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 Altercare Newark North Inc. during CMS and state inspections, most recent first.
A resident with multiple comorbidities and a stage 4 heel pressure ulcer had care plans and physician orders in place for wound treatment and pressure-relief interventions. A wound NP changed the wound care regimen, but the new orders were not transcribed for a week, delaying implementation of the updated treatment. Later, when the NP discontinued the use of calcium alginate, the facility’s orders were not updated and staff continued to apply dressings containing calcium alginate. Facility leadership confirmed both the delay in implementing the new orders and the continued use of a discontinued product, despite a policy requiring verification of physician orders for wound treatments.
A resident with multiple respiratory and cardiac diagnoses was admitted with a physician's order for scheduled Ipratropium-Albuterol nebulizer treatments every 6 hours. The order was incorrectly transcribed into the EMAR as a PRN (as needed) medication instead of scheduled. The error was identified two days after admission during a review of the new admission checklist and was confirmed by the DON.
The facility's kitchen was not maintained in a clean and sanitary manner, affecting all 68 residents who consumed food from it. Observations revealed issues such as an open, unlabeled package of bacon, food splatter on meal trays, and dirty, broken kitchen tiles. The dishwasher failed to reach the required temperature for proper sanitation, and attempts to fix it were unsuccessful. The facility's policy required daily cleaning to ensure sanitation, which was not followed.
The facility did not conduct the required two-step tuberculin skin test (TST) for two newly hired employees, a Staff Coordinator and an Activities Coordinator. This oversight was confirmed during an interview and had the potential to affect all 68 residents.
The facility failed to monitor and document the nutritional status of several residents, leading to significant weight changes that were not addressed. A resident experienced a significant weight loss, which was not addressed in her medical records, and there was inconsistent documentation of her meal intake. Another resident experienced significant weight changes that were not addressed, and a reweigh was not completed as required. A third resident experienced drastic weight fluctuations, with only one nutritional note addressing a weight gain, and no interventions were discussed for other significant changes. Additionally, a resident was not administered the prescribed nutritional supplement, leading to weight loss.
The facility failed to notify physicians of significant weight changes for three residents, as identified through medical record reviews and interviews. A resident experienced significant weight fluctuations, including an 18.6% loss and a 12.3% gain, without physician notification. Another resident lost 11.1% of their weight over six months, and a third resident had multiple significant weight changes, all without physician notification. The dietitian informed nursing staff of these changes, but they did not notify the physicians.
A facility failed to ensure a resident, who required substantial assistance for bathing, received baths or showers per her preferences. Despite consistent refusals over several months, there was no documented plan to address these refusals or offer alternatives. Staff confirmed that refusals were documented but not reported to the physician, and the resident expressed dissatisfaction with her bathing schedule.
A resident with a complex medical history experienced four unwitnessed falls over two months, yet the facility failed to conduct additional fall risk assessments. Despite the resident's cognitive intactness and conditions like end-stage renal disease and difficulty walking, the initial assessment indicated no fall risk. Interviews with staff confirmed the lack of reassessment, which contradicted the facility's Fall Prevention policy requiring assessments with significant changes.
A facility failed to justify the use of psychotropic medications for a resident with multiple diagnoses, including dementia. The resident's care plan included monitoring and non-pharmacological interventions, but physician orders for medications like Seroquel and Celexa lacked specific diagnoses. The DON confirmed the absence of appropriate diagnoses, noting dementia was not suitable for these medications.
A resident with intact cognition and multiple diagnoses was found with unsecured medications on his bedside table without a nurse present. The LPN initially believed the resident had taken his morning medications, but upon returning, found them still there. Facility policy required observation to ensure ingestion, which was not followed, leading to the deficiency.
A resident with severe cognitive impairment and multiple diagnoses was not provided the prescribed mechanical soft diet, as observed during a breakfast meal. Despite a physician's order to downgrade the diet due to food pocketing, the resident received a sausage patty cut into pieces larger than quarters. The kitchen was not updated with the correct diet order, and the diet change was not communicated to the kitchen.
