Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Wellington during CMS and state inspections, most recent first.
A cognitively impaired resident with a known history of elopement was allowed to leave their unit unescorted after an LPN deactivated the elevator's wander guard system. Upon reaching the lobby, the resident exited the facility through a rear door after a receptionist disengaged the wander guard alarm, enabling the resident to leave unsupervised. The absence was not discovered until hours later during rounds, and the resident was eventually found in a nearby town and returned to the facility.
The facility failed to maintain proper sanitation and labeling practices in the kitchen and nutrition refrigerators. Observations included soiled and wet pans, an unlabeled oatmeal cup, and unlabeled food items in refrigerators. The CSD and nursing staff acknowledged these issues, which were not in compliance with facility policies.
The facility exhibited deficiencies in infection control practices, including improper use of PPE and inadequate hand hygiene. An LPN entered a COVID-19 positive resident's room without full PPE, and housekeeping staff failed to remove PPE inside rooms. A Unit Secretary wore her mask improperly, and CNAs did not perform hand hygiene during meal service. These actions occurred despite prior staff education on proper procedures.
The facility failed to properly document the receipt and administration of controlled substances, as evidenced by incomplete DEA 222 Forms and discrepancies in Controlled Drug Administration Records (CDAR). An LPN admitted to not signing the CDAR immediately after administering medication, and the facility's policies lacked guidance on DEA 222 forms and CDAR documentation.
The facility failed to maintain a medication error rate below 5%, with a surveyor observing three errors out of twenty-six opportunities. Errors included administering Docusate Sodium in tablet form instead of capsules and preparing to open Phenytoin Sodium Extended Capsules, which should not be crushed or opened. The nurse did not follow medication orders or cautionary instructions, and the DON confirmed that medications should be administered as ordered.
The facility failed to properly store medications on two medication carts, as observed by a surveyor. On Cart 2, a foil package of budesonide inhalant suspension and a foil package of DuoNeb were found without dates indicating when they were opened. Similarly, on Cart 1, a DuoNeb solution was also undated. Both the UM/LPN and the LPN confirmed that these medications should have been dated. The facility's policy did not include information on dating opened nebulizer solutions, leading to the deficiency.
The facility failed to maintain resident dignity during a meal service, as CNAs left trays and garbage on tables and one CNA stood while feeding a resident, which was acknowledged as inappropriate.
A facility failed to accurately document and review a resident's advance directives, as the EMR did not reflect the DNH status indicated on the resident's POLST form. Despite the resident's severe cognitive impairment and multiple diagnoses, there was no care plan related to advance directives, and staff interviews revealed lapses in the process for updating and ensuring the accuracy of these directives.
A facility failed to accurately code the MDS for two residents, resulting in incorrect gender identification. One male resident was coded as female, and one female resident was coded as male, contrary to their Admission Records. The RN MDS coordinator acknowledged the errors, which were identified during a surveyor's review.
A facility failed to follow infection control standards for a resident's respiratory care. The nasal cannula tubing was not changed as per policy and was found on the floor instead of being stored in a plastic bag. The resident, with a history of congestive heart failure and other conditions, was receiving oxygen therapy. Staff acknowledged the lapses in protocol, which were confirmed by the DON.
A resident was administered Tamsulosin, a medication not approved for use in women, without proper documentation or justification. Despite the resident's cognitive intactness and the presence of a urinary catheter, the facility failed to provide a rationale for the off-label use of the medication, leading to a deficiency in medication management practices.
A resident returned from hemodialysis with syringes still attached to their catheter, which should have been removed at the clinic. The oversight was discovered by the resident's family, and the facility failed to conduct a proper post-treatment assessment. Documentation and communication lapses were identified, as the dialysis communication report was not consistently returned, and the nurse did not thoroughly check the catheter site.
A resident was inadvertently given Dakin's solution, a wound cleanser, instead of water to take with oral medication after an RN prepared the solution in a drinking cup and mistakenly handed it to the resident. The resident experienced a burning sensation upon ingestion and reported it immediately. The incident occurred due to failure to follow facility procedures for wound care preparation and medication administration, as confirmed by staff interviews and policy review.
Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired resident with a history of elopement and a severely impaired BIMS score was identified as being at risk for wandering and elopement. The resident's care plan included interventions requiring staff to accompany them to meals and scheduled activities. Despite these interventions, the resident was allowed to leave the unit unescorted in their wheelchair after an LPN deactivated the elevator's wander guard system, permitting the resident to travel alone to the lobby. Upon arrival in the lobby, the resident approached the rear exit door, which was equipped with a wander guard alarm. The receptionist at the desk disengaged the alarm, allowing the resident to exit the facility through the rear door. Video footage confirmed that the resident left the building unaccompanied and was last seen on camera propelling their wheelchair through the parking lot and out of view. Staff did not notice the resident's absence until a dinner tray was found untouched during rounds several hours later. The facility's failure to provide adequate supervision and to follow the care plan interventions for a resident at high risk for elopement resulted in the resident leaving the premises unsupervised. The resident was not located until several hours later, when they were found in a nearby town and returned to the facility. The incident occurred despite the wander guard system being operational and no equipment malfunctions being reported.
Sanitation and Labeling Deficiencies in Kitchen and Refrigerators
Penalty
Summary
The facility failed to maintain proper sanitation practices in the kitchen and nutrition refrigerators, leading to potential foodborne illness risks. During a kitchen tour, the surveyor observed that some half sheet pans were soiled with white debris and others were wet when they should have been dry before stacking. Additionally, an undated and unlabeled paper cup containing oatmeal was found on a countertop, which the Culinary Service Director (CSD) acknowledged should not have been there and removed it. In the nutrition refrigerators on the second and third floors, several items were found unlabeled, including tubs of sea salt caramel ice cream, a jar with an unknown food item wrapped in foil, and a carton of eggnog. The Registered Nurse Unit Manager (RN/UM) and Licensed Practical Nurse (LPN) acknowledged that these items should have been labeled with the resident's name and date. The CSD confirmed that these were not facility-stocked items and stated that they would follow up to identify the owners or dispose of the items if necessary. The facility's policies on sanitization and food brought by family/visitors were reviewed, revealing that equipment and utensils should be cleaned and sanitized, and food items should be labeled and stored properly. However, the policies did not address specific drying protocols for dishware and cookware. The Licensed Nursing Home Administrator (LNHA) acknowledged the expectation for personal food items to be labeled and stored correctly, indicating a team effort was needed to ensure compliance with these standards.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to appropriate infection control practices, particularly in the use of Personal Protective Equipment (PPE) and hand hygiene. An LPN entered the room of a COVID-19 positive resident without wearing the required PPE, which included an N-95 respirator mask, gown, and gloves. Despite being aware of the facility's policy, the LPN only wore a surgical mask and gloves, failing to don a gown. Additionally, housekeeping staff were observed exiting rooms of residents on Transmission-Based Precautions (TBP) without removing their PPE, which included gowns and gloves, inside the room as required. Further observations revealed that a Unit Secretary was wearing her surgical mask improperly below her nose and mouth while in the hallway. This was attributed to her not being re-inserviced after returning from vacation. Similarly, during a meal service, four Certified Nursing Assistants (CNAs) did not perform hand hygiene before distributing lunch trays or assisting residents with meal setup, which is a critical step in preventing the spread of infection. The report also highlighted multiple instances where housekeeping staff did not follow proper PPE doffing procedures, such as removing soiled PPE in the hallway instead of inside the resident's room. These actions were observed despite the staff having been previously educated on the correct procedures. The Infection Preventionist and Director of Housekeeping confirmed that staff had been in-serviced on these protocols, yet compliance was not consistently observed during the surveyor's visit.
Deficient Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, specifically in the documentation and handling of controlled substances. The deficiency was identified through a review of DEA 222 Forms and Controlled Drug Administration Records (CDAR). The DEA 222 Form used to order controlled substances was not properly filled out, as the section for recording the number received and the date received was left blank. This form was associated with an order for Schedule II controlled substances, including oxycodone tablets, intended for emergency backup supply. Additionally, discrepancies were found in the CDAR forms for two controlled substances on a medication cart, where the documented available doses did not match the physical quantity present. During the survey, a Licensed Practical Nurse (LPN) admitted to not signing the CDAR immediately after administering medication, citing being in a rush as the reason. The facility's Director of Nursing (DON) confirmed that the staff should document on the CDAR when the medication is removed from the packaging. The surveyor also noted that the facility's policies on medication labeling and storage, as well as administering medications, did not include pertinent information regarding DEA 222 forms or CDAR documentation. This lack of proper documentation and adherence to procedures led to the identified deficiencies.
