Big Oak Rehabilitation and Healthcare Center

Inspectors wroteComplaint #2793788Based on observation and interview it was determined that the facility had insufficient staffing in the kitchen to carry out the duties of the food service operations competently. This deficient practice was evidenced by the following: Cross-reference: F803On 3/23/26 at 10:30 AM, during a Resident Council Meeting with the surveyor, 5 of 6 alert and oriented residents in attendance (#5, #12, #37, #67, and #73) stated that the facility did not have a cook for one day the week prior and they were served cold food for all three meals. The residents stated the facility brought around a cart and handed out cereal and milk for breakfast. On 3/23/25 at 10:44 AM, the surveyor observed the Food Service Director (FSD) making lunch. When the surveyor asked if there was a cook, the FSD stated that there was no cook today, so he was covering all the meals. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris and failed to have a cover over the opening of 3 of 3 garbage containers/dumpsters. This deficient practice was evidenced by the following:On 3/20/26 at approximately 10:00 AM, the surveyor, accompanied by the Food Service Director (FSD), observed three (3) yard dumpsters that were designated for garbage in the facility parking lot. 3 of 3 dumpsters designated for garbage had the contents of bagged trash exposed due to the dumpster lids not being closed. Each dumpster had two (2) plastic lids to cover the dumpster opening. [...]

Inspectors wroteBased on interview, record review, and a review of pertinent facility documents, it was determined that the facility failed to consistently implement their Antibiotic Stewardship Program (ASP), a program designed to improve clinical outcomes and reduce harm by promoting and monitoring the appropriate use of antibiotics. This deficiency was identified for 5 of 5 residents (Resident #5, #18, #19, #39, and #61) reviewed for antibiotic use and was evidenced by the following: On 3/23/26 at 9:15 AM, the Infection Preventionist (IP) provided the facility's antibiotic stewardship binders for the years 2025 and 2026. A review of the facility's Antibiotic Stewardship line list for February 2026 revealed the following residents were prescribed antibiotics while at the facility: 1. Resident #5 was prescribed an antibiotic on 2/7/26 for 7 days for cellulitis [a skin or soft tissue infection (SSTI)]. [...]

Inspectors wroteBased on observation, interview and review of facility menus, it was determined that the facility failed to ensure that staff were following the menu. This deficient practice was evidenced by the following: Cross-reference F802On 3/23/26 at 10:30 AM, during a Resident Council Meeting with the surveyor, 5 of 6 alert and oriented residents (Resident #5, #12, #37, #67, and #73) stated that there was no cook one day the week prior and they were served cold food all three meals. The residents stated the facility brought around a cart and handed out cereal and milk for breakfast. On 3/23/26 at 12:55 PM, the surveyor interviewed a Dietary Aide (DA) that confirmed that she was aware of a day the past week when there was no cook. The DA stated that the cook called out sick and the FSD was also ill. [...]

Inspectors wroteComplaint #: NJ176956 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/4/24 at 9:45 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. When the surveyor and the FSD approached the designated handwashing sink, a dietary staff member removed items from the sink. When asked what the items were, the FSD stated the dietary staff member removed a fork and spatula from the sink that was used to make sandwiches. The FSD further stated that there should not be food prep items in the designated handwashing sink. There was no signage to indicate the sink was to be used for handwashing purposes only. 2. [...]

