Inspection Reports for
Careone At Wellington

Complaint # NJ186848 involved a cognitively impaired resident with a history of elopement who eloped on 2025-05-26. The complaint was substantiated with findings of inadequate supervision and improper deactivation of wander guard alarms by staff. The Immediate Jeopardy was identified and later resolved with corrective actions.

The facility failed to provide adequate supervision to Resident #1, who eloped from the facility after staff deactivated wander guard alarms allowing the resident to exit unescorted. This resulted in an Immediate Jeopardy situation that was later corrected by the facility through staff re-education, system reassessment, and implementation of a removal plan.

The survey included complaint investigations for complaint numbers NJ 170228 and 175455. The complaints involved issues such as resident dignity during meal service, accuracy of assessments, respiratory care, and medication errors. The complaints were substantiated as deficiencies were cited.

Deficiencies were cited in multiple areas including resident rights, exercise of rights, accuracy of assessments, respiratory care, pharmacy services, infection control, life safety code compliance, and emergency preparedness. Corrective actions and plans of correction were provided for all cited deficiencies.

Complaint NJ00170288 was substantiated based on interviews, medical record review, and documentation showing failure to properly monitor and assess a resident's dialysis access site post-treatment, resulting in syringes being left connected to the catheter for 18 hours.

The facility failed to ensure that residents receiving hemodialysis received services consistent with professional standards of practice, evidenced by a resident having two syringes left connected to their dialysis catheter for approximately 18 hours without nursing intervention. Documentation and communication discrepancies were noted regarding post-dialysis assessments.

The facility was found deficient in multiple areas including failure to maintain resident dignity during meals, inaccurate documentation of advance directives, errors in Minimum Data Set coding, improper respiratory therapy practices, dialysis care deficiencies, pharmaceutical service documentation errors, medication administration errors, improper medication storage, food safety and sanitation issues, and breaches in infection prevention and control practices.

Complaint investigation based on complaints NJ00179638, NJ00176252, and NJ00175455. The facility was found not in substantial compliance. The complaint regarding accident hazards was substantiated based on interviews, record reviews, and facility document review. The complaint related to staffing ratios was substantiated based on facility document review.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to ensure a resident's safety related to accident hazards and medication administration. Additionally, the facility failed to meet required staffing ratios as mandated by the State of New Jersey.

Complaint #: NJ00179638. The complaint involved accidental ingestion of Dakin's solution by Resident #1. The complaint was substantiated based on interviews, record review, and facility documents.

The facility failed to ensure resident safety when a nurse inadvertently gave a resident Dakin's solution instead of water with medication. The nurse did not follow proper procedures for wound care preparation or medication administration. The resident did not require hospitalization, and the nurse involved was terminated.

The facility was found to be in substantial compliance with emergency preparedness requirements but had multiple deficiencies related to abuse reporting, comprehensive care planning, pressure ulcer prevention, respiratory care, dialysis, food safety, staffing, life safety code violations, and fire safety systems.

The complaint involved two incidents of resident-to-resident verbal altercations that were not reported to the NJDOH within 24 hours as required. The incidents involved Residents #62, #195, and #55. The facility confirmed the delays and acknowledged noncompliance with reporting regulations.

The facility failed to report two resident-to-resident verbal altercation incidents within the required 24-hour timeframe to the NJDOH. Investigations showed verbal exchanges without physical contact, and the facility acknowledged the delays in reporting these incidents according to federal and state regulations.

The complaint investigation was based on allegations that the facility failed to report resident-to-resident verbal altercations to NJDOH within 24 hours as required. The investigation substantiated that two incidents involving Residents #62, #195, and #55 were not reported timely. The facility acknowledged the delays and lack of documentation for timely reporting.

The facility failed to timely report two resident-to-resident verbal altercation incidents to NJDOH within 24 hours as required. Additional deficiencies included failure to develop comprehensive care plans for oxygen therapy, failure to obtain physician orders for wound treatments and oxygen therapy, failure to ensure oxygen therapy was administered as ordered, failure to monitor and document dialysis access site assessments, and improper food storage and labeling practices.

Complaint # NJ00165718. The facility was found deficient in CNA staffing ratios during the complaint survey. The deficiency was substantiated as the facility failed to meet minimum staffing requirements.

The facility was found not in compliance with New Jersey staffing regulations, failing to meet minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts and 3 of 14 evening shifts reviewed, potentially affecting all residents.

Multiple deficiencies were cited including failure to notify residents in writing of room changes, failure to report and investigate alleged abuse, failure to develop appropriate care plans for resident-to-resident abuse, failure to follow physician orders and update code status, failure to follow resident care plans leading