A resident with severe cognitive impairment and multiple diagnoses did not receive timely laboratory tests as ordered by the physician. Despite a stat order for a CBC and CMP due to bilateral edema, the tests were delayed by four days, and a subsequent CBC order was not completed. The facility's contract with the lab specified 24/7 stat services, which were not adhered to, leading to a deficiency finding.
A resident was recorded without consent by an agency STNA in the common area, violating the facility's privacy policy. The STNA admitted to recording the resident and herself dancing, claiming it was a playful moment. The incident was reported by another STNA who saw the video on social media. The facility's investigation confirmed the recording but found no willful intent to harm.
A facility failed to transcribe physician orders and obtain blood sugars for a resident with diabetes and other medical conditions. The resident's hospital transfer orders required finger stick blood sugars before meals and at bedtime, but there was no documented evidence that these orders were followed. The DON confirmed the oversight.
A resident with a postoperative wound infection did not receive the ordered wound vacuum treatment due to procedural errors and miscommunication. The wound vacuum was delayed and not applied, as the agency nurse was unfamiliar with its use, and the treatment administration record was incorrectly scheduled. This led to the resident being transferred back to the hospital for evaluation.
Failure to Implement and Update Wound Care Orders for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to follow and timely implement wound care orders for a resident with a stage 4 pressure ulcer on the right heel. The resident was admitted with multiple diagnoses including type 2 diabetes, paroxysmal atrial fibrillation, and chronic kidney disease, and had care plans identifying a right heel pressure injury and risk for further skin breakdown, with interventions such as pressure-redistribution devices and monitoring for wound changes. Physician orders dated 01/06/26 directed cleansing the right heel wound with normal saline or wound cleanser, applying fluffed Mesalt, and covering with bordered gauze once daily and as needed, which remained in place until discontinued on 03/26/26. On 03/19/26, a wound NP documented that the resident’s right heel treatment would be changed to cleansing with normal saline, applying a nickel-thick layer of Santyl, followed by calcium alginate and a silicone super absorbent dressing daily and as needed. However, this new treatment order was not transcribed into the resident’s wound care orders until 03/26/26, resulting in a one-week delay in implementing the updated regimen. Further, when the wound NP saw the resident again on 04/09/26 and noted that the ordered treatment no longer included calcium alginate, the facility’s wound care orders still listed calcium alginate as part of the active treatment, and staff continued to apply a dressing containing calcium alginate. The DON confirmed the delay in implementing the 03/19/26 orders, the ADON confirmed continued use of calcium alginate after it was discontinued, and the wound NP reported being unaware that her wound care orders were not being followed, despite a facility wound care policy requiring verification of physician orders for treatments.
Incorrect Transcription of Scheduled Respiratory Medication Order
Penalty
Summary
A deficiency occurred when a resident's physician-ordered medication for Ipratropium-Albuterol, intended to be administered by nebulization every 6 hours on a scheduled basis, was incorrectly transcribed into the facility's Electronic Medication Administration Record (EMAR) as an as-needed (PRN) medication rather than as a scheduled dose. This error was identified during a review of the resident's medical and hospital discharge records, which showed that all other medications were transcribed correctly except for this respiratory treatment. The resident had diagnoses including influenza, chronic pain, acute and chronic respiratory failure with hypoxia, and heart failure, making accurate respiratory medication administration critical. The Director of Nursing (DON) confirmed in an interview that the breathing treatment order was not entered into the EMAR as prescribed by the physician. The facility's new admission check-off list was completed two days after the resident's admission, at which point the transcription error was discovered. The resident also brought the issue to the DON's attention, and the error was subsequently corrected. However, the resident left the facility against medical advice shortly after. Facility policy requires that medications be administered as prescribed and in accordance with good nursing practices, which was not followed in this instance.