Inspectors wroteBased on observation, interviews, and review of facility documentation, it was determined that the facility failed to a.) follow appropriate infection control practices by not performing hand hygiene during the meal pass for 1 of 2 units (West Wing) observed, and b.) have a water management program in place to prevent the growth of Legionella (a waterborne pathogen). The deficient practice was evidenced by the following: On 12/5/24 at 12:09 PM, the surveyor observed the following during the meal pass on the [NAME] Wing unit: Certified Nursing Assistant (CNA) #2 picked up a tray from the meal cart, brought it to room [ROOM NUMBER]-B, and set up the tray for the resident. The CNA then left the room without performing hand hygiene and picked up another tray from the meal cart, brought it to room [ROOM NUMBER]-A, and set up the tray for the resident. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan (ICCP) to include a.) a resident's use of anticoagulant medication (blood thinning medication) and, b.) a resident's hospice services. This deficient practice was identified for 1 of 5 residents (Resident #70) reviewed for medication regimen and 1 of 2 residents (Resident #37) reviewed for hospice and was evidenced by the following: 1.) On 12/5/24 at 12:21 PM, the surveyor observed Resident #70 eating lunch in his/her room. On 12/6/24 at 11:29 AM, the surveyor reviewed the medical record for Resident #70. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: atrial fibrillation (A-Fib; [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to accurately utilize an infection assessment tool for 7 of 7 residents (Resident # #11, #39, #54, #65, #70, #328, #329) reviewed that were prescribed antibiotic medications in the facility. This deficient practice was evidenced by the following: A review of the facility's Antibiotic Stewardship line list for September, October and November 2024, revealed the following residents were prescribed antibiotics while at the facility: 1. Resident #328 was prescribed an antibiotic on 9/4/24 for seven (7) days for a skin infection. The line list further indicated that in infection assessment tool was completed with antibiotic use criteria not met. 2. Resident #11 was prescribed an antibiotic on 9/18/24 for five (5) days for a tooth infection. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the pneumococcal vaccination or the influenza vaccination was offered to residents upon admission to the facility for 4 of 5 residents (Resident #14, #66, #69, and #70) reviewed for immunizations. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Pneumococcal Vaccine for Adults Aged >19 Years: [...]

