Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Fair Lawn Edge during CMS and state inspections, most recent first.
A facility failed to implement a procedure for the safe acquisition and receipt of Methadone, a controlled substance, by assigning an unlicensed CNA to pick up and transport Methadone from an outside clinic for several residents. The CNA used a locked box and key, transported the medication in a personal vehicle, and delivered it to nursing staff, despite facility policy requiring controlled substances to be handled by a licensed nurse. Interviews confirmed the absence of a specific policy for this process.
Surveyors observed multiple deficiencies in environmental cleanliness and safety, including stained tiles, peeling safety strips, accumulation of dust and substances on vents, and lack of privacy curtains in shower rooms. Staff interviews confirmed these areas should have been maintained according to facility policy, but required cleaning and repairs were not completed.
A resident was transferred to another facility without receiving the required Notice of Medicare Non-coverage (NOMNC) within the mandated timeframe. Review of records and staff interviews confirmed that the NOMNC was either missing or dated incorrectly, and staff could not provide a valid explanation for the discrepancy.
Two residents did not receive medications in accordance with physician orders: one did not receive pain medication prior to wound care as ordered, and another received a medication with blood pressure and heart rate parameters without required documentation of those vitals at the time of administration. Nursing staff and management confirmed that orders were not followed or clarified, and facility policy requiring adherence to physician orders and documentation of vital signs was not met.
A resident with COPD and asthma did not receive required follow-up care, including a pulmonology consult and a CT scan, as ordered after hospital discharge. Although physician orders and facility policy required these services, there was no documentation that the consult or scan occurred, nor any explanation for the missed appointments. Facility leadership confirmed the lack of records and were unable to account for the missed follow-up care.
Surveyors identified failures in infection prevention and control, including dusty fans blowing onto uncovered clean linens and resident clothing, cluttered and unclean laundry and linen storage areas, and improper disposal of used items such as a surgical mask and washcloth. Staff confirmed that these practices did not meet facility policy for sanitary handling and storage of linens and waste.
The facility failed to supervise and secure two exit-seeking residents, resulting in their elopement. One resident with severe cognitive impairment exited through an unsecured door, while another resident with discontinued out-of-pass privileges was allowed to go outside without verification. Both incidents highlight lapses in supervision and policy adherence.
The facility failed to adhere to acceptable standards of nursing practice, including improper medication preparation, failure to adjust medication times for a dialysis patient, incorrect oxygen administration, and delayed implementation of dietician recommendations.
The facility failed to maintain proper infection control during a pressure ulcer treatment, did not administer zinc oxide as ordered, and neglected to conduct quarterly Braden Scale assessments for a resident with multiple health issues.
The facility failed to properly store and label medications, as observed during an inspection of a medication cart. An opened bottle of Acetylcysteine 20% was found without a label or documentation of the date and time it was opened. The medication was believed to belong to a resident with orders for Acetylcysteine inhalation every 6 hours. The Director of Nursing could not explain the improper storage.
The facility failed to provide the mandatory annual dental care services for a resident who had intact cognition and multiple diagnoses, including Depression and Hypertension. Despite being a Medicaid recipient, there was no documentation of dental visits or refusals since the resident's admission.
The facility failed to maintain proper kitchen sanitation and food storage practices. Boxed items were stacked above 18 inches from the ceiling in the walk-in freezer, and a Dietary Chef used a non-disinfected thermometer to check the temperature of ground pork, leading to contamination.
The facility failed to maintain proper infection control practices during medication administration. An LPN on the 3rd floor did not scrub his soapy hands away from running water before rinsing, and another LPN on the 4th floor scrubbed her hands for only 5 seconds instead of the required 20 seconds. Both LPNs could not explain their actions.
