Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Altercare Newark South Inc. during CMS and state inspections, most recent first.
Surveyors found that several medications, including insulin pens and topical treatments, were either undated, expired, or lacked current physician orders, with some stored improperly in resident rooms and the medication storage area. The DON and ADON confirmed the presence of expired, undated, and unauthorized medications, indicating failures in medication labeling, storage, and removal procedures.
A resident with multiple chronic conditions who required assistance with personal care did not receive a requested shower before a scheduled medical appointment. Despite the facility's policy to provide showers as needed and upon request, staff did not document or provide the requested care, as confirmed by interviews with the resident, a CNA, and the DON.
Staff administered Insulin Lispro to a resident instead of the physician-ordered Insulin Aspart, as confirmed by medication cart observation and staff interview. The resident, who required assistance with medication administration and had multiple medical conditions including diabetes, did not have a physician order for Insulin Lispro, yet this medication was used.
A resident with multiple risk factors for pressure ulcers developed a severe heel wound after staff failed to consistently implement and document physician-ordered preventive measures and wound care. Despite care plans and orders for offloading boots and specific wound treatments, these interventions were not reliably provided or recorded, leading to the progression of the ulcer to Stage IV and requiring manual debridement.
A resident with severe cognitive impairment and on hospice care did not have their DNR status or advance directives clearly documented in the designated sections of the medical record or care plan. Although a DNR order existed as a PDF in various non-standard sections of the electronic record, there was no documentation in the physical chart or in the advance directive section, and the face sheet incorrectly indicated no advance directives. Staff confirmed that in the absence of clear documentation, the resident would be treated as full code, contrary to the resident's actual DNR-CC status.
The facility did not follow prescribed medication parameters for one resident, administering midodrine inconsistently with the physician's order, and failed to ensure another resident received an effective antibiotic for a UTI, continuing treatment with Keflex despite lab results showing resistance. These actions affected two residents reviewed for unnecessary medications.
A resident receiving hospice care was observed lying in bed with a bag containing a soiled incontinence brief left on the floor at the foot of the bed. The improper disposal of the soiled brief was confirmed by a Regional RN, indicating a failure to maintain a clean and sanitary environment.
A resident with oxygen dependence and hoarding behaviors was observed using an oxygen concentrator surrounded by clothing, trash, and other items that partially blocked the device's air intake. Staff confirmed the unsafe setup and acknowledged ongoing difficulties in maintaining a safe environment, despite manufacturer guidelines requiring unobstructed ventilation.
A resident with a history of atrial fibrillation and an artificial heart valve was prescribed Coumadin at a higher dose without a neurology consultation. The facility failed to conduct required weekly INR tests, leading to a critically high INR level. The resident developed significant bruising, which was not identified as a side effect of the medication. Despite administering Vitamin K, the facility did not conduct additional INR tests, and the resident's condition declined, resulting in their expiration.
A facility failed to notify a resident's physician about missed consultation appointments and laboratory studies. The resident, with a history of serious medical conditions, was not properly followed up after a hospital discharge, and a CT scan result was not communicated to the physician. Additionally, an INR test was missed, and the physician was not informed, violating the facility's anticoagulant therapy policy.
