Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer and contact person for the notice |
Inspection Report
Routine
Census: 109
Capacity: 111
Deficiencies: 6
Dec 13, 2024
Visit Reason
The inspection was a routine recertification survey conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The survey identified multiple deficiencies related to resident rights, safe environment, quality of care, medication management, staffing, and life safety code compliance. Deficiencies included failure to provide showers as scheduled, inadequate infection control, medication errors, insufficient staffing, and fire safety violations.
Deficiencies (6)
| Description |
|---|
| Failure to provide showers to residents as scheduled and document refusals. |
| Failure to maintain a safe, clean, comfortable, and homelike environment, including air circulation and housekeeping issues. |
| Medication errors including failure to administer medications as ordered and failure to document properly. |
| Failure to provide sufficient nursing staff to meet residents' needs. |
| Failure to maintain fire safety equipment and ensure proper egress door function. |
| Failure to provide emergency preparedness training and documentation. |
Report Facts
Census: 109
Total Capacity: 111
Deficiency counts: 6
Staffing Deficiency: 14
Fire extinguishers inspected: 39
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 2
Nov 25, 2024
Visit Reason
The inspection was conducted based on complaints NJ00178451 and NJ00173120 to investigate medication administration and staffing deficiencies at CareOne at Oradell.
Findings
The facility was found not in substantial compliance with pharmacy services requirements related to medication administration errors for a resident, and deficient in staffing ratios for certified nursing assistants (CNAs) on multiple shifts. Corrective actions and plans to prevent recurrence were documented.
Complaint Details
Complaint investigation based on complaints NJ00178451 and NJ00173120. The medication error complaint was substantiated as evidenced by interviews, record reviews, and pharmacy audit. Staffing deficiencies were documented based on facility records and surveyor observations.
Severity Breakdown
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure and provide the correct medication for a resident according to the Physician's Order when the facility's pharmacy sent a different medication. | Level D |
| Failure to maintain required minimum staffing ratios for CNAs on 12 of 14 day shifts and deficient CNAs to total staff on 1 of 14 evening shifts. | — |
Report Facts
Census: 106
Staffing Deficiency Counts: 12
Staffing Deficiency Counts: 1
Inspection Report
Routine
Census: 118
Capacity: 154
Deficiencies: 7
Sep 8, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included review of complaints and focused on compliance with federal and state regulations.
Findings
The facility was found to be out of compliance with multiple regulatory requirements including grievance procedures, accuracy of assessments, comprehensive care plans, discharge summaries, infection control, staffing, medication administration, and emergency preparedness. Deficiencies were cited in areas such as resident rights, quality of care, infection prevention, and sufficient nursing staff.
Deficiencies (7)
| Description |
|---|
| Failure to maintain a grievance log and follow grievance procedures as required by regulation. |
| Inaccurate Minimum Data Set (MDS) assessments and failure to complete comprehensive care plans for residents. |
| Failure to complete accurate discharge summaries and ensure proper discharge planning. |
| Failure to provide sufficient nursing staff to meet residents' needs and maintain required staffing ratios. |
| Inadequate infection prevention and control practices including hand hygiene and use of personal protective equipment. |
| Medication errors including failure to follow physician orders and incomplete medication administration records. |
| Failure to maintain and test emergency power systems and comply with life safety code requirements. |
Report Facts
Census: 118
Total Capacity: 154
Deficiencies cited: 7
Staffing ratios: 7
Staffing ratios: 4
Inspection Report
Life Safety
Census: 118
Capacity: 154
Deficiencies: 1
Aug 24, 2023
Visit Reason
A Life Safety Code Survey was conducted on 08/24/2023 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found noncompliant due to failure to complete the required three-year load bank test on the emergency generator as per NFPA 110 standards, potentially affecting all 118 residents. The facility subsequently completed the test and implemented a maintenance log and audit process.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the three-year load bank test was completed on the emergency generator in accordance with NFPA 110 standards. | SS=F |
Report Facts
Occupied beds: 118
Total licensed capacity: 154
Deficiency correction completion date: Sep 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Maintenance Director | Confirmed the three-year load bank test had not been completed |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 4
Jan 21, 2022
Visit Reason
The inspection was conducted as a complaint survey triggered by complaints NJ151035, NJ148557, and NJ150492, including a COVID-19 Focused Infection Control Survey by the New Jersey Department of Health.
Findings
The facility was found not in compliance with several regulatory requirements including failure to maintain resident dignity by not covering urinary collection bags, failure to notify responsible parties of significant changes in resident condition, failure to properly assess and document pressure ulcers, and failure to maintain mandated direct care staff-to-resident ratios.