Unlicensed Staff Assigned to Retrieve and Transport Methadone
Penalty
Summary
The facility failed to develop and implement a procedure for the safe acquisition and receipt of physician-ordered Methadone, a controlled substance, from a third-party clinic. Instead, the facility assigned an unlicensed staff member, a Certified Nursing Assistant (CNA), to travel to the outside clinic to pick up Methadone for multiple residents. The CNA transported the Methadone in a locked box with the key in her possession, using her personal vehicle, and delivered it to the facility's nursing staff. Interviews with the CNA, the Director of Nursing (DON), and review of facility documents confirmed that this practice occurred over several weeks, and that there was no specific policy or procedure in place for this process. The facility's existing policy stated that controlled substances should be delivered and signed for by a licensed nurse, but this was not followed in the case of Methadone pickups from the clinic. Further interviews revealed that the consultant pharmacist did not consider the Methadone clinic under his jurisdiction, and the DON acknowledged the lack of a specific policy for Methadone retrieval, relying instead on a general narcotic policy. Nursing staff interviewed stated that CNAs should not handle or deliver narcotics or any type of medication, as they are not licensed to do so. The facility's corporate office also lacked a specific policy for this process. The deficiency was identified through observations, interviews, and document reviews conducted by surveyors, and was cited under relevant state regulations.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as evidenced by multiple observations on both the 3rd and 4th floors, including both shower rooms. During a tour with the Housekeeping Director, the surveyor observed a shower chair with a ripped cover, a plastic tray on the floor, stained wall tiles and moldings, peeling safety strips in several shower cubicles, and significant discoloration and staining on ceiling tiles. The soiled utility room also had ceiling tiles with brownish discoloration. The 4th floor clean linen room and pantry area were found with heavy accumulations of grayish substances on ceiling vents, and the eyewash area in the nursing station had a heavy accumulation of dust. In the 4th floor dining room, a vent above two residents seated near vending machines was observed with a heavy accumulation of blackish substances, with a total of ten residents and two staff present in the room at the time. Interviews with the Housekeeping Director, RN/Unit Manager, LPN Supervisor, and Assistant Director of Nursing confirmed that these areas should have been cleaned and maintained according to facility policy. Facility documentation, including the Safe and Homelike Environment Policy and Routine Bathroom/Shower Cleaning Policy, outlined requirements for maintaining a sanitary, orderly, and comfortable environment, but these were not followed as evidenced by the observed deficiencies. No specific medical history or conditions of the residents involved were noted in the report.
Failure to Provide Timely Notice of Medicare Non-Coverage Prior to Resident Transfer
Penalty
Summary
The facility failed to issue the required Notice of Medicare Non-coverage (NOMNC) or Form CMS-10123 to a resident who was being transferred to another healthcare facility. Review of the resident's progress notes indicated a transfer occurred, but there was no documented evidence in the electronic medical record that the NOMNC was completed or any explanation for its absence. The physician certification and re-certification form was reviewed, and a NOMNC letter was provided by the Licensed Nursing Home Administrator (LNHA), but the dates on the letter did not align with the resident's actual discharge date. The NOMNC letter was signed by the resident with a date that was after the actual transfer, indicating the notice was not provided within the required timeframe. Interviews with facility staff, including the Director of Social Services (DSS), LNHA, and Director of Nursing (DON), confirmed that the NOMNC should have been signed at least two days prior to discharge, but this did not occur. The DSS could not provide an explanation for the incorrect date, and the LNHA acknowledged that the date should have been checked before the resident signed the form. The DON confirmed that the resident left for another nursing home and that the NOMNC should have been completed, but it was not done in accordance with regulatory requirements.