Medication Administration Errors Exceeding 5% Error Rate
Penalty
Summary
The facility failed to ensure that medications were administered with an error rate of less than 5%, resulting in a medication error rate of 15.38% during an observation. The surveyor observed three nurses administering medications to six residents, with three errors occurring out of twenty-six opportunities. The errors involved two residents, one of whom was unsampled, and were administered by one nurse. The errors included administering Docusate Sodium in tablet form instead of the prescribed capsule form and preparing to open Phenytoin Sodium Extended Capsules, which should not be crushed or opened, for a resident with difficulty swallowing. The surveyor noted that the nurse did not adhere to the medication orders and failed to follow cautionary instructions, such as separating Phenytoin from calcium by at least two hours. Additionally, the nurse left a vial of Budesonide on top of a medication cart while searching for other medications, indicating a lack of proper medication management. The Director of Nursing confirmed that medications should be administered as ordered and that staff should follow medication cautions or warnings, contacting the physician or pharmacy if there are any issues or questions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications on two of the three medication carts inspected, as observed by the surveyor. During the inspection of Cart 2 on the 2nd floor, the surveyor, accompanied by the Unit Manager/Licensed Practical Nurse (UM/LPN), found a foil package of budesonide inhalant suspension and a foil package of albuterol/ipratropium inhalant solution (DuoNeb) without dates indicating when they were originally opened. The UM/LPN confirmed that these medications should have been dated upon opening. Similarly, on Cart 1, the surveyor, in the presence of the LPN on duty, found a foil package of DuoNeb solution also lacking an opening date. The LPN acknowledged that the vial should have been dated. The surveyor reviewed the facility's policy on Medication Labeling and Storage, which did not include information on dating opened packaging of nebulizer solutions. Additionally, the manufacturer packaging information for both DuoNeb and budesonide specified the time frames within which the medications should be used once opened. The facility's failure to adhere to these guidelines and properly label the medications led to the deficiency noted in the report.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain the dignity of residents during a dining observation on the third floor, involving four Certified Nursing Aides (CNAs). During a lunch meal, the CNAs distributed trays to residents and left them on the table underneath each resident's plate. Additionally, three insulated lids were left in the middle of the tables, and the CNAs placed wrappers and garbage inside those lids, which remained on the tables throughout the entire meal. Furthermore, one CNA was observed standing while feeding an unsampled resident, which was acknowledged by the CNA as inappropriate, as she should have been seated while feeding the resident.
Failure to Accurately Document and Review Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation and review of a resident's advance directives, specifically for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, heart failure, and atrial fibrillation. The resident's paper chart included a POLST form indicating DNR, DNI, and DNH directives, signed by the resident's representative and an advance practice provider. However, the electronic medical record (EMR) did not reflect the DNH status, and there was no care plan related to advance directives. Interviews with facility staff revealed that the process for updating and ensuring the accuracy of advance directives was not followed. The LPN/UM confirmed the discrepancy in the EMR and stated that nursing staff should have ensured the EMR was updated. The Assistant Director of Social Services indicated that social services assess residents for advance directives, but the responsibility for ensuring the POLST directives are carried out lies with the nursing staff. The facility's policy requires that information about advance directives be prominently displayed and communicated to direct care staff, which was not adhered to in this case.
Inaccurate MDS Gender 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 gender identification. Resident #67, who is male according to the Admission Record, was incorrectly coded as female in both the entry and comprehensive MDS assessments. Similarly, Resident #70, identified as female in the Admission Record, was inaccurately coded as male in the MDS assessments. These errors were identified through a review of the electronic medical records and the MDS assessments by the surveyor. The Registered Nurse (RN) MDS coordinator, responsible for ensuring the accuracy of MDS assessments, acknowledged the inaccuracies upon review with the surveyor. The MDS coordinator stated that the guidance from the MDS 3.0 Manual was followed, yet the errors persisted. The surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about these concerns, highlighting the facility's failure to adhere to federal guidelines requiring that resident gender on the MDS match the information in the Social Security system.
Failure to Adhere to Infection Control Standards in Respiratory Care
Penalty
Summary
The facility failed to adhere to infection control standards in the management of respiratory care for a resident. Specifically, the nasal cannula (NC) tubing used for oxygen delivery was not changed according to the facility's policy, which required a change every Tuesday on the night shift. The NC tubing was observed to be dated 12/18/24, indicating it had not been changed by 12/24/24 as required. Additionally, the NC tubing was found on the floor and not stored in a plastic bag, which is against infection control measures. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) acknowledged these lapses in protocol. The resident involved had a medical history that included congestive heart failure, schizophrenia, and major depressive disorder, and was receiving oxygen therapy as part of their care plan. The resident's cognitive status was intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The facility's Director of Nursing (DON) confirmed that the policy required NC tubing to be changed every 7 days and stored properly when not in use. The surveyor's observations and interviews with staff highlighted the failure to follow these established procedures, leading to the deficiency noted in the report.
