Above average — CMS composite of the measures below.
The next survey window likely opens 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 Parsippany during CMS and state inspections, most recent first.
Surveyors identified that the facility failed to properly document and communicate required information during acute transfers and discharges for two residents. In one case, NTACF forms lacked resident representative details and did not include bed-hold or reserve payment information. In another case, a discharge summary was missing the resident or representative's signature, lacked evidence of communication, and contained outdated vital signs, with no physician discharge order documented.
Dignity and meal service concerns during lunch: A CNA was observed standing while feeding a resident, and the RN had to gesture for the CNA to sit before continuing. In another dining room, one resident was left waiting to be fed while others were already eating, and a meal tray was not placed in front of the resident until after the surveyor asked about it. The DON acknowledged that it was not appropriate for a resident to wait while everyone else was eating and that residents have the right to be served meals at the same time.
A resident was observed in bed with the call bell on the floor and not within reach. The resident had diagnoses including brain cancer, HTN, and generalized muscle weakness, and the care plan identified a fall risk with an intervention to reinforce calling for assistance. A CNA later placed the call bell on the bed after the surveyor noted it was inaccessible, and the facility policy stated the call light should be accessible when the resident is in bed.
Two residents had incomplete SNFABN notices when Medicare Part A coverage ended. The forms left required fields blank, including the reason services were ending, the estimated daily cost, and the resident or RR decision options; one form used “Medicaid rate” instead of a dollar amount. Interviews with the DSW, LPN CRC, BOM, and LNHA showed confusion about the required billing information and no documented explanation for the missing entries.
A facility failed to revise comprehensive care plans to match current resident status. One resident’s CP still addressed an indwelling urinary catheter even though the catheter had been removed and the resident returned from the hospital without one. Another resident’s CP continued to list contact isolation for ESBL UTI, while surveyors observed enhanced barrier precautions posted outside the room and the resident was not listed on the facility’s contact isolation report.
Incorrect Daily Staffing and Census Posting: The facility failed to ensure the NHRCSR accurately reflected licensed nurse staffing, CNA staffing, and resident census at the start of the shift on two observed days. Surveyors found the posted census did not match the alphabetical census list or Daily Attendance Report, and the LNHA confirmed the posted census was inconsistent and that the SC posted a projected census before later updating it.
An RN administered acetaminophen to a resident who reported leg pain rated 4, but the resident’s MAR contained unclear PRN pain orders, including duplicate Tylenol and tramadol orders for moderate pain and no pain scale order to distinguish mild, moderate, or severe pain. The resident was cognitively intact and admitted with a right femur fracture; the CP noted duplicate and missing PRN indications, and the DON acknowledged the acetaminophen order had no indication and that there was a duplicate moderate-pain order.
An expired e-kit was found on Unit 1 on the bottom shelf of a bookcase that also held resident charts. The inventory sheet attached to the kit identified it as kit #47, while the facility CP report for the unit inspection incorrectly indicated the kit contents were in date. The CP stated expired or soon-to-expire items should be replaced and returned to the pharmacy, and acknowledged the facility had difficulty getting the pharmacy to pick up expired e-kits.
Facility Assessment Missing Staffing Contingency Plan and Required Ratios: The LNHA and DON stated the facility had 90 residents plus 1 bed hold, but the most current FA dated 9/11/25 did not include the required CNA-to-resident ratio or a staffing contingency plan. The LNHA provided a staffing grid based on a census of 98 and later produced an older draft FA dated 6/9/24 that contained some contingency plan information, while stating the general staffing backup plan was to contact agency partners, continue hiring, and offer referral bonuses.
A resident admitted for respite care with anoxic brain damage and depression had no physician H&P in either the paper chart or EHR when the surveyor reviewed the record. The DON confirmed the H&P was not completed in the chart, and a physician progress note was later entered after surveyor inquiry. The LNHA later found a paper H&P filed among other resident records and stated it should have been in the resident’s medical record and readily accessible.
A resident with multiple chronic conditions and diabetic foot ulcers did not receive care in accordance with professional standards when repeated recommendations from the wound care consultant for physician follow-up, including consideration of antibiotics and a bone scan, were not documented as communicated to or acted upon by the primary physician. Nursing staff noted changes in the wound's condition, but there was no evidence of required physician notification or follow-up in the medical record, contrary to facility policy.