Failure to Follow Physician Orders and Document Medication Parameters
Penalty
Summary
The facility failed to consistently follow professional standards of clinical practice by not adhering to physician orders for medication administration and by not clarifying ambiguous orders for two residents. In the first instance, a resident with Alzheimer's disease, diabetes mellitus, and a stage 4 sacral pressure ulcer had a physician's order for tramadol to be administered before wound care. However, documentation showed that the pain medication was only given once daily in the morning, while wound treatments were performed during the evening and night shifts, contrary to the physician's order. The LPN assigned to the resident's care confirmed that the order should have been clarified since the wound care was not performed on the day shift, and the medication was not administered as intended prior to the wound treatment. In the second instance, another resident with heart failure, hypertension, and benign prostatic hyperplasia had a physician's order for finasteride with specific parameters to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the medication administration records over several months revealed that nurses documented administration of the medication but did not record the required blood pressure and heart rate at the time of administration. Interviews with nursing staff and management confirmed that it was expected for nurses to check and document these vital signs per the physician's order, but this was not consistently done. The lack of documentation meant there was no evidence that the medication was administered in accordance with the specified parameters. Both deficiencies were confirmed through interviews with nursing staff and review of facility policies, which require medications to be administered as ordered by the physician and for vital signs to be recorded when medications have specific parameters. The facility's own policies also state that medications must be given in accordance with orders, including any required time frames, and that vital signs should be documented on the medication administration record when applicable.
Failure to Provide Physician-Ordered Follow-Up Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care as specified by hospital discharge orders and physician instructions, in accordance with professional standards and facility policies. The resident, who had a history of COPD with acute exacerbation and asthma, was discharged from the hospital with instructions for follow-up care, including a pulmonology consult within one month and a follow-up CT scan in July. Physician orders were present in the medical record for these follow-ups, and the facility's policy required timely requests for such services. Despite these orders, there was no documentation that the resident received the required pulmonology consult or the follow-up CT scan. The DON and other facility leadership confirmed that while attempts were made for the pulmonologist to see the resident, there was no record of the resident being unavailable or of the consult being completed. Similarly, there was no documentation explaining why the CT scan was not performed as ordered. The lack of documentation and follow-through on these physician-ordered services constituted a failure to provide care according to the resident's needs and professional standards. Interviews with facility staff, including the DON and the Regional VP of Clinical Services, revealed that they were unaware of the reasons for the missed appointments and acknowledged the absence of required documentation. The facility's own policies emphasized the importance of providing physician-ordered services and maintaining proper records, but these were not followed in this instance, resulting in the identified deficiency.
Deficient Infection Control in Linen, Laundry, and Waste Handling
Penalty
Summary
The facility failed to ensure proper handling and storage of linen and laundry, as well as proper disposal of garbage, in accordance with infection prevention and control standards and the facility's own policies. During a tour of the laundry area, surveyors observed an electric fan with heavy dust accumulation blowing air toward uncovered, clean resident clothing, and a floor littered with crumpled papers, candy wrappers, and dust. The laundry folding table, intended for clean clothes, was cluttered with personal items, food, and miscellaneous objects. Both the laundry staff and the Housekeeping Director confirmed these observations and acknowledged that the conditions did not meet cleanliness expectations. In the clean linen room, another electric fan with significant dust buildup was found blowing air onto uncovered, clean linens, blankets, towels, and gowns. The floor was also dusty, and a used surgical mask was found discarded on the floor. Additionally, three ceiling tiles showed dried brownish discoloration, identified as water condensation, directly above clean, uncovered linens. The Housekeeping Director confirmed that the fan should have been cleaned, garbage should not be on the floor, and the linens were now considered contaminated due to dust exposure. During inspection of a shower room, a wet, used washcloth was found on the floor of a shower cubicle, which the Housekeeping Director stated should have been properly disposed of by the CNA after use. The Infection Preventionist Nurse acknowledged responsibility for environmental rounds but did not provide an explanation for why these deficiencies were not previously identified. The facility's policy requires clean linen to be handled, stored, and transported in a sanitary manner to prevent contamination, which was not followed in these instances.