Kitchen Sanitation and Dishwasher Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all 68 residents who consumed food from the kitchen. Observations revealed several issues, including an open, unlabeled, and undated package of bacon in the refrigerator, and a silver cart with meal trays covered in food splatter and debris. The kitchen had missing, broken, and chipped tiles under the dishwasher, with a buildup of dirt and dust. The oven hood and the wall above it were covered in grease stains, and the wall next to the oven had dark drip stains. Additionally, the window blinds near the dishwasher were dirty, covered in food splatter, and broken, while the kitchen flooring was chipped and broken in multiple places. The ceiling had food splatters and stains, and areas around ceiling vents were covered in dust. The dishwasher was observed to have been run multiple times without reaching the expected temperature of 180 degrees Fahrenheit, and the sanitation level was insufficient to sanitize the dishes. Dietary Coordinator #181 confirmed these observations and reported that chemicals were added to counteract the low temperature, but the sanitation level remained inappropriate. Despite attempts to fix the dishwasher, it continued to fail in meeting temperature and sanitation requirements. The facility's policy, dated January 2020, stated that all kitchen areas should be cleaned daily to ensure proper sanitation, which was not adhered to in this instance.
Failure to Conduct Tuberculosis Testing for New Employees
Penalty
Summary
The facility failed to ensure that two new employees, a Staff Coordinator and an Activities Coordinator, were tested for tuberculosis as required by the facility's tuberculosis risk assessment. The risk assessment specified that healthcare workers should undergo a baseline two-step tuberculin skin test (TST) upon hire and with exposure, with the results maintained in the employees' files. However, upon review of the employee files, it was found that these two employees, hired on August 5, 2024, did not have the two-step TST performed. This oversight was confirmed during an interview with the Staff Coordinator, who acknowledged that the tests were not completed. This failure had the potential to affect all 68 residents in the facility, as the facility census was 68.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and document the nutritional status of several residents, leading to significant weight changes that were not addressed. Resident #53 experienced a significant weight loss of 18.6% over one month and 19.6% over three months, which was not addressed in her medical records. Despite being admitted to hospice care, there was no nutrition assessment completed to address her significant change in condition. Additionally, there was inconsistent documentation of her meal intake, and her significant weight changes were not addressed according to the facility's policy. Resident #14 also experienced significant weight changes, with a weight loss of 11.1% over six months and 12.4% over three months, followed by a significant weight gain of 8.5% over one month. These changes were not addressed in her medical records, and a reweigh was not completed as required. The dietitian's annual nutrition progress note did not address these significant weight changes, indicating a lack of monitoring of the resident's nutritional status. Resident #21 experienced drastic weight fluctuations, including a 39% weight gain in one week and a 31% weight gain over 50 days. Despite these significant changes, there was only one nutritional note addressing a weight gain, and no interventions were discussed or implemented for the other significant weight changes. Resident #37, who was at risk for altered nutrition, was not administered the prescribed nutritional supplement when consuming less than 50% of meals, leading to a 7% weight loss in one month. The lack of adherence to physician orders and inadequate documentation contributed to the deficiencies in the residents' nutritional care.
Failure to Notify Physicians of Significant Weight Changes
Penalty
Summary
The facility failed to notify physicians of significant weight changes for three residents, which was identified during a review of medical records and interviews. Resident #53 experienced a significant weight loss of 18.6% over one month and 19.6% over three months, followed by a significant weight gain of 12.3% over three months. Despite these changes, there was no evidence that the physician was notified. Interviews with the Regional Nurse Consultant and Registered Dietitian confirmed that the dietitian generated reports of significant weight changes and informed nursing staff, who were responsible for notifying the physician, but this did not occur. Resident #14 experienced a significant weight loss of 11.1% over six months and 12.4% over three months, with no evidence of physician notification. Similarly, Resident #21 had multiple significant weight changes, including a 39% weight gain in one week and an 11% weight loss in six days, without documentation of physician notification. The facility's process involved the dietitian notifying nursing staff of significant weight changes, but the nursing staff failed to notify the physicians, as confirmed by interviews with the Regional Nurse Consultant and Registered Dietitian.
