Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 The Highlands during CMS and state inspections, most recent first.
A resident with an unstageable pressure ulcer received wound care from an RN who failed to follow infection control protocols, including not cleaning the overbed table, not changing gloves between tasks, and not performing hand hygiene after the procedure. Unused supplies were returned to the treatment cart without sanitization, and the RN acknowledged these breaches when interviewed by surveyors.
A resident with COPD did not receive multiple doses of prescribed Breo Ellipta inhaler and Triamcinolone cream because the medications were not available, and there was insufficient documentation that the pharmacy or physician was contacted as required. An LPN noted intentions to follow up, but could not provide evidence of communication, and the DON confirmed that backup inhalers and steroid creams were not stocked. The facility's policy required timely administration and documentation, which was not met in this case.
A resident with severe cognitive and mobility impairments was found unresponsive on the floor after a fire alarm, and the facility failed to conduct a thorough investigation as required by policy. Only one witness statement was collected despite multiple staff being present, and other staff were not interviewed about the incident. The DON and administrator determined the fall was cardiac in origin, but the required comprehensive investigation, including gathering all witness accounts, was not completed.
A resident with multiple health conditions, including severe malnutrition and impaired cognition, was not weighed weekly as ordered by a physician and as required by facility policy. Only the admission weight was documented, with no further weights recorded during the required period. Staff interviews and record reviews confirmed the absence of weekly weight documentation.
The facility failed to report injuries of unknown origin for two residents with severe cognitive impairment to the NJDOH, as required by their policy. One resident had multiple skin tears, and another had an unexplained injury in the perineal area. Despite documentation by nursing staff, there was no evidence of reporting to the authorities.
The facility failed to revise care plans for two residents after incidents indicating changes in their conditions. One resident experienced multiple skin tears, and another had a skin opening in the perineal area. Despite these incidents being documented, care plans were not updated to include new interventions. Staff acknowledged the oversight, contrary to facility policy requiring care plan updates after significant condition changes.
The facility failed to maintain dignity during mealtime for two residents needing assistance with eating. One CNA was observed standing while feeding a resident and using her cellphone, while another CNA was seen sitting on a resident's bed and using a facility tablet instead of interacting with the resident. Both residents had severe cognitive impairments and required assistance with meals.
The facility failed to maintain the confidentiality of resident information when a paper with resident photos, names, room numbers, and vital signs was left on top of a medication cart, accessible to anyone passing by. The RN assigned to the cart incorrectly believed there were no HIPAA violations, but the facility's administration later agreed that private medical information was improperly exposed.
The facility failed to complete and transmit a Minimum Data Set (MDS) - Discharge Assessment for a resident within the mandated timeframe. The MDS Coordinator acknowledged the oversight, and the facility's administration was informed of the issue.
The facility failed to accurately code the MDS for two residents, leading to discrepancies in their medical records. One resident was incorrectly coded as discharged to a hospital instead of home, and another resident's fall was inaccurately documented as having a major injury. These errors were confirmed by the MDS Coordinator and discussed with the facility's administration.
The facility failed to accurately document and clarify the administration of medication for three residents, leading to deficiencies in care. Conflicting orders for hand splints, unavailability of prescribed Lidocaine patches and Miconazole powder, and incorrect dosage of Sertraline were observed.
A resident with multiple diagnoses was observed receiving oxygen at 4 LPM instead of the prescribed 2 LPM. The LPN confirmed the incorrect setting but could not explain the deviation from the physician's order. The facility's policy on oxygen administration was not followed.
The facility failed to ensure that the primary physician signed and dated monthly physician orders for four residents, resulting in orders being 70 days overdue. This was confirmed through interviews and record reviews.
The facility failed to ensure that the responsible physician conducted face-to-face visits and wrote progress notes at least once every sixty days for a resident with multiple diagnoses, including End Stage Renal Disease and Major Depressive Disorder. All visits were conducted by an APN, with no documented evidence of the physician's visits.
The facility failed to remove expired and discontinued medications from active inventory, as evidenced by the presence of outdated drugs in medication carts and improper storage conditions. Staff were unable to explain the discrepancies, and the facility's policy on medication removal was not consistently followed.
A CP failed to clarify the medication dosage for a newly admitted resident, who reported receiving an incorrect dose of sertraline for anxiety. The resident had been receiving 75 mg prior to admission but was given only 50 mg daily since admission. The CP did not receive the hospital discharge medication list and only reviewed the medications entered in the electronic medical record, leading to the discrepancy.
