Our Ladys Center for Rehabilitation & Healthcare

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 06/01/2026 from 9:46 AM until 10:27 AM the surveyor, accompanied by the Food Service Director (FSD) observed the following in the kitchen: 1. In the walk-in refrigerator there was ham wrapped in plastic wrap that was not labeled with an open or use by date. The FDS said that the ham should be labeled and removed the ham from the refrigerator. 2. Also, in the walk-in refrigerator 4 boxes of juices and a crate filled with milk cartons were on the floor. The FDS said they should not be stored on the floor. 3. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide a safe, clean, and homelike environment for 2 of 2 stairwells observed in the resident courtyard reviewed under the Environmental Task. The deficient practice was evidenced by the following:On 06/01/2026 at 11:28 AM during initial tour, the surveyor observed the resident courtyard. At that time the surveyor observed two stairwells on both sides of the resident courtyard. At that time, the surveyor observed garbage at the base of both stairwells that included foam containers, foam cups and paper plates. On 06/04/2026 at 12:40PM upon return to the resident courtyard, the surveyor observed garbage that included foam, containers, foam cups and paper plates at the base of both stairwells. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to include resident directed self-tracheostomy care. This deficient practice was identified for 1 of 35 residents reviewed for resident-centered care plans (Resident #7), and was evidenced by the following: On 06/01/2026 at 9:54 AM resident #7 was observed in their room exiting the bathroom. At that time the surveyor observed Resident #7's tracheostomy (surgical opening in the neck for artificial airway). Resident #7 communicated to the surveyor through written words that he/she performed their own tracheostomy care including suctioning. A review of Resident #7's Minimum Data Set (MDS; an assessment tool) revealed that Resident #7 had a Brief Interview of Mental Status (BIMS) of 15, indicating that Resident #7 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice by failing to ensure physician orders were followed for 1 of 4 residents (Resident #137) reviewed for respiratory care. This deficient practice was evidenced by:On 06/01/2026 at 10:41 AM during the initial tour, the surveyor observed Resident # 137 sitting on the side of the bed. Resident # 137's nasal cannula (a tube delivering oxygen into the nose) was not on the resident and was draped over the nightstand. On 06/02/2026 at 12:15 PM, the surveyor observed Resident # 137 in their room sitting in a wheelchair. Resident # 137's nasal cannula was in a bag, and the oxygen concentrator was turned off. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 3 nurses administer medications for 4 residents, errors were observed for 3 of 4 residents (Resident #64, Resident #175 and Resident #198). There were 29 opportunities for error with 15 errors observed resulting in an error rate of 51% as evidenced by the following: During the medication pass observation on 06/02/2026 from 9:37 AM until 9:51 AM, the surveyor observed the following: At 9:37 AM, the surveyor observed Licensed Practical Nurse #1 (LPN #1) prepare seven medications for Resident #179, including the following: Metformin HCL 500 mg (milligram) oral tablet, give one tablet by mouth two times a day, which included a pharmacy cautionary to take with food. [...]

Inspectors wroteNJ Complaint: 2605819 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant medication errors. The deficient practice was evidenced by the following: NJ Complaint: 2605819 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant medication errors. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documents, it was determined that the facility failed to use appropriate infection control practices specifically by a) failing to use personal protective equipment and entered resident room with wound treatment cart, for 1 of 2 residents reviewed under Pressure Ulcer/Injury (Resident #13) and c) respiratory equipment for 1 of 4 residents reviewed for respiratory care. (Resident #177). The deficient practice was evidenced by the following: On 06/01/2026 at 11:16 AM surveyor #1 observed signage that indicated Resident #13 was on Enhanced Barrier Precautions (EBP). The signage indicated that high-contact resident care activities required staff to wear a gown and gloves, high-contact. The signage indicated high-contact care activities included wound care. [...]

