Inspection Reports for Careone At Somerset Valley
1621 Route 22 West, NJ, 08805
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
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 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 contact for questions about the notice |
Inspection Report
Routine
Census: 55
Capacity: 64
Deficiencies: 8
Nov 7, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations related to NJ complaint numbers 169236, 172000, 172533, and 173607.
Findings
The facility was found deficient in multiple areas including reasonable accommodations for resident needs, professional standards in care, activities of daily living, sufficient nursing staff, medication error rates, infection prevention and control, and life safety code compliance. Deficiencies were identified through observation, interviews, and record reviews, with corrective actions planned and education provided to staff.
Complaint Details
The survey was complaint-driven based on NJ complaint numbers 169236, 172000, 172533, and 173607. The complaints involved issues such as delayed call light response, insufficient nursing staff, and medication errors. The facility was found substantiated for these complaints with multiple deficiencies cited.
Severity Breakdown
Level D: 2
Level E: 2
Level F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure resident's bedside table and call light were accessible, resulting in delayed response to call light. | Level D |
| Facility failed to follow professional standards of practice in medication administration for Resident #40. | Level E |
| Facility failed to provide necessary services for activities of daily living for 2 of 13 residents reviewed. | Level E |
| Facility failed to provide sufficient nursing staff to meet resident needs and timely call bell response. | Level F |
| Facility failed to maintain medication error rate below 5%, with observed medication errors resulting in a 7.6% error rate. | Level D |
| Facility failed to maintain sprinkler system inspection and testing documentation as required by NFPA 25 standards. | Level F |
| Facility failed to maintain generator inspection and testing documentation and missed required monthly tests. | Level F |
| Facility failed to maintain smoke barrier penetrations in accordance with NFPA 101 Life Safety Code. | Level F |
Report Facts
Residents present: 55
Total licensed beds: 64
Medication error rate: 7.6
Certified Nurse Aide staffing deficiency: 14
Overnight shift staffing deficiency: 2
Required RN staffing hours: 177
Actual RN staffing hours: 168
Required RN staffing hours: 197.25
Actual RN staffing hours: 168
Medication doses administered: 30
Medication errors: 3
Sprinkler system inspection frequency: 1
Generator inspection frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided in-service education on call bell policy and medication administration |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding call bell response and resident care |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding staffing and resident care |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding call bell delays and staffing |
| Food Service Director | Food Service Director | Conducted audits of meal tray delivery |
| Regional Environmental Services Director | Environmental Services Director | Conducted pressure gauge inspection for sprinkler system |
| Maintenance Director | Director of Maintenance | Conducted generator and sprinkler system inspections |
| Infection Preventionist | Infection Preventionist | Provided in-service education on infection control policies |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 6
Sep 21, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to communicate medication unavailability to physicians, improper food storage and labeling, failure to maintain required minimum direct care staff-to-shift ratios, life safety code violations including egress door locking issues, kitchen fire suppression system inspection deficiencies, and sprinkler system maintenance issues.
Severity Breakdown
SS=D: 2
SS=E: 1
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to communicate the unavailability of medications from the pharmacy to the physician in accordance with professional standards. | SS=D |
| Facility failed to store, label, and date potentially hazardous foods to prevent food-borne illnesses. | SS=D |
| Facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. | — |
| Exit doors in the means of egress were equipped with locks that could restrict emergency use, specifically hook-type deadbolt locks on sliding doors at the front entrance. | SS=F |
| Kitchen ansul fire suppression system monthly inspection tag was blank, indicating failure to perform required monthly inspections. | SS=E |
| Fire sprinkler cabinets lacked required wrench to change sprinkler heads in the event of activation. | SS=F |
Report Facts
Census: 55
Staffing Deficiencies: 13
Staffing Deficiencies: 13
Staffing Deficiencies: 14
Staffing Deficiencies: 7
Staffing Deficiencies: 7
Staffing Deficiencies: 14
Extra sprinkler heads: 12
Inspection Report
Routine
Census: 50
Deficiencies: 0
Oct 14, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Jul 28, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint numbers NJ144696, NJ140329, and NJ143836 to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility failed to ensure a resident received care according to professional standards by not promptly notifying the physician of abnormal test results, potentially delaying treatment and interventions. This affected one resident who was later transferred to acute care and admitted to the hospital.
Complaint Details
Complaint Intake NJ143836 indicated the facility did not comply with quality of care requirements due to failure to notify the physician promptly of abnormal test results for Resident #3, which delayed treatment.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to promptly notify the physician of abnormal test results for a resident, potentially delaying treatment and interventions. | SS=D |
Report Facts
Census: 47
Sample Size: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Found Resident #3 on the floor, assessed the resident, and reported to the physician |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Cared for Resident #3 on first shift and assessed the resident |
| Medical Director | Medical Director | Commented on the delay in reporting test results and confirmed no harm was caused |
| Director of Nursing | Director of Nursing | Reported on the procedure for reporting test results and noted the charge nurse no longer worked at the facility |
| Occupational Therapist | Occupational Therapist | Worked with Resident #3 and notified nurse of resident's condition |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 0
Jun 16, 2021
Visit Reason
The inspection was conducted as a standard annual survey combined with a COVID-19 Focused Infection Control Survey to assess compliance with long term care facility regulations and infection control practices.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities and in compliance with infection control regulations related to COVID-19 as recommended by CMS and CDC.
Report Facts
Sample size: 15
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 0
Jan 7, 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.
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: 5
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Nov 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health due to concerns about infection control practices related to COVID-19.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to ensure appropriate infection control practices and monitoring of a visitor to an end-of-life resident to prevent the spread of infection. Observations revealed improper PPE use and cross-contamination risks between cohort zones, and failure to screen a visitor from the attached Assisted Living Residence (ALR).
Complaint Details
The visit was complaint-related due to concerns about infection control during the COVID-19 outbreak. The facility failed to screen a visitor from the attached Assisted Living Residence and allowed cross-contamination risks between cohort zones. The visitor was observed not wearing a facial covering properly and traveling through multiple zones without proper screening.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure appropriate infection control practices and monitoring of a visitor to an end-of-life resident to prevent spread of infection. | SS=D |
Report Facts
Census: 35
Sample size: 5
Plan of correction completion date: Jan 8, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided information about cohort zones and infection control practices. |
| Licensed Nursing Home Administrator | LNHA | Confirmed outbreak and cohort zone details. |
| Unit Manager | Unit Manager (UM) | Confirmed room assignments and cohort zones. |
| Certified Nursing Assistant #1 | CNA | Observed improperly disposing gowns in hallway bins. |
| Licensed Practical Nurse | LPN | Observed disposing gowns in hallway bins. |
| Occupational Therapist | OT | Observed disposing gowns in hallway bins and described PPE use. |
| Physical Therapy Assistant | PTA | Observed cleaning face shield and PPE use. |
| Executive Director | Executive Director (ED) of ALR | Confirmed outbreak in ALR and lack of awareness of visitor traveling to SNF unit. |
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