The facility failed to maintain proper kitchen sanitation practices and discard potentially hazardous foods. An opened bottle of expired molasses was found, and dietary aides were observed with improper hair restraints and jewelry, violating facility policies. The Culinary Director and other officials acknowledged these deficiencies.
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through multiple periods where the facility did not meet the minimum staffing requirements for CNAs on both day and evening shifts. Specific instances included days with significantly fewer CNAs than required, such as only 1 CNA for 97 residents on certain shifts. The issue was discussed with the facility's administration, who did not provide further information.
The facility failed to maintain complete and accessible medical records for a resident. The resident's primary physician's progress notes were not documented in the hybrid medical records, and the physician was out of the country, making the notes inaccessible. The facility's policy requires that physician progress notes be maintained and documented upon each visit.
A CNA was observed holding a soiled bag while assisting a resident with their meal, touching the resident's meal tray and utensils. The CNA then placed the bag on a bedside table, sanitized her hands, and discarded the bag. The Administrator and Clinical Lead RN acknowledged the infection control breach.
Infection Control Breach During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to maintain proper infection control standards during wound care treatment for a resident with an unstageable pressure ulcer. The RN gathered wound care supplies and placed them directly on the overbed table without cleaning the surface or using a clean barrier. During the dressing change, the RN removed the soiled dressing and, without changing gloves, proceeded to cleanse the wound, apply ointment, and pack the wound, all with the same contaminated gloves. The RN also used the same gloves to handle a pen from her pocket to date the dressing and did not sanitize the overbed table after completing the procedure. The resident involved had multiple diagnoses, including cognitive communication deficit, peripheral vascular disease, depression, and anxiety disorders, and was admitted with a severe, unstageable pressure ulcer on the sacrum. The resident was on Enhanced Barrier Precautions, as indicated by signage on the door. The RN's actions during the wound care procedure did not align with the facility's policy, which requires cleaning the bedside stand, establishing a clean field, performing hand hygiene at multiple steps, and using clean technique throughout the dressing change. After completing the wound care, the RN removed her gloves but did not perform hand hygiene before leaving the resident's room. Unused supplies that had been brought into the resident's room were returned to the treatment cart without being sanitized. The RN acknowledged these breaches in infection control when interviewed, and the Director of Nursing confirmed the observed deficiencies.
Failure to Provide Timely Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that two prescribed medications, Breo Ellipta Aerosol and Triamcinolone topical cream, were obtained and administered in a timely manner for one resident. The resident, who had a diagnosis of chronic obstructive pulmonary disease (COPD), had physician's orders for both medications, but multiple doses were not administered over several days. The electronic medication administration record (EMAR) showed that the medications were repeatedly marked as not available, with documentation indicating follow-up with the pharmacy, but there was no evidence that the pharmacy or physician was consistently contacted as required. Progress notes documented by an LPN indicated intentions to follow up with the pharmacy when the medications were unavailable, but there was a lack of documentation confirming that the pharmacy or physician was actually contacted. The LPN stated during interview that she would call the pharmacy and physician if medications were out of stock for more than three days, but could not provide evidence of these communications in the progress notes. Additionally, the LPN acknowledged that there were no backup medications available in the facility for inhalers or steroid creams, and that they had to wait for the pharmacy to deliver the medications. The Director of Nursing (DON) confirmed that while some backup medications were available in the facility, there were no backup inhalers or steroid creams. The DON stated that nurses should call the physician for follow-up orders or alternative medications when a medication is not available, and that all such actions should be documented in the progress notes. Upon review, the DON acknowledged that there was insufficient documentation of pharmacy and physician notification, and that continued documentation of medication unavailability without further action was not appropriate. The facility's policy required medications to be administered in a safe and timely manner as prescribed.
Failure to Conduct Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to follow its Accidents and Incidents - Investigating and Reporting policy by not conducting a thorough investigation after a resident was found on the floor following a fire alarm. The resident, who had severe cognitive impairment, significant mobility limitations, and multiple medical diagnoses including atrial flutter and diabetes, was found unresponsive with low blood oxygen and blood pressure, requiring emergency transport. Documentation showed that the fall was unwitnessed, and only one witness statement was collected, despite several staff being present on the unit at the time of the incident. Interviews with other staff members who were on duty revealed that they were not interviewed or asked to provide statements regarding the incident. The facility was unable to provide additional witness statements or documentation about the circumstances of the fall. The Director of Nursing and the Administrator determined the fall was cardiac in origin after reviewing hospital records, but the facility did not complete a comprehensive investigation as required by policy, which mandates prompt initiation and documentation of investigations, including collecting witness accounts and other pertinent data.
