South Orange Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at South Orange Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Sep 27, 2022

  Based on observations, record review and interview, the facility Administration failed to maintain an effective maintenance program to address roof leaks and failed to address identified concerns with water intrusion to maintain resident safety. On 7/11/2022, the facility failed to address identified concerns to ensure the roof of the building was maintained to prevent water intrusion and possible ceiling collapse. The facility used approximately 40 basins placed above the ceiling tiles throughout the facility to collect water from leaks in the roof. Several saturated ceiling tiles had fallen in resident rooms, with one that fell and cracked the light fixture above a resident's bed. […]

• Immediate jeopardy, widespreadF837Sep 27, 2022

  Based on observations, interview and record review, the facility's Governing Body failed to implement policies regarding the management and operation of the facility to ensure the building's roof was maintained to prevent water intrusion and possible roof collapse and failed to maintain a safe environment for residents, staff, and visitors. On 7/11/2022, the facility administration failed to address identified concerns to ensure the roof of the building was maintained to prevent water intrusion and possible ceiling collapse. The facility used approximately 40 basins placed above the ceiling tiles throughout the facility to collect water from leaks in the roof. […]

• Immediate jeopardy, widespreadF921Sep 27, 2022

  Based on observation, interview and record review, the facility failed to ensure the roof was maintained to prevent water intrusion and subsequent failure of other life safety systems such as fire walls and possible ceiling collapse, which compromised the safety of 107 residents. On 7/11/2022, the facility failed to address identified concerns to ensure the roof of the building was maintained to prevent water intrusion and possible ceiling collapse. The facility used approximately 40 basins placed above the ceiling tiles throughout the facility to collect water from leaks in the roof. Several saturated ceiling tiles had fallen in resident rooms, with one that fell and cracked the light fixture above a resident's bed. […]

• Immediate jeopardy, isolatedF689Dec 28, 2021

  Based on observation, interview, and record review, the facility failed to prevent a physically impaired vulnerable resident from exiting the facility and failed to ensure the exit door was alarmed or monitored by staff for 1 of 1 resident reviewed for actual elopement, of a total sample of 7 residents reviewed for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been hit by a car or become lost. On 11/07/21 at approximately 12:42 PM, resident #1 exited the facility through an unlocked exit door on the North Wing long hallway. […]

• No harm, potential for more than minimal, patternF694Feb 13, 2025

  Based on observation, interview, and record review the facility failed to administer intravenous (IV) antibiotic and maintain an intravenous access site according to professional standards for 1 of 1 resident sampled for IVs, of a total sample of 40 residents, (#91). Findings: Review of resident #91's medical record revealed he was admitted to the facility on [DATE] with diagnoses of chronic osteomyelitis left ankle and foot, other specified noninfective gastroenteritis and colitis, generalized abdominal pain, pressure ulcer of left heel, unspecified stage. […]