A facility failed to maintain proper kitchen sanitation practices, as a chef was observed performing hand hygiene incorrectly by scrubbing hands for less than the required 15 seconds. The facility's policy specifies a minimum of 15 seconds for hand scrubbing, but the chef only scrubbed for 12 and 8 seconds in two separate instances.
A facility failed to accurately code the MDS for a resident, incorrectly documenting the discharge status as to an acute hospital instead of home. The error was acknowledged by the MDS Coordinator and confirmed by the facility's clinical staff. The resident had a medical history including pneumonitis and diabetes.
A facility failed to initiate a baseline care plan for a resident admitted with a stage 2 pressure ulcer. Despite the resident's severe cognitive impairments and documented pressure ulcer, the care plan did not address this condition. The Director of Nursing acknowledged the oversight, which was contrary to the facility's care plan policy.
The facility failed to clarify medication administration routes for a resident who was NPO, did not document a nursing assessment for a resident transferred for surgery, and neglected to document colostomy care for another resident. These deficiencies were acknowledged by the nursing staff, indicating lapses in adhering to standard procedures and documentation requirements.
A facility failed to consistently assess and document post-dialysis care for a resident with End Stage Renal Disease, as evidenced by incomplete records in the Hemodialysis Communication binder. Despite the care plan's requirement for coordination with the dialysis center, numerous instances of incomplete documentation were found from May to August 2024. Interviews with the RN Supervisor and DON confirmed the oversight, and the DON acknowledged the use of outdated forms lacking necessary sections.
The facility failed to administer medications on time and did not notify the physician for a resident with Depression and Sepsis. Gabapentin and Vancomycin were administered late on multiple occasions, and there was no documentation of notifying the primary care physician or evidence of harm to the resident.
Deficient Documentation and Notification During Transfers and Discharges
Penalty
Summary
The facility failed to ensure proper documentation and notification regarding acute transfers and discharge procedures for two residents. For one resident who experienced unplanned transfers to an acute hospital, the Notice of Transfer to Acute Care Facility (NTACF) forms did not include required information about the resident representative (RR), such as contact details and confirmation of notification. Additionally, there was no documentation that the RR was informed about the facility's bed-hold policy or reserve payment, as required by both facility policy and state regulations. The Director of Nursing (DON) and Director of Admissions (DA) confirmed that these omissions occurred, and the forms were not fully completed, including missing the billing rate information. For another resident who was discharged, the discharge summary lacked the signature of the resident or RR, and there was no evidence that the discharge summary or instructions were communicated to them. The discharge summary also contained outdated vital signs, with the last recorded measurements taken several hours before the actual discharge time. Furthermore, there was no documented physician order for the discharge, and the facility's policy requiring assessment and documentation of the resident's condition at discharge was not followed. These deficiencies were identified through interviews and record reviews conducted by surveyors, who found that the facility did not adhere to its own policies or regulatory requirements regarding notification, documentation, and communication with residents and their representatives during transfers and discharges.
Dignity and meal service concerns during lunch
Penalty
Summary
The facility failed to maintain the dignity of two unsampled residents during lunchtime dining observations in two dining rooms. In unit 2, CNA #1 was observed standing while feeding Resident #44 with a weighted spoon and a three-compartment dish plate. The surveyor, UC, RN, RN/UM, and DON all observed the CNA continuing to feed the resident while standing, and the RN had to gesture for the CNA to sit down before the CNA complied. Resident #44's care plan did not include any direction or preference for staff to stand while feeding, and the record review found no documented evidence that standing while feeding was the resident's preference. In unit 1, the surveyor observed 15 residents in the dining area with four staff feeding residents and a recreation staff member assisting others. Resident #39 was seated in a Geri chair with a side table and had no meal tray in front of them, while other residents were eating lunch. Another resident, Resident #115, was also observed without actively eating at that time. The recreation staff member stated that all residents in the dining area had received and started lunch around 12:00 PM except Resident #39, who was waiting for the nurse to feed the resident, and stated that the two trays on the side table were for Residents #39 and #115. The LPN later placed the meal on the side table near Resident #39 and left without feeding the resident, and CNA #2 then began feeding Resident #39. The facility's Meal Delivery Times indicated lunch service was scheduled for 12:15 PM, with a possible variance of plus or minus 10 minutes. The DON stated that it was not appropriate for a resident to wait to be fed while everyone else was eating and acknowledged that residents' rights included being served meals at the same time. The facility's Resident Rights Policy stated that employees shall treat all residents with kindness, respect, and dignity, and the Dining Room Audits Policy stated that residents at each table are to be served together.