Failure to Document and Perform Weekly Weights for At-Risk Resident
Penalty
Summary
The facility failed to follow its policy on Weight Assessment and Intervention and did not adhere to physician orders for weekly weights for one resident. The resident in question was admitted with multiple diagnoses, including anemia, Type 2 diabetes, severe protein-calorie malnutrition, muscle weakness, dysphagia, and cognitive communication deficit. The resident's Minimum Data Set indicated severely impaired cognition and a therapeutic diet, with a care plan identifying risk for malnutrition and an intervention to be weighed as ordered. Physician orders specified weekly weights for four weeks, but documentation showed only an initial weight recorded on admission, with no further weights documented during the required periods. Interviews with facility staff, including a CNA, DON, and RD, confirmed that the only documented weight for the resident was on admission, and no evidence was provided to show that weekly weights were obtained as ordered. The facility's own policy required weights to be recorded upon admission and at intervals established by the interdisciplinary team or as ordered, with documentation in the medical record. The lack of documented weekly weights was confirmed through review of the electronic medical record, weight summary, and weekly weight sheets, as well as by staff interviews.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents to the New Jersey Department of Health, as required by their policy on Abuse, Neglect, Exploitation, or Misappropriation. Resident #2, who had severe cognitive impairment due to dementia, was found with multiple skin tears on different occasions. These incidents were documented by various nursing staff, but the facility could not provide evidence that these injuries were reported to the NJDOH. The facility's policy mandates immediate reporting of such injuries to the administrator and relevant authorities, but this was not adhered to. Similarly, Resident #4, who also had severe cognitive impairment and was dependent on assistance for all activities of daily living, was found with an unexplained injury in the perineal area. This incident was documented by an LPN, but again, there was no evidence that it was reported to the NJDOH. The facility's policy clearly states that all injuries of unknown origin must be reported immediately to the appropriate authorities, but this procedure was not followed in these cases.
Failure to Revise Care Plans After Incidents
Penalty
Summary
The facility failed to ensure that the care plans (CP) for two residents were revised following incidents that indicated a change in their condition. Resident #2, who was admitted with diagnoses including dementia and muscle weakness, experienced multiple skin tears over several months. Despite these incidents being documented in incident reports (IR), the CP was not updated to include new interventions to prevent recurrence. The Registered Nurse (RN) responsible acknowledged that the CP should have been revised at the time of the incidents but admitted it was an oversight. Similarly, Resident #4, who had severe cognitive impairment and required assistance with activities of daily living, experienced a skin opening in the perineal area. This incident was reported, but the CP was not updated to reflect this change in condition. The Unit Manager and Director of Nursing both stated that the CP should be updated immediately following such incidents, but they could not explain why it was not done in this case. The facility's policy requires CPs to be revised when there is a significant change in a resident's condition, which was not adhered to in these instances.
Failure to Maintain Dignity During Mealtime
Penalty
Summary
The facility failed to maintain dignity during mealtime for two residents who needed assistance with eating. For Resident #27, a CNA was observed standing while feeding the resident a supplement and simultaneously holding her personal cellphone. The CNA admitted to standing because she was assisting another resident in the same room. Resident #27 had severe cognitive impairment and required assistance with meals. The facility's policy mandates that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, which includes not standing over them while assisting with meals. The facility's Administrator and Clinical Lead RN acknowledged that the CNA should have been seated and attentive while feeding the resident. For Resident #72, a CNA was observed sitting at the end of the resident's bed, looking at an electronic device instead of interacting with the resident during mealtime. The ADON confirmed that the device was a facility tablet used for documentation. The CNA admitted to completing documentation while supervising the resident's meal, which was against the facility's policy. Resident #72 had severe cognitive impairment and required set-up or clean-up assistance for meals. The ADON and VPSCP acknowledged that the CNA should not have been sitting on the resident's bed or using the tablet at that time and should have been interacting with the resident.
