Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
175% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
108 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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
Complaint Investigation
Deficiencies: 2
Oct 23, 2025
Visit Reason
The inspection was conducted based on complaint survey #NJ00187927 regarding infection control breaches during wound care and pharmaceutical service deficiencies related to medication administration.
Findings
The facility failed to maintain infection control standards during wound care for one resident with pressure ulcers and failed to provide timely pharmaceutical services for medications prescribed to another resident, resulting in minimal harm or potential for harm.
Complaint Details
Complaint #NJ00187927 involved infection control breaches during wound care for Resident #2 and pharmaceutical service failures for Resident #1. The complaint was substantiated with observations, interviews, and record reviews confirming the deficiencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain infection control standards and procedures during wound care treatment for Resident #2, including improper glove use, wound cleansing technique, and failure to sanitize surfaces. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pharmaceutical services by not obtaining and administering two medications (Breo Ellipta Aerosol and Triamcinolone topical cream) in a timely manner for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication doses not administered: 5
Medication doses not administered: 3
Brief Interview for Mental Status score: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented medication holds and follow-up with pharmacy; interviewed regarding medication administration failures |
| Director of Nursing | Director of Nursing (DON) | Confirmed infection control breaches and pharmaceutical service deficiencies; interviewed regarding facility policies and practices |
| Registered Nurse | Registered Nurse (RN) | Observed performing wound care with infection control breaches |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 28, 2025
Visit Reason
The inspection was conducted based on Complaint #NJ00174157 regarding the facility's failure to promptly report an injury of unknown origin to the New Jersey Department of Health for one resident.
Findings
The facility failed to timely report an acute fracture of the distal femur for Resident #143 to the NJDOH. The fracture was identified on 5/17/24, but the report was not sent until after an email instruction on 5/23/24, five days later. Interviews with the Director of Nursing and Licensed Nursing Home Administrator confirmed the delay and lack of proof of timely reporting.
Complaint Details
Complaint #NJ00174157 involved failure to promptly report an injury of unknown origin. The complaint was substantiated by record reviews and interviews confirming delayed reporting beyond required timelines.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely report an injury of unknown origin to the New Jersey Department of Health for Resident #143. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 2
Mental status score: 10
Date fracture identified: May 17, 2024
Date fracture reported: May 23, 2024
Reporting timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding reporting procedures and delay | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding reporting procedures and lack of proof of timely submission | |
| President of Special Clinical Projects | Sent email instructing DON to send report to NJDOH |
Inspection Report
Complaint Investigation
Deficiencies: 7
May 21, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to inform residents about medications, failure to report injuries of unknown origin promptly, inaccurate resident assessments, incomplete care plans, improper respiratory care, medication documentation errors, and infection control during medication administration.
Findings
The facility failed to inform residents or their representatives about medication risks and alternatives, failed to report an injury of unknown origin timely, inaccurately coded Minimum Data Set assessments for multiple residents, failed to develop comprehensive care plans for residents requiring oxygen and urinary catheters, did not follow physician orders for oxygen therapy, documented medication administration errors, and failed to follow infection control procedures during medication administration.
Complaint Details
Complaint #NJ00174157 involved failure to timely report an injury of unknown origin to the New Jersey Department of Health for Resident #143. The injury was a left distal femur fracture identified on 5/17/24 but reported late.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to inform residents or their representatives in advance of treatment risks and benefits, options, and alternatives to residents receiving antipsychotic and opioid medications. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to timely report an injury of unknown origin to the New Jersey Department of Health for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to accurately code the Minimum Data Set (MDS) for 7 of 12 residents reviewed for MDS coding accuracy. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to develop and implement comprehensive person-centered care plans including oxygen use and indwelling urinary catheter for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to follow physician's order and create a physician's order for oxygen therapy for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to document physician's order as prescribed accurately for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to follow appropriate infection control procedures during medication administration by not changing gloves between different medication types. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for MDS coding accuracy: 7
Residents reviewed for care plan deficiencies: 2
Residents reviewed for respiratory care deficiencies: 2
Residents reviewed for medication documentation deficiency: 1
Residents affected by infection control deficiency: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
May 16, 2025
Visit Reason
The inspection was conducted based on complaint NJ00180728 to investigate allegations related to failure in conducting thorough investigations after a resident was found on the floor following a fire alarm, and failure to follow facility policy for weekly resident weights.