Call Bell Not Within Reach of Resident in Bed
Penalty
Summary
The facility failed to ensure that Resident #9’s call bell was within reach and accessible while the resident was in bed. During an initial tour, the surveyor observed the resident in bed with the call bell on the floor, not on the bed and not within the resident’s reach. When asked whether they used the call bell for help, the resident shrugged their shoulders. A CNA then entered the room and placed the call bell on the bed next to the resident after the surveyor’s observation. Resident #9’s record showed diagnoses including malignant neoplasm of the brain, essential hypertension, and generalized muscle weakness. The resident’s MDS indicated a BIMS score of 99, showing the resident was unable to complete the interview. The care plan dated 11/11/25 identified the resident as at risk for falls and included an intervention to reinforce the need to call for assistance. The facility’s policy stated that the call light should be accessible to the resident when in bed.
Incomplete Beneficiary Notices for Medicare Coverage Ended
Penalty
Summary
The facility failed to thoroughly complete the required written beneficiary notices for two residents, identified in the report as Residents #7 and #44, when their Medicare Part A coverage ended and they remained in the facility. For Resident #44, the SNF Beneficiary Protection Notification review showed the last covered Medicare A day was 12/3/25, and the SNFABN form contained blanks for the care area that was no longer occurring daily, the estimated cost per day per item or service, and the resident or resident representative’s decision options after Medicare A coverage ended. The resident’s MDS also showed end of PPS with an ARD of 12/3/25. For Resident #7, the SNF Beneficiary Protection Notification review showed the last covered Medicare A day was 5/31/25, and the SNFABN form contained blanks for the estimated cost per day per item or service and the decision options for the resident or resident representative. The form included handwritten information of “Medicaid rate” instead of a dollar amount. The resident’s MDS also showed end of PPS with an ARD of 5/31/25. The report states there was no documented evidence in either resident’s medical record explaining why the information was left blank, including the reason for ending Medicare Part A for Resident #44, the dollar amount the resident or resident representative would incur if services continued, and the resident or resident representative’s decision. During interviews, the LPN Clinical Reimbursement Coordinator stated she covered for Social Work to notify the resident or resident representative of the required beneficiary notice and acknowledged the SNFABN should be thoroughly filled out, but was unsure whether the dollar amount was required and had no explanation for the blanks. The Director of Social Work stated she was responsible for sending the NOMNC and SNFABN, but was unaware of the facility rates and said she left messages rather than speaking with the resident representative, and she had no answer for why the forms were incomplete. The Business Office Manager stated the private pay rate was $675, Medicaid had a fixed daily rate that changes annually, and Medicare rates vary by resident MDS RUG, but had no response when asked whether the SNFABN should contain a specific dollar amount. The LNHA later acknowledged the forms were not fully completed, including the rate, and stated the residents had transitioned from Medicare to Medicaid, but the transition for the new billing rate was not completed or fulfilled according to regulation.
Care Plans Not Updated to Match Current Resident Status
Penalty
Summary
The facility failed to update and revise comprehensive care plans to reflect residents’ current status. For one resident admitted with multiple fractures and anemia, the comprehensive care plan included a focus area for use of an indwelling urinary catheter, but the resident’s physician orders did not include an indwelling catheter and progress notes documented that the catheter had been removed without complication. The record also reflected that after a hospitalization and return to the facility, the resident did not have an indwelling catheter, yet the care plan remained unchanged and still addressed catheter use. For another resident admitted with diagnoses including UTI, cognitive communication deficit, cough, and neurogenic bladder, the comprehensive care plan included infection of urinary tract with ESBL in urine and an intervention to maintain contact isolation precautions. However, the facility’s order listing for residents maintained on contact isolation did not include this resident. Surveyors observed a posted sign for enhanced barrier precautions outside the resident’s room, and the DON confirmed the sign was present, but the care plan did not reflect enhanced barrier precautions and instead continued to document contact isolation precautions. During interviews, the RN stated the resident no longer had an indwelling catheter and acknowledged she did not update the care plan. The RN/UM stated that when the resident returned from the hospital, the nurse should have resolved the indwelling catheter care plan. For the second resident, the DON stated that care plans were revised collaboratively, but did not explain why the care plan was not updated to match the observed enhanced barrier precautions. The facility policy stated that care plans are revised when a resident’s condition changes and when a resident is readmitted from a hospital stay.
