Inspection Reports for
Care One At Somerset Valley Assisted Living
1621 Route 22 West, Bound Brook, NJ, 08805
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
82% occupied
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights regarding their health information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Date: Nov 7, 2024
Visit Reason
The inspection was conducted based on complaints regarding inadequate resident care, including failure to provide timely incontinence care, delayed call bell response, inaccessible meals and water, and insufficient nursing staff.
Complaint Details
The investigation was triggered by complaints NJ 169236 and 173607 regarding inadequate care including delayed call bell response, insufficient incontinence care, and staffing shortages. The complaints were substantiated with observations, interviews, and record reviews confirming the deficiencies.
Findings
The facility failed to ensure timely incontinence care, prompt call bell response, accessibility of meals and water for dependent residents, and adequate staffing levels. Staffing deficiencies were documented with specific shortfalls in RN and CNA hours and ratios over multiple weeks.
Deficiencies (3)
Failure to ensure resident's bedside table and call light were accessible, resulting in unmet needs for Resident #112.
Failure to provide appropriate incontinence care for Residents #110 and #112.
Failure to provide sufficient nursing staff to meet residents' needs, including timely incontinence care, call bell response, and meal accessibility.
Report Facts
Residents assigned per CNA: 22
RN staffing hours deficit: 9
RN staffing hours deficit: 25
RN staffing hours deficit: 29.25
CNA staffing deficit: 2
CNA staffing deficit: 3
CNA staffing deficit: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Apologized to Resident #112 for bedside table and call light accessibility issues and moved the table closer. |
| Certified Nurse Aide #1 | CNA | Observed incontinence care issues and confirmed Resident #110's brief was saturated and care was delayed. |
| Certified Nurse Aide #2 | CNA | Regular assigned CNA for Resident #112, unfamiliar with resident's routine. |
| Certified Nurse Aide #3 | CNA | Reported caring for 22 residents on night shift and difficulty managing call bell response. |
| Director of Nursing | DON | Acknowledged staffing issues and was aware of staffing ratios but could not comment on acuity-based staffing. |
| Staffing Coordinator | SC | Reported staffing CNAs according to census and acknowledged difficulty staffing certain shifts. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 7, 2024
Visit Reason
The inspection was conducted based on complaints regarding inadequate resident care including inaccessible call lights and bedside items, medication administration errors, insufficient nursing staff, delayed incontinence care, and infection control deficiencies.
Complaint Details
Complaint numbers NJ 169236 and 173607 triggered the investigation focusing on resident care concerns including accessibility of call lights, medication administration, incontinence care, staffing levels, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights and bedside items were accessible to residents, medication administration outside physician parameters, inadequate incontinence care, insufficient nursing staff leading to delayed care, medication errors exceeding 5%, improper medication labeling and storage, and failure to maintain infection control standards including improper cleaning of shared equipment and inadequate signage and PPE availability for Enhanced Barrier Precautions (EBP).
Deficiencies (7)
Failed to ensure resident's bedside table and call light were accessible, resulting in unmet needs and delayed response.
Administered Midodrine medication outside physician parameters, risking adverse reactions.
Failed to provide timely incontinence care to residents, resulting in prolonged soiling and discomfort.
Failed to provide sufficient nursing staff to meet resident needs, causing delays in care and unmet needs.
Medication error rate exceeded 5%, with 3 errors in 30 doses observed.
Medications were not labeled or dated upon opening; expired insulin remained in active inventory.
Failed to maintain infection control practices including improper cleaning of shared glucometer, improper storage of respiratory equipment, inadequate hand hygiene, and lack of clear EBP signage and PPE availability.
Report Facts
Medication error rate: 7.6
Midodrine doses administered outside parameters: 13
Resident census per CNA: 22
Required vs actual RN staffing hours: -9
Required vs actual RN staffing hours: -25
Required vs actual RN staffing hours: -37.25
Required vs actual CNA staffing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Apologized to Resident #112 for bedside table and call light accessibility issues; involved in infection control interviews |
| Director of Nursing | DON | Acknowledged staffing issues and call bell concerns; interviewed regarding medication administration and infection control |
| Licensed Practical Nurse | LPN | Observed administering medications with errors; acknowledged medication errors and improper infection control practices |
| Certified Nurse Aide #1 | CNA | Observed and interviewed regarding incontinence care delays and staffing |
| Certified Nurse Aide #2 | CNA | Interviewed regarding staffing and resident care routines |
| Certified Nurse Aide #3 | CNA | Interviewed about night shift staffing and call bell response delays |
| Infection Preventionist | IP Nurse / ADON | Interviewed regarding infection control practices and EBP signage |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Aug 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ 00160638) to determine compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.
