Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Valley during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and diagnoses including cellulitis, atelectasis, and muscle weakness was care planned as an elopement risk with a WanderGuard bracelet and interventions such as accompaniment to meals, frequent rounding, and redirection. Despite this, the resident, known to wander and whose photo was posted throughout the facility, was able to leave the building after a WanderGuard alarm sounded at the lobby exit. Surveillance showed the receptionist manually deactivated the alarm without identifying its source, and the resident, dressed in a jacket and carrying envelopes, walked behind the receptionist and exited, appearing as a visitor. Staff interviews revealed that clinical staff believed alarms should not be turned off until the resident was located, while the receptionist reported she had been trained to silence the alarm by entering a code and then visually checking from the desk, contributing to the resident’s undetected elopement.
Failure to Check Temperatures of Altered Food Before Serving: Dietary staff did not obtain temperatures for altered foods, including Pureed, Soft & Bite Sized, and Minced & Moist items, before serving. The DM stated altered foods were not temperature checked and regular texture food temperatures were used instead, while the Administrator agreed separate checks were unnecessary. The RD and DON stated all food, regardless of texture, should be verified in the correct temperature range prior to service.
Resident Not Invited to Care Conference: A resident with COPD and intact cognition was not invited to her care conference to discuss discharge planning. The care conference was held by phone with the interdisciplinary team and the resident's cousin, but the resident did not attend and the record did not document that she was invited or refused. The resident stated she was not told what was going on and wanted to know when she was going home.
A resident with CKD, dementia, and CHF was given Vancomycin prophylactically for C-diff despite a negative C. difficile PCR result. Staff stated the resident did not have active C. difficile and that the medication was being used because of loose stools and a past history of C. difficile, while the facility referenced McGeer criteria for antibiotic stewardship.
A facility failed to accurately code the MDS for a resident, resulting in a deficiency. The resident, admitted with metabolic encephalopathy, acute kidney failure, and diabetes, was discharged home, but the MDS was incorrectly coded as a discharge to a hospital. This error was confirmed by the MDS Coordinator and other facility staff, highlighting a lapse in adherence to the facility's comprehensive assessment policy.
A resident with multiple health conditions was observed receiving oxygen at 3.5 LPM instead of the prescribed 4 LPM. The resident, who was cognitively intact, confirmed the discrepancy. The LPN acknowledged the error and adjusted the oxygen setting. The facility's policy on oxygen administration was not followed, as confirmed by the DON.
A survey revealed improper storage of medications, including a controlled substance, in a medication cart on one unit. An LPN was unaware of the medications' presence, and the ADON could not identify the residents they belonged to. The facility's policy for storing and destroying controlled substances was not followed, leading to this deficiency.
Failure to Prevent Elopement of Identified Wander-Risk Resident Despite WanderGuard System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent an elopement by a resident identified as an elopement risk. The resident was admitted with diagnoses including cellulitis of the abdominal wall, atelectasis, and muscle weakness, and had a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s care plan, initiated shortly after admission, identified elopement risk related to new admission/change of environment and included interventions such as use of a Wanderguard on the left wrist, accompanying the resident to meals and activities, checking placement and function of the security bracelet, and engaging the resident in activities and conversation to keep them occupied. Despite these planned interventions, the resident was able to leave the facility without staff knowledge. On the date of the incident, the facility’s FRE to the state documented that the resident eloped, triggering a Code Grey for a missing resident. Review of surveillance footage by the Administrator and Environmental Services Director showed that the WanderGuard alarm system activated and that the receptionist manually reset the alarm when no one was visible in the immediate lobby area. After the code was entered to disengage the alarm, the resident appeared from behind the receptionist, dressed in a jacket and carrying large envelopes, and exited through the door, presenting as a visitor. The resident later reported to the surveyor that they had “escaped,” walked out, and walked home, stating they made sure not to get caught, although they did not recall all details. The