A facility failed to ensure proper use of PPE to prevent COVID-19 transmission. A resident in airborne isolation had their door open, and an STNA entered the room with only a surgical mask, contrary to the required N95 mask, eye protection, and gown. The STNA then entered other residents' rooms without changing the mask or performing hand hygiene. Staff interviews revealed confusion about PPE requirements, and the facility's policy was not followed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple failures in medication management within the facility. For one resident with a history of acute respiratory failure, muscle weakness, dysphagia, diabetes, hypertension, and heart disease, an open and used insulin pen was found on the medication cart without a date indicating when it was opened. The Assistant Director of Nursing confirmed the insulin pen was undated, opened, and used. For another resident with hypertension, congestive heart failure, diabetes, and chronic kidney disease, both an Insulin Lispro pen and a Lantus pen were found open, used, and undated on the medication cart, as verified by the ADON. Additionally, a third resident with multiple chronic conditions, including COPD, asthma, diabetes, and heart failure, had several medications and topical treatments at the bedside without any current physician orders for those items. The Director of Nursing confirmed these medications were present without orders and removed them from the room. Further inspection of the medication storage room revealed several expired medications, including children's acetaminophen, aspirin, multivitamins with iron, vitamin E soft gels, and nicotine patches. An opened and undated tuberculin vial was also found in the refrigerator, along with multiple lancets lacking expiration dates. The Director of Nursing verified the presence of these expired and undated items. Facility policy requires that medications be dated when opened and that expired medications be removed from active supply, but these procedures were not followed, resulting in expired and improperly labeled medications being available for use.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including COPD, asthma, rheumatoid arthritis, muscle weakness, and a need for personal assistance with personal care, did not receive timely assistance with activities of daily living as required by their care plan. The resident was admitted with significant medical needs and required supervision or touching assistance for showers, dressing, footwear, and personal hygiene. Documentation showed the resident requested a shower before a scheduled medical appointment, but there was no record or progress note indicating that the shower was provided on the requested date. Interviews with the resident, a CNA, and the DON confirmed that the resident's request for a shower prior to the appointment was not fulfilled, and there was no documentation to support that the care was provided as per facility policy. The facility's policy required staff to offer and assist with bathing according to the resident's care plan, including extra showers upon request or before appointments. The failure to provide the requested assistance resulted in non-compliance with the facility's own standards and regulatory requirements.
Incorrect Insulin Administered Due to Medication Error
Penalty
Summary
Facility staff failed to administer the physician-ordered medication for a resident who required assistance with medication administration. The resident, admitted with diagnoses including acute respiratory failure with hypercapnia, muscle weakness, dysphagia, Type II Diabetes Mellitus, hypertension, and atherosclerotic heart disease, had a physician order for Insulin Aspart U-100 to be given subcutaneously before meals, with specific instructions to hold if blood sugar was less than 150. Review of the medication administration record showed staff documented administration of Insulin Aspart as ordered. However, observation of the medication cart revealed that an open and used Insulin Lispro pen, not Insulin Aspart, was present and had been used for this resident. The Assistant Director of Nursing confirmed that the Insulin Lispro pen belonged to the resident and had been used to provide insulin, despite no physician order for Insulin Lispro.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized pressure ulcer prevention and treatment program for a resident who was at risk for pressure ulcers due to multiple medical conditions, including chronic kidney disease, diabetes, and impaired mobility. Despite being identified as at risk and having care plans and physician orders in place for preventive measures such as skin prep, offloading boots, and pressure redistribution, there was a lack of consistent implementation and documentation of these interventions. The resident was dependent on staff for mobility and application of protective devices, yet there was no evidence that offloading boots were consistently used or documented, and CNAs were not directed to use them until months after the initial care plan was developed. A significant deficiency occurred when the resident developed an unstageable pressure ulcer on the left heel, which later progressed to a Stage IV ulcer requiring manual debridement. There was a failure to implement physician-ordered treatments in a timely manner, as orders for specific wound care products such as Mesalt and bordered dressings were not entered or followed for an extended period. Instead, only skin prep and betadine were applied for several days, contrary to the wound physician's recommendations. Documentation was also lacking regarding the rationale for treatment changes and the resident's wound status during critical periods. Interviews with staff revealed confusion and lack of clarity regarding the resident's compliance with care, with no documented evidence of refusal or non-compliance, despite some staff and physician notes suggesting otherwise. The resident was described as dependent on staff for care and did not refuse treatments, though she expressed discomfort due to ticklishness. The absence of proper documentation, failure to follow physician orders, and lack of consistent preventive interventions directly contributed to the development and worsening of the resident's pressure ulcer.
Failure to Clearly Document Advance Directives in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directives were clearly documented and accessible in the medical record. Record review showed that the resident, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease, was admitted to hospice care. Despite this, there was no documentation of advance directives, code status, or DNR orders in the designated sections of the electronic medical record, the orders section, or the care plan. The only evidence of a DNR order was found as a PDF uploaded multiple times to various non-standard sections of the electronic record, and there was no DNR documentation in the physical medical record binder or behind the Advance Directive tab. The printed face sheet incorrectly indicated that no advance directives were selected for the resident. Staff interviews confirmed that the facility's practice was to keep advance directives and code status documentation in the front of the resident's physical chart, and in the absence of such documentation, the resident would be considered a full code. This was reiterated even for residents on hospice care. The resident's emergency contact confirmed the resident's DNR-CC status, but this was not reflected in the accessible medical record or care plan as required by facility policy, which states that the DON or designee must ensure appropriate orders are documented in the medical record and plan of care.