Failure to Maintain Confidentiality of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of resident information on the Electronic Health Records system. This deficiency was observed when a surveyor noticed a paper with resident photos, names, room numbers, and vital signs placed on top of a medication cart. The paper was accessible to anyone passing by, including family members, which compromised the privacy of the residents' medical information. The Registered Nurse (RN) assigned to the medication cart confirmed that the paper was a roster used to document important information about the residents. Despite being informed by the surveyor that the paper contained private medical information, the RN incorrectly believed that there were no HIPAA violations. The facility's Licensed Nursing Home Administrator and the President of Special Clinical Projects later agreed that the nurse had revealed private medical information that should have been covered from view.
Failure to Complete and Transmit MDS - Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) - Discharge Assessment in accordance with federal guidelines for one resident. The deficiency was identified during a review of the facility's assessment tasks and the resident's electronic medical record. The resident was discharged to the community, but the required Discharge Assessment MDS was not completed or transmitted within the mandated timeframe. The MDS Coordinator acknowledged that the Discharge MDS for the resident was missed. The surveyor reviewed the resident's MDS 3.0 Assessment History and found no Discharge Assessment MDS for the discharge date. According to the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual, a Discharge Assessment must be completed and transmitted within specific timeframes. The facility's Licensed Nursing Home Administrator and the President of Clinical Special Project were informed of the concern, but no further information was provided.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to discrepancies in their medical records. For Resident #105, the discharge MDS was incorrectly coded as a discharge to a short-term general hospital, while the patient was actually discharged home. This error was confirmed by the MDS Coordinator upon review. The resident had diagnoses including Chronic Kidney Disease, Hematuria, Anemia, and Muscle Weakness, and the error was identified during a review of the patient's discharge summary and instructions form dated 11/3/23. The issue was brought to the attention of the facility's President of Special Clinical Projects and Licensed Nursing Home Administrator, who acknowledged the need for accurate MDS coding but provided no further information at the time of the surveyor's inquiry. For Resident #47, the MDS was inaccurately coded to reflect a fall with a major injury, which did not occur. The resident, who had diagnoses including Metabolic Encephalopathy, Urinary Tract Infection, Severe Protein-Calorie Malnutrition, and Dysphagia, was observed in the day room and had a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. The MDS Coordinator admitted that the section documenting falls was coded in error, as the resident only experienced one fall with no injury. This discrepancy was also discussed with the facility's LNHA and VPSCP, who did not provide additional information to the surveyor.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to accurately document and clarify the administration of medication for three residents, leading to deficiencies in care. Resident #39 had conflicting physician orders for the application of hand splints, with one order stating the splints should be applied from 12:00 PM to 4:00 PM and another from 4:00 PM to 10:00 PM. Despite the conflicting orders, the splints were observed on the resident outside of these times, and the facility staff could not explain the discrepancy. Resident #43 reported that a Lidocaine 5% Patch, prescribed for daily application, was not available and had not been applied as documented. The surveyor confirmed with the pharmacy that the patch had never been sent, yet the facility's records falsely indicated it had been applied. Additionally, Resident #43's Miconazole Antifungal Powder, also prescribed for daily use, was not available until a specific date, despite documentation showing it had been applied daily. Resident #21, who was prescribed Sertraline for anxiety, reported receiving a lower dosage than prescribed prior to admission. The facility's records did not reflect any change in dosage, and attempts to contact the responsible physician and nurse were unsuccessful. The facility's policies on medication management were not followed, leading to the resident receiving an incorrect dosage of medication.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders related to the use of continuous oxygen therapy for a resident. The resident, who had diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Essential Hypertension, and Chronic Systolic Heart Failure, was observed receiving oxygen at 4 Liters per minute (LPM) instead of the prescribed 2 LPM. This discrepancy was noted during two separate observations by the surveyor on the same day. The resident's care plan and physician's orders clearly indicated that oxygen should be administered at 2 LPM, but this was not adhered to by the facility staff. When the surveyor brought this to the attention of the Licensed Practical Nurse (LPN) caring for the resident, the LPN confirmed the incorrect oxygen setting but could not provide an explanation for the deviation from the physician's order. The facility's policy on oxygen administration, which requires verification of physician orders and proper documentation of oxygen settings, was not followed. The Director of Nursing (DON) and the President of Special Clinical Project were informed of the issue, and it was acknowledged that oxygen should be administered according to physician orders.
