Dec 11, 2020
Visit Reason
The inspection visit was conducted based on a complaint identified as NJ 141696.
Complaint Details
Complaint number NJ 141696 was investigated and the facility was found compliant.
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 visit.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 155
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints #NJ00136022 and #NJ00139059.
Complaint Details
Complaint #NJ00136022 and #NJ00139059 were investigated and the facility was found to be in compliance.
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: 156
Deficiencies: 3
Date: Nov 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to ensure appropriate hand hygiene for some staff, proper use of personal protective equipment (PPE), and maintaining cleanliness of linen carts according to CDC guidelines.
Deficiencies (3)
Failure to practice appropriate hand hygiene noted for 2 of 4 staff.
Improper use of personal protective equipment (PPE) noted for 2 of 2 staff.
Failure to ensure linen cart kept by methods that ensure cleanliness in accordance with CDC guidelines.
Report Facts
Sample size: 2
Staff positive for COVID-19: 3
Hand washing duration observed: 25
Hand washing duration observed: 8
Hand washing duration observed: 13
Hand washing recommended duration: 20
Weekly audits: 4
Staff audited weekly: 10
Monthly audits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Informed surveyor about COVID-19 positive staff and facility units |
| CNA #1 | Certified Nursing Aide | Observed performing inadequate hand hygiene and wiping sink after washing hands |
| CNA #2 | Certified Nursing Aide | Observed improper glove use and insufficient hand washing |
| RN/UM #1 | Registered Nurse/Unit Manager | Provided information on infection control practices for clean unit |
| RN/UM #2 | Registered Nurse/Unit Manager | Provided information on infection control practices for clean unit |
| CNA #3 | Certified Nursing Aide | Observed wearing gloves in hallway and leaving linen cart uncovered |
| Infection Preventionist Nurse | Infection Preventionist Nurse (IPN) | Provided infection control policies and observed staff practices |
| LNHA | Licensed Nursing Home Administrator | Discussed concerns with surveyors |
| Regional Nurse | Regional Nurse | Discussed concerns with surveyors |
| Regional Director | Regional Director | Discussed concerns with surveyors |
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