Incorrect Daily Staffing and Census Posting
Penalty
Summary
The facility failed to ensure that the Nursing Home Resident Care Staffing Report (NHRCSR) accurately reflected the licensed nurse staffing, certified nursing assistant staffing, and resident census at the beginning of the current shift on 2 of 5 observed days. On 12/15/25 at 9:00 AM, the survey team observed the NHRCSR posted at the front desk showing a census of 85 for the day shift, while the LNHA later provided an alphabetical census listing a total census of 90 and confirmed that the census was 90. On 12/16/25 at 9:00 AM, the posted NHRCSR showed a resident census of 90, but the LNHA then provided a Daily Attendance Report listing a total census of 94, and stated there was one bed hold, leaving 93 residents present in the facility. During interview, the LNHA stated that the Staffing Coordinator was responsible for posting the staffing report in the morning and that the SC posted the projected census and then updated it when she arrived. When asked whether the posted census and the alphabetical census list should be consistent, the LNHA acknowledged that they were not consistent. At 10:09 AM on 12/16/25, the DON provided an updated NHRCSR showing a revised census of 94. On 12/19/25, the LNHA and DON confirmed that the posted staff census was incorrect for the two observed days.
Unclear PRN pain orders led to unnecessary medication use
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary medications when an RN administered acetaminophen during a medication pass for leg pain rated as 4. The resident was cognitively intact with a BIMS score of 15 and had been admitted with diagnoses including a fracture of the right femur and essential hypertension. At the time of the med pass, the resident reported leg pain, and the RN gave acetaminophen 325 mg, 2 tablets. Review of the EMR showed PRN orders for acetaminophen 325 mg, 2 tablets every 6 hours for pain, as well as tramadol 50 mg every 12 hours PRN for moderate pain and another tramadol 50 mg every 12 hours PRN for severe pain. The record did not include a physician order for a pain scale, and the orders did not clearly distinguish which medication should be used for which level of pain. The consultant pharmacist identified a duplicate Tylenol PRN order and missing indications for mild and severe pain, and asked that the orders be clarified so all pain levels were covered. During the survey, the DON acknowledged that the acetaminophen order given at the time had no indication and that there was a duplicate order for moderate pain. The facility policy on administering medications did not address duplicate orders or sequencing of PRN orders.
Expired E-Kit Stored on Unit
Penalty
Summary
The facility failed to properly store medication per manufacturer specifications and standards of practice for 1 of 1 emergency medication kits observed in the medication storage area. During inspection of Unit 1, the surveyor observed an e-kit on the bottom shelf of a bookcase that also contained resident charts. The inventory sheet attached to the kit showed the shortest expiration date for a medication in the kit and identified the kit as #47. The facility’s Consultant Pharmacist report for the unit inspection reflected that the contents of each emergency kit were in date, despite the surveyor’s observation of an expired e-kit. The surveyor interviewed the Consultant Pharmacist by telephone, and the pharmacist stated that unit inspections were performed and that expired or soon-to-expire items should be replaced and returned to the pharmacy. The pharmacist acknowledged that the facility had been having difficulty getting the pharmacy to pick up expired e-kits and stated the kit should have been removed from the unit. The survey team then notified the LNHA and DON of the expired e-kit, and the DON stated it would be returned to the pharmacy that day. The facility’s Medication Labeling and Storage Policy stated that outdated medications or biologicals are to be returned through the dispensing pharmacy, and the Pharmacy Services policy stated the consultant pharmacist is to determine the contents of the emergency supply and review medication storage areas at least monthly for proper storage and expired medications.
Facility Assessment Missing Staffing Contingency Plan and Required Ratios
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was reviewed and updated to identify the services and procedures needed to protect the health, safety, and welfare of all residents, specifically regarding a contingency plan for staffing and the mandatory staffing ratios. During the entrance conference, the LNHA and DON stated the facility had a census of 90 residents plus 1 bed hold, with 118 licensed beds. The LNHA provided a 17-page Facility Assessment dated 9/11/25. The staffing attachment in that assessment was based on a census of 98 residents, divided between two units, and listed CNA staffing by shift, but it did not include the required CNA-to-resident ratio of 1 CNA to 8 residents on the day shift. The assessment also did not contain any information about a contingency plan for staffing. When asked about the completeness of the assessment, the LNHA stated that the plan was complete and described a general approach of contacting agency partners, continuing to hire, and offering referral bonuses if staffing requirements were not met, but acknowledged that this was not specific in the facility assessment. The LNHA later produced a binder labeled FA that contained a draft Facility Assessment dated 6/9/24, which included some staffing contingency plan information that was not included in the updated 9/11/25 assessment. In the presence of the DON, the LNHA stated that the assessment continued in the book. The facility policy stated that the assessment is conducted annually and used to determine staffing needs, contingency planning, and continuity of operations, but the most current assessment provided did not include the contingency plan or the staffing ratio information.
