Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Careone At Livingston during CMS and state inspections, most recent first.
A resident with extensive burns and skin grafts did not receive timely or correctly ordered burn treatment as recommended by a consulting physician. The order for cocoa butter application was delayed and entered at a lower frequency than prescribed, and the product was not available for use until several days after approval. Both the LPN and DON confirmed the delay and the incorrect frequency of administration.
A resident assessed as low risk for pressure ulcers developed a facility-acquired pressure injury that was not promptly assessed or documented. Initial nursing notes described skin changes, but no wound assessment or new interventions were implemented at the time. The wound was not measured or staged until ten days later, and treatment orders were delayed. The DON confirmed that required assessment and documentation were not completed when the wound was first identified.
Late MDS Transmission: The facility failed to transmit required MDS assessments on time for three residents. A resident with dementia had a discharge return not anticipated assessment completed but not submitted, another resident with dementia had a quarterly MDS completed but not submitted, and a resident with CKD had an annual MDS completed and submitted late. The MDS Specialist RN confirmed the late and missing transmissions and stated there was no check-and-balance system.
Failure to provide an individualized activity program for a resident with intact cognition and major physical limitations. The resident’s MDS showed little interest or pleasure in doing things and identified preferences such as music, animals, reading, news, fresh air, and religious services, but no activity assessment or activity care plan was found in the record. Staff reported the resident stayed in bed, had not attended group activities, and had not received planned 1:1 activities based on her interests, despite stating she wanted group activities and to go outside.
Incorrect Diet Texture Served to a Resident with Dysphagia: A resident with dysphagia, missing teeth, and documented swallowing and self-feeding difficulty was ordered a heart healthy minced and moist diet, but was served regular texture meals instead. Family members reported the wrong texture at meals and prevented the resident from eating hot dog and chicken items that were not consistent with the ordered diet. Staff, including the Dining Room Lead, RD, UM LPN, ST, and DON, confirmed the tray card and meal service reflected regular texture rather than the prescribed minced and moist texture.
A resident with multiple chronic conditions, including CHF and leukemia, did not consistently receive an ordered cyanocobalamin supplement because the pharmacy did not have the prescribed dose available. MAR review showed multiple missed administrations, and staff notes documented the medication was unavailable on several occasions. Interviews with the LPN/UM, DON, and consultant pharmacist confirmed ongoing pharmacy delivery problems and that the physician was not documented as being aware of the issue until the order was changed to a dose the facility had in stock.
Two residents had inaccurate ADL documentation showing showers and/or tub baths that did not occur. One resident with paraplegia and a stage four pressure ulcer, and another resident with CVA-related hemiplegia/hemiparesis, both stated they had only received bed baths since admission, while the UM and DON confirmed staff had incorrectly coded bed baths as showers. The shower room had shower stalls and no tubs.
The facility failed to electronically transmit the MDS within the required 14 days for three residents and did not complete the discharge assessment for one resident. The delays were attributed to the lack of a full-time MDS Coordinator since December 2023, with only a part-time coordinator working remotely and regional staff overseeing the assessments.
A resident with anemia and chronic kidney disease did not receive Procrit as prescribed due to the LPN's failure to obtain necessary lab results, follow up with the pharmacy, or contact the physician for further instructions. The DON acknowledged the LPN did not follow proper procedures, leading to missed doses of Procrit on multiple occasions.
The facility failed to ensure medications were administered without error, resulting in a 12% error rate. Errors included improper timing of Glipizide administration, incorrect dosage of Docusate, and use of an incorrect Lidospot patch instead of the prescribed lidocaine 5% patch. These deficiencies were identified for two residents.
Delay and Incomplete Implementation of Burn Treatment Orders
Penalty
Summary
The facility failed to promptly implement a physician's recommendation for burn treatment and did not ensure the treatment was ordered at the recommended frequency. A resident with a history of extensive burns and skin grafts, who was cognitively intact, was admitted with orders from a Burn/Wound center physician to apply cocoa butter to all healed areas three times daily. However, the physician order entered into the Electronic Medical Record (EMR) two days after the consultation specified application only once per day shift and only to certain areas, not matching the recommended frequency or coverage. Further review showed that the cocoa butter was not available until several days after the order was approved, resulting in a delay in treatment. Interviews with the LPN and DON confirmed that the treatment was not provided as frequently as recommended and that there was a delay in obtaining the medication. The DON was unaware of both the delay in receiving the cocoa butter and the discrepancy in the frequency of administration compared to the physician's recommendation.