Inspectors wroteOn 12/16/2024 at 10:08 AM during initial tour surveyor # 2 observed pillowcases tucked in the window of the bathroom on unit B room [ROOM NUMBER]. Also observed on unit B in room [ROOM NUMBER] A-side, surveyor # 2 observed the wall next to the bed with scratches and peeling paint. On 12/19/2024 at 09:54 AM during a tour of the Unit C and D nourishment room surveyor # 2 observed the following: 1. Under the sink there was a water bottle with a blue substance not labeled and a sponge open to air. 2. The ice machine was observed with white stains on the front and the tray was filled with water and rust was noted on the rack in the tray. 3. A stack of 3 paper cups were observed facing up and open to air. During an interview on 12/19/2024 at 09:57 AM with surveyor # 2, Registered Nurse/Unit manger #1 (RN/UM) said that the cups should be facing down to keep germs out. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all medications and biologicals were stored and labeled properly in medication carts. The deficient practice was identified for 4 of 5 medication carts reviewed under the Medication Storage and Labeling Task. The deficient practice was evidenced by the following: On 12/16/2024 at 12:47 PM, the surveyor inspected the D-Hall medication cart. At that time, the surveyor observed two, loose tablets in the second drawer of the medication cart. Secondly, the surveyor observed one, multi-use vial of Insulin Lispro (fast-acting medication used to treat blood sugar levels) and one, multi-use vial of Lantus (long-acting medication used to treat blood sugar levels) undated. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide reasonable accommodation of a resident, specifically by having the resident's call device on the floor while the resident was in bed. The deficient practice was identified for 1 of 4 residents (Resident # 320) reviewed under the Environmental Task. A review of Resident # 320's admission Record located in the Electronic Medical Record revealed a diagnoses of but not limited to, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region (Infection of the bone). On 12/16/2024 at 10:15 AM, the surveyor observed Resident # 320 in bed. At that time, their call device was on the floor, outside of reach of Resident # 320. On 12/20/2024 at 9:40 AM, the surveyor observed Resident # 320 in bed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility A.) failed to maintain medication records that were complete with staff signatures according to professional standards of clinical practice. This was identified for 1 of 32 residents reviewed (Resident #23) and it was determined that the facility B.) failed to follow the physician orders with regard to medications (meds) with parameters for 1 of 34 residents (Residents #51) reviewed. This deficient practice was identified 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 pertinent facility documents, it was determined that the facility failed to provide nail care to a resident who was unable to carry out activities of daily living (ADLs). This deficient practice occurred for 1 of 3 residents (Resident #122) reviewed for nail care and was evidenced by the following: On 12/17/24 at 12:38 PM, the surveyor observed Resident #122 sitting on the edge of their bed. The surveyor observed resident's both arms were shaking, and their nails were long, squared (Square shape) with sharp edges. On 12/18/24 at 11:47 AM, the surveyor observed Resident #122 sitting in their bed. Resident #122's nails were long, squared with sharp edges. Resident #122 stated I don't remember when my nails were cut last, and further stated, I am going to ask my family to bring me a nail cutter. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure medication administration times were sequenced to accommodate a resident's hemodialysis (HD) schedule in accordance with professional standards of practice. This deficient practice was identified for 1 of 2 residents reviewed on hemodialysis (Resident #43), and was evidenced by the following: On 12/18/2024 at 09:17 AM, the surveyor observed Resident #43 in their room. Resident #43 stated that the facility gets him/her to dialysis on time. The surveyor reviewed the medical record for Resident #43. The medical reflected Resident # 43 had a primary diagnosis of but not limited to anemia and end stage renal disease. [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents A.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission, B.) were seen by the physician or nurse practitioner every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 4 of 34 residents (Resident #51, #52, #119, and #122) reviewed for physician visits. This deficient practice was evidenced by the following: 1.) A review of Resident #51's hybrid (electronic and paper) medical records (MR) from May 2024 - December 2024 revealed the following: [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices specifically, by staff not wearing a personal-protective gown while entering a room under Contact Precautions. The deficient practice observed for 1 of 2 residents (Resident # 320) reviewed for Transmission-Based Precautions under the Infection Control task. The deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. [...]

Inspectors wroteFACILITY F812 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/14/2023 at 9:20 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the walk-in refrigerator a previously opened box contained shelled eggs. The box was open, and the eggs were exposed. The box was sitting on the floor of the walk-in refrigerator. 2.- In addition, a bulk bottle of Ranch dressing and a bottle of bulk BBQ sauce were previously opened. The bottles did not have an open or use by date. A pan contained Jello and was covered with clear plastic wrap. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, safe and sanitary environment. This was identified for 3 of 4 units and was evidenced by the following: During the initial tour of B hall on 11/14/2023 at 10:58 AM the surveyor observed the following; -privacy curtain between the beds in room B 09 had dark stains on it. -The floor at foot of A bed had a dark orange/brown stain. -The floor was observed to have brown pieces of debris scattered on it. -There was no foot board on A bed. On 11/15/23 at 9:23 AM, the surveyor observed the radiator cover between rooms [ROOM NUMBERS] on B hall in disrepair, with chipped paint. Multiple doorways into resident rooms on B hall observed with chipped paint. During a tour of A hall on 11/17/2023 at 9:19 AM, the surveyor observed the following: [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests by failing to remove insect traps filled with carcasses from a resident's room and failing to remove dead insect carcasses from a resident dining area. The deficient practice was observed for 1 of 8 residents (resident # 71) and 1 of 2 Dining Areas under the Environmental Task. The deficient practiced was evidenced by the following: On 11/14/2023 at 10:37 AM during the initial tour, the surveyor met Resident # 71 in his/her room. At that time, the resident said he/she that insects were observed in the room on multiple occasions. At that time, the surveyor observed two insect traps underneath the baseboard heater. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement a comprehensive, person-centered care plan to prevent fall and fall related injury for 1 of 34 residents reviewed (Resident #52). This deficient practice was evidenced by: On 11/14/2023 at 10:50 AM during initial tour, the surveyor observed Resident #52 resting in bed. There was no floor mat on the floor. On 11/17/2023 at 08:10 AM, the surveyor observed Resident #52 resting in bed and watching TV. The floor mat was not on the floor. During that time, the surveyor observed Resident #52's room and did not see the floor mat. The surveyor also observed a bed alarm pad placed underneath Resident #52, with gray cord extending on the floor and not connected to the powering device (a box with batteries which makes the alarm work). [...]

