Inspection Reports for CareOne at Livingston
68 Passaic Ave, Livingston, NJ 07039, United States, NJ, 07039
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025, did not identify any deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to resident care, including medication administration errors, delays in treatment, pressure ulcer care, and issues with resident assessment data transmission. Complaint investigations found some substantiated issues with admission agreements, discharge notices, and documentation, but most complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record suggests some improvement over time, with the latest inspection showing no deficiencies after prior reports noted multiple issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
81% occupied
Based on a March 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: 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
Complaint Investigation
Deficiencies: 2
Date: Oct 23, 2025
Visit Reason
The inspection was conducted based on Complaint NJ #2599517 to investigate allegations related to delays and inaccuracies in implementing physician-recommended burn treatment orders and deficiencies in pressure ulcer care.
Complaint Details
Complaint NJ #2599517 involved failure to timely implement a physician's burn treatment recommendation and failure to order treatment at the recommended frequency for Resident #1, and failure to properly assess and treat a facility-acquired pressure ulcer for Resident #3.
Findings
The facility failed to ensure timely implementation and correct frequency of a burn treatment for Resident #1, and failed to properly assess and intervene for a facility-acquired pressure ulcer in Resident #3, including lack of documented wound assessment and delayed treatment.
Deficiencies (2)
Failure to implement physician-recommended burn treatment frequency and delay in medication availability for Resident #1.
Failure to provide appropriate pressure ulcer care, including lack of documented wound assessment and delayed interventions for Resident #3.
Report Facts
Total body surface area burned: 79
Basic Interview for Mental status score: 15
Wound measurement: 10
Wound measurement: 7
Wound measurement: 0
Days delay in wound treatment order administration: 7
Date of wound identification: Jul 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding process of implementing consultation recommendations and medication orders. | |
| Director of Nursing (DON) | Interviewed regarding awareness of medication order delays and wound care deficiencies. | |
| Advanced Practice Nurse | Documented a late entry progress note failing to address new wound. | |
| Licensed Practical Nurse Unit Manager (LPNUM) | Completed skin note conflicting with wound specialist assessment. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident assessments, activities, nutrition, pharmaceutical services, and medical record accuracy.
Findings
The facility was found deficient in multiple areas including failure to timely transmit resident assessment data, failure to provide meaningful individualized activities, failure to provide prescribed therapeutic diet textures, failure to ensure consistent medication administration, and inaccurate medical record documentation regarding resident bathing.
Deficiencies (5)
Failure to ensure timely transmission of Minimum Data Set (MDS) assessments for three residents.
Failure to provide meaningful, individualized activity program for one resident, including lack of care plan development and activity assessment.
Failure to provide prescribed therapeutic minced and moist diet texture to one resident, serving regular texture food instead.
Failure to ensure one resident received medications as ordered, with missed doses due to medication unavailability.
Failure to maintain accurate medical records for two residents regarding bathing, with records indicating showers or tub baths that were not provided.
Report Facts
Residents sampled: 22
Missed medication doses: 6
Medication administration opportunities: 14
Resident weight: 113.6
Body Mass Index (BMI): 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Specialist Registered Nurse (RN) | Confirmed assessments for residents R28 and R50 were not submitted timely and R67's assessment was submitted late | |
| Certified Nursing Assistant (CNA)1 | Reported Resident 4 was alert, oriented, dependent on staff, and did not participate in activities | |
| Recreation Assistant (RA) | Reported making rounds and offering activities but Resident 4 did not participate in group activities | |
| Director of Recreation | Reported no activity evaluation or care plan was created for Resident 4 until surveyor inquiry | |
| Family Member (F)1 | Reported Resident 70 was served incorrect diet textures on multiple occasions | |
| Dining Room Lead and Registered Dietitian (RD) | Verified Resident 70 was served inappropriate food texture and explained tray card system error | |
| Unit Manager Licensed Practical Nurse (LPN) | Reported correcting diet order for Resident 70 and explained tray card system glitch | |
| Speech Therapist (ST) | Confirmed Resident 70's prescribed diet texture and risk of aspiration from incorrect food texture | |
| Director of Nursing (DON) | Acknowledged diet texture error for Resident 70 and medication administration issues for Resident 72 | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Discussed medication administration issues for Resident 72 and communication with physician and pharmacy | |
| Licensed Practical Nurse 2 (LPN2) | Described procedure for handling unavailable medications and communication with physician | |
| Licensed Practical Nurse 1 (LPN1) | Described procedure for handling unavailable medications and communication with physician | |
| Consultant Pharmacist | Confirmed ongoing pharmacy delivery problems and proper procedures for medication order changes | |
| Unit Manager Licensed Practical Nurse (LPN) | Reported Resident 4 and Resident 71 had not received showers or tub baths despite documentation |
Inspection Report
Annual Inspection
Census: 58
Capacity: 72
Deficiencies: 6
Date: 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.