Failure to Address Bathing Preferences and Refusals
Penalty
Summary
The facility failed to ensure that a dependent resident, who was cognitively intact and required substantial assistance for bathing, was able to take baths or showers according to her preferences. The resident, who had a complex medical history including syncope, cardiac arrest, and cognitive communication deficit, among other conditions, consistently refused baths and showers over a period of several months. Despite these refusals, there was no documented plan or mechanism in place to address the resident's preferences or refusals, nor was there evidence that alternatives were offered as per the care plan. The facility's staff, including an LPN and the DON, confirmed that refusals were documented but not reported to the physician or addressed with alternative solutions. The resident expressed dissatisfaction with not receiving baths or showers as desired, and there was no documentation indicating that the physician was notified to discuss the refusals or explore potential changes in the resident's medical condition that might explain her behavior. This lack of communication and planning contributed to the deficiency in providing adequate care for the resident's activities of daily living.
Failure to Reassess Fall Risk After Multiple Falls
Penalty
Summary
The facility failed to adequately assess a resident after multiple falls to ensure they remained in the safest environment possible. The resident, who was cognitively intact, had a complex medical history including end-stage renal disease, repeated falls, and difficulty walking, among other conditions. Despite these factors, the resident's fall risk assessment, conducted shortly after admission, indicated they were not at risk for falls. No subsequent fall risk assessments were completed after the resident experienced four unwitnessed falls over a two-month period. Interviews with facility staff, including the Regional Nurse Consultant and the Director of Nursing (DON), confirmed the absence of additional fall risk assessments following the falls. The DON acknowledged that the falls were related to changes in the resident's condition, such as adjusting to a new environment and refusals to attend dialysis. The facility's Fall Prevention policy mandates fall risk assessments upon admission, quarterly, with significant changes, and annually, but these were not adhered to in this case, leading to a deficiency in maintaining resident safety.
Lack of Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper justification for the use of psychotropic medications for a resident, affecting one out of five residents reviewed for unnecessary medications. The resident had a range of diagnoses, including rhabdomyolysis, fracture of nasal bones, paroxysmal atrial fibrillation, dysphagia, chronic diastolic heart failure, hemiplegia and hemiparesis affecting the left non-dominant side, cerebral infarction, and unspecified dementia. The resident's comprehensive Minimum Data Set (MDS) 3.0 assessment indicated severely impaired cognition. Despite these conditions, the facility did not provide appropriate diagnoses for the psychotropic medications prescribed, including Seroquel, Celexa, and Haloperidol. The resident's plan of care included interventions such as monitoring for side effects, offering non-pharmacological approaches, and consulting psychological or psychiatric services. However, the physician orders for psychotropic medications lacked specific diagnoses, with some orders indicating target behaviors like refusal of care instead of a medical diagnosis. An interview with the Director of Nursing confirmed that the necessary diagnoses were not included in the orders for the antipsychotics and antidepressants, and dementia was not an appropriate diagnosis for these medications.
Medication Security Lapse for Resident
Penalty
Summary
The facility failed to ensure that medications were secured appropriately for Resident #223, who was observed with a medication cup containing nine pills on his bedside table without a nurse present. The resident, who had intact cognition, was admitted with diagnoses including hallucinations, rhabdomyolysis, spinal stenosis, epilepsy, alcohol abuse, and atherosclerotic heart disease. The resident's physician orders included several medications to be administered in the morning, but there was no indication in the medical record that the resident was authorized to self-administer medications. During an interview, an LPN reported that she believed the resident had taken his pills when she initially gave them to him. However, upon returning to the room, she found the pills still present and verified they were the resident's morning medications. The facility's policy on medication administration required that residents be observed to ensure the complete ingestion of medications, which was not adhered to in this instance. This oversight led to the deficiency as the resident's medications were not secured and were left unattended.
Failure to Provide Correct Diet Texture
Penalty
Summary
The facility failed to provide a resident with the diet texture as ordered, affecting one of five residents reviewed for nutrition. The resident, who had severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and chronic kidney disease, was observed eating a breakfast meal that did not comply with the prescribed mechanical soft diet. Despite a physician's order to downgrade the resident's diet due to food pocketing, the resident was served a sausage patty cut into pieces larger than quarters. An interview with a Transitional Nurse Specialist revealed that the kitchen had not been updated with the correct diet order, and a Regional Nurse Consultant confirmed that the diet change was never communicated to the kitchen.