Failure to Ensure Monthly Physician Order Reviews
Penalty
Summary
The facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was current and accurate. This deficiency was observed for four residents. Resident #76, who had diagnoses including End Stage Renal Disease and Major Depressive Disorder, had physician orders that were 70 days overdue for review. Similarly, Resident #51, with diagnoses such as Heart Failure and Alzheimer's Disease, also had physician orders 70 days overdue. Resident #47, with diagnoses including Metabolic Encephalopathy and Dysphagia, and Resident #27, with diagnoses such as Fracture of the right clavicle and Dementia, both had physician orders overdue by the same duration. The surveyor's review of the residents' electronic medical charts revealed that the primary physician had not signed the Order Summary Reports for these residents. Interviews with the Nurse Practitioner and the facility's Regional Registered Nurse confirmed that the physician orders must be reviewed and signed electronically every month, which had not been done. The facility's Licensed Nursing Home Administrator and the President of Special Clinical Projects acknowledged the deficiency but provided no further information.
Failure to Ensure Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days. This deficiency was identified for one resident, who was admitted with diagnoses including End Stage Renal Disease, Major Depressive Disorder, Cognitive Communication Deficit, and Muscle Weakness. The resident had a Brief Interview for Mental Status score indicating moderately impaired cognition. The review of the physician's progress notes revealed that all visits were conducted by an Advanced Practice Nurse (APN) and not by the physician, with no documented evidence of the physician visiting and examining the resident at least every 60 days. During an interview, the APN confirmed that the physician orders must be reviewed and signed electronically every month but admitted that she had not reviewed and signed the resident's physician orders. The Licensed Nursing Home Administrator and the President of Special Clinical Projects acknowledged that the physician failed to conduct a face-to-face visit at least every 60 days, as required.
Failure to Remove Expired and Discontinued Medications
Penalty
Summary
The facility failed to ensure that expired and discontinued medications were removed from active inventory in accordance with professional standards of clinical practice. During an inspection, the surveyor found that the [NAME] Unit Nursing Station lacked an Emergency Kit, and the staff could not explain its absence. Additionally, the surveyor discovered an opened Humalog Kwik pen that should have been discarded after 28 days and a Mucomyst solution that should have been discarded after 96 hours, both of which were still in use past their recommended disposal times. The refrigerator storing these medications was also found to be at an incorrect temperature of 28 degrees Fahrenheit, instead of the required 36 to 46 degrees Fahrenheit range. The surveyor observed an LPN removing discontinued medications from a medication cart, which included medications for multiple residents who had either been discharged or moved to different rooms. These medications were not removed from the cart in a timely manner, leading to the accumulation of expired and discontinued drugs. Specific examples included medications for residents who had been discharged as far back as several months prior, yet their medications were still present in the cart. Further inspection revealed expired medications in the medication carts, including bottles of Aspirin Enteric Coated 81 mg with expiration dates that had either passed or been obscured. The facility's monthly Consultant Pharmacist Unit Inspection Reports indicated that expired medications were a recurring issue. Despite the facility's policy requiring the removal of expired and discontinued medications, these practices were not consistently followed, as evidenced by the surveyor's findings and the inability of staff to provide explanations for the discrepancies.
Consultant Pharmacist Fails to Clarify Medication Dosage for New Admission
Penalty
Summary
The Consultant Pharmacist (CP) failed to clarify the medication dosage for a newly admitted resident, Resident #21, during the initial medication review. Resident #21, who was admitted with diagnoses including sepsis, anxiety, and muscle weakness, reported receiving an incorrect dose of sertraline (Zoloft) for their anxiety. The resident had been receiving 75 mg of sertraline prior to admission but was given only 50 mg daily since admission. Despite reporting this discrepancy to a staff member, no corrective action was taken, and the issue remained unresolved for about a week before the surveyor's interview with the resident. The surveyor's review of Resident #21's medical records confirmed the discrepancy. The hospital records indicated that the resident was receiving 75 mg of sertraline, while the facility's physician orders documented a 50 mg dose. The CP's initial medication review noted that the hospital discharge medication list was not available at the time of review, and the CP only reviewed the medications entered in the electronic medical record. The CP admitted to not questioning the 50 mg order observed in December 2023, as the hospital discharge medication list was not provided. Interviews with the CP and the facility's President of Special Clinical Projects (VPSCP) revealed that the process for reviewing new admissions' medication regimens was not followed correctly. The CP stated that a remote pharmacist would review the hospital discharge medication list if the CP could not visit within 48 hours of admission. However, the CP did not receive the necessary hospital discharge medication list for Resident #21. The VPSCP acknowledged the error and stated that the medication regimen should have been reviewed with the resident and physician, and the hospital medication list should have been faxed to the CP group. The facility could not explain why the CP did not receive the discharge medication record.
