Inspection Reports for
CareOne at Parsippany Assisted Living
200 Mazda Brook Rd, Parsippany, NJ 07054, United States, NJ, 07054
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 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
12
9
6
3
0
Occupancy
Latest occupancy rate
83% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 19, 2025
Visit Reason
The inspection was conducted based on Complaint NJ #409369 to investigate the facility's failure to properly document acute transfers and discharge summaries for residents, including communication with residents or their representatives regarding bed-hold policies and discharge instructions.
Complaint Details
Complaint NJ #409369 was substantiated with findings that the facility failed to properly document and communicate acute transfers and discharge summaries, including bed-hold policies and discharge instructions, for residents #106 and #110.
Findings
The facility failed to ensure that acute transfers were properly documented and communicated to residents or their representatives, including reserve payment information. Additionally, the discharge summary for a resident lacked signatures, current vital signs, and documented physician orders, compromising safe and orderly discharge procedures.
Deficiencies (2)
Failure to document acute transfer and communicate reserve payment and bed-hold policy to resident or representative for Resident #106.
Discharge summary for Resident #110 lacked resident or representative signature, current vital signs, and documented physician discharge order.
Report Facts
Residents affected: 2
Date of survey completion: Dec 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Informed surveyor about responsibilities and acknowledged facility deficiencies |
| Director of Nursing | DON | Responsible for notices of transfer and involved in documentation deficiencies |
| Director of Admission | DA | Responsible for obtaining resident or representative signatures on admission packets |
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 | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 7, 2025
Visit Reason
The inspection was conducted based on Complaint #409367 to investigate allegations that the facility failed to ensure a resident received appropriate treatment and care for wound care in accordance with professional standards and facility policies.
Complaint Details
Complaint #409367 was substantiated based on observation, interview, and record review showing failure to follow up with the primary physician on wound care consultant recommendations and lack of documentation of physician progress notes or incident reports related to the resident's worsening wound.
Findings
The facility failed to ensure proper communication and follow-up with the primary physician regarding wound care consultant recommendations for antibiotics and bone scan for Resident #1's diabetic foot ulcers. Documentation of physician progress notes and incident reports related to the worsening wound were absent, indicating deficient wound care management.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically related to wound care for Resident #1.
Report Facts
Wound measurements: 6
Wound measurements: 10
Wound measurements: 0.3
Wound measurements: 4
Wound measurements: 3
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented wound care progress notes and communication with ADON and physician |
| ADON | Assistant Director of Nursing | Interviewed regarding wound care communication and incident reporting |
| DON | Director of Nursing | Interviewed regarding wound care communication and documentation |
| ID APN | Infectious Disease Advanced Practice Nurse | Consulted on 10/30/24 regarding resident's wound infection status and antibiotic recommendations |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ182185.
Complaint Details
Complaint number NJ182185 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs.
Report Facts
Sample size: 10
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 13, 2024
Visit Reason
The inspection was conducted based on a complaint (NJ165579) regarding the facility's failure to initiate a baseline care plan for a resident admitted with a stage 2 pressure ulcer.
Complaint Details
Complaint #: NJ165579. The complaint was substantiated as the facility failed to initiate a baseline care plan for Resident #62 who was admitted with a stage 2 pressure ulcer.
Findings
The facility failed to create and implement a baseline care plan addressing a stage 2 pressure ulcer for Resident #62 upon admission. The Director of Nursing acknowledged that the care plan did not address the pressure ulcer, which was confirmed through record review and interviews.
Deficiencies (1)
Failure to initiate a baseline care plan for a resident admitted with a stage 2 pressure ulcer.
Report Facts
Residents reviewed: 3
Pressure ulcer size: 3
Pressure ulcer size: 2
Pressure ulcer size: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and acknowledged that the care plan did not address the pressure ulcer on admission |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 13, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident care, medication administration, dialysis services, kitchen sanitation, and documentation practices at Careone at Parsippany nursing home.
Findings
The facility was found deficient in multiple areas including inaccurate coding of resident assessments (MDS), failure to document nursing assessments and colostomy care, incorrect medication routes for an NPO resident, inconsistent post-hemodialysis documentation, and inadequate kitchen hand hygiene practices. All deficiencies were associated with minimal harm or potential for harm affecting a few to many residents.