Failure to Obtain Timely Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory tests as ordered by the physician for Resident #24, who was admitted with multiple diagnoses including dementia, anxiety disorder, and hypertension. On 12/09/24, the resident exhibited bilateral edema, prompting the nurse to contact the physician, who ordered stat laboratory blood tests, specifically a complete blood count (CBC) and a complete metabolic panel (CMP). However, the laboratory did not draw the resident's blood until 12/13/24, four days after the initial order, without any documentation explaining the delay. Further, on 12/16/24, another order for a CBC was placed, but the laboratory results from 12/16/24 to 01/07/25 did not include the CBC. The Director of Nursing confirmed that the facility did not ensure the completion of the laboratory tests as ordered. The contract with the laboratory indicated that stat services were available 24/7, with results to be reported within five hours, yet this protocol was not followed. This deficiency was investigated under Complaint Number OH00161041.
Unauthorized Recording of Resident by Agency STNA
Penalty
Summary
The facility failed to ensure that residents were not recorded without their consent or knowledge, affecting one resident who was recorded by an agency State Tested Nursing Assistant (STNA) in the common area. The resident, who had an intact cognition for daily decision-making abilities, did not recall the event and reported no issues or concerns with caregivers. The agency STNA admitted to recording the resident and herself dancing, claiming it was a playful moment without malicious intent. The incident was reported by another STNA who saw the video on social media and recognized the resident and the facility. The facility's investigation revealed that the agency STNA recorded the resident without consent, which violated the facility's policy on videotaping and photographing residents. The policy mandates that residents be protected from invasion of privacy through unauthorized recordings. Despite the agency STNA's claim of no ill intent, the facility determined that the recording occurred, although it could not substantiate willful intent to harm. The agency STNA was placed on a Do Not Return list, and the staffing agency was notified of the incident.
Failure to Transcribe Physician Orders and Obtain Blood Sugars
Penalty
Summary
The facility failed to ensure that physician's orders were transcribed and blood sugars were obtained as ordered for a resident. The resident, who was admitted with multiple diagnoses including a fracture of the right lower leg, anemia, anxiety, liver laceration, right talus fracture, and diabetes, had hospital transfer orders for finger stick blood sugars to be taken before meals and at bedtime. However, a review of the facility's physician orders, treatment, and medication administration record showed no documented evidence that these orders were transcribed or that the blood sugars were obtained. An interview with the Director of Nursing confirmed that the order for finger stick blood sugars was not carried over or completed. This deficiency was investigated under a specific complaint number.
Failure to Provide Ordered Wound Care Treatment
Penalty
Summary
The facility failed to provide the ordered wound care treatment for a resident who was admitted with a postoperative wound infection. The resident was discharged from the hospital with specific orders for a wound vacuum system to be applied to the left upper anterior thigh/groin area, with changes scheduled for Mondays and Thursdays. However, the wound vacuum was not applied as ordered, and the resident's wound was left open to air, leading to the resident being transferred back to the hospital for evaluation. The deficiency occurred due to a series of miscommunications and procedural errors. The Director of Nursing (DON) revealed that a new process for ordering the wound vacuum was in place, but the order was not received by the supplier on time, resulting in a delay. Although the wound vacuum eventually arrived, it was not applied because the agency nurse on duty was unfamiliar with its application. Additionally, the treatment administration record (TAR) was incorrectly scheduled, and there was no documentation of alternative treatment while the wound vacuum was unavailable. This oversight affected the resident's care and was investigated under a specific complaint number.
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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 Newark
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Newark South Inc. | 3.6 mi | ★★★★★ | 3 | 0 |
| Newark Nursing & Rehab | 3.7 mi | ★★★★★ | 37 | 0 |
| Arlington Care Center | 3.7 mi | ★★★★★ | 7 | 0 |
| Flint Ridge Nrsg & Rehab Ctr | 3.9 mi | ★★★★★ | 2 | 0 |
| The Laurels Of Heath | 4.5 mi | ★★★★★ | 23 | 0 |
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