Complaint Details
The complaint investigation included multiple complaint intake numbers NJ151035, NJ148557, and NJ150492. The facility was found not in compliance with federal and state regulations based on these complaints.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure resident dignity by not placing privacy covers over urinary collection bags for 2 residents out of 4 observed. | SS=D |
| Failure to notify responsible party of significant change in condition for 1 resident. | SS=D |
| Failure to assess and document newly discovered pressure ulcers for 1 resident. | SS=D |
| Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law for 14 of 14 day shifts reviewed. | — |
Report Facts
Census: 120
Sample size: 6
Staffing deficiency counts: 14
Required CNAs: 14
Actual CNAs: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding privacy cover deficiency, notification failures, and pressure ulcer documentation. | |
| Administrator | Interviewed regarding privacy cover deficiency and notification failures; unavailable for some interviews. | |
| Assistant Director of Nursing | Interviewed regarding pressure ulcer observations and documentation. |
Inspection Report
Routine
Census: 100
Deficiencies: 4
Jun 30, 2021
Visit Reason
The facility underwent a standard routine survey to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident rights, professional nursing standards, infection prevention and control, and mandatory staffing ratios. Deficiencies included failure to maintain resident dignity and privacy, medication administration errors, inadequate infection control practices, and insufficient staffing ratios.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to consistently provide services preserving dignity of residents, including knocking before entering rooms and maintaining privacy during care. | SS=D |
| Failure to adhere to professional nursing standards including leaving medication unattended, not checking medication labels three times, and not initialing treatment records. | SS=D |
| Failure to implement infection control protocols including improper glove use, inadequate hand hygiene, failure to sanitize equipment, and improper PPE use on isolation unit. | SS=E |
| Failure to meet minimum staffing ratios for Certified Nurse Aides on day, evening, and night shifts. | — |
Report Facts
Census: 100
Sample Size: 27
Staffing Ratios: 8
Staffing Ratios: 10
Staffing Ratios: 14
Staffing Ratios: 10
Staffing Ratios: 11
Staffing Ratios: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to resident dignity violations and medication administration errors |
| LPN #2 | Licensed Practical Nurse | Named in findings related to resident dignity violations, medication administration errors, and infection control breaches |
| LPN #3 | Licensed Practical Nurse | Named in infection control deficiencies including failure to sanitize equipment and hand hygiene |
| LPN #4 | Licensed Practical Nurse | Named in infection control deficiencies including failure to wear gloves and hand hygiene |
| Nurse Practitioner | Named in infection control deficiency related to improper hand hygiene and failure to sanitize stethoscope | |
| Resident Council President, Resident #9 | Interviewed regarding staff entering rooms without knocking | |
| Administrator | Interviewed regarding infection control and staffing concerns | |
| Director of Nursing | Interviewed regarding infection control and staffing concerns | |
| Staffing Coordinator | Interviewed regarding staffing ratios and hiring efforts |
Inspection Report
Life Safety
Deficiencies: 2
Jun 25, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 06/25/21 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found noncompliant due to failure to provide automatic emergency illumination along means of egress and improper use of electrical power strips in patient care areas. Corrective actions included replacing exit lights with battery backup lighting and removing power strips in resident rooms, installing additional wall outlets.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide automatic emergency illumination that would automatically operate along a means of egress. | SS=E |
| Failure to ensure that the use of electrical power strips in patient care vicinities complied with NFPA 99 requirements. | SS=D |
Report Facts
Number of exit lights replaced: 32
Audit frequency: 3
Audit duration: 90
Random audit frequency: 3
Audit period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified findings and responsible for testing battery backup lighting and auditing resident rooms for power strip use. | |
| Regional Physical Plant Manager | Verified findings regarding emergency lighting and power strip use. | |
| Administrator | Informed of findings during exit conference and acknowledged unawareness of power strip issue. | |
| Director of Nursing | Informed about power strip issue. |
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 2
Mar 11, 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 not to be in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure staff knowledge of cleaning chemicals and proper hand hygiene practices according to CDC guidelines. Deficiencies included improper use of disinfectants and failure to perform hand hygiene after glove removal.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure workers are knowledgeable of the cleaning chemical used in the workplace for 3 of 3 staff. | SS=E |
| Failure to practice appropriate hand hygiene for 2 of 8 staff observed in accordance with CDC guidelines. | SS=E |
Report Facts
Sample size: 5
Contact time for disinfectant: 1
Contact time for disinfectant: 3
Contact time for disinfectant: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse#1 | RN | Used 80% alcohol solution incorrectly for disinfecting blood pressure apparatus and could not state contact time |
| Registered Nurse#2 | RN | Used hand sanitizer instead of disinfectant for blood pressure apparatus and could not state contact time |
| Housekeeper#1 | Housekeeper | Used disinfectant spray on handrails but unaware of correct 10-minute contact time, stated 3 minutes |
| Housekeeper#2 | Housekeeper | Removed gloves and failed to perform hand hygiene |
| Housekeeper#3 | Housekeeper | Removed gloves and failed to perform hand hygiene |
| Infection Preventionist Nurse | IPN | Informed surveyors about correct disinfectant use and hand hygiene requirements |
| Director of Nursing | DON | Provided information about residents tested and facility units, and was present during survey |
| Licensed Nursing Home Administrator | LNHA | Present during survey and aware of infection control concerns |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
Dec 4, 2020
Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ00139358.
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 # NJ00139358 was investigated and the facility was found to be in compliance.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 69
Deficiencies: 1
Nov 27, 2020
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code, Chapter 8:39, Standards for Mandatory Resident Rights of Long Term Care Facilities, including adherence to infection control requirements during the COVID-19 pandemic.
Findings
The facility failed to comply with Executive Directive No. 20-026 by not having a qualified Infection Control Preventionist. The Infection Prevention Nurse (IPN) was not certified but was in the process of completing required courses. The facility relied on a physician Infection Preventionist for limited consultation. A plan of correction was submitted to address these deficiencies.
Deficiencies (1)
| Description |
|---|
| Failure to have a qualified Infection Control Preventionist as required by Executive Directive No. 20-026. |
Report Facts
Census: 69
Hours per week dedicated to Infection Control by IPN: 25
Hours per week Infection Prevention consultation by physician IP: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Infection Prevention Nurse (IPN) | Served as facility Infection Prevention Nurse, not certified but completing APIC course | |
| Director of Nursing (DON) | Participated in entrance conference and provided information about infection control staffing | |
| Assistant Director of Nursing (ADON) | Served as Infection Prevention Nurse | |
| Physician Infection Preventionist (IP) | Provided weekly Respirator Fit Testing and infection prevention consultation |
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