facility subsequently contacted the resident at home and a staff member escorted the resident back. Interviews with staff revealed inconsistent understanding and practices regarding the WanderGuard system and response to alarms. CNAs, an LPN, and an RN described the resident as a known wanderer and elopement risk whose picture was posted throughout the facility, and they stated that staff would respond to WanderGuard alarms by locating the resident and redirecting them. The ADON and DON stated that policy and expectation were that staff should locate the source of the alarm before deactivating it, and that it was not policy to manually turn off the alarm before the resident was located. In contrast, the receptionist reported that her practice, and how she had been trained, was to type in the code to stop the alarm when it sounded, look around from the front desk, and only if she could not locate the source would she check outside visually from her position and notify leadership, stating she could not leave the front desk. The LNHA acknowledged that surveillance footage showed the receptionist deactivating the alarm without identifying the source, and that the resident, who often sat in the Magnolia lounge near the lobby sensors, went behind the receptionist and left the building while appearing to be a visitor. Further observations by the surveyor showed that when a WanderGuard was activated near the Magnolia lounge, the alarm could not be heard until entering the lobby area, and that the alarm disengaged when the device was moved away from the sensor. In another test with the LNHA, the alarm did not shut off until a manual code was entered. On a separate occasion, the surveyor observed the resident sitting in the Magnolia lounge triggering the WanderGuard alarm, which stopped once the resident was redirected away from the area. The facility’s written policy on wandering and elopements stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. Despite this policy and the resident’s identified elopement risk and care plan interventions, the resident was able to exit the facility undetected after the receptionist manually disengaged the alarm without confirming the source, resulting in the resident’s elopement.
Failure to Check Temperatures of Altered Food Before Serving
Penalty
Summary
The facility failed to ensure that temperatures were obtained for all altered food before serving. The deficiency involved residents who received Pureed, Soft & Bite Sized, and Minced & Moist diets, including seven residents on Pureed diets, seven residents on Soft & Bite Sized diets, and two residents on Minced & Moist diets out of 85 residents reviewed for diet texture. The facility's policy stated that mechanically altered hot foods prepared for a modified consistency diet must remain above 135 degrees F during preparation or be reheated to 165 degrees F for hot service. During an observation, regular textured foods on the steam table were temperature checked with the Dietary Manager present, and the foods observed were within the safe temperature range. However, review of 23 Food Temperature/Sanitation Records showed dietary staff had not obtained temperatures for the Small & Bite Sized, Minced & Moist, and Pureed foods. The DM stated that altered foods were not temperature checked and that regular textured food temperatures were used for altered foods as well. The Administrator stated the altered foods did not need separate temperature checks because the regular texture food temperatures were satisfactory. The RD stated that all food, regardless of texture, should be in the correct temperature range, and the DON stated that all food should be verified as being in the correct temperature range prior to serving.
Resident Not Invited to Care Conference
Penalty
Summary
The facility failed to ensure that Resident 66 was invited to her scheduled care plan conference. The resident was admitted with a diagnosis of chronic obstructive pulmonary disease with exacerbation, and her annual MDS showed a BIMS score of 14 out of 15, indicating she was cognitively intact. The facility policy titled Care Planning - Interdisciplinary Team stated that care plan meetings are to be scheduled at the best time for the resident and family when possible, and if resident participation is not practicable, an explanation is to be documented in the medical record. The care conference progress note documented that a family meeting was held by phone with Social Services, Rehab, Nursing, Nutrition, and the resident's cousin participating, and the resident's overall goal was discharge to the community. However, the record did not show that Resident 66 attended or was invited to the conference. During interview, the resident stated that staff do not tell her what is going on and that she would like to know when she is going home. The SSA stated she normally asks alert and oriented residents if they want to attend and would document if the resident was asked and refused or attended, and the DON stated residents should always be invited to their care conference and any refusal should be documented.