Failure to Supervise and Secure Exit-Seeking Residents
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired, exit-seeking resident, resulting in the elopement of Resident #353. The resident, who had severe cognitive impairment and a history of exit-seeking behavior, was able to leave the facility through an unsecured exit door. The door was left unsecured because a staff member deactivated the alarm system to access the dumpster area, allowing the resident to exit the facility. The resident was found several blocks away from the facility, adjacent to a wide, double-lane roadway, posing a serious and immediate risk to their health and safety. Additionally, the facility failed to follow its elopement policy, which resulted in the elopement of Resident #355. Despite the resident's out-of-pass (OOP) privileges being discontinued, the front desk receptionist allowed the resident to go outside to smoke without verifying with the nursing staff. The resident subsequently eloped and was later arrested due to an outstanding warrant. The receptionist did not follow the facility's policy of confirming OOP status with the nursing staff and ensuring that residents only smoked in designated areas. Both incidents highlight significant lapses in the facility's supervision and security measures, as well as failures to adhere to established policies for managing residents at risk of elopement. These deficiencies resulted in immediate jeopardy situations, endangering the residents involved.
Removal Plan
- Door monitor initiated
- Elopement and wandering residents' policy reviewed
- In-service education with all staff on Identification of Residents at Risk for Elopement, Elopement and Wandering policies
- Daily door checks initiated
- Ongoing education to staff regarding elopement precautions and policies, keypad access doors and door safety education
- Weekly inspection of exit doors and function
- Quality assurance performance improvement project to review and interpret all audit findings
Multiple Deficiencies in Nursing Practice
Penalty
Summary
The facility failed to adhere to acceptable standards of nursing practice, as evidenced by multiple deficiencies observed by the surveyor. One significant issue involved the improper preparation of medications for administration. An LPN was found to have prepared medications for four residents in advance, stacking the medication cups on top of each other without proper labeling. This practice led to confusion and the inability to identify the medications and residents without referring to the electronic medication administration record (eMAR). Additionally, the LPN failed to sign out controlled substances from the inventory sheet when removed, which is against the facility's policy and best practices for medication administration. Another deficiency was identified in the scheduling of medication times for a resident undergoing dialysis. The resident's medication times were not adjusted to accommodate their dialysis schedule, resulting in missed doses. The facility's protocol requires medications to be scheduled around dialysis times, but this was not followed, leading to multiple instances where the resident did not receive their prescribed medication. The facility's policy on hemodialysis did not include guidelines for adjusting medication times, contributing to this oversight. The facility also failed to administer oxygen according to the physician's order for one resident. The resident was observed receiving oxygen at a rate of 8 liters per minute, contrary to the physician's order of 2 liters per minute. The LPN responsible for the resident confirmed the discrepancy but did not provide an explanation for the incorrect administration rate. Additionally, the facility did not act upon the recommendations made by the Registered Dietician in a timely manner for a resident with a feeding tube. The recommendations for adjusting the resident's nutritional intake and hydration were not entered into the electronic medical record as active orders, leading to a delay in the resident receiving the appropriate care.