Complaint Details
Complaint numbers NJ 154054, 162302, 162357, 162411, 163471, 163604, 164470, 164814, 165442, 167384 were investigated 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.
Deficiencies (6)
Failure to electronically transmit Minimum Data Set (MDS) assessments within required timeframes for multiple residents.
Failure to provide pharmaceutical services in accordance with professional standards, including failure to administer medication as ordered for Resident #21.
Medication administration error rate of 12% observed during medication administration to residents, including incorrect timing and dosage.
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.
Carbon monoxide detectors for Direct-Vent Gas Fireplaces were battery operated and not electrically supervised to the fire alarm system.
Report Facts
Census: 58
Total Capacity: 72
Medication administration error rate: 12
Staffing deficiency: 5
Staffing deficiency: 5
Inspection Report
Routine
Deficiencies: 3
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident assessment data transmission, pharmaceutical services, medication administration, and medication error rates.
Findings
The facility failed to electronically transmit Minimum Data Set (MDS) assessments within required timeframes for multiple residents and failed to complete a discharge assessment for one resident. Additionally, the facility did not ensure administration of a medication according to physician's orders for one resident and had a medication administration error rate of 12% during observed medication passes.
Deficiencies (3)
Failure to electronically transmit Minimum Data Set (MDS) assessments within 14 days of completion for multiple residents and failure to complete discharge assessment for one resident.
Failure to provide pharmaceutical services in accordance with professional standards by not ensuring administration of Procrit medication according to physician's order for one resident.
Medication administration error rate of 12% observed during medication pass, including errors in timing of Glipizide administration, incorrect dosage of Colace, and incorrect patch strength for Lidocaine.
Report Facts
Residents reviewed for MDS transmission: 24
Residents reviewed for medication management: 5
Medication administration opportunities observed: 25
Medication administration errors observed: 3
Medication administration error rate: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed administering Glipizide not 30 minutes before meal as ordered |
| Licensed Practical Nurse #2 | LPN | Observed administering incorrect dosage of Colace and incorrect Lidocaine patch strength |
| Director of Nursing | DON | Interviewed regarding medication administration and lab result procedures |
| Licensed Nursing Home Administrator | LNHA | Met with survey team regarding medication administration issues |
| MDS Coordinator/RN | MDSC/RN | Provided validation reports and interviewed about MDS coordinator staffing |
| Regional MDS Coordinator/RN | Regional MDSC/RN | Interviewed about late MDS assessments and staffing |
| Consultant Pharmacist | CP | Interviewed about medication equivalency and administration timing |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Date: Nov 13, 2023
Visit Reason
The inspection was conducted based on multiple complaints alleging noncompliance with regulatory requirements at the facility.
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.
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.
Deficiencies (3)
Failure to implement the facility's Admission Agreement policy for 1 of 6 residents reviewed.
Failure to provide 30-day written notice before transfer or discharge for 2 of 6 residents reviewed.
Failure to accurately code resident's Minimum Data Set (MDS) assessment for 1 of 6 residents reviewed.
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
Deficiencies: 3
Date: Nov 13, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to implement the facility's admission agreement policy, failure to provide timely discharge notification to residents' representatives, and failure to accurately code resident assessments.
Complaint Details
The complaint investigation (Complaint #NJ00166633) was triggered by allegations that the facility failed to implement admission agreement policies, failed to provide timely discharge notices to residents' representatives, and failed to accurately code resident assessments. The investigation included interviews with facility staff, residents' representatives, and review of medical records and facility policies.