Inspectors wroteBased on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to offer residents an updated COVID-19 vaccine for 4 of 5 residents (Resident #14, #66, #69, and #70) reviewed for immunizations. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Use of COVID-19 Vaccines for Persons Aged >6 Months: Recommendations of the Advisory Committee on Immunization Practices (ACIP) - United States, 2024-2025 Weekly / September 19, 2024 / 73(37);819-824 On June 27, 2024, the Advisory Committee on Immunization Practices recommended 2024-2025 COVID-19 vaccination with a Food and Drug Administration (FDA)-authorized or approved vaccine for all persons aged >6 months. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and sanitary medication storage room. This deficient practice was identified in 1 of 2 medication storage rooms (West Wing med room) and was evidenced as follows: On 12/5/2024 at 9:04 AM, the surveyor entered the medication (med) storage room located on the [NAME] Wing, accompanied by Licensed Practical Nurse (LPN) #1; upon entering, there was a musty odor and the following was observed: The floor tile was discolored with stains and small particles in various areas. The floor was raised and buckled in the area closest to the left wall. There was a crack extending across the ceiling. There was piping that was detached piping laying on the floor in front of the sink. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain the resident's furnishings and living area in a clean and home like environment. This deficient practice was identified for 1 of 2 residents (Resident #66) on 1 of 2 nursing units (West Unit) reviewed for a clean, comfortable, home like environment and was evidenced by the following: 1. On 12/4/24 at 10:44 AM, the surveyor entered Resident #66's room and observed that the floor was visibly dirty and was soiled with both dried paint and debris. The resident's over bed table frame was rusty. The surveyor reviewed the medical record for Resident #66. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facilty failed to ensure that an allegation of staff to resident abuse was immediately reported to a supervisor in accordance with the facility abuse policy to ensure the safety of all residents at the facility . This deficient practice was identified for 1 of 1 resident (Resident #33) reviewed for abuse and was evidenced by the following: On 12/6/24 at 9:04 AM, the surveyor completed a tour of the East Unit with Certified Nursing Assistant (CNA) #3. When interviewed, CNA #3 stated that on 12/5/24, Resident #65 reported that an aide twisted his/her roommate's fingers.(Resident #33) . The surveyor asked CNA #3 when she was supposed to report an allegation of abuse? CNA #3 stated that she was supposed to report any allegation of abuse to her supervisor right away. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident hospitalization. This deficient practice was identified for 1 of 1 resident (Resident #20) reviewed for hospitalization and was evidenced by the following: On 12/4/24 at 10:22 AM, during the initial tour the surveyor observed Resident #20 lying in bed with their eyes closed. On 12/6/24 at 10:00 AM, the surveyor reviewed the medical record for Resident #20. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: cognitive communication deficit, chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), and muscle weakness. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain a professional standard of practice by ensuring a physician's order was in place for monitoring a resident's blood glucose levels. This deficient practice was identified during medication administration record review for 1 of 3 residents (Resident #25) on dialysis and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a wound treatment in accordance with the physician's orders, the facility policy, and professional standards of nursing practice. This deficient practice was identified for 1 of 3 residents (Resident #66) reviewed for pressure ulcers and was evidenced by the following: On 12/5/24 at 12:23 PM, the surveyor observed Resident #66 lying awake in bed on a large air mattress and the sheets were disheveled beneath the resident and left parts of the mattress uncovered. The resident had a gauze bandage that covered the resident's left ankle and shin that was dated 12/1/24. When interviewed, the resident stated that they also had a wound on their bottom. Certified Nursing Assistant (CNA) #1 was present and had begun to set the resident up to eat lunch. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) adjust medication administration times to accommodate for scheduled dialysis times and b.) notify the physician that the resident missed medications during dialysis times. This deficient practice was identified for 1 of 3 residents (Resident #25) reviewed for dialysis and was evidenced by the following: On 12/4/24 at 10:12 AM, the surveyor observed that Resident #25 was not in their room. A review of the admission Record, an admission summary, revealed the resident had diagnoses that included, but were not limited to: end-stage renal (kidney) disease, dependence on renal dialysis, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and diabetes mellitus. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store medications properly. This deficient practice was observed in 1 of 4 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 12/5/24 at 2:14 PM, the surveyor observed the East Wing high treatment cart in the hallway next to the conference room. A tube of Santyl ointment 250 grams (gm) and a bottle of Nystatin External Powder 100000 UNIT/GM were left on the treatment cart, unattended by a licensed nurse. The surveyor knocked on the Nursing Office door to notify a licensed nurse. Licensed Practical Nurse/Unit Manager (LPN/UM) #1 confirmed that the medication was on the cart and immediately removed the medication. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure adaptive dining equipment was provided to a resident during meal service as ordered by the physician and indicated on the resident's individual comprehensive care plan (ICCP). This deficient practice was identified for 1 of 1 resident (Resident #35) reviewed for adaptive dining equipment and was evidenced by the following: On 12/4/24 at 12:32 PM, during a lunch meal observation, the surveyor observed Resident #35's clothes contained droppings of pudding. The diet slip on the resident's lunch tray indicated that the resident should have built-up utensil handles, a sippy cup, and a curved spoon. The resident's lunch tray had a built-up fork, a standard spoon and knife, and the cranberry juice and milk were in their original containers with no sippy cup. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to a.) keep the dumpster area free of garbage and debris and b.) have a cover over the opening of 2 of 3 dumpsters. This deficient practice was evidenced by the following: On 12/4/24 at 10:30 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's designated garbage disposal area. There were three garbage dumpsters that each contained two lids. Two of the garbage dumpsters each had one lid open, exposing trash bags inside. There was also garbage on the ground between the two open garbage dumpsters which included single-use gloves, plastic water bottles, plastic packaging, single-serve juice containers, plastic cup lids, paper debris, and cardboard. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure the required committee members, specifically the Licensed Nursing Home Administrator (LNHA), was present for 1 of 4 Quality Assurance and Performance Improvement (QAPI) quarterly meetings reviewed. This deficient practice was evidenced by the following: On 12/4/24 at 10:10 AM, during the entrance conference with the LNHA and the Nurse Consultant (NC), the surveyor requested the last four quarters of the QAPI sign-in sheets. On 12/5/24 at 10:15 AM, the NC provided the last four quarters of the QAPI sign-in sheets. At that time, the surveyor requested the NC to identify the staff members that signed the sheets. On 12/5/24 at 10:24 AM, the NC provided the updated sign-in sheets, which revealed the LNHA did not sign in for the January 2024 QAPI meeting. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis schedule for 1 of 1 resident (Resident #28) reviewed for dialysis. This deficient practice was evidenced by the following: On 08/23/2023 at 9:40 AM, Resident #28 was observed sitting in a wheelchair getting items out of his/her closet. Resident #28 said he/she goes to dialysis on Monday, Wednesday, and Friday. Resident #28 stated that he/she usually back to the facility by lunch time. A review of the Electronic Medical Record revealed Resident #28 was admitted to the facility with diagnoses including but not limited to, End Stage Renal Disease, Diabetes, Dependence on dialysis and Hypertension. [...]

