Deficiencies (last 3 years)
Deficiencies (over 3 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
175% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
62% occupied
Based on a May 2025 inspection.
This facility has shown a decline 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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their 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 | NJDHSS Privacy Officer listed as contact for this notice |
Inspection Report
Routine
Deficiencies: 6
Date: Jul 31, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident dignity, medication use, assessments, care planning, bed rail use, and infection control practices at Careone at Holmdel nursing home.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity regarding urinary catheter privacy, inadequate monitoring of antipsychotic medication effects, inaccurate resident assessments, incomplete care plans for PTSD, improper use and consent for bed rails, and failure to follow enhanced barrier precautions for infection control. All deficiencies were cited with minimal harm and affected a few residents.
Deficiencies (6)
Failure to promote dignity by not covering urinary drainage bag for Resident 63.
Failure to monitor target behaviors for antipsychotic medication (Seroquel) for Resident 28.
Failure to ensure accurate Minimum Data Set (MDS) assessment for Resident 3 regarding dialysis.
Failure to develop a care plan with interventions for PTSD for Resident 9.
Failure to assess alternatives and obtain proper consent for bed rail use for Residents 57 and 8.
Failure to follow enhanced barrier precautions (PPE gown use) for residents on EBP for Residents 73 and 63.
Report Facts
Residents reviewed: 24
Residents with indwelling catheters reviewed: 13
Residents reviewed for unnecessary medications: 5
Residents reviewed for side rails: 24
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 2 | CNA | Mentioned in relation to urinary drainage bag privacy and infection control PPE use |
| Certified Nursing Assistant 5 | CNA | Mentioned in relation to infection control PPE use |
| Licensed Practical Nurse 3 | LPN | Interviewed about monitoring antipsychotic medication side effects |
| Director of Nursing | DON | Interviewed regarding medication monitoring, care planning, bed rail use, and infection control |
| MDS Coordinator 1 | MDSC | Confirmed inaccurate MDS assessment for Resident 3 |
| MDS Coordinator 2 | MDSC | Confirmed inaccurate MDS assessment for Resident 3 |
| Registered Nurse 1 | RN | Interviewed about PTSD diagnosis and care planning |
| Administrative Unit Manager | AUM | Interviewed about PTSD care plan awareness |
| Licensed Practical Nurse 5 | LPN | Interviewed about bed rail consent and alternatives |
| Certified Nursing Assistant 6 | CNA | Observed and interviewed regarding infection control PPE use |
| Infection Preventionist | IP | Interviewed about staff PPE compliance and re-education |
| North Manager | MGRN | Interviewed about urinary drainage bag privacy |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00173227, NJ00185677, and NJ00185653 to assess compliance with long term care facility regulations.
Complaint Details
Complaint investigation based on complaints NJ00173227, NJ00185677, NJ00185653. The facility was found to be deficient in CNA staffing ratios during the complaint period and prior to survey. The facility was not in substantial compliance with New Jersey licensure standards but no residents were adversely affected by the staffing deficiencies.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards for licensure of Long Term Care Facilities due to deficiencies in meeting mandatory staffing ratios, specifically CNA staffing shortages during specified periods. The facility leadership acknowledged ongoing staffing challenges and has implemented corrective actions including audits, hiring incentives, and scheduled recruitment efforts.
Deficiencies (1)
Failure to ensure staffing ratios were met, with CNA staffing deficient on 14 of 14 day shifts from 03/17/2024 to 03/30/2024 and on 10 of 14 day shifts from 04/13/2025 to 04/26/2025.
Report Facts
Census: 81
Sample Size: 3
Deficient CNA staffing days: 14
Deficient CNA staffing days: 10
Required CNAs: 11
Actual CNAs: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Offered conditional employment to 1 Licensed Practical Nurse and 1 Certified Nursing Assistant pending criminal background checks; involved in staffing audits and corrective actions |
Inspection Report
Annual Inspection
Census: 86
Capacity: 120
Deficiencies: 12
Date: Mar 13, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to timely reporting of alleged violations, pressure ulcer treatment and documentation, nutrition and hydration monitoring, parenteral/IV fluid management, pharmacy services, infection prevention and control, emergency preparedness including subsistence needs, and life safety code compliance including corridor doors and smoke barriers.
Deficiencies (12)
Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment within required timeframes.
Failure to document pressure ulcer measurements and obtain physician orders for wound treatment upon admission.
Failure to obtain, record and monitor resident weights on admission, readmission and weekly as per professional standards.
Failure to obtain physician orders for parenteral/IV fluids and to discontinue IV lines after treatment completion.
Failure to follow physician orders for medication administration with parameters, resulting in medication given when contraindicated.
Failure to ensure staff wear appropriate personal protective equipment including eye protection for residents on droplet precautions.
Failure to designate a qualified full-time Infection Preventionist for the facility.
Failure to maintain adequate emergency water supply for residents in event of loss of normal water supply.
Failure to maintain adequate emergency food supply consistent with facility policy and emergency preparedness plan.
Failure to maintain corridor doors in good repair, including a damaged janitor closet door that negated smoke resistance.