Failure to Timely Assess and Intervene for Facility-Acquired Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident, assessed as low risk for pressure ulcers, developed a facility-acquired pressure ulcer. Initial nursing documentation noted blanchable, thick, hard, indurated skin on the left buttock, but no wound assessment was completed at the time of identification. The physician and family were notified, but subsequent progress notes and monthly summaries failed to address or document the new wound. There was a lack of timely and thorough wound assessment, as the wound was not measured or staged until ten days after initial identification, at which point it was found to be an unstageable pressure injury by the wound specialist. The care plan for the resident included general interventions for skin integrity, such as barrier cream and preventative skincare, but no new interventions were added when the wound was first identified. Documentation conflicted regarding when specialty support surfaces were provided, and there were no corresponding physician orders or care plan entries for these interventions at the time of wound identification. Treatment orders for the wound were not initiated until several days after the wound was first noted, and the first administration of the treatment occurred a week later. Interviews with the DON confirmed that the wound was facility-acquired and that an initial assessment and documentation were not completed as required. The DON acknowledged that a documented assessment and measurement should have occurred when the wound was first identified. Facility policy required evaluation, reporting, and documentation of skin changes, as well as ongoing review of interventions, but these steps were not followed in this case.
Late MDS Transmission
Penalty
Summary
The facility failed to ensure that three residents’ MDS assessments were transmitted within the required timeframe. Review of the CMS RAI manual showed that discharge return not anticipated, annual, and quarterly assessments must be completed and transmitted within specified time limits after the ARD or completion date. In this sample, R28 was readmitted with a diagnosis of dementia and had a discharge return not anticipated MDS with an ARD of 04/29/25; the MDS was completed on 05/05/25, but there was no evidence it was submitted, and the assessment history stated it was never added to a batch. R50 was readmitted with a diagnosis of dementia and had a quarterly MDS with an ARD of 07/15/25; the MDS was completed on 07/29/25, but there was no evidence it was submitted, and the assessment history stated it was never added to a batch. R67 was admitted with chronic kidney disease and had an annual MDS with an ARD of 10/10/24; the MDS was completed on 10/31/24 and submitted on 11/04/24, and the assessment history showed the annual assessment was batched and accepted on 11/04/25. During interview, the MDS Specialist RN confirmed that the assessments for R28 and R50 were not submitted within the appropriate timeframe and stated that R67’s assessment was completed and submitted late.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to ensure that one resident with intact cognition and significant physical limitations was provided a meaningful, individualized activity program. The resident was admitted with diagnoses including paraplegia and a stage four pressure ulcer, had a BIMS score of 15 out of 15, and was identified on the admission MDS as having little interest or pleasure in doing things half or more of the days in the assessment period. The MDS also showed activity preferences that were important to the resident, including listening to music and being around animals, with other preferences such as reading, keeping up with the news, going outside for fresh air, and participating in religious services noted as somewhat important. The CAA Summary indicated the resident triggered for further assessment in the area of Activities and that Activities would be addressed on the Care Plan. However, the EMR contained no activity assessment beyond the MDS/CAA, no activity progress notes, and no activity care plan. The Activity CAA Worksheet identified only a prior preference for group activities and noted depression or anxiety and unstable health problems as factors affecting participation. The Director of Recreation reviewed the record and confirmed there was no Activity Evaluation and no activity care plan for the resident. During interviews, the resident stated she would like to go to group activities and would love to go outside, but she had not participated in any group activities since admission and had not gone outside. She reported staying in bed most of the time, using therapy as her main daily activity, and occasionally watching television or reading books. Staff stated she required a Hoyer lift to get out of bed and had not attended activities, while the Recreation Assistant said she did daily room rounds and brought an activity cart but did not have planned one-to-one visits based on the resident’s interests. The Director of Recreation stated the resident liked dogs, but the resident had not been provided pet visits through the activity programming.