Failure to Follow Medication Parameters and Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure that medication parameters were properly followed for two residents. For one resident with a history of urinary tract infection, chronic kidney disease, and low blood pressure, midodrine was ordered to be held if the systolic blood pressure exceeded 130 mmHg. However, the medication was instead held when the systolic blood pressure was less than 130 mmHg, contrary to the physician's order. Additionally, on one occasion, the medication was held without a blood pressure being recorded. This indicates that staff did not adhere to the prescribed parameters for medication administration. For another resident with multiple complex diagnoses, including sepsis and chronic respiratory failure, the facility failed to ensure the resident received an appropriate antibiotic for a urinary tract infection. The resident was started on Keflex, but subsequent urine culture and sensitivity results showed the infecting organisms were not susceptible to this antibiotic. Despite this, the antibiotic therapy was not changed, and the culture results were not communicated in a timely manner to the prescriber, as required by the facility's antibiotic stewardship policy.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for one resident out of three reviewed for environmental conditions. During an observation, a resident with diagnoses including malignant neoplasm of the prostate, secondary malignant neoplasm of the bladder and bone, and Alzheimer's disease, who was also receiving hospice services, was found lying in bed with a bag containing a soiled incontinence brief placed on the floor at the foot of the bed. The bed was positioned with the left side and foot against the walls. This finding was confirmed by a Regional RN, who acknowledged that the soiled brief should have been disposed of properly.
Unsafe Oxygen Administration Due to Obstructed Concentrator
Penalty
Summary
The facility failed to ensure safe oxygen administration practices for a resident with a history of asthma, dysphagia, dyspnea, dependence on supplemental oxygen, and obstructive sleep apnea. Physician orders required the resident to receive continuous oxygen via nasal cannula, and the care plan noted hoarding behaviors with interventions to address safety concerns. Multiple observations revealed that the resident's oxygen concentrator was surrounded by clothing, plastic cups, cardboard boxes, and trash, with items partially obstructing the air intake vent. The concentrator was sometimes not powered on, but at other times was in use with the intake vent still partially blocked. Staff interviews confirmed awareness of the resident's hoarding behaviors and the ongoing challenge of maintaining a safe environment. The LPN acknowledged the unsafe use of the concentrator, and a corporate nurse confirmed that the device's air intake should remain unobstructed during use. The manufacturer's user manual also specifies the need for unobstructed ventilation, with the device kept six to twelve inches away from other objects. Despite these requirements, the resident's room environment was not maintained in a manner that ensured safe oxygen administration.
Failure to Monitor Anticoagulant Therapy Leads to Resident's Decline
Penalty
Summary
The facility failed to ensure proper monitoring and administration of anticoagulant medication for a resident with a history of atrial fibrillation and an artificial heart valve. The resident was prescribed Coumadin (warfarin) and had previously been treated for a subdural hematoma. Upon admission to the facility, the resident was ordered to resume Coumadin at a higher dose without a neurology consultation. The facility did not conduct the required weekly International Normalized Ratio (INR) tests to ensure the medication was at a therapeutic level. The resident developed significant bruising, which was not identified by the facility as a potential side effect of the anticoagulant medication. An INR test eventually revealed a critically high level, necessitating the administration of Vitamin K to counteract the effects of Coumadin. Despite this, the facility failed to conduct additional INR tests as ordered, and the resident's condition continued to decline. The resident was unable to take medications due to a significant decline in condition and eventually expired. The facility did not have a care plan in place for monitoring the side effects of Coumadin, and there was no documentation of physician notification regarding the resident's condition or the missed INR tests.
Removal Plan
- Regional Nurse Consultant #201 reviewed the records (including Coumadin orders, PT/INR, physician notification) for Resident #24, the only resident on Coumadin at the facility.
- A plan was noted for Resident #24 to have laboratory testing (PT/INR) completed as ordered, PT/INR results reported within eight hours to the physician, signs and symptoms of elevated INRs identified and reported to the physician by a licensed nurse.
- In-service education for licensed nurses by the Director of Nursing (DON) via lecture began on the following topics: anticoagulation policy, signs and symptoms of bleeding related to Coumadin usage, lab policy, and change in resident condition or status which included abnormal labs.
