Big Oak Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Big Oak Rehabilitation and Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF802Mar 26, 2026

  Complaint #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. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2024

  Complaint #: 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. […]

• No harm, potential for more than minimal, widespreadF880Dec 11, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF814Mar 26, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF881Mar 26, 2026

  Based 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. […]