Complaint Details
Complaint #: NJ 00160638. The complaint was substantiated based on observations, interviews, and record reviews indicating medication administration failures for Resident #3.
Findings
The facility was found not in substantial compliance due to failure to implement and enforce medication administration policies, resulting in one resident (Resident #3) not receiving prescribed medication for a total of 5 days. Documentation deficiencies and lack of proper notification for missed medications were also noted.
Deficiencies (2)
Failure to implement and enforce policies regarding medication administration, documentation, and notification for missed medication for Resident #3.
Failure to ensure medications were administered in accordance with prescriber's orders for Resident #3.
Report Facts
Census: 52
Days medication not administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Clinical Services (RDCS) | Interviewed regarding medication administration and documentation. | |
| Administrator | Interviewed regarding medication administration issues and family complaint. | |
| Assistant Executive Director (AED) | Interviewed regarding medication administration. | |
| LPN Supervisor | Interviewed regarding medication administration. | |
| Licensed Practical Nurse (LPN) | Wrote progress notes regarding missing medication and ordering STAT medication. | |
| Former Director of Nursing (DON) | Worked with back-up pharmacy to obtain medication and should have documented follow-ups. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The inspection was conducted based on Complaint #NJ 160833 to investigate the facility's failure to communicate the unavailability of medications from the pharmacy to the physician in accordance with professional standards of practice.
Complaint Details
Complaint #NJ 160833 involved failure to notify physicians about missed medication doses due to pharmacy delays. The complaint was substantiated with findings of missing documentation and staff acknowledgment of the communication failure.
Findings
The facility failed to notify physicians about missed medication doses due to pharmacy delivery delays for two residents, resulting in missed doses of Lantus insulin and rifaximin. Documentation of physician notification was lacking despite policy requirements, and interviews with staff and physicians confirmed the communication gaps.
Deficiencies (1)
Failure to communicate the unavailability of medications from the pharmacy to the physician for Resident #16 and Resident #217, resulting in missed doses of Lantus insulin and rifaximin.
Report Facts
Residents affected: 2
Missed Lantus doses: 4
Medication doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Interviewed regarding medication communication and documentation for Resident #16. |
| Director of Nursing | DON | Acknowledged documentation problems and responsibility for medication reorder and physician notification. |
| Licensed Nursing Home Administrator | LNHA | Acknowledged facility documentation problems regarding missed medication notifications. |
| Licensed Practical Nurse weekend supervisor | LPN/WS | Interviewed about medication verification and physician notification process for Resident #217. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 21, 2023
Visit Reason
The inspection was conducted based on Complaint #NJ 160833 to investigate the facility's failure to communicate the unavailability of medications from the pharmacy to the physician in accordance with professional standards of practice.
Complaint Details
Complaint #NJ 160833 was substantiated based on observations, interviews, and document reviews showing the facility did not notify physicians of missed medication doses due to pharmacy delays and failed to document such notifications. The complaint also included food safety violations.
Findings
The facility failed to notify the physician about missed medication doses due to pharmacy delivery delays for two residents, resulting in missed doses of insulin and rifaximin. Documentation of physician notification was lacking, and the facility acknowledged a documentation problem. Additionally, the facility failed to properly store, label, and date potentially hazardous foods, risking food-borne illnesses.
Deficiencies (2)
Failure to communicate unavailability of medications from pharmacy to physician, resulting in missed doses of Lantus insulin and rifaximin for residents.
Failure to store, label, and date potentially hazardous foods properly, risking food-borne illnesses.
Report Facts
Residents affected: 2
Missed Lantus doses: 4
Medication doses missed: 1
Food items discarded: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Interviewed regarding medication administration and documentation practices |
| Director of Nursing | DON | Acknowledged documentation problems and responsibility for medication reorder and physician notification |
| Licensed Nursing Home Administrator | LNHA | Acknowledged documentation problems regarding missed medication notifications |
| Food Service Director | FSD | Observed and discussed food storage and labeling deficiencies |
| Licensed Practical Nurse weekend supervisor | LPN/WS | Interviewed about medication verification and notification process |
| Resident's physician | Interviewed regarding notification expectations for missed medications |
Inspection Report
Deficiencies: 0
Date: Jun 16, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Careone at Somerset Valley, summarizing the findings of a regulatory inspection completed on June 16, 2021.
Findings
No health deficiencies were found during the inspection.
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