Missing and Inaccessible H&P in Resident Record
Penalty
Summary
The facility failed to maintain a complete, accurate, and readily accessible medical record for a resident’s History and Physical (H&P). Resident #109 was admitted for respite care and had diagnoses including anoxic brain damage not elsewhere classified and depression. The resident’s MDS reflected short-term memory problems and moderately impaired cognitive skills for daily decision making. During record review, the surveyor found no physician H&P in the closed paper chart or in the EHR, and the LNHA confirmed there were no additional records available at that time. The DON also reviewed the EHR and confirmed that the primary physician had not completed an H&P in the record. A physician progress note was later created in the EHR after the surveyor’s inquiry, with an effective date matching the admission period, but it was still in progress and not completed. The DON stated that the physician said the H&P had been done on paper after admission but had not been placed in the resident’s medical record. The LNHA later stated the H&P was found between other resident files and acknowledged it should have been in the resident’s medical record and accessible.
Failure to Communicate and Document Physician Notification for Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the facility's own policies and procedures regarding wound care. The resident in question had multiple diagnoses, including type 2 diabetes mellitus, peripheral vascular disease, hypertension, heart failure, difficulty walking, and generalized muscle weakness. The resident was cognitively intact and had been assessed as having diabetic foot ulcers. Over the course of several weeks, wound care consultant (WCC) notes documented ongoing issues with the resident's left and right plantar heel ulcers, including changes in wound size, presence of odor, and recommendations for further interventions such as antibiotics and a bone scan. Despite repeated recommendations from the WCC to consult with the primary physician regarding possible antibiotics and a bone scan, there was no documentation in the medical record indicating that these recommendations were communicated to or acted upon by the primary physician. Progress notes from nursing staff indicated awareness of changes in the wound's condition, such as worsening appearance and odor, and stated that the Assistant Director of Nursing (ADON) and WCC would be notified. However, there was no follow-up documentation confirming that the physician was informed or that the recommended interventions were considered or implemented. Interviews with facility staff, including the ADON, LPN, and Director of Nursing (DON), revealed that the expected protocol was to notify the physician and document such communication in the electronic medical record when a wound worsened or when the WCC made recommendations. Upon review, the DON and LNHA were unable to find any incident reports, physician progress notes, or documentation of physician notification regarding the WCC's recommendations for the resident's wounds. This lack of documentation and follow-up constituted a failure to provide care in accordance with professional standards and the facility's policies.
Improper Hand Hygiene Observed in Kitchen
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, which could potentially lead to foodborne illness. During a follow-up tour of the kitchen, a surveyor observed a chef performing hand hygiene incorrectly. The chef scrubbed their hands with soap for only 12 seconds during one instance and 8 seconds during another, instead of the required 15 seconds as per the facility's handwashing policy. The chef acknowledged the mistake, believing they had scrubbed for 20 seconds. The facility's handwashing policy, revised in October 2023, specifies that hands should be scrubbed for at least 15 seconds, covering all surfaces of the hands and fingers. Despite reviewing these concerns with the Licensed Nursing Home Administrator, Director of Nursing, and Regional Clinical Nurse, no further information was provided to the surveyor.
MDS Coding Error for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency in the management of care. The surveyor found that the Discharge Assessment MDS for a resident incorrectly indicated that the resident was discharged to an acute hospital, while the nursing/clinical progress notes documented that the resident was discharged home. The MDS Coordinator admitted to making a mistake in coding the discharge status, which was confirmed during an interview with the surveyor. The resident involved had a medical history that included pneumonitis, Lyme disease, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. The error in coding was identified during a review of the resident's closed medical chart and was acknowledged by the facility's Regional Clinical Nurse, Licensed Nursing Home Administrator, and Director of Nursing. The facility's policy requires that any person completing any portion of the MDS assessment certifies the accuracy of their work, which was not adhered to in this instance.