Failure to maintain smoke barriers with sealed penetrations to resist passage of smoke and fire.
Failure to maintain required minimum direct care staff-to-shift ratios as mandated by the State of New Jersey.
Report Facts
Census: 86
Total Capacity: 120
Deficient CNA staffing days: 13
Emergency water supply: 132
Emergency water supply updated: 216
Emergency water supply total: 492
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an injury of unknown origin resulting in serious bodily injury to a resident (Resident #20).
Complaint Details
Complaint # NJ 169012 involved failure to report an injury of unknown origin resulting in serious bodily injury to Resident #20 within 2 hours to the New Jersey Department of Health. The complaint was substantiated with findings that the incident was reported late (reported on 11/6/23 at 7:00 PM for an injury occurring on 11/5/23 at 8:14 PM).
Findings
The facility failed to report a serious injury to the New Jersey Department of Health within the required 2-hour timeframe. Additionally, deficiencies were found related to infection prevention practices, including failure to ensure staff wore appropriate PPE for COVID-19 precautions and failure to designate a qualified full-time Infection Preventionist Nurse for a period of time.
Deficiencies (3)
Failure to timely report suspected abuse, neglect, or injury of unknown origin resulting in serious bodily injury to proper authorities.
Failure to ensure staff wore appropriate personal protective equipment (PPE) to prevent the potential spread of COVID-19.
Failure to designate a qualified infection preventionist to be responsible for the infection prevention and control program from 12/1/23 until 2/18/24.
Report Facts
Date of injury: Nov 5, 2023
Date injury reported: Nov 6, 2023
Laceration size: 15
Laceration size: 10
Blood loss: 1
Number of stitches: 20
Date of wound care treatment: Mar 8, 2024
Date of survey completion: Mar 13, 2024
Date CNA PPE in-service: Jan 5, 2024
Date IPN training completed: Feb 19, 2024
IPN vacancy period: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged late reporting of injury and performed Infection Preventionist duties during vacancy. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Acknowledged reporting requirements and provided timeline for Infection Preventionist Nurse. |
| Infection Preventionist Nurse #1 | Infection Preventionist Nurse (IPN) | Newly designated IPN who completed CDC training on 02/19/2024 and interviewed during survey. |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Observed not wearing appropriate eye protection while caring for COVID-19 positive resident. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 120
Deficiencies: 8
Date: Mar 13, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to timely report an injury of unknown origin, pressure ulcer care, nutritional monitoring, IV fluid administration, medication administration, infection control practices, infection preventionist designation, and emergency water supply.
Complaint Details
Complaint # NJ 169012 and NJ# 164959 involved failure to timely report injury, pressure ulcer care, and other care deficiencies.
Findings
The facility was found deficient in multiple areas including failure to report a serious injury within required timeframes, inadequate documentation and treatment of pressure ulcers, failure to obtain and document resident weights as required, improper management of peripheral IV lines, medication administration errors, failure to ensure staff wore appropriate PPE for COVID-19 precautions, lack of a designated qualified infection preventionist for a period, and insufficient emergency water supply.
Deficiencies (8)
Failure to timely report an injury of unknown origin resulting in serious bodily injury to the NJ Department of Health within 2 hours.
Failure to document measurement of pressure ulcers and obtain physician's order for wound care for a resident admitted with a community-acquired pressure ulcer.
Failure to obtain, record, and monitor weights on admission, readmission, and weekly as required.
Failure to obtain physician order to maintain peripheral IV access and discontinue peripheral IV access after completion of IV antibiotic.
Failure to follow physician orders for administration of blood pressure medication (Midodrine) including administering when systolic blood pressure was above 100.
Failure to ensure staff wore appropriate PPE including eye protection when caring for a resident on COVID-19 droplet precautions.
Failure to provide a designated qualified Infection Preventionist Nurse from 12/1/23 until 2/18/24.
Failure to maintain sufficient emergency water supply for residents and staff for three days as required.
Report Facts
Residents reviewed for pressure ulcers: 3
Residents reviewed for nutrition: 6
Facility licensed capacity: 120
Facility census: 86
Emergency water supply cases initially counted: 22
Emergency water supply cases recounted: 36
Emergency water supply cases after ordering: 82
Peripheral IV antibiotic treatment days: 9
Midodrine administration errors: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Interviewed regarding peripheral IV line management and medication administration errors |
| Director of Nursing | DON | Acknowledged delayed injury reporting, medication errors, and infection preventionist role coverage |
| Licensed Nursing Home Administrator | LNHA | Provided timeline for Infection Preventionist Nurse and emergency water supply information |
| Infection Preventionist Nurse #1 | IPN | Newly designated Infection Preventionist Nurse starting 2/18/24 |
| Certified Nursing Assistant | CNA | Observed not wearing appropriate eye protection for COVID-19 precautions |
| Food Service Director | FSD | Provided information on emergency water supply counts |
| Director of Maintenance | DM | Interviewed regarding emergency water supply ordering responsibility |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 6
Date: Dec 7, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to thoroughly investigate an allegation of abuse, failure to ensure preventive measures for pressure ulcers, failure to apply positioning devices as ordered, improper storage of catheter bags, and medication administration errors.
