Our Ladys Center for Rehabilitation & Healthcare

In the surveyor’s words

From the most serious findings on record at Our Ladys Center for Rehabilitation & Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF808Jun 1, 2022

  C#: NJ 1, NJ 5 Based on observations, interviews, medical record review, and review of other pertinent facility documents on [DATE] & [DATE], it was determined that the facility failed to (a) prepare a mechanical soft diet at the correct texture and consistency, (b) obtain a Physician's Order and notify the Physician of a change in diet and (c) follow the residents plan of care for a resident who had a history of Dysphagia. The facility also failed to follow its policies titled Care Plans, Therapeutic and Mechanically Altered Diets, the 2018 DHCC (Dietetics in Health Care Communities) Manual of NJ (New Jersey), Textured Modified Diets, Resident Nutrition Services, Change in Resident Condition and Physician Orders. […]

• No harm, potential for more than minimal, widespreadF812Jun 16, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 22, 2023

  FACILITY 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. […]

• No harm, potential for more than minimal, patternF584Dec 31, 2024

  Complaint # 179819 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep all areas clean, in good repair and, a bed rail in place. The deficient practice was identified for 3 of 4 residents reviewed under the Environmental Task and 4 out 4 nourishment rooms. The deficient practice was evidenced by the following: On 12/16/2024 at 10:01 AM during the initial tour of the facility, the surveyor # 1 observed Resident # 11's bathroom. At that time, surveyor # 1 observed a toilet paper dispenser mounted to the wall that was crooked and appeared loose. There were also stains located on the floor near the resident's window. Lastly, surveyor # 1 observed stains on the wall outside the bathroom door. […]

• No harm, potential for more than minimal, patternF761Dec 31, 2024

  Based 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. […]