Failure to Initiate Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to initiate a baseline care plan for a resident who was admitted with a stage 2 pressure ulcer. The resident, who had been admitted with several diagnoses including Nontraumatic Intracerebral Hemorrhage, Acute Respiratory Failure, and Dysphagia, was found to have severely impaired decision-making skills and memory problems. Despite these conditions, the resident's interdisciplinary person-centered comprehensive care plan did not identify the presence of a pressure ulcer upon admission. The deficiency was identified during a review of the resident's medical records and confirmed through an interview with the Director of Nursing, who acknowledged the omission. The facility's policy on care plans, which requires interventions to be derived from a comprehensive assessment, was not followed in this case. The care plan failed to address the pressure ulcer, which was documented in the admission nursing assessment, indicating a lapse in the facility's adherence to its own policies and procedures.
Deficiencies in Medication Administration, Documentation, and Colostomy Care
Penalty
Summary
The facility failed to clarify a physician's order for medication administration for a resident who was NPO (nothing by mouth). Resident #22, who had a PEG-tube for feeding, was observed to have incorrect medication routes documented in their medical records. The medications were ordered to be given by mouth, despite the resident's NPO status. This discrepancy was acknowledged by the nursing staff, indicating a failure to ensure that the medication administration route was appropriate for the resident's condition. In another instance, the facility did not document a nursing assessment for Resident #64, who was transferred to the hospital for a scheduled surgical procedure. The medical records lacked documentation of a full body assessment, vital signs, and communication with the resident's family regarding the transfer. The absence of these records suggests a failure to adhere to standard procedures for documenting resident care and communication during hospital transfers. Additionally, the facility failed to document colostomy care for Resident #262 as per the physician's orders. The medical records did not reflect the required documentation of colostomy care and output every shift, as mandated by the facility's policy. This oversight was confirmed by the nursing staff, who acknowledged that the documentation should have been recorded in the electronic Treatment Administration Record (eTAR).
Incomplete Documentation of Post-Dialysis Care
Penalty
Summary
The facility failed to ensure consistent assessment, documentation, and monitoring of a resident undergoing hemodialysis. The deficiency was identified for a resident with diagnoses including End Stage Renal Disease, Diabetes, and Dementia, who attended dialysis sessions three times a week. The resident's care plan required coordination with the dialysis center and adjustments in medication as needed. However, the facility's documentation practices were found lacking, as evidenced by incomplete post-treatment records in the Hemodialysis Communication binder. The surveyor's review of the communication records from May to August 2024 revealed numerous instances of incomplete documentation, particularly in the post-dialysis treatment section. Interviews with the RN Supervisor and the DON confirmed that the nursing staff failed to consistently fill out the necessary communication sheets. The DON acknowledged the oversight and noted that older forms lacking the post-dialysis section were initially used, prompting a change in documentation forms. Despite this, the facility's policy required thorough documentation and assessment post-dialysis, which was not adhered to in this case.
Failure to Administer Medications on Time and Notify Physician
Penalty
Summary
The facility failed to administer medications in accordance with the acceptable standard of nursing practice and did not follow the facility policy on Medication Administration and Physician Services for one resident. Resident #2, who was admitted with diagnoses including Depression and Sepsis, had orders for Gabapentin and Vancomycin. The medications were not administered at the scheduled times on multiple occasions in May 2023. Specifically, Gabapentin was administered late on several days, and Vancomycin was also given late on three occasions. There was no documentation indicating that the resident's primary care physician was notified about the late administration of these medications, nor was there any evidence of harm to the resident from the late administration in the progress notes reviewed from May 1 to May 16, 2023. During interviews, a registered nurse stated that if medications were not administered on time, the nurse would document the delay and notify the doctor. However, this procedure was not followed in the case of Resident #2. The Director of Nursing confirmed that medications should be administered according to the schedule and that any deviations should be documented and reported to the physician. The facility's policy on administering medication, dated May 21, 2019, also stipulated that medications should be administered within one hour of their prescribed time and that any deviations should be documented and reported. This policy was not adhered to in the case of Resident #2, leading to the identified deficiency.
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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 Parsippany Troy Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Troy Hills Center | 1 mi | ★★★★★ | 3 | 0 |
| Careone At Hanover Township | 3.1 mi | ★★★★★ | 1 | 0 |
| Livia Health And Senior Living | 3.4 mi | ★★★★★ | 9 | 0 |
| Oaks At Denville, The | 4.1 mi | ★★★★★ | 1 | 1 |
| Fallsview Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 1 | 0 |
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