St. Mary's Center for Rehabilitation & Healthcare

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to revise a care plan when there was a change in the physician's orders for fluid restrictions for 1 of 3 residents sampled for dialysis (a treatment that removes waste products from the blood), (Resident #232). This deficient practice was evidenced by the following:During the initial tour on 04/23/2026 at 11:47 AM, the surveyor observed Resident #232 resting in bed. A review of the admission Record revealed Resident #232 was admitted to the facility with diagnoses including, but not limited to, end-stage renal disease (a medical condition where the kidneys stop functioning) and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure an environment was free from accident hazards by failing to place assistive devices, specifically bilateral floor mats, to prevent avoidable accidents for 2 of 2 residents (Resident #43 and #147) investigated for Accidents. The deficient practice was evidenced by the following:1) On 04/23/2026 at 10:28 AM, during the initial tour of the facility, the surveyor observed Resident # 147 in their room in bed. The surveyor observed one floor mat on its side leaning against the wall on the far side of the room. On 04/24/2026 at 09:42 AM, the surveyor observed Resident #147 sleeping on his/her left side in bed. The surveyor observed one brown floor mat on its side leaning against the wall on the far side of the room. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice specifically by not having a physician's order for oxygen administration. The deficient practice was identified for 1 of 6 (Resident # 5) residents reviewed for Respiratory Care. The deficient practice was evidenced by the following:On 04/23/2026 at 9:58 AM, during the initial tour, the surveyor observed Resident #5 in their room lying in bed. At that time, the surveyor observed a nasal cannula (tube that delivers oxygen through the nares) applied to Resident #5. At that time the survey observed the oxygen condenser to be on and the resident was receiving 3L of oxygen through the nasal cannula. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility staff failed to ensure that respiratory equipment was stored in a manner that prevented contamination, in accordance with infection prevention and control standards, for 3 of 6 residents reviewed for respiratory care (Resident #5, Resident #79, and Resident #86). The deficient practice was evidenced by the following: On 04/23/2026 at 10:22 AM, during the initial tour, surveyor #1 observed Resident #86's nebulizer mask (a medical device that converts liquid medication into a fine mist for inhalation into the lungs) lying in the nightstand drawer, open to air. [...]

Inspectors wroteBased on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain acceptable standards of essential kitchen equipment in a safe and operable condition. This deficient practice was evidenced by the following:During initial tour of the kitchen on 04/23/2026 at 10:05 AM, the surveyor observed the following in the kitchen with the Food Service Director (FSD):The stove had no knobs. The FSD stated that the knobs had been broken for 1 month and ordered more. FSD stated we are supposed to be getting a new stove. On the portable holding temperature box, the gaskets (rubber seal) were falling off. The FSD stated the box is new, but this can happen because of the high heat. During an interview with the surveyor on 04/23/2026 at 11:48 AM, FSD acknowledged that there should be knobs on the stove top. [...]

Inspectors wroteCOMPLAINT #: 2578601, NJ00183769, NJ00185789 Based on interviews, medical record review, and review of other pertinent facility documents on 08/28/2025 and 09/08/2025, it was determined that the facility failed to notify a provider timely when prescribed treatments and medications were not administered as ordered. This deficient practice was identified for two of three residents (Resident # 1 and Resident #3) reviewed for unadministered medication or treatments. This deficient practice was evidence by the following:Complaint#: 2578601, NJ00183769, NJ00185789 1.) According to the admission Record (AR), Resident #1 was admitted to facility with diagnoses including but not limited to: [...]

Inspectors wroteComplaint #: NJ183456 Based on observation, interview, and record review, it was determined that the facility failed to accommodate resident preferences with specific food items that were documented on the resident's meal tickets. This deficient practice was identified for 4 out of 6 sampled residents, Resident #1, #2, #4, and #5 and was evidenced by the following: According to the admission Record (an admission summary), Resident #2 was admitted with diagnoses that included but were not limited to Hypertension (high blood pressure) and Abnormalities of Gait and Mobility (changes in walk pattern). According to the Minimum Data Set (MDS), an assessment tool dated 2/4/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. [...]