Findings
The facility failed to properly investigate a fall incident involving Resident #6 after a fire alarm and did not provide sufficient witness statements or documentation. Additionally, the facility failed to follow physician orders and facility policy for weekly weighing of Resident #6, with no documented weights after admission weight on 11/02/2024.
Complaint Details
Complaint NJ00180728 involved allegations that the facility failed to investigate a fall incident involving Resident #6 after a fire alarm and failed to follow weight assessment policies and physician orders for weekly weights. The complaint was substantiated by interviews, record reviews, and facility document reviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, specifically failure to conduct a thorough investigation after Resident #6 was found on the floor following a fire alarm. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough food/fluids to maintain a resident's health, specifically failure to follow policy and physician orders for weekly weights for Resident #6. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for accidents and incidents: 3
BIMS score: 6
Resident height: 64
Resident weight: 113
Physician order duration: 28
Shift hours: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Wrote progress note and completed Nurse Fall Investigation related to Resident #6's fall. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Provided witness statement about finding Resident #6 on the floor after fire alarm. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding weight measurements and documentation. |
| Registered Nurse #1 | Registered Nurse | Worked on same unit during incident; interviewed but did not recall providing statements. |
| Director of Nursing | Director of Nursing | Interviewed and stated fall was due to cardiac event and confirmed weight documentation practices. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed and responsible for investigation determinations related to Resident #6's fall. |
| Registered Dietician | Registered Dietician | Interviewed and confirmed importance of weighing residents as ordered and lack of weight documentation for Resident #6. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 12, 2024
Visit Reason
The inspection was conducted based on Complaint # NJ 00174172 to investigate the facility's failure to timely report injuries of unknown origin and to follow facility policy on abuse, neglect, exploitation, or misappropriation reporting and investigating for two residents.
Findings
The facility failed to report injuries of unknown origin to the New Jersey Department of Health and did not follow their policy for reporting and investigating abuse for Residents #2 and #4. Additionally, the facility failed to revise the care plans for these residents following incidents of skin tears and injuries, despite multiple incident reports and interviews confirming these deficiencies.
Complaint Details
Complaint # NJ 00174172 involved failure to report injuries of unknown origin and failure to follow facility policy on abuse reporting and investigation for Residents #2 and #4. The complaint was substantiated based on interviews, medical record reviews, and facility document reviews conducted on 8/8/2024 and 8/12/2024.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or injury of unknown origin to proper authorities for Residents #2 and #4. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to revise residents' care plans within 7 days of comprehensive assessment or after significant changes for Residents #2 and #4. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for investigation and reporting: 5
Incident Report dates: 6
Brief Interview for Mental Status (BIMS) scores: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Completed incident reports and stated care plans were not revised due to oversight. |
| LPN #1 | Licensed Practical Nurse | Completed incident reports related to Resident #2's skin tears. |
| LPN #2 | Licensed Practical Nurse | Completed incident report on 3/22/24 regarding Resident #2's skin tear. |
| LPN #3 | Licensed Practical Nurse | Completed incident report on 4/24/24 regarding Resident #4's injury. |
| LPN #4 | Licensed Practical Nurse | Documented progress notes related to Resident #2's skin tear. |
| CNA #1 | Certified Nursing Assistant | Reported observations of Resident #2's skin tears and bandaging. |
| Director of Nursing | Director of Nursing | Stated care plans should be updated at time of incident but could not explain why they were not. |
| Unit Manager/LPN | Unit Manager/Licensed Practical Nurse | Stated care plans must be updated immediately when there is a change in condition. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 2
Aug 12, 2024
Visit Reason
The inspection was conducted based on Complaint #NJ00174172 to investigate allegations of failure to report abuse, neglect, exploitation, or mistreatment and failure to revise residents' care plans appropriately.
Findings
The facility was found not in substantial compliance due to failure to report alleged violations involving abuse and neglect for two sampled residents and failure to revise care plans timely for two residents after incidents. Corrective actions and education were planned and implemented.