Deficiencies (6)
Failed to accurately code the Minimum Data Set (MDS) discharge status for Resident #61.
Failed to ensure nursing documentation of assessments and communication for Resident #64 transferred for surgery.
Failed to document colostomy care and clarify physician orders for Residents #22, #64, and #262.
Failed to ensure correct medication administration routes for Resident #22 who was NPO.
Failed to consistently assess, document, and monitor Resident #10 after hemodialysis treatments.
Failed to maintain proper kitchen sanitation practices, specifically inadequate hand hygiene by kitchen staff.
Report Facts
Residents reviewed for MDS coding accuracy: 20
Residents reviewed for documentation deficiencies: 12
Hemodialysis communication forms reviewed: 37
Incomplete post-dialysis documentation forms: 26
Medications with incorrect route orders: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse/MDS Coordinator | Acknowledged miscoding Resident #61's discharge MDS | |
| Licensed Nursing Home Administrator (LNHA) | Provided facility policies and acknowledged documentation deficiencies | |
| Regional Clinical Nurse (RCN#1 and RCN#2) | Acknowledged errors in MDS assessments and medication routes | |
| Director of Nursing (DON) | Acknowledged documentation and medication route errors | |
| Licensed Practical Nurse (LPN#1) | Described colostomy care documentation requirements | |
| Registered Nurse (RN#3) | Acknowledged incorrect medication routes for Resident #22 | |
| Chef #1 | Chef | Observed performing inadequate hand hygiene in kitchen |
| Registered Nurse Supervisor (RN/S) | Stated communication sheets needed consistent completion |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Date: Jun 27, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ 00174402) to assess compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.
Complaint Details
Complaint #: NJ 00174402. The complaint was substantiated based on interviews, record reviews, and policy review showing failure to document incidents properly in the medical record.
Findings
The facility was found not in substantial compliance due to failure to implement its policy on Accident/Incident Reporting, specifically failing to document a fall incident in the medical record of Resident #2. Incident reports were not part of the medical record as required, and appropriate documentation in nurse's notes was missing.
Deficiencies (2)
Failure to ensure implementation of Accident/Incident Reporting policy to document incidents in resident's medical record for Resident #2.
Failure to document a fall incident in the medical record of Resident #2, including lack of assessment details and nurse notification.
Report Facts
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Director of Wellness / Registered Nurse (DOW/RN) | Interviewed regarding failure to document Resident #2's incident and fall in the medical record. |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Documented progress notes related to Resident #2's fall but failed to notify Registered Nurse as required. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
The inspection was conducted based on complaint NJ00165681 to investigate allegations that the facility failed to administer medications according to acceptable nursing standards and facility policy for medication administration and physician services.
Complaint Details
Complaint NJ00165681 was investigated. The complaint was substantiated with findings that medications were not administered on schedule and the physician was not notified. No harm to the resident was documented.
Findings
The facility failed to administer medications on schedule for Resident #2, with documented late administrations of Gabapentin and Vancomycin. There was no evidence that the primary care physician was notified of these delays, nor was there documented harm to the resident. Facility staff confirmed the policy requires timely medication administration and notification if medications are late.
Deficiencies (1)
Failure to administer medications according to scheduled times for Resident #2, including late administration of Gabapentin and Vancomycin.
Report Facts
Medication late administration dates: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN #1) | Interviewed regarding medication administration and documentation practices | |
| Administrator | Interviewed regarding medication administration policies | |
| Director of Nursing (DON) | Interviewed regarding medication administration policies and nurse responsibilities |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 24, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to dental care services, medication administration, and pharmaceutical services at the nursing home.
Findings
The facility failed to accurately code a resident's oral/dental status on assessments, failed to provide mandatory annual dental care services for a resident, failed to administer prescribed medication timely for one resident, and had discrepancies in controlled substance reconciliation and documentation.
Deficiencies (4)
Failed to accurately code a resident's oral/dental status on the resident's most recent quarterly and annual Minimum Data Set (MDS) assessments.
Failed to provide mandatory annual dental care services for a resident, including lack of dental consultation orders and documentation.
Failed to acquire and administer a medication per Physician's Order for one resident.
Failed to accurately reconcile controlled substances stored in medication carts, including discrepancies in narcotic counts and improper destruction documentation.