Inspectors wroteBased on interview and record review and review of other facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 4 of 5 resident's reviewed for unnecessary medications (Resident #61, Resident #1, Resident #3, and Resident #27), and was evidenced by the following: On 8/29/2023 at 10:42 AM, the Surveyor #1 reviewed the medical records for Resident #61. According to the admission Record, Resident #61 was admitted to the facility with the following but not limited to diagnoses: Type 2 diabetes mellitus, paranoid schizophrenia, generalized anxiety disorder, and depressive disorder. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to use appropriate precautions to disinfect and store respiratory equipment to prevent the risk of infections. The deficient practice was observed in 3 of 3 residents (Resident #320, Resident #1, and Resident #3) reviewed for Respiratory Care. This deficient practice was evidenced by the following: 1.) On 08/24/2023 at 10:03 AM, Surveyor #1 observed a bilevel positive airway pressure (BiPAP) device on Resident #320's nightstand with a face mask on top of the device. The face mask was exposed to the environment. The mask appeared to have white and yellow liquid substance from within. On 08/28/2023 at 11:01 AM, Surveyor #1 observed Resident #320's BiPAP face mask on top of the device. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation it was determined that the facility failed to ensure residents call device was within reach of the residents. The deficient practice occurred for 2 of 5 residents (Residents #38, #32). The deficient practice was evidenced by the following: A.) On 08/24/2023 at 09:43 AM, during the initial tour of the facility, Surveyor #1 observed Resident #38 in bed in his/her room. Surveyor #1 observed the call device attached to the cord near the wall input out of reach from the resident. On 08/28/2023 at 09:57 AM, Surveyor #1 observed Resident #38 in bed in his/her room. Surveyor #1 observed the call device attached to the cord near the wall input out of reach from the resident. On 08/29/2023 at 08:48 AM, Surveyor #1 observed Resident #38 in bed in his/her room. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. The deficient practice was identified for 1 of 1 resident (Resident #271) investigated for Bladder and Bowel Incontinence and was evidenced by the following: A review of Resident #271's admission Record revealed diagnoses of but not limited to; epileptic seizures related to external cause (brain disorder that causes recurring seizures), nondisplaced fracture of seventh cervical vertebra, multiple fractures of ribs, difficulty in walking, and major depressive disorder. [...]

Inspectors wroteC/O# NJ160875 Based on observation, interviews, and record review, as well as review of facility documentation, it was determined that the facility 1.) failed to follow their policies and procedures for investigating and reporting of accidents and incidents that occur in the facility and 2.) the facility failed to ensure a resident who was a known fall risk and sustained multiple falls, had new or revised interventions to prevent subsequent falls or injuries. This deficient practice occurred for 2 of 4 residents reviewed for accidents (Resident #120 and Resident #49) and was evidenced by the following: 1. The admission Record revealed that Resident #120 was admitted to the facility with the following but not limited to diagnoses: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to follow professional standards of practice by providing a respiratory treatment without physician's order for 1 of 3 residents (Resident #320) reviewed for Respiratory Care. This deficient practice was evidenced by the following: On 08/28/2023 at 11:01 AM, the surveyor observed a bilevel positive air pressure (BiPAP) device in Resident #320's room. The face mask on top of the device appeared to have white and yellow liquid substance inside of it. The mask was exposed to the environment. At that time, Resident #320 stated, I have been using it [BiPAP] every night when asked by the Surveyor if he was using the BiPAP device. On 08/29/2023 at 08:47 AM, the surveyor observed the face mask on top of the BiPAP device. [...]