Complaint Details
Complaint #NJ00174172 was substantiated as the facility failed to report alleged violations and failed to revise care plans for residents #2 and #4 as required by regulation and facility policy.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment to the New Jersey Department of Health and follow facility policy for 2 of 5 sampled residents. | SS=D |
| Failure to ensure residents' care plans were revised timely after incidents for 2 of 5 residents reviewed. | SS=D |
Report Facts
Census: 108
Sample Size: 5
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in relation to incident reports and care plan revision deficiencies. |
| LPN #1 | Licensed Practical Nurse | Named in relation to incident reports and failure to report. |
| LPN #2 | Licensed Practical Nurse | Named in relation to incident reports. |
| LPN #3 | Licensed Practical Nurse | Named in relation to incident reports. |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Jul 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00175467 to determine compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on the complaint visit. However, a deficiency was identified related to failure to maintain required minimum staff-to-resident ratios on 13 of 14 day shifts.
Complaint Details
Complaint # NJ00175467. The facility was found to be in substantial compliance based on this complaint visit.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 13 of 14 day shifts. |
Report Facts
Census: 102
Deficiency days: 13
CNA staffing counts: 7
CNA staffing counts: 12
CNA staffing counts: 8
CNA staffing counts: 10
CNA staffing counts: 11
CNA staffing counts: 11
CNA staffing counts: 8
CNA staffing counts: 6
CNA staffing counts: 10
CNA staffing counts: 11
CNA staffing counts: 12
CNA staffing counts: 12
CNA staffing counts: 10
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Jan 12, 2024
Visit Reason
The inspection was conducted based on complaints regarding medication administration inaccuracies and insufficient staffing at Careone at the Highlands nursing facility.
Findings
The facility failed to accurately document and clarify medication administration for three residents and failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Complaint Details
Complaint #NJ00154940, Complaint #NJ00153394, Complaint #NJ00150195, Complaint #NJ00151010. The complaints involved medication administration errors and staffing shortages.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to accurately document and clarify the administration of medication for 3 of 36 residents, including conflicting physician orders and missing medication applications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey during multiple reviewed periods. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 93
Staffing deficiencies: 8
Staffing deficiencies: 2
Staffing deficiencies: 13
Staffing deficiencies: 9
Staffing deficiencies: 10
Staffing deficiencies: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed regarding hand splint application for Resident #39 | |
| Regional Director of Education and Development | Interviewed and observed Resident #39; clarified splint application orders | |
| Licensed Practical Nurse (LPN) | Interviewed regarding medication administration for Resident #43 | |
| President of Special Clinical Projects | Provided facility policies and discussed medication review process | |
| Licensed Nursing Home Administrator (LNHA) | Met with surveyor regarding medication review process | |
| VP Special Clinical Projects and Acting Licensed Nursing Home Administrator | Discussed staffing shortages with surveyor |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 23
Jan 12, 2024
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 resident rights, personal privacy, accuracy and timeliness of resident assessments, medication administration, infection control, staffing ratios, and life safety code compliance.
Complaint Details
Complaint numbers NJ00167793, NJ00167387, NJ00166908, NJ00166506, NJ00164636, NJ00164205, NJ00162689, NJ00162265, NJ00160759 were investigated during this recertification survey.