Findings
The facility failed to provide a signed admission agreement for Resident #3, failed to provide 30-day written discharge notices to residents' representatives for Residents #3 and #4, and inaccurately coded the discharge plan on Resident #3's Minimum Data Set (MDS). The facility also failed to provide physician orders indicating notification and agreement for the discharges. Interviews and record reviews confirmed these deficiencies.
Deficiencies (3)
Failure to implement the facility's admission agreement policy for Resident #3.
Failure to provide timely 30-day written discharge notification to residents' representatives for Residents #3 and #4.
Failure to accurately code Resident #3's Minimum Data Set (MDS) discharge plan.
Report Facts
Residents reviewed: 6
Residents affected: 1
Residents affected: 2
BIMS score: 3
Discharge dates: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON #1 | Director of Nursing | Named in relation to discharge process and failure to provide 30-day notice |
| Social Worker (SW #1) | Social Worker | Interviewed regarding discharge planning and MDS coding error |
| Social Worker (SW #2) | Social Worker | Documented progress notes and interviewed regarding discharge planning |
| Regional Marketing and Business Development (RMBD) | Regional Marketing and Business Development | Involved in communication with residents' families about transfers |
| VPO | Vice President of Operations | Provided information about discharge decisions and maintenance issues |
| Maintenance Director (MD) | Maintenance Director | Interviewed regarding maintenance issues related to discharge |
| Primary Care Physician (PCP) | Primary Care Physician | Interviewed regarding awareness of residents' transfers |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to consistently implement the policy on Charting and Documentation for residents, with blanks in multiple dates and shifts and missing signatures.
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
Deficiencies: 4
Date: Jan 4, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, medication storage, hospice services, infection prevention and control, and other nursing home care standards.
Findings
The facility was found deficient in maintaining accountability for oxygen therapy, proper medication storage including controlled substances, coordination of hospice care, and infection prevention and control practices including PPE use and hand hygiene.
Deficiencies (4)
Failed to maintain accountability for oxygen therapy for 1 of 1 resident reviewed for respiratory care.
Failed to store medication at the appropriate temperature and failed to store controlled substances in a manner that would prevent loss or diversion.
Failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs.
Failed to follow appropriate measures to prevent and control the spread of infection, including improper PPE use and hand hygiene by staff.
Report Facts
Medication refrigerators inspected: 2
Oxygen setting: 2
Dates of hospice nurse visits: Hospice nurse visits occurred on 11/29/21, 12/1/21, 12/8/21, and 12/13/21.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Discussed oxygen use and documentation for Resident #32. | |
| Unit Manager/Registered Nurse (UM/RN) | Confirmed oxygen setting and discussed oxygen documentation. | |
| Licensed Nursing Home Administrator (LNHA) | Discussed oxygen order clarification and medication storage issues. | |
| Director of Nursing (DON) | Discussed oxygen use, medication storage, infection control concerns. | |
| Registered Nurse Unit Manager (RNUM) | Interviewed about hospice nursing progress notes and care plan. | |
| Lab Technician (LT) | Observed failing to follow infection control protocols including hand hygiene and PPE use. | |
| Dietary Aide (DA) | Observed entering resident room without proper PPE and hand hygiene. | |
| Licensed Practical Nurse (LPN) | Interviewed about Dietary Aide's improper PPE use. | |
| Infection Preventionist (IP) | Discussed infection control concerns with surveyor. |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 5
Date: 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.
Deficiencies (5)
Failure to maintain accountability for respiratory therapy for 1 resident.
Failure to store medication at appropriate temperature and failure to store controlled substances securely.
Failure to consistently provide coordination between facility staff and hospice agency staff to meet resident nursing needs.
Failure to follow appropriate infection prevention and control measures including hand hygiene, PPE usage, and droplet precautions.
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
Date: 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.
Deficiencies (1)
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.
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
Date: Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145472, NJ144952, and NJ144922.
Complaint Details
Complaint numbers NJ145472, NJ144952, and NJ144922 were investigated and found to be unsubstantiated as the facility was in compliance.
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.
Report Facts
Sample size: 6
Inspection Report
Routine
Census: 52
Deficiencies: 0
Date: 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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