Inspectors wroteBased 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 12/02/2024 from 9:35 until 10:00 AM, the surveyor, accompanied by the Dietary Director (DD) observed the following in the kitchen: 1. In the walk-in refrigerator, on an orange tiered cart, 15 bags of hot dog rolls with a received by date of 11/11/24. The DD stated he will get rid of them. 2. In the walk-in refrigerator on the second shelf, an opened plastic container of prepared cucumber salad with a received by date of 11/21/24. The DD stated he will get rid of the cucumbers. 3. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to explicitly contain any language to inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and failed to contain any language allowing the resident or anyone else to communicate with federal, state, or local officials. The deficient practice has the potential to affect all residents that signed the binding arbitration clause. The deficient practice was evidenced by the following: A review of the the facility admission packet included an Arbitration Agreement, titled, Voluntary, Binding Arbitration. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to keep all areas clean specifically the hallways by leaving linen bundled up outside the linen cart and in the soiled-utility rooms by leaving trash bags on the floor, stacked up, and untied. The deficient practice was identified on 2 of 4 units reviewed under the Environment Task. The deficient practice was evidenced by the following: On 12/03/2024 at 11:08 AM in the St. [NAME] hallway, the surveyor observed linen including towels and blankets unfolded and piled onto the outside handle of the linen cart. On the same date at 12:15 PM in the St. [NAME] Soiled Utility room, the surveyor observed linens overflowing and not bagged from the receptacle, two trash bags were placed on top of the trash receptacle also. On the same date at 12:19 PM in the St. [...]

Inspectors wroteComplaint: NJ170170; NJ169828 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for a resident that had repeated falls. This deficient practice was identified for 1 of 2 Residents (Resident #347) reviewed for falls and was evidenced by the following: On 12/03/2024 at 11:40 AM, the surveyor requested all accidents and/or investigations from the facility for Resident #347 during the year of 2023. The facility provided fall investigations for incidents that occurred on 2/27/23, 4/23/23, and 4/28/23. Upon review of document titled, Incident Audit Report (IR) dated 2/27/2023 at 4:00 PM revealed under Nursing Description: Called to room [ROOM NUMBER] by CNA [Certified Nursing Assistant] and noted resident sitting on floor next to bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that facility staff failed to use appropriate infection control practices, specifically by failing to wear a gown during high-contact activity in a resident's room who was under Enhanced Barrier Precautions. The deficient practice was identified for 1 of 3 residents (Resident # 190) reviewed for Respiratory Care. The deficient practice was evidenced by the following: A review of Resident # 190's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Enhanced Barrier Precautions every shift for [catheter]/wound. The order continued, Enhanced Barrier Precautions (EBP) adherence during high contact resident activities. Must wear Gown & Gloves during: [...]

Inspectors wroteREPEAT DEFICIENCY Complaint # NJ 159503, NJ 160417, NJ 162667 Based on observation, interview, and review of facility documentation it was determined that the facility failed to consistently serve foods at safe and appetizing temperatures. This deficient practice was identified for 2 of 2 units reviewed and was evidenced by the following: 1. On 10/05/23 At 12:25 PM, the surveyor observed large stainless trays with lunch food arrive to the day room one steam table. There were 13 residents seated in day room one waiting for lunch to be served. All of the other unit residents from the first floor had lunch in their rooms. The food service staff began making lunch trays from the steam table. As the trays were being prepared for the residents some trays were handed to the residents in day room one and other trays were placed on a silver open tray cart to be distributed to resident rooms. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement Program's (QAPI) sources of quantitative data was being analyzed to evaluate program effectiveness and implement new processes. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to F 804 F During the standard survey, the surveyors conducted meal observations on 10/5/23 and on 10/10/23. On 10/5/23 beginning at 12:25 PM, the surveyor observed the lunch service in day room one. The surveyor observed the lunch tray preparation begin at 12:25 PM, and ended with the last lunch tray served at 1:05 PM. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to monitor and document the amount of fluids administered on a resident on hemodialysis with fluid restriction. This deficient practice was identified for 1 of 2 residents reviewed for dialysis, Resident #171, and was evidenced by the following: On 10/04/23 at 12:09 PM, the surveyor observed Resident #171 in their room and observed an unmarked white cup with a lid on the overbed table. The resident stated the cup contained water and would drink the water but not too much. The resident opened the cup and showed surveyor the contents of the cup. The resident further stated that they received hemodialysis three times a week and was also on a fluid restriction. The surveyor observed a picture of a water pitcher taped next to Resident #171's room number and name on the door. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to a.) properly label, date and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and dishware in a manner to prevent microbial growth and cross contamination and c.) ensure activity staff were wearing hair nets when entering the kitchen. This deficient practice was observed and evidenced by the following: 1. On 10/03/2023 at 09:45 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the Assistant Food Service Director (AFSD) attempt to remove two boxes of croissants that were not properly labeled with open or discard dates. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) practice appropriate hand hygiene between residents after direct contact with residents during meal service on 1of 2 units (day room [ROOM NUMBER]) b.) perform hand hygiene when handling a contaminated item from the floor on 1 of 2 units (day room [ROOM NUMBER]) and c.) ensure that a urinary catheter drainage bag was stored in a manner to prevent the spread of infection forone of five residents reviewed for urinary catheters and urinary tract infections (UTIs), Resident #137. This deficient practice was evidenced by the following: 1. On 10/4/23 at 12:13 PM, the surveyor observed meal service on the second floor day room [ROOM NUMBER]. At 12:13 PM, the surveyor observed the food truck arrived on the second floor day room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promoted his/her quality of life for a.) a resident whose preference was to attend church services and was not provided their breakfast tray in a timely manner for 1 of 35 residents (Resident #108) and b.) a resident whose preference was to get out of bed was not honored 1 of 35 residents, (Resident #55) reviewed for Resident Rights. This deficient practice was evidenced by the following: 1. On 10/4/23 at 12:34 PM, during the lunch meal observation on the second floor day room, Resident #108 stated that they didn't receive their breakfast tray until 9:30 AM yesterday morning, which made them late for church. Resident #108 stated that they were uncomfortable going into church late and felt bad holding up the transportation staff. [...]

