Oakland Rehabilitation and Healthcare Center

Inspectors wroteBased on interviews and review of pertinent documentation, it was determined that the facility failed to ensure the facility-wide assessment included a) an assessment with regard to use of non-certified Nursing Aides (NAs) to address the need of those residents under NAs care and b.) revised the facility assessment to address the contingency plan that included staffing guidelines. This failure had the potential to affect all 199 residents who currently live in the facility. This deficient practice was evidenced by the following: On 5/22/25 at 9:49 AM, Surveyor#1 (S#1) met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) during an entrance conference, the LNHA informed S#1 that the current census was 199 (total number of residents). The LNHA stated that currently there were three NAs working at the facility. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 1 of 4 units (2E Unit) and 1 of 1 dining room, and was evidenced by the following: 1. During an initial tour of the facility on 5/22/25 at 11:10 AM, in 2E Unit, the surveyor observed upon entry to Resident Room#215 (RR#215), the ceiling tile near the window had brownish discoloration. The surveyor observed the 1st bed with broken basin and wedge for positioning under the resident's bed, and the floor was dusty. The 1st bed overhead light with another wedge for positioning. The resident in the 1st bed stated that they were unaware that there was a basin under their bed and probably that was the one they (nursing aides) use for cleaning the resident. [...]

Inspectors wroteRefer F 835Based on interviews and a review of pertinent facility documents, it was determined that the facility failed to ensure that a.) a non-certified Nursing Aide (NA#1) received the required training and competencies needed prior to receiving their own assignment and rendering resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming and b.) NAs did not work past 120 days without being certified as a nursing aide. This deficient practice was identified for 2 of 3 NAs reviewed (NA#1 and NA#2) who provided direct care to residents on 4 of 4 nursing units. NA#1 was hired on 9/16/24, to provide care to the residents. NA#1 began independent resident care assignments on 9/27/24, and was not enrolled in a state approved Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP) until 1/13/25. [...]

Inspectors wroteRefer to F 728Based on interview and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as herself, implemented the facility's policies and procedures including a.) the hiring and utilization of non-certified Nursing Assistants (NAs) to ensure NAs were trained with the appropriate competencies and completed modules prior to receiving their own independent resident care assignment and b.) NAs did not work past 120 days without being certified as a nursing aide. This deficient practice was identified for 1 of 3 NAs (NA#1) reviewed, who worked on 4 of 4 nursing units. Interviews on 5/28/25, with staff and the LNHA, revealed that NA#1 was hired on 9/16/24, to provide care to the residents and worked past 120 days (1/13/25) without being certified as a nursing aide. [...]

Inspectors wroteBased on observations and interviews on 5/22/2025 in the presence of the Regional Director of Plant Operations (RDPO) and the Maintenance Director (MD), it was determined that the facility failed to ensure that all devices used to initiate call bell notifications were properly functioning. This deficient practice had the potential to affect 60 residents and was evidenced by the following: An observation at 12:45 PM revealed that the shower room near room [ROOM NUMBER] contained 2 shower stalls and a toileting area. Three of 3 resident call bell pull stations did not function when tested by the MD. An observation at 1:31 PM revealed that the shower room near room [ROOM NUMBER] contained 2 shower stalls and a toileting area. One of 3 resident call bell pull stations did not function when tested by the MD. In interview at the time, the MD confirmed the observations. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to treat a resident in a dignified and respectful manner for 2 of 38 residents (Residents #22 and #28) reviewed. This deficient practice was evidenced by the following: 1. On 5/23/25 at 9:21 AM, during a tour on a unit, the surveyor observed the nurse's medication (med) cart in front of the door to Resident #22's room and the door was open. The surveyor observed from the hallway into the room, no privacy curtain drawn. The Registered Nurse (RN) wore a disposable gown and gloves, was seated in a chair at the resident's bedside facing away from the door. A private duty aide was seated across from the resident's bed with their back facing away from the door. The resident was lying in their bed, with the head of bed elevated and dressed in a long-sleeved shirt and long pants. [...]