Inspectors wroteComplaint # NJ163585 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide the needed care and services in accordance to professional standards of practice that met the resident's physical needs by not obtaining laboratory diagnostics, specifically a blood test as ordered by the physician for the next day. The deficient practice was discovered for 1 of 3 residents (Resident # 355) investigated for Change of Condition. The deficient practice was evident by the following: A review of Resident # 355's Electronic Medical Record (EMR) revealed that he/she had diagnoses of but not limited to a fracture of unspecified part of right clavicle, subsequent encounter for fracture with routine healing, paroxysmal atrial fibrillation (irregular heart rhythm), and chronic obstructive pulmonary disease (lung disease). [...]

Inspectors wroteResident #133 Based on observation, interview, review of the medical record (MR) and review of other pertinent facility documents, it was determined that the facility failed to consistently ensure communication with a contracted dialysis facility according to facility policy and procedure. This deficient practice was evidenced for 1 of 1 resident (Resident #133) investigated for dialysis. This deficient practice was evidenced by the following: On 11/16/2023 at 09:06 AM Resident #133 stated to the surveyor that they had attended dialysis for approximately (1) year and is transported via the facility contracted transportation service. Resident #133 stated that he/she had no issues with transportation. Resident #133 also stated that he/she does not take a communication binder when attending dialysis and does not recall staff checking his/her dialysis site upon return to the facility. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to have a Quality Assurance and Process Improvement Committee (QAPI) and Quality Assurance Assessment (QAA) that consisted of the minimum required members by failing to include the facility's Medical Director in any of the provided attendance sheets. The Medical Director's attendance was not documented on 10 of 10 attendance sheets provided by the facility. The deficient practice was evidenced by the following: On 11/20/2023 at 12:24 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) said that the facility-provided Quality Assurance Meeting signature sheets are the same signature sheets for QAPI Committee. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to use appropriate hand hygiene and proper disinfection while providing wound care to residents. The deficient practice was observed A.) for 1 of 1 resident (Resident # 85) investigated for Pressure Ulcers/Injury and B.) 1 of 2 residents (Resident #109) investigated for Skin Condition. The deficient practices were evident by the following: A.) A review of Resident # 85's Electronic Medical Record (EMR) revealed a Nutrition Note in the progress notes dated 11/3/2023. The Nutrition Note revealed that Resident # 85 had an unstageable pressure ulcer to the sacral area. A review of Resident # 85's Significant Change 5-Day Minimum Data Set (MDS) dated [DATE] revealed under section, M that Resident # 85 was at risk for pressure ulcers/injury. [...]

Inspectors wroteBased on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to ensure documentation in the resident's medical record of the information provided regarding the benefits and risks of immunization and the administration or the refusal of the vaccine, specifically the pneumococcal vaccination (vaccine used to prevent pneumonia). This deficient practice was identified for 3 of 5 residents (Resident # 135, Resident #63, & Resident # 109) reviewed for immunization status. This deficient practice was evidenced by the following: 1.) A review of the Electronic Medical Record (EMR) revealed that Resident #135 had diagnoses including but not limited to: Diabetes Mellitus type 2 (a disease of inadequate control of blood levels of glucose), dysphagia (difficulty swallowing), hyperlipidemia (high cholesterol). [...]

Inspectors wroteBased on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure resident call devices where within reach of the residents for 2 of 32 sampled residents, (Resident #99 and Resident #201). This deficient practice was evidenced by the following: 1.) During the initial tour of the facility on 11/14/2023 at 10:58 AM, Resident #99 was observed lying in bed and the call bell was observed on the floor, under the overbed table and under a can out of the reach of the resident. Resident did not respond when asked if he/she uses the call bell. On 11/15/2023 at 9:22 AM, Resident #99 was observed to be lying in bed and the call bell was observed to be inside the top drawer of the dresser that was next to the bed. The call bell was not in reach of the resident. [...]