Severity Breakdown
SS=D: 18
SS=E: 7
Deficiencies (23)
| Description | Severity |
|---|---|
| Facility failed to maintain resident rights during mealtime assistance, including staff standing and use of personal electronic devices. | SS=D |
| Facility failed to maintain confidentiality of resident information on Electronic Health Records system. | SS=D |
| Facility failed to complete and transmit a Discharge Minimum Data Set (MDS) assessment timely for Resident #84. | SS=D |
| Facility failed to accurately code Minimum Data Set (MDS) assessments for Residents #105 and #47. | SS=D |
| Facility failed to accurately document and clarify medication administration for Residents #39, #43, and #21. | SS=D |
| Facility failed to follow physician orders related to oxygen administration for Resident #15. | SS=D |
| Facility failed to ensure monthly physician orders were signed by attending physicians for Residents #76, #51, #47, and #27. | SS=D |
| Facility failed to ensure responsible physician conducted face-to-face visits and wrote progress notes at least every 60 days for Resident #76. | SS=D |
| Facility failed to ensure expired and discontinued medications were removed from active inventory and emergency kit was missing. | SS=D |
| Facility failed to clarify medication dosage for newly admitted Resident #21 during initial medication review. | SS=D |
| Facility failed to maintain proper kitchen sanitation including expired food and improper staff attire. | SS=D |
| Facility failed to comply with minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | SS=D |
| Facility failed to maintain complete and readily accessible medical records for Resident #42, missing physician progress notes. | SS=D |
| Facility failed to provide 1 of 9 designated exit discharge doors with readily accessible and unobstructed exit signage. | SS=E |
| Facility failed to provide continuous lighting with two lamps for 3 of 9 exit discharge doors. | SS=E |
| Facility failed to ensure fire-rated doors to hazardous areas were separated by smoke resisting partitions. | SS=E |
| Facility failed to provide smoke detectors in rooms open to exit access corridors. | SS=E |
| Facility failed to properly install sprinklers in resident rooms #139 and #127. | SS=D |
| Facility failed to perform monthly visual inspection of 3 of 24 portable fire extinguishers and maintain inspection records. | SS=D |
| Facility failed to ensure 6 of 32 corridor doors resisted passage of smoke due to gaps, propped doors, and hold open devices. | SS=E |
| Facility failed to ensure fire rated corridor double doors fully functioned and lacked annual inspection documentation. | SS=E |
| Facility failed to install a permanent emergency generator and provide electrical wiring in accordance with National Electrical Code. | SS=E |
| Facility failed to prohibit use of extension cords and power strips beyond temporary installation in nursing office. | SS=D |
Report Facts
Census: 94
Deficiency counts: 25
Staffing ratios: 12
Staffing ratios: 8
Fire extinguisher count: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Conducted rounds and audits related to meal assistance, medication administration, and infection control | |
| Regional Maintenance Director | Responsible for corrective actions related to fire safety, emergency generator, and facility maintenance | |
| Licensed Practical Nurse (LPN2) | Observed removing discontinued medications from medication cart | |
| Pharmacist | Conducted medication reviews and audits | |
| Surveyor | Conducted observations and interviews during inspection |
Inspection Report
Routine
Deficiencies: 13
Jan 12, 2024
Visit Reason
The inspection was a routine survey to assess compliance with federal and state regulations related to resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, confidentiality breaches of resident information, incomplete Minimum Data Set (MDS) assessments, inaccurate MDS coding, medication administration errors, improper oxygen therapy, overdue physician order reviews, lack of physician face-to-face visits, expired and discontinued medications not removed from inventory, failure of consultant pharmacist to clarify medication dosages, improper kitchen sanitation practices, incomplete medical records, and inadequate infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to maintain dignity during mealtime for residents needing assistance, including CNAs standing over residents and using electronic devices instead of attending to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain confidentiality of resident information on Electronic Health Records system, with resident information visible on medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete and transmit Minimum Data Set (MDS) Discharge Assessment within required timeframe for Resident #84. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately code MDS assessments for Residents #47 and #105. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately document and clarify medication administration for Residents #39, #43, and #21, including incorrect medication dosages and undocumented medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow physician orders related to oxygen therapy for Resident #15; oxygen was set at 4 LPM instead of ordered 2 LPM. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents' primary physician signed and dated monthly physician orders for Residents #76, #51, #47, and #27. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure responsible physician conducted face-to-face visits and wrote progress notes at least every 60 days for Resident #76. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure expired and discontinued medications were removed from active inventory, including expired aspirin and improperly stored medications. | Level of Harm - Minimal harm or potential for actual harm |