Antibiotic Use Without Clear Justification
Penalty
Summary
The facility failed to ensure that one of two residents reviewed for antibiotic use, Resident 71, received an antibiotic with justification for its use. The facility's policy stated that its Antibiotic Stewardship Program is intended to monitor antibiotic use in residents, and the McGeer Infection Symptom Tracking criteria were reviewed as the standard for infection surveillance. Resident 71 was admitted with diagnoses including chronic kidney disease, dementia, and congestive heart failure, and a lab result showed C. difficile PCR was negative. Despite the negative C. difficile result, Resident 71 was ordered Vancomycin HCL solution 250 mg/5 mL, 2.5 mL by mouth every 6 hours for prophylaxis for C-diff for 10 days. Staff interviews indicated the resident did not have active C. difficile, and the antibiotic was being given prophylactically because of loose stools and a history of C. difficile. The ADON/IP stated the doctor wanted to finish the course of antibiotics and that there were references to two loose stools in the progress notes, while the DON stated it was important to follow the McGeer Infection Symptom Tracking Criteria for Antibiotic Stewardship.
Inaccurate MDS Coding 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 discovered that the discharge MDS for a resident was incorrectly coded as a discharge to an acute hospital, while the progress notes indicated that the resident was actually discharged home. This discrepancy was identified during a review of the resident's closed medical record and was confirmed by the Clinical Reimbursement Coordinator (MDSC), who acknowledged the error in coding. The resident in question had been admitted to the facility with diagnoses including metabolic encephalopathy, acute kidney failure, and diabetes mellitus. Despite the MDSC's initial belief that the resident was discharged home, the MDS was inaccurately coded, which was later confirmed by the facility's staff, including the Licensed Nursing Home Administrator and the Director of Nursing. The facility's policy on comprehensive assessments, which should align with the Resident Assessment Instrument (RAI) User Manual, was not adhered to in this instance, resulting in the coding error.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of continuous oxygen therapy for a resident diagnosed with Chronic Obstructive Pulmonary Disease, Essential Hypertension, Morbid Obesity, and Obstructive Sleep Apnea. The resident, who was cognitively intact, was observed receiving oxygen at 3.5 liters per minute (LPM) instead of the prescribed 4 LPM. This discrepancy was noted during two separate observations by the surveyor, and the resident confirmed that their oxygen should be set at 4 LPM. Upon reviewing the resident's medical records, it was confirmed that the physician's order specified oxygen at 4 LPM with humidification via nasal cannula. The Licensed Practical Nurse (LPN) responsible for the resident was informed of the incorrect setting and acknowledged the error, subsequently adjusting the oxygen to the correct level. The facility's policy on oxygen administration, which requires verification of physician orders and documentation of oxygen flow rate, was not followed in this instance. The Director of Nursing confirmed that oxygen should be administered according to physician orders, but no further explanation was provided for the oversight.
Improper Medication Storage and Documentation
Penalty
Summary
The facility failed to properly store controlled and non-controlled medications securely, as observed during a survey on Unit 2. The surveyor found a medication cup containing Doxycycline 100mg and Oxycodone IR 5mg in the top drawer of a medication cart, which was not properly secured. The Licensed Practical Nurse (LPN) on duty was unaware of the medications' presence and could not identify the resident to whom they belonged. The Assistant Director of Nursing (ADON) also could not identify the medications' owner and acknowledged the need for an investigation into the improper storage, especially concerning the Class II controlled substance, Oxycodone. The Omnicell printout revealed that Doxycycline was removed for one resident on a previous date, and two Oxycodone tablets were removed for another resident, although only one tablet was administered. The LPN responsible for administering the Oxycodone admitted to forgetting to destroy the extra tablet. The facility's policy requires controlled substances to be stored in a double-locked area and destroyed by two nurses if not administered, which was not followed in this instance. The residents involved had various medical conditions, including fractures, diabetes, and anxiety disorders. The facility's failure to adhere to its controlled substances policy and ensure proper medication storage and documentation led to this deficiency. The Director of Nursing and other staff members were unable to provide further information during the surveyor's investigation.
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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 Westwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerson Health Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Careone At Oradell | 1.4 mi | ★★★★★ | 3 | 0 |
| Dellridge Health & Rehabilitation Center | 3.1 mi | ★★★★★ | 1 | 0 |
| New Jersey Veterans Memorial Home At Paramus | 3.1 mi | ★★★★★ | 2 | 0 |
| Buckingham At Norwood, The | 3.2 mi | ★★★★★ | 12 | 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.