Inspection Reports for
Careone At Oradell

Complaint #175734 involved concerns about medication administration delays and insufficient nursing staff.

The survey identified multiple deficiencies including failure to honor resident shower schedules, inadequate environmental cleanliness, medication administration errors including potential drug interactions and delayed medication delivery, insufficient nursing staff and supplies, improper medication storage, incomplete facility assessment, and failure to offer or document influenza and pneumococcal vaccinations for several residents.

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.

Complaint #NJ178354 and #175734 involved allegations of unclean environment, medication administration issues, staffing shortages, and inadequate supplies. The complaints were substantiated based on observations, interviews, and record reviews.

The facility was found deficient in maintaining a safe, clean, and homelike environment, timely and accurate medication administration for multiple residents, sufficient nursing staff to meet resident needs, and adequate linen and incontinence supplies. The facility failed to update and implement an adequate facility assessment to address these issues.

Complaint #NJ00178451 regarding incorrect medication provided to Resident #1. The complaint was substantiated based on interviews, records review, and pharmacy audit.

The facility failed to ensure Resident #1 received the correct medication as ordered; the pharmacy inadvertently sent Anagrelide 1 mg instead of Anastrozole 1 mg, which was administered multiple times. The error was discovered through medication review and pharmacy audit, with no adverse effects reported for the resident.

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.

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.

Complaints NJ00154889, NJ00160781, and NJ00157351 involved grievances about missing clothes, inaccurate MDS coding, failure to follow clinical recommendations, incomplete discharge summaries, and inadequate treatment and documentation of pressure ulcers.

The facility failed to maintain proper grievance documentation and logs, inaccurately coded MDS assessments for residents, failed to ensure professional standards in treatment documentation and follow-through, and did not provide complete and accurate discharge summaries including necessary clinical information and medication reconciliation. Additionally, a pressure ulcer was not properly assessed, documented, or communicated prior to discharge.

Complaint investigations were conducted based on multiple complaint numbers including NJ00154889, NJ00160781, NJ00157351, NJ00163185, NJ00166154, and others related to grievances, clinical care, staffing, infection control, and medication management.

The facility was found deficient in multiple areas including failure to properly document and investigate grievances, inaccurate resident assessments, failure to follow professional standards of care, incomplete discharge summaries, inadequate fall investigations and interventions, insufficient staffing levels, medication administration errors, improper infection control practices, and lack of dedicated infection preventionist involvement in QAPI.

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.

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.

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.

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.

The facility was found deficient in multiple areas including failure to preserve resident dignity by staff entering rooms without knocking, improper medication administration practices such as leaving medications unattended and not checking labels three times, failure to maintain infection control protocols including inadequate hand hygiene and improper use of personal protective equipment (PPE), and failure to properly document treatment administration. These deficiencies were associated with minimal harm or potential for actual harm affecting a few to some residents.

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.

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.

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.

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.