St Mary's Center for Rehabilitation & Healthcare

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Dec 6, 2024

  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 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. […]

• No harm, potential for more than minimal, widespreadF847Dec 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF804Oct 19, 2023

  REPEAT 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. […]

• No harm, potential for more than minimal, widespreadF865Oct 19, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF806Feb 27, 2025

  Complaint #: 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. […]