Unnecessary Medication Administration in Female Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving the administration of Tamsulosin (Flomax) to a female resident. The resident was admitted with diagnoses including COVID-19, heart disease, and a urinary tract infection, and was cognitively intact with a BIMS score of 15 out of 15. The resident had a urinary catheter inserted, and Tamsulosin was prescribed for urinary retention management after the catheter was placed. However, the use of Tamsulosin, which is indicated for benign prostatic hyperplasia in men and not approved for use in women, was not supported by documentation in the resident's medical record regarding its off-label use or a benefit versus risk assessment. The Nurse Practitioner acknowledged the off-label use of Tamsulosin in the female resident but did not document the rationale or any potential benefits in the medical record, considering it a common practice. The surveyor's interview with the Director of Nursing and the Licensed Nursing Home Administrator revealed that the facility did not provide further pertinent information to justify the use of Tamsulosin in this case. The lack of documentation and justification for the off-label use of Tamsulosin in a female resident constitutes a deficiency in the facility's medication management practices.
Failure to Ensure Proper Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis (HD) received services consistent with professional standards of practice. The deficiency was identified when a resident returned from an HD clinic with two empty syringes still connected to their dialysis access site, a permanent intravenous catheter in the upper chest. These syringes, used to flush the catheter with saline post-treatment, should have been removed at the clinic. The oversight was discovered by the resident's family member the following day, who alerted facility staff. The resident, admitted with conditions including end-stage renal disease and dependence on HD, had moderate cognitive impairment. Facility records indicated that the resident's dialysis site was to be assessed for infection or bleeding every shift. However, documentation revealed that the post-treatment assessment was not properly conducted or recorded. The nurse who received the resident back from HD did not perform a thorough check of the catheter site and failed to notice the syringes. Additionally, the dialysis communication report, which should accompany the resident to and from the clinic, was not consistently returned to the facility nurse. Interviews with the Director of Nursing (DON) and the Licensed Practical Nurse (LPN) involved highlighted discrepancies in the documentation and communication processes. The facility's policies required documentation of dialysis treatment and post-treatment observations, but these were not adhered to in this instance. The DON acknowledged the need for proper assessment and documentation upon the resident's return from HD, which was not adequately performed, leading to the deficiency.
Resident Given Wound Cleanser Instead of Water with Oral Medication
Penalty
Summary
A deficiency occurred when a resident was given a clear liquid by mouth to take with their medication, which was later identified as Dakin's solution (Sodium Hypochlorite 0.25%), a wound cleanser, instead of water. The registered nurse responsible for the incident had prepared the Dakin's solution in a drinking cup at the treatment cart and, after being interrupted by the resident requesting pain medication, inadvertently handed the cup containing the wound cleanser to the resident along with their oral medication. The resident immediately reported a burning sensation upon swallowing the liquid, and the incident was reported to the nurse practitioner, primary care physician, and poison control. The resident involved had a history of right femur fracture, hypertensive heart disease, bacteremia, repeated falls, and was cognitively intact according to the most recent assessment. The resident required supervision or assistance with activities of daily living. Facility records and interviews confirmed that the nurse did not follow established procedures for wound care preparation, which require pouring liquid solutions directly onto gauze and not into drinking cups, and also failed to adhere to medication administration protocols that prohibit keeping treatment supplies on medication carts and using inappropriate containers for wound solutions. Observations and interviews with staff revealed that medication carts were to be used exclusively for medications, while treatment carts were designated for wound care supplies. The director of nursing and unit manager both confirmed that the nurse's actions were not in line with facility policy or professional standards. The nurse involved was terminated following the incident and did not respond to follow-up inquiries from facility leadership.
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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 Hackensack
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Prospect Heights Llc | 0.7 mi | ★★★★★ | 21 | 0 |
| Complete Care At Regent Llc | 0.9 mi | ★★★★★ | 0 | 0 |
| Atlas Rehabilitation And Healthcare At Maywood | 1.5 mi | ★★★★★ | 25 | 0 |
| Alaris Health At The Chateau | 1.8 mi | ★★★★★ | 4 | 0 |
| Careone At Teaneck | 1.9 mi | ★★★★★ | 0 | 0 |
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