Inspectors wroteComplaint # NJ 159668 Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to maintain the call bell within reach for two of thirty-five residents (Resident #19) and (Resident #82) reviewed for accommodation of needs and was evidenced by the following: 1. A review of Resident #19's admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, dementia, diabetes mellitus, bipolar disorder, and unsteadiness on feet. A review of Resident #19's Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/12/23, indicated Resident #19 was cognitively impaired, and required supervision of one staff for bed mobility and transfers. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to inform, and provide written information to all adult residents concerning the right to formulate an advance directive. This deficient practice was identified for 1 of 35 residents reviewed (Resident #19) and was evidenced by the following: 1. On 10/11/23 at 9:01 AM, the surveyor observed Resident #19 seated in a wheelchair next to the left side of the bed. The resident greeted the surveyor with a smile. On 10/11/23 at 11:55 AM, the surveyor and Nursing Assistant (NA) observed Resident #19 lying in bed with their eyes closed. On 10/12/23 at 9:26 AM, the surveyor observed Resident #19 seated in a chair eating breakfast. [...]

Inspectors wroteBased on interviews, medical record review (MR), and other pertinent facility documentation, it was determined that the facility failed to report an an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 2 residents reviewed for accidents and incidents (Resident # 57). This deficient practice was evidenced by the following: On 10/3/23 at 11:42 AM, the resident was observed sleeping in bed with face partially covered by blanket. Resident #57 did not acknowledge surveyor's presence. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted with diagnosis which included Atherosclerotic Heart Disease (buildup of fats, cholesterol, and other substances in and on the artery wall). [...]

Inspectors wroteBased on interviews, record review, and other pertinent facility documentation, it was determined that the facility failed to timely and thoroughly investigate an injury of unknown origin for 1 of 2 residents reviewed for accidents and incidents (Resident # 57). This deficient practice was evidenced by the following: On 10/3/23 at 11:42 AM, the resident was observed sleeping in bed with face partially covered by blanket. Resident #57 did not acknowledge surveyor's presence. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted with diagnosis which included Atherosclerotic Heart Disease (buildup of fats, cholesterol, and other substances in and on the artery wall). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care for 2 of 35 residents, (Resident's #79 and #249) reviewed resident assessment. This deficient practice was evidenced by the following: 1. A review of Resident #79's admission Record reflected that the resident had diagnoses which included but were not limited to; dementia and nutrtional deficiency. A review of Resident #79's progress notes written by a wound care Nurse Practioner on 8/15/2023 at 12:38 PM revealed that the resident was seen for a sacral area wound that was identified as moisture associated skin damage MASD. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident's preferred gender and name. This deficient practice was identified for 1 of 35 residents (Resident #146) reviewed for care plans and was evidenced by the following: On 10/3/2023 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager(LPN/UM #3), who reported that Resident #146 had a preferred gender and name. On 10/4/2023 at 12:14 PM, the surveyor observed the resident seated in a reclining chair at a table identified as Table 2, which identified Resident #146 with their non-preferred name. On 10/10/23 at 11:26 AM, a surveyor overheard a staff member repeatedly calling Resident #146 by their non-preferred name. [...]

