Inspection Reports for CareOne at Livingston
68 Passaic Ave, Livingston, NJ 07039, United States, NJ, 07039
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Notice
Deficiencies: 0
Nov 19, 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 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Annual Inspection
Census: 58
Capacity: 72
Deficiencies: 6
Mar 14, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to encoding/transmitting resident assessments, pharmacy services and medication administration, medication error rates, staffing ratios, and life safety code violations including electrical and fire safety issues.
Complaint Details
Complaint numbers NJ 154054, 162302, 162357, 162411, 163471, 163604, 164470, 164814, 165442, 167384 were investigated during this survey.
Severity Breakdown
SS=E: 2
SS=D: 1
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to electronically transmit Minimum Data Set (MDS) assessments within required timeframes for multiple residents. | SS=E |
| Failure to provide pharmaceutical services in accordance with professional standards, including failure to administer medication as ordered for Resident #21. | SS=E |
| Medication administration error rate of 12% observed during medication administration to residents, including incorrect timing and dosage. | SS=D |
| Failure to maintain minimum direct care staff-to-resident ratios as mandated by New Jersey State requirements. | — |
| Nonmetallic Sheathed Cable exposed without required 15-minute fire-rated thermal barrier in mechanical room. | SS=F |
| Carbon monoxide detectors for Direct-Vent Gas Fireplaces were battery operated and not electrically supervised to the fire alarm system. | SS=F |
Report Facts
Census: 58
Total Capacity: 72
Medication administration error rate: 12
Staffing deficiency: 5
Staffing deficiency: 5
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Nov 13, 2023
Visit Reason
The inspection was conducted based on multiple complaints alleging noncompliance with regulatory requirements at the facility.
Findings
The facility was found noncompliant with admissions policy, discharge notice requirements, and accuracy of resident assessments. Specifically, the facility failed to implement its admission agreement policy, did not provide 30-day written discharge notices to residents or their representatives, and inaccurately coded resident assessment data.
Complaint Details
Complaint #NJ00166633 involved failure to provide proper admission agreements and discharge notices, and inaccurate resident assessment coding. The facility discharged residents without proper 30-day notice and failed to document discharge plans appropriately. The facility also inaccurately coded the discharge plan section of a resident's MDS.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement the facility's Admission Agreement policy for 1 of 6 residents reviewed. | SS=D |
| Failure to provide 30-day written notice before transfer or discharge for 2 of 6 residents reviewed. | SS=D |
| Failure to accurately code resident's Minimum Data Set (MDS) assessment for 1 of 6 residents reviewed. | SS=D |
Report Facts
Complaint numbers: 4
Census: 57
Sample size: 7
Deficiency completion dates: Plan of correction completion date 12/22/2023 for all deficiencies
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Social Worker | Interviewed regarding discharge planning and MDS coding |
| Social Worker #2 | Social Worker | Documented progress notes related to resident discharge |
| Social Worker #3 | Social Worker | Documented progress notes related to resident discharge |
| Admission Director | Interviewed regarding missing Admission Agreement and corrective actions | |
| Administrator | Licensed Nursing Home Administrator (LNHA) | Interviewed regarding missing Admission Agreement and discharge procedures |
| Maintenance Director | Interviewed regarding alleged maintenance issues related to resident transfers | |
| Regional Marketing and Business Development (RMBD) | Interviewed regarding family communications about resident transfers | |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding discharge instructions and 30-day notice |
| Vice President of Operations (VPO) | Interviewed regarding resident transfers and maintenance issues | |
| Resident #3's Primary Physician | Primary Care Physician | Interviewed regarding awareness of resident transfers |
| Resident #4's Guardian | Interviewed regarding discharge process and lack of notice |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
May 12, 2022
Visit Reason
The inspection was conducted based on a complaint survey (Complaint #: NJ00154618) to determine compliance with 42 CFR Part 483 Subpart B for Long Term Care facilities.
Findings
The facility failed to consistently implement their policy on Charting and Documentation for 2 of 3 residents reviewed, with multiple dates and shifts lacking signatures and documentation for care tasks such as bed mobility, personal hygiene, and toileting. Interviews with staff confirmed that documentation was required but not consistently completed.
Complaint Details
Complaint #: NJ00154618. The complaint investigation found the facility non-compliant with documentation requirements for residents' care. The complaint was substantiated based on record review and interviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to consistently implement the policy on Charting and Documentation for residents, with blanks in multiple dates and shifts and missing signatures. | SS=D |
Report Facts
Sample size: 3
Deficiency correction completion date: Jun 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Certified Nursing Assistant | Interviewed regarding documentation practices |
| Nurse Supervisor (NS #1) | Nurse Supervisor | Interviewed regarding documentation oversight and responsibility |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 5
Jan 4, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. A COVID-19 Focused Infection Control Survey was conducted in conjunction with the recertification survey.
Findings
Deficiencies were cited related to respiratory care accountability, medication storage and labeling, hospice services coordination, infection prevention and control practices, and staffing ratios. The facility was found compliant with COVID-19 infection control regulations but had multiple deficiencies in other areas.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to maintain accountability for respiratory therapy for 1 resident. | SS=D |
| Failure to store medication at appropriate temperature and failure to store controlled substances securely. | SS=D |
| Failure to consistently provide coordination between facility staff and hospice agency staff to meet resident nursing needs. | SS=D |
| Failure to follow appropriate infection prevention and control measures including hand hygiene, PPE usage, and droplet precautions. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law. | — |
Report Facts
Census: 85
Sample Size: 21
Deficiency counts: 9
Deficiency counts: 2
Required CNA staffing: 11
Actual CNA staffing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Mentioned in relation to respiratory therapy accountability deficiency | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding medication storage and staffing deficiencies | |
| Director of Nursing (DON) | Involved in corrective actions and monitoring for multiple deficiencies | |
| Licensed Practical Nurse (LPN) | Interviewed regarding dietary aide PPE usage | |
| Lab Technician (LT) | Observed and interviewed regarding infection control deficiencies | |
| Dietary Aide (DA) | Observed and interviewed regarding infection control deficiencies | |
| Registered Nurse Unit Manager (RNUM) | Interviewed regarding hospice documentation |
Inspection Report
Life Safety
Census: 114
Capacity: 120
Deficiencies: 1
Jan 4, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 01/04/2022 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 occupancy.
Findings
The facility was found to be in noncompliance with Life Safety Code requirements, specifically regarding the improper storage of compressed oxygen cylinders. One of sixteen portable oxygen cylinders was found unsecured and improperly stored outside the protective storage cage, posing a risk of tipping, rupture, and damage.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to store cylinders of compressed oxygen in a manner that would protect the cylinders against tipping, rupture, and damage in accordance with NFPA 99; one oxygen cylinder was found unsecured on the ground outside the protective storage cage. | SS=D |
Report Facts
Certified beds: 120
Census: 114
Portable oxygen cylinders: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding oxygen cylinder storage deficiency | |
| Environmental Services Director | Removed unsecured oxygen cylinder and responsible for ongoing monitoring | |
| Nurse Staff Educator | Educated staff on proper oxygen cylinder storage | |
| Administrator | Informed of the finding and agreed with the deficiency |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145472, NJ144952, and NJ144922.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483 Subpart B for Long Term Care facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ145472, NJ144952, and NJ144922 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 6
Inspection Report
Routine
Census: 52
Deficiencies: 0
Nov 30, 2020
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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
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