Inspectors wroteBased on interviews, review of medical records, and pertinent facility documentation, it was determined that the facility failed to notify the Resident's Physician (RP) of a change in condition for 1 of 38 residents (Resident # 85) reviewed. This deficient practice 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 1 of 38 residents (Resident #135) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: A review of the Centers for Medicare & Medicaid Services (CMS's) Resident Assessment Instrument (RAI; helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Version 3.0 Manual, October 2024, reflected, definitions for injury except major, includes skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with bladder patterning was completed and monitored in accordance with resident's comprehensive assessment and facility's policy and procedure. This deficient practice was identified for 1 of 1 resident (Resident #111) reviewed for bladder and bowel (B & B) incontinence. This deficient practice was evidenced by the following: On 5/22/25 at 11:10 AM, the surveyor observed Resident #111 lying on bed, awake, able to respond to surveyor's inquiries appropriately. At that same time, the surveyor observed the toilet room, inside resident's room with a commode. On 5/23/25 at 9:03 AM, the surveyor observed the Certified Nursing Aide (CNA) inside the resident's room while the resident was lying on bed with call bell within reach. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure a.) recommendation to upgrade the resident's diet was followed for resident identified as at risk for nutritional problem and b.) monitored weight according to the physician's order, and care plan interventions, for 1 of 3 residents, Resident#113, reviewed for nutrition. This deficient practice was evidenced by the following: On 5/22/25 at 11:00 AM, the surveyor observed Resident#113 inside their room with a Certified Nursing Aide (CNA) providing morning care to the resident. The surveyor reviewed the medical records of Resident #113 and revealed: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents received timely and appropriate incontinence care to achieve their highest practical wellbeing. This deficient practice was identified for 1 of 2 residents, Resident#113, reviewed, and was evidenced by the following: On 5/22/25 at 11:00 AM, the surveyor observed Resident#113's door was closed with a linen cart outside the door. Inside the resident's room, there was a strong smell of urine. The surveyor observed a Certified Nursing Aide (CNA) providing incontinence care to Resident#113. The CNA showed the resident's soaked incontinence brief. [...]

Inspectors wroteBased on interviews and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate documentation of the receipt of a controlled substance for 13 Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on 3 Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) out of 15 reviewed. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wrote3. On 5/28/25 at 8:54 AM, Surveyor#2 (S#2) observed Licensed Practical Nurse#2 (LPN#2) assigned to the med cart (med-cart) located on the 2nd Floor, prepare and administer due meds to Resident #162. S#2 observed LPN#2 prepare and administer ferrous sulfate 325 mg (iron, a med that is a mineral used to treat anemia or low iron in the blood) and calcium carbonate 500 mg with vitamin D 200 u (unit) (calcium, a med that is a mineral used to treat low blood calcium and strengthen the bones along with the resident's other meds). Both the iron and calcium were scheduled to be given at 9:00 AM per the PO. S#2 asked LPN#2 if there were any drug interaction warning in the eMAR for the calcium or iron. LPN#2 could not locate any interaction warnings. S#2 asked LPN#2 if there were any drug interaction warnings on the containers for iron or calcium. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to follow a physician's order for medications with a parameter and acceptable professional standards of practice for 1 of 28 residents, Resident#54, reviewed. The deficient practice is 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 5 medication carts observed on 1 of 4 nursing units of the facility. This deficient practice 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteComplaint # 172385 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain medical records that were accurate and easily accessible. This deficient practice was evidenced by the following: On 5/22/25 at 1:32 PM, the surveyor requested from the Director of Nursing (DON) the Certified Nurse Assistant (CNA) unit assignment sheets for the facility's 4 units for the day shift for 3/19/24, 3/20/24, and 3/21/24. On 5/23/25 at 12:13 PM, the facility provided a computer printout of the staff in the facility for 3/19/25, 3/20/25, and 3/21/25. The surveyor requested from the Licensed Nursing Home Administrator (LNHA), the CNA assignment sheets for the facility's 4 units for the day shift for the three dates. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to follow appropriate use of personal protective equipment (PPE) and the physician's order for Enhanced Barrier Precautions (EBP). This deficient practice was identified on 1 of 1 contracted staff (Hospice Aide), failed to follow appropriate infection control practices to prevent the spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, revealed, EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure five residents reviewed for abuse (Resident (R) 1, R5, R13, R14, and R32) out of 32 sampled were free from physical abuse. This failure increased the risk of other vulnerable residents for further physical abuse.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure a potential allegation of abuse for two of seven residents reviewed for abuse in the sample of 32 was reported timely to the State Survey Agency (SSA). Specifically, the facility failed to report R1's suspicious bruising of the upper arm and an allegation of physical abuse which involved Certified Nurse Aide (CNA)10 and Resident (R) 5 to the SSA timely. This failure increased the risk of other vulnerable residents for further physical abuse.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure a thorough investigation into allegations of abuse for two of seven residents reviewed for abuse (Resident (R) 1 and R5) out of 32 sampled residents. This failure increased the risk of other vulnerable residents for further physical abuse.