| Consultant pharmacist failed to clarify medication dosage for newly admitted Resident #21 during initial medication review. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain proper kitchen sanitation practices including expired food and dietary staff not fully complying with uniform policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain complete and readily accessible medical records for Resident #42; physician progress notes were missing due to physician being out of the country. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain proper infection control practices during dining observation; CNA held soiled bag while assisting resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents observed during dignity deficiency: 26
Residents affected by dignity deficiency: 2
BIMS score: 0
BIMS score: 4
Days overdue for physician order review: 70
Medication expiration date: 202305
Medication discard after opening: 28
Medication discard after opening: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Aide (CNA) | Observed standing and holding cellphone while feeding Resident #27 | |
| Certified Nurse's Aide (CNA) #2 | Observed sitting on Resident #72's bed using electronic device during feeding | |
| Assistant Director of Nursing (ADON) | Acknowledged CNA #2's inappropriate behavior during feeding | |
| Registered Nurse (RN) | Assigned to medication cart with exposed resident information | |
| MDS Coordinator | Acknowledged missed Discharge MDS for Resident #84 | |
| MDS Coordinator | Acknowledged errors in MDS coding for Residents #47 and #105 | |
| Licensed Practical Nurse (LPN) | Administered medications to Resident #43; unable to explain missing Lidocaine patch | |
| Regional Director of Education and Development | Clarified conflicting orders for hand splints on Resident #39 | |
| Licensed Nursing Home Administrator (LNHA) | Informed of multiple deficiencies and acknowledged issues | |
| President of Special Clinical Projects (VPSCP) | Acknowledged multiple deficiencies and issues with medication and care | |
| Director of Nursing (DON) | Provided facility policy on oxygen administration | |
| Consultant Pharmacist (CP) | Failed to clarify medication dosage for Resident #21 | |
| Regional Clinical Nurse | Reported missing physician progress notes for Resident #42 | |
| Certified Nursing Assistant (CNA) | Observed holding soiled bag during dining | |
| Dietary Aide (DA) #1 | Observed with hair not fully restrained | |
| Dietary Aide (DA) #2 | Observed wearing large, hooped earrings |
Inspection Report
Routine
Census: 103
Deficiencies: 0
Jul 7, 2022
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 to be in compliance with 42 CFR §483.80 infection control regulations and CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 10
COVID-19 positive in house: 9
Inspection Report
Routine
Census: 102
Deficiencies: 0
May 10, 2022
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: 6
COVID+ in house: 20
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Oct 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ 142736.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint number NJ 142736 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 20, 2021
Visit Reason
Annual inspection survey completed on 09/20/2021 for Careone at the Highlands nursing home.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Census: 92
Deficiencies: 1
Sep 20, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically regarding staffing ratios.
Findings
The facility was found not in compliance with the minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey, failing to meet the required CNA to resident ratio on 13 out of 14 day shifts.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. |
Report Facts
Residents on day shift: 91
Certified Nurse Aides (CNAs): 7
Certified Nurse Aides (CNAs): 11
Certified Nurse Aides (CNAs): 9
Certified Nurse Aides (CNAs): 9
Residents on day shift: 96
Certified Nurse Aides (CNAs): 9
Certified Nurse Aides (CNAs): 10
Certified Nurse Aides (CNAs): 9
Certified Nurse Aides (CNAs): 10
Residents on day shift: 95
Certified Nurse Aides (CNAs): 8
Certified Nurse Aides (CNAs): 8
Residents on day shift: 92
Certified Nurse Aides (CNAs): 9
Certified Nurse Aides (CNAs): 11
Certified Nurse Aides (CNAs): 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Interviewed by surveyor and confirmed facility awareness of staffing shortages | |
| Director of Nursing or designee | Responsible for monitoring staffing ratios daily and documenting weekly reviews |
Inspection Report
Life Safety
Deficiencies: 1
Sep 20, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant due to failure to provide mechanical ventilation in 1 of 7 resident bathrooms inspected, specifically the Occupational Therapy resident's bathroom, which lacked an exhaust system and a window. No residents were affected, and corrective actions included installation of an exhaust fan and ongoing monthly inspections.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide ventilation for 1 of 7 resident bathrooms inspected, specifically no exhaust system in the Occupational Therapy resident's bathroom. | SS=D |
Report Facts
Resident bathrooms inspected: 7
Deficient bathrooms: 1
Exhaust fan installation date: Sep 28, 2021
Monthly inspection duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during inspection and confirmed lack of exhaust system | |
| Licensed Nursing Home Administrator | Notified of the finding during Life Safety Code exit |
Inspection Report
Abbreviated Survey
Census: 87
Deficiencies: 0
Jan 28, 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 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: 91
Deficiencies: 0
Jan 8, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00134852, NJ00137543, NJ00136349, and NJ00138835.
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
The survey was complaint-driven with four complaint numbers referenced. The facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 11
Inspection Report
Routine
Census: 91
Deficiencies: 0
Jan 8, 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 and recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
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