- Seven nurses were educated. The remaining four nurses would be educated before working their next scheduled shift.
- The facility implemented a plan for all newly hired nurses to receive the education prior to working the floor.
- The facility Lab Testing and Results policy was reviewed by the Executive Director and Director of Nursing.
- All 18 Certified Nursing Assistants (CNA) were educated by the DON via lecture on the signs and symptoms of bleeding that must be reported to the charge nurse.
- The facility implemented a plan for all newly hired CNAs to receive the education prior to working the floor.
- MDS Nurse #106 completed a care plan review to ensure signs and symptoms of bleeding were addressed for residents receiving anti-coagulants.
- The facility identified and reviewed the care plan for 10 residents receiving anticoagulant medications.
- The Director of Nursing (DON) or designee would complete audits on all residents receiving Coumadin daily for two weeks, then three times a week for two weeks, then weekly for two weeks and then as needed to ensure PT/INR labs were obtained per order, notification to physician of PT/INR results were within eight hours and to ensure any signs and symptoms of bleeding were noted and reported to the physician as soon as practicable.
- The DON or designee would complete audits of five residents on anti-coagulant therapy three times a week for four weeks to ensure signs and symptoms of bleeding were addressed in the resident's care plan for residents receiving anti-coagulant medications.
- Any concerns identified with the audits will be forwarded to the Quality Assurance (QA) committee weekly for four weeks and as needed for immediate follow-up.
- The administrator will be responsible for ongoing compliance.
Failure to Notify Physician of Missed Appointments and Lab Tests
Penalty
Summary
The facility failed to ensure timely notification of Resident #44's physician regarding missed consultation appointments and laboratory studies. Resident #44, who had a history of traumatic subdural hemorrhage, dysphagia, cerebral infarction, seizures, hypertension, atrial fibrillation, and congestive heart failure, was admitted to the facility after a hospital stay for a spontaneous subdural hematoma. The hospital discharge instructions included follow-up with a CT scan and neurology consultation, which were not properly communicated to the physician. The CT scan conducted on 10/01/25 showed concerning results, but there was no evidence that the physician was informed. Additionally, the resident missed a neurology appointment due to hospitalization, and the appointment was not rescheduled upon return to the facility. Further deficiencies were noted in the management of Resident #44's anticoagulation therapy. The resident was on Coumadin, requiring regular INR monitoring. An INR test scheduled for 01/06/25 was not completed, and there was no documentation that the physician was notified of this lapse. Interviews with the DON and Regional Nurse confirmed that the physician was not informed of the missed lab test, contrary to the facility's anticoagulant therapy policy, which mandates physician notification for all abnormal lab results. These failures in communication and follow-up contributed to the deficiency identified during the complaint investigation.
Failure to Follow COVID-19 PPE Protocols
Penalty
Summary
The facility failed to ensure staff followed infection control procedures, specifically the proper use of personal protective equipment (PPE), to prevent the transmission of COVID-19. This deficiency was observed in the care area of a resident who was placed in airborne isolation after testing positive for COVID-19. Despite the resident's care plan addressing transmission-based precautions, staff did not adhere to the required PPE protocols. An STNA was observed entering the resident's room wearing only a surgical face mask, instead of the required N95 mask, eye protection, and gown. The STNA then proceeded to enter other residents' rooms without changing the mask or performing hand hygiene. Interviews with staff revealed a misunderstanding of the PPE requirements, with some staff believing that full PPE was only necessary for direct patient care. The resident preferred to have their door open due to fear when it was closed, which was confirmed by both the resident and staff. The facility's policy on infection control and COVID-19 protocol specified the use of N95 masks, eye protection, and gowns in isolation rooms, but this was not followed. The administrator acknowledged the confusion among staff regarding the difference between enhanced barrier precautions and isolation precautions.
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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) |
|---|---|---|---|---|
| Arlington Care Center | 1.1 mi | ★★★★★ | 7 | 0 |
| The Laurels Of Heath | 1.5 mi | ★★★★★ | 23 | 0 |
| Newark Nursing & Rehab | 1.7 mi | ★★★★★ | 37 | 0 |
| Flint Ridge Nrsg & Rehab Ctr | 1.8 mi | ★★★★★ | 2 | 0 |
| Altercare Newark North Inc. | 3.6 mi | ★★★★★ | 1 | 0 |
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