Inspectors wroteBased on interview, record review, document review and policy review, the facility failed to have an effective antibiotic stewardship program when the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotic was ordered for a urinary tract infection (UTI) in order to reduce the development of antibiotic-resistance organisms for one of three residents (Resident (R) 11) reviewed for UTIs out of 32 sampled residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure staff followed care planned interventions to prevent falls for one of two residents (Resident (R) 10) reviewed for falls out of a total sample of 37 residents. This failure resulted in harm to R10 who was admitted to the hospital with a right femur fracture after sustaining a fall from being turned in bed by staff without assistance.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to promote a dignified dining experience when staff served meals to residents who were seated at overbed tables in the hallway for 15 of 55 residents who resided on the facility's Unit 2E. Findings Include During an observation on 02/27/23 at 5:36 PM, staff on the facility's Unit 2E, which included resident rooms from 201 to 231, served meals to residents who were seated in the hallway. Eleven residents, with cognitive impairments, were served and ate their evening meal while seated at an overbed table in the hallway. During an observation on 02/27/23 at 5:40 PM, no residents were eating their evening meal in the facility's 200-hall dining room. During an observation on 02/28/23 from 5:21 PM to 5:31 PM, staff on Unit 2E served meals to residents who were seated in the hallway. [...]

Inspectors wroteBased on observations, interview, record review and policy review the facility failed to ensure that the kitchen was maintained in a sanitary manner for 185 out of 188 residents (3 residents were receiving tube feedings). Specifically, unit pantry refrigerators were found to contain unlabeled food items brought in by residents' family and were observed to have grime and food residue on the inside.

Inspectors wroteBased on staff interviews and facility policy review, the facility failed to ensure their designated Infection Preventionist (IP) completed specialized training in infection prevention before assuming the position of infection preventionist. This failure had the potential to affect the residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure one of 35 residents(Resident (R) 179) had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Specifically, R179 was readmitted to the facility to a locked dementia care unit after previously having been admitted to the subacute rehabilitation unit.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to complete documentation of residents' wishes for treatment in the Practitioner Orders for Life-Sustaining Treatment (POLST-used as directions to emergency health personnel in the event of cardiac or respiratory failure)) for three of four residents (Resident (R) 116, R393, and R394) reviewed for advance directives in a total sample of 35 residents. This failure created the potential for residents to not have their wishes known should they suffer a health emergency.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to provide a discharge plan and develop a discharge care plan for one of three residents (Resident (R) 112) reviewed for discharge out of a total sample of 37 residents. This failure increased the risk of incomplete discharge planning for residents wanting to be discharged from the facility.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 190) reviewed for closed records had a discharge recapitulation of stay, a medication reconciliation, and a discharge plan of care. This failure has the potential to have any resident that may discharge not have the information required regarding medical appointments, medication regimen, and other information for a successful discharge.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the attending physician acted upon the pharmacist recommendations for one of five residents (Resident (R)161) reviewed for unnecessary medications out of a total sample of 35 residents. This failure increases the risk that residents will continue to receive unnecessary medications that potentially could cause serious adverse effects.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure proper injection technique was used for one of one residents (Resident (R) 138) reviewed for insulin during medication administration. This failure had the potential to result in the wrong dose of insulin administered to the resident.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 1 of 32 residents reviewed, Resident#116, and was evidenced by the following: On 3/18/21 at 11:09 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that Resident #116 was cognitively impaired and on hospice care. On 3/18/21 at 11:37 AM, during the tour, the LPN/UM informed the surveyor that the hospice nurse comes to the facility at least 1 to 2 times a week. The resident was seated in a wheelchair in their room. [...]