Failure to Maintain Infection Control and Conduct Required Assessments
Penalty
Summary
The facility failed to maintain proper infection control practices during the treatment of a pressure ulcer for Resident #25. During the treatment, the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) did not perform handwashing prior to the start of the treatment and did not change gloves after cleaning the pressure ulcer before applying the dressing. Additionally, the foam dressing used was not from a new, unopened package, and the overbed table used during the treatment was not disinfected afterward. These actions were confirmed by the ADON during an interview with the surveyor. Resident #25, who was admitted with diagnoses including anemia, Type 2 diabetes mellitus with hyperglycemia, and severe protein-calorie malnutrition, had a significant change in status with an unstageable pressure ulcer that was not present on admission. The resident's Treatment Administration Record (TAR) indicated that zinc oxide was to be applied to the sacrum every shift as a preventative measure. However, there were multiple instances where the TAR was left blank, indicating that the zinc oxide was not administered as ordered. Furthermore, the facility failed to conduct quarterly Braden Scale for Predicting Pressure Sore Risk (BSFPPSR) assessments for Resident #25. The last documented BSFPPSR assessment was in March 2023, with no quarterly assessments recorded for the rest of the year. This was confirmed by the Unit Manager/LPN and the Director of Nursing (DON), who acknowledged that the assessments were not completed as required. The facility's policies on wound care and assessment frequency were not adhered to, leading to these deficiencies.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and accurately label medications, as observed during an inspection of the 2nd floor low medication cart. The surveyor found an opened 10ml bottle of Acetylcysteine 20% that was not labeled and lacked documentation of the date and time it was opened. The bottle's label indicated it should be stored in a refrigerator after opening and discarded after 96 hours. The 2nd floor UM/LPN confirmed that the medication should not have been stored without a label, date, or time opened. The Director of Nursing could not explain why the medication was stored improperly. The medication was believed to belong to a resident who had an order for Acetylcysteine Solution 20% 10 ml to be inhaled via nebulizer every 6 hours for mucous secretions. The resident was admitted with diagnoses including Acute Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. The resident's Comprehensive Minimum Data Set (MDS) indicated an intact cognition with a BIMS score of 15 out of 15. The deficiency was noted during a review of the resident's electronic medication administration record (eMAR) and confirmed by the surveyor's interview with the staff.
Failure to Provide Annual Dental Care Services
Penalty
Summary
The facility failed to provide the mandatory annual dental care services for a resident. Resident #56, who was admitted to the facility on 2/9/2023 and was a recipient of Medicaid effective 3/19/23, did not receive an annual examination and treatment by a dentist. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 15 out of 15, had diagnoses including Depression, Post Traumatic Stress Disorder, Anorexia, Hypertension, and a Fracture of the left femur. Despite these conditions, there was no documentation of dental visits or refusals of dental visits. This deficiency was confirmed by the facility's Regional Registered Nurse on 4/23/24.
Improper Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and store potentially hazardous foods correctly, leading to a risk of foodborne illness. During a kitchen inspection, the surveyor observed multiple boxed items stacked above 18 inches from the ceiling inside the walk-in freezer. The Food Service Director (FSD) acknowledged the issue and stated that the boxes would be rearranged to comply with storage guidelines. Additionally, during lunch meal preparation, the Dietary Chef (DC) checked the temperature of ground pork using a non-disinfected thermometer. The FSD had handed the thermometer to the DC, who then used it without disinfecting the probe. When questioned, the DC assumed the FSD had disinfected the thermometer. The FSD admitted fault and stated that the ground pork would be discarded due to contamination. Facility policies reviewed by the surveyor confirmed the requirement for proper storage and sanitation practices, which were not followed in these instances.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed by the State Surveyor. On the 3rd floor, an LPN was seen putting his soapy hands immediately under running water without scrubbing them away from the water first. The LPN could not explain why he did not follow the proper handwashing procedure. Similarly, on the 4th floor, another LPN scrubbed her soapy hands for only 5 seconds away from the water before rinsing them clean, instead of the required 20 seconds. This LPN also could not explain why she did not adhere to the handwashing policy. The facility's Handwashing/Hand Hygiene Policy requires that hands be vigorously lathered with soap and rubbed together for a minimum of 20 seconds before rinsing thoroughly under running water. The Director of Nursing and the Assistant DON were informed of these observations, and medpass evaluations for the involved LPNs were provided, showing that requirements were met during previous evaluations. However, no further information was provided to explain the deficient practice observed during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Paterson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barnert Subacute Rehabilitation Center, Llc | 0.9 mi | ★★★★★ | 0 | 0 |
| Maple Glen Center | 2.3 mi | ★★★★★ | 20 | 0 |
| Doctors Subacute Healthcare, Llc | 2.8 mi | ★★★★★ | 6 | 0 |
| Atlas Rehabilitation Healthcare At Daughters Of Mo | 2.9 mi | ★★★★★ | 2 | 0 |
| Alaris Health At The Chateau | 3.3 mi | ★★★★★ | 4 | 0 |
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