Deficiencies (6)
Facility failed to thoroughly investigate an allegation of abuse for 1 of 20 sampled residents.
Facility failed to ensure preventive measures to prevent/promote healing of pressure ulcers were in place and consistently followed for 1 of 4 residents.
Facility failed to apply a positioning device as ordered by the physician for 1 of 1 residents reviewed for positioning.
Facility failed to ensure that the catheter bag was stored in a manner to prevent infection for 1 of 3 residents reviewed for care.
Facility failed to ensure medication error rates were below 5%, with a 9.38% error rate observed during medication administration.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Census: 99
Medication administration opportunities: 32
Medication administration errors: 3
Medication error rate: 9.38
Certified Nurse Aides (CNAs) required: 14
Certified Nurse Aides (CNAs) present: 8
Inspection Report
Life Safety
Deficiencies: 1
Date: Dec 7, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/01/2021 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant due to failure to provide a functioning battery backup emergency light above the emergency generator's transfer switch. The emergency light did not function properly during testing, and the issue was verified by the facility's Maintenance Director. The light was immediately repaired on 12/07/2021.
Deficiencies (1)
Failure to provide a functioning battery backup emergency light above the emergency generator's transfer switch.
Report Facts
Date of survey completion: Dec 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Maintenance Director | Verified the emergency light deficiency during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 7, 2021
Visit Reason
The inspection was conducted due to an allegation of abuse involving Resident #39 and to investigate other care concerns including pressure ulcer care, medication administration, and catheter care.
Complaint Details
The complaint investigation focused on an allegation of abuse for Resident #39, which was found not to have been properly investigated by the facility. The allegation involved Resident #39 stating that a man was trying to hurt them, but no incident report or investigation was documented at the time.
Findings
The facility failed to thoroughly investigate an allegation of abuse for Resident #39, failed to ensure preventive measures for pressure ulcers for Resident #71, failed to apply a positioning device as ordered for Resident #453, failed to properly store Foley catheter drainage bags for Resident #18, and had a medication administration error rate of 9.38% involving Residents #87 and #454.
Deficiencies (5)
Failed to thoroughly investigate an allegation of abuse for Resident #39.
Failed to ensure preventive measures to prevent/promote healing of pressure sores for Resident #71, including failure to off-load the right heel and apply dressing as ordered.
Failed to apply a positioning device (abductor pillow) as ordered for Resident #453.
Failed to store Foley urinary catheter drainage bag properly to prevent urinary tract infection for Resident #18.
Medication administration errors observed including failure to prime insulin pen injector, incorrect administration of Senna medication, and incorrect dose of Vitamin C for Residents #87 and #454.
Report Facts
Medication administration opportunities: 32
Medication administration errors: 3
Medication administration error rate: 9.38
Insulin dose: 15
Senna dose: 8.6
Vitamin C dose ordered: 500
Vitamin C dose administered: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Administered insulin pen without priming and administered incorrect Senna medication | |
| Registered Nurse (RN) | Administered incorrect dose of Vitamin C | |
| Director of Nursing (DON) | Provided insulin pen administration instructions and discussed medication observation process | |
| Certified Nursing Assistant (CNA) | Involved in care of Residents #39, #71, and #18; provided statements regarding allegations and catheter bag storage | |
| Assistant Director of Nursing (ADON) | Interviewed regarding Resident #71 care and medication administration | |
| Unit Manager (UM) | Interviewed regarding Resident #39 and Resident #87 medication | |
| Physical Therapist | Interviewed regarding Resident #453 hip precautions and abductor pillow use | |
| Infection Control Preventionist (IP) | Provided education on Foley catheter drainage bag storage | |
| Consultant Pharmacist (CP) | Provided medication administration observation and education | |
| Consultant Pharmacist Director of Operations (DCP) | Discussed OTC medication purchasing and medication observation process |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Aug 2, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145544, NJ143676, and NJ145982 regarding alleged violations at the facility.
Complaint Details
Complaint Intake NJ145982 involved failure to report an allegation of staff to resident abuse and failure to provide a summary of the final investigation for Resident #1. The allegation was investigated and found unsubstantiated, but the facility did not report it to the NJDOH as required.
Findings
The facility was found not in compliance with 42 CFR Part 483, Subpart B, due to failure to report an allegation of staff to resident abuse to the New Jersey Department of Health and failure to provide a summary of the final investigation for one resident. The investigation concluded that abuse was unsubstantiated, but the facility did not report the allegation as required.
Deficiencies (1)
Failure to report an allegation of staff to resident abuse to the New Jersey Department of Health and failure to provide a summary of the final investigation for one resident.
Report Facts
Census: 105
Sample Size: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Investigated the incident, did not report the allegation or submit a summary of investigation findings |
| CNA #1 | Certified Nurse Aide | Assisted in transferring Resident #1 and provided statements about the transfer |
| CNA #5 | Certified Nurse Aide / Newly licensed Registered Nurse | Assisted in transferring Resident #1 and provided statements about the transfer |
Inspection Report
Routine
Census: 85
Deficiencies: 0
Date: Jan 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
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