Report Facts
Residents reviewed for MDS assessments related to dental care: 20
Residents reviewed for dental care services: 17
BIMS score: 7
BIMS score: 13
Medication discrepancy: 1
Medication discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) MDS Coordinator | Interviewed regarding MDS assessments and dentition evaluation. | |
| Assistant Director of Nursing (ADON) | Discussed concerns regarding dental care and medication administration. | |
| Licensed Nursing Home Administrator (LNHA) | Provided facility policies and discussed concerns. | |
| Certified Nursing Aide (CNA) | Interviewed about Resident #229's condition and medication needs. | |
| Registered Nurse (RN) | Interviewed about medication administration and controlled substance reconciliation. | |
| Consultant Pharmacist (CP) | Interviewed about medication availability and controlled substance procedures. | |
| Regional Registered Nurse (RRN) | Interviewed regarding dental consultation and resident care. | |
| Director of Nursing (DON) | Interviewed regarding dental referral procedures and facility audits. | |
| Unit Manager | Interviewed about admission assessments and physician orders. |
Inspection Report
Routine
Deficiencies: 0
Date: Nov 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with New Jersey Administrative Code 8:36 infection control regulations and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with the applicable infection control regulations and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 13, 2020
Visit Reason
The inspection was conducted based on complaints regarding a cognitively impaired resident (Resident #4) repeatedly wandering into other residents' rooms, causing distress and safety concerns among residents and staff.
Complaint Details
The complaint investigation focused on Resident #4's intrusive wandering into other residents' rooms, causing distress to Resident #28 and others. The investigation also included infection control concerns related to Resident #25's MRSA infection and food safety and sanitation issues.
Findings
The facility failed to implement timely and effective interventions to prevent Resident #4 from intrusive wandering into other residents' rooms, causing anxiety and distress to Resident #28 and others. Additionally, the facility failed to place a resident with a MRSA infection on appropriate transmission-based precautions and had multiple deficiencies in food storage, hand hygiene, and medication storage cleanliness.
Deficiencies (5)
Failed to implement and revise interventions in a timely manner to prevent a cognitively impaired resident from repeatedly wandering into other residents' rooms.
Failed to store potentially hazardous foods at safe temperatures and maintain proper food storage practices.
Failed to ensure proper handwashing techniques by staff.
Failed to maintain medication storage areas and medication carts in a clean and sanitary manner to prevent microbial growth and cross contamination.
Failed to implement transmission-based precautions for a resident with a positive MRSA wound culture.
Report Facts
Episodes of intrusive wandering: 53
Episodes of intrusive wandering: 16
Temperature: 79
Temperature: 45
BIMS score: 15
BIMS score: 3
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #28 | Resident who was repeatedly intruded upon by Resident #4 wandering into their room. | |
| Resident #4 | Resident with intrusive wandering behavior into other residents' rooms. | |
| Certified Nurse Aide (CNA) | CNA caring for Resident #4 and witnessed wandering behavior. | |
| Psychiatric Nurse Practitioner (NP) #1 | Psychiatric Nurse Practitioner | Provided psychiatric care and medication management for Resident #28. |
| Social Worker (SW) | Social Worker | Handled grievances and concerns related to Resident #28's complaints about wandering. |
| RN Unit Manager (UMRN) | Registered Nurse Unit Manager | Involved in care planning and grievance meetings for Resident #28. |
| Licensed Clinical Social Worker (LCSW) | Licensed Clinical Social Worker | Provided counseling and support to Resident #28. |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding Resident #4's wandering and facility policies. |
| Administrator | Facility Administrator | Provided statements regarding Resident #4's wandering and Resident #28's grief. |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Agency nurse who reported on Resident #4's wandering behaviors. |
| Assistant Director of Nursing / Infection Preventionist (ADON/IP) | Assistant Director of Nursing / Infection Preventionist | Provided infection control oversight and statements regarding MRSA precautions and medication cart cleaning. |
| Director of Culinary Services (DCS) | Director of Culinary Services | Provided information and observations regarding food storage and kitchen sanitation. |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Observed with medication cart cleanliness issues. |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Observed with medication cart cleanliness issues. |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Observed with medication cart cleanliness issues. |
| Licensed Practical Nurse (LPN) #5 | Licensed Practical Nurse | Observed with medication cart cleanliness issues. |
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