Inspectors wroteComplaint # 159668 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to obtain a physician's order (PO) for a resident who was transferred to the hospital. This deficient practice was identified for 1 of 4 residents reviewed for hospitalization (Resident #249) 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 observations, interview, and record review it was determined that the facility failed to a.) document and monitor a resident that had an external defibrillator life vest (an external device worn on the chest to stop an abnormal heart rhythm), and obtain physician orders for monitoring of a resident's life vest and b.) follow a physicians order for daily wound dressing changes. This deficient practice was identified for Resident #396, 1 of 1 resident reviewed for life vests and Resident #398 1 of 3 residents reviewed for wound care and was evidenced by the following: 1. On 10/03/23 at 10:35 AM, during the initial tour of the facility the surveyor observed Resident #396 in the bed. Resident #396 told the surveyor he/she came to the facility for therapy following angioplasty (unblocking of a blood vessel) for the leg. [...]

Inspectors wroteComplaint # 159668 Based on record review, staff interviews, and facility policy review, the facility failed to ensure a newly identified area of skin breakdown was assessed and treated in a timely manner for 1 of 3 residents (Resident #249) reviewed for pressure ulcers and was evidenced by the following: The surveyor reviewed the medical record for Resident #249. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Atrial Fibrillation. A review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 5/17/23, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which demonstrated moderately impaired cognition. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order. This deficient practice was identified for 1 of 1 resident (Resident #137) reviewed for respiratory care, and was evidenced by the following: On 10/03/23 at 10:41 AM, the surveyor observed Resident #137 resting in bed watching television (TV). The resident was receiving humidified oxygen by nasal cannula (NC) from a concentrator, which the surveyor observed to be set to 1.5 liters per minute (lpm). On 10/04/23 at 11:19 AM, the surveyor observed Resident #137 sitting in a wheelchair in their room watching TV. The resident was receiving oxygen by nasal cannula with the oxygen concentrator set to 1.5 lpm. [...]

Inspectors wroteComplaint # NJ 155924 Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure: a.) the accurate documentation of the administration of controlled medication for one unsampled resident (unsampled Resident #4) identified upon inspection of 1 of 8 medication carts (Rose Garden cart #1), b.) the shift to shift controlled medication count record was completed for 1 of 8 medication carts, (Rose Garden cart #2), c.) accurate documentation for the destruction of controlled medication for one unsampled resident (unsampled Resident #5) identified upon inspection of 1 of 8 medication carts (Rose Garden cart #2), and d.) medication was received timely from the provider pharmacy 1 of 35 residents (Resident #246) reviewed. These deficient practices were evidenced by the following: 1. [...]

Inspectors wroteComplaint # 159668 Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was provided water consistent with the need to maintain resident hydration. This deficient practice was identified for 1 of 1 resident (Resident #59) reviewed for choices and was evidenced by the following: On 10/03/2023 at 11:08 at 10:56 AM, the surveyor observed the resident seated in a wheelchair by the doorway. Resident #59 stated that they were not offered water and had to request water that day. When asked if water was offered throughout the day, Resident #59 denied. On 10/04/2023 at 11:46 AM, the surveyor observed the resident sitting by the doorway of their room. There was no water cup at the resident's bedside. The resident stated that they had requested water and did not get any that day. [...]

Inspectors wroteComplaint # 159668 Based on interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice by not documenting pertinent clinical documentation on the resident's medical record for a resident who was transferred to the hospital. This deficient practice was identified for 1 of 4 residents (Resident #249) reviewed for hospitalization and was evidenced by the following: The surveyor reviewed the medical record for Resident #249. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Atrial Fibrillation. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care for 2 of 35 residents (Resident's #115 and #119 ) reviewed for resident assessment. This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #115 had diagnoses which included but were not limited to; kidney disease and nutrional deficiency. A review of Resident #115's progress note revealed that the resident was discharged from the facility on 8/14/23 and readmitted on [DATE]. A review of Resident #115's MDS records revealed that there was no entry MDS completed when the resident was readmitted back to the facility. 2. According to the admission Record, Resident #119 had diagnoses which included but were not limited to; [...]