Failure to Maintain Kitchen Sanitation and Discard Expired Foods
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and discard potentially hazardous foods in a manner to prevent foodborne illness. During a kitchen tour, the surveyor observed an opened one-gallon bottle of molasses with an expired use-by date on a storage shelf below Chef Preparation Table #3. Additionally, dietary aide #1 was observed with hair not fully restrained under their hairnet, and dietary aide #2 was wearing large, hooped earrings, both of which are against the facility's policies. The Culinary Director (CD) confirmed that the molasses should have been discarded and that dietary staff should have their hair fully restrained and not wear large, hooped earrings. The facility's policies, including the Food and Nutrition Services Department Employee Uniform Policy and the Food Receiving and Storage policy, were reviewed and found to be in violation. The policies clearly state that jewelry should be kept to a minimum and that foods should be labeled, dated, and monitored to ensure they are used by their use-by date or discarded. The Licensed Nursing Home Administrator (LNHA) and the President of Special Clinical Projects (VPSCP) acknowledged the deficiencies and confirmed that the observed practices were not in compliance with the facility's policies.
Failure to Maintain Minimum Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Reports for four distinct periods. During these periods, the facility consistently did not meet the minimum staffing requirements for Certified Nursing Assistants (CNAs) on both day and evening shifts. For example, during the two-week period beginning 09/12/2021 and ending 09/25/2021, the facility was not in compliance for 8 of 14 day shifts and 2 of 14 evening shifts. Similar deficiencies were noted in the periods from 12/19/2021 to 01/01/2022, 5/14/2023 to 5/27/2023, and 12/17/2023 to 12/30/2023, with multiple shifts falling short of the required CNA staffing levels. The specific instances of non-compliance included days where the number of CNAs was significantly below the required minimum. For example, on 12/27/2021, there was only 1 CNA for 97 residents on the day shift, whereas at least 12 CNAs were required. Similarly, on 12/26/2021, there were only 3 CNAs for 97 residents on the day shift. These staffing shortages were observed across multiple shifts and dates, indicating a pattern of insufficient staffing that could potentially impact the quality of care provided to the residents. The surveyor discussed the lack of required staff with the Registered Nurse VP Special Clinical Projects and Acting Licensed Nursing Home Administrator, who did not provide any further information. The facility's failure to meet the mandated staffing ratios was documented as a violation of NJAC 8:39-5.1(a) and NJAC 8:39-27.1(a), highlighting a significant deficiency in the facility's ability to provide adequate care to its residents as per state regulations.
Failure to Maintain Complete and Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for one of the residents reviewed. During an observation, the resident was found to be awake, alert, and verbally responsive. However, a review of the resident's hybrid medical records revealed that there were no physician progress notes documented by the resident's primary physician. The Regional Clinical Nurse confirmed that the physician was out of the country and the notes were in the physician's office, making them inaccessible to the facility. The facility's policy requires that physician progress notes be maintained for each resident and that the attending physician must write, sign, and date the notes upon each visit. The Regional Clinical Nurse and the Licensed Nursing Home Administrator acknowledged that the physician's documentation should be stored in the resident's hybrid medical record, but no additional documentation was provided. This failure to maintain complete and accessible medical records was identified as a deficiency by the surveyor.
Infection Control Breach During Dining Observation
Penalty
Summary
The facility failed to maintain proper infection control practices during a dining observation. A Certified Nursing Assistant (CNA) was observed holding a clear plastic bag containing a dirty bib while assisting a resident with their meal. The CNA touched the resident's meal tray and utensils while holding the soiled bag. After placing the bag on a bedside table in the hallway, the CNA sanitized her hands and then discarded the bag in the dirty utility room. The Administrator and the Clinical Lead RN acknowledged the CNA's failure to adhere to infection control practices when informed of the incident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Edison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Woodlands | 0.6 mi | ★★★★★ | 1 | 0 |
| Complete Care At Plainfield Llc | 1 mi | ★★★★★ | 0 | 0 |
| Hartwyck At Oak Tree | 1.6 mi | ★★★★★ | 0 | 0 |
| Ashbrook Care & Rehabilitation Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Brighton Gardens Of Edison | 2.5 mi | ★★★★★ | 1 | 0 |
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