Incorrect Diet Texture Served to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that one resident with dysphagia received the physician-ordered therapeutic minced and moist diet texture. R70 was admitted with diagnoses including difficulty swallowing, had missing teeth, and was documented by the Nutrition Evaluation and Speech Therapist as having swallowing difficulty, self-feeding difficulty, and food pocketing in the mouth. Her care plan included a goal to tolerate the prescribed diet texture and fluid consistency without signs and symptoms of aspiration, and the diet order in the EMR remained heart healthy with minced and moist texture throughout her stay. During the weekend, R70 was served regular texture food instead of the ordered minced and moist texture. The family member present at meals stated R70 was served a hot dog on a bun for lunch on one day and a regular piece of chicken on another day, and the family prevented her from eating those items. The family member reported the incorrect texture to nursing and speech therapy. The tray card for lunch showed heart healthy regular texture, and the daily spreadsheets showed that regular texture meals included a hot dog and baked chicken, while minced and moist meals should have been ground hot dog and ground chicken with gravy or sauce. Staff interviews confirmed the mismatch between the physician’s order and the food served. The Dining Room Lead and RD verified that R70 had been served inappropriate food, and the UM LPN stated she observed an untouched whole piece of chicken with a tray card indicating regular texture instead of minced and moist. The UM stated she rewrote the diet communication form, while the RD and DON stated they did not know how the tray card system changed the texture and that there was no mechanism to track who or when the change occurred. The ST confirmed the resident’s diet texture had not changed and stated that serving regular texture foods created a potential choking or aspiration risk for R70.
Medication Not Consistently Available as Ordered
Penalty
Summary
The facility failed to ensure that one resident received medications from the pharmacy as ordered by the physician. Resident 72 was admitted with diagnoses including wedge compression fracture of T11-T12 vertebra with routine healing, chronic myeloid leukemia, protein-calorie malnutrition, and congestive heart failure. The resident had an order for Cyanocobalamin Oral Tablet 250 MCG, one tablet by mouth in the evening for supplement, which was later discontinued. Review of the MAR showed the medication was not administered on multiple occasions and was given for only eight of fourteen opportunities. Progress notes documented that on several dates the medication was unavailable for administration. The only documented physician contact regarding the issue occurred later, when staff informed the physician that the 250 MCG dose was not available and that 100 MCG and 500 MCG were in stock; the physician then ordered the 100 MCG dose. The record did not show that the physician had previously been made aware that the ordered dose was not consistently available. During interviews, the LPN/UM stated she was not aware why the resident was not consistently receiving the medication and would find out. The DON and LPN/UM stated the nurse had contacted the physician and the order was changed to a dose the facility kept in stock, but they also confirmed there was no documentation that the physician had been aware the original dose was not readily available. Staff interviews reflected that nurses were expected to contact the pharmacy and physician when a medication was unavailable and document the issue in the EMR, and the consultant pharmacist confirmed there had been ongoing concerns with pharmacy delivery.
Inaccurate Bathing Documentation for Two Residents
Penalty
Summary
Medical records were inaccurate for two residents reviewed for ADLs because the documentation showed showers and/or tub baths that had not actually occurred. The facility’s policy required all services provided to residents to be documented in the medical record, but the records for one resident with paraplegia and a stage four pressure ulcer, who was dependent on staff for showers and rarely got out of bed, showed multiple showers and tub baths despite staff and the resident stating she had only received bed baths since admission. The Unit Manager and DON both confirmed the shower and tub bath documentation was inaccurate, and the DON stated a CNA had coded bed baths as showers. A second resident with a CVA, hemiplegia, and hemiparesis, who required substantial to maximal assistance with bathing and had a BIMS score of 15, also had records showing multiple showers even though the resident stated she had only received bed baths since admission. The Unit Manager stated the resident had received only bed baths previously and that the first shower occurred later, while the DON confirmed the aide had not coded the shower records accurately and that the resident had not received showers before that time. Observation of the facility’s shower room showed three shower stalls and no tubs for tub baths.
Failure to Timely Transmit MDS and Complete Discharge Assessment
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) within the required 14 days of completing the resident's assessment, as mandated by the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficiency was identified for three residents. Resident #25's Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 12/11/23, was not submitted until 1/9/24. Resident #26's Admission MDS assessment, with an ARD of 2/13/24, was not submitted until 2/29/24. Resident #39's Annual MDS assessment, with an ARD of 10/21/23, was not submitted until 11/16/23, and a Quarterly MDS assessment with an ARD of 1/21/24 was not submitted until 2/8/24. The MDS Coordinator/RN confirmed these delays and attributed them to the lack of a full-time MDS Coordinator since December 2023, with only a part-time coordinator working remotely and regional staff overseeing the assessments. Additionally, the facility failed to complete the discharge assessment for Resident #48, who was discharged home on 11/30/24. The resident's electronic MDS records showed an Entry/MDS 3.0 accepted on 11/17/23 and a Medicare-5 day/MDS 3.0 completed on 11/24/23, but no discharge MDS was present. The Regional MDSC/RN acknowledged the missing discharge MDS during an interview and stated that she would open a discharge MDS immediately. The deficiencies were confirmed through interviews with the MDS Coordinator/RN and the Regional MDSC/RN, who both acknowledged the late submissions and the missing discharge assessment. The facility management did not provide any additional information during the survey team's meeting. According to the Long-Term Care Facility RAI 3.0 User's Manual, the MDS must be completed and transmitted within 14 days of the assessment being completed, and a discharge assessment must be completed and transmitted within 14 days of the discharge date.
Failure to Administer Procrit According to Physician's Order
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring the administration of Procrit according to a physician's order for a resident with anemia and chronic kidney disease. The resident's medical record indicated a physician's order for Procrit to be administered subcutaneously every Wednesday evening, with the condition to hold the medication if hemoglobin (Hgb) levels were 10 or greater. However, the electronic Medication Administration Record (eMAR) and nursing Progress Notes (ePN) showed discrepancies in the administration and documentation of Procrit, including instances where the medication was not administered due to the absence of Hgb results or lack of medication supply, without proper follow-up or documentation by the Licensed Practical Nurse (LPN). The LPN failed to obtain necessary lab results, follow up with the pharmacy, or contact the physician for further instructions, leading to missed doses of Procrit on multiple occasions in February and March. The Director of Nursing (DON) acknowledged that the LPN did not follow proper procedures for ensuring the lab results were obtained and the medication was administered according to the physician's order. The DON explained that on one occasion, the resident had gone to the hospital, resulting in no lab results to base the administration of Procrit. On another occasion, the lab results were obtained but not posted in time, and the LPN used outdated Hgb results to make a decision. Additionally, the LPN documented that the medication was not available on two dates but did not follow up with the pharmacy or report the issue to the next shift or administration. The facility's policy for administering medications states that medications should be administered in a safe and timely manner, as prescribed, and any results achieved should be recorded in the resident's medical record. The DON and Licensed Nursing Home Administrator (LNHA) stated that moving forward, any medication not available from the provider pharmacy should be reported to administration for additional follow-up to ensure either obtaining the medication or follow-up by a physician. The DON acknowledged that the LPN had attended an in-service training on the procedure to follow when a medication was not available but did not adhere to the procedure.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 12%. During the medication administration observation, the surveyor observed four nurses administering medications to six residents, with three errors out of 25 opportunities. One error involved an LPN administering Glipizide to an unsampled resident without ensuring it was given 30 minutes before the meal as required by the physician's order. Another error involved an LPN administering two capsules of Docusate 100mg to Resident #26 without confirming the correct dosage, as the order did not specify the strength or dosage. Additionally, the same LPN administered a Lidospot patch containing 4% lidocaine and 1% menthol instead of the prescribed lidocaine 5% patch, which was not available in the medication cart. The surveyor confirmed these errors through interviews with the LPNs and the Consultant Pharmacist, as well as a review of the electronic Medication Administration Record (eMAR) and medication information sheets. The facility's policy on administering medications, which requires medications to be administered in accordance with prescriber orders and within one hour of the prescribed time, was not followed. The policy also mandates that the individual administering the medication checks the label three times to verify the right resident, medication, dosage, time, and method of administration before giving the medication. These deficiencies were identified for two of the six residents observed during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Livingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inglemoor Rehabilitation And Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Cheshire Home | 2.7 mi | ★★★★★ | 8 | 0 |
| Livingston Post Acute Care | 2.7 mi | ★★★★★ | 21 | 0 |
| Stratford Manor Rehabilitation And Care Center | 2.9 mi | ★★★★★ | 10 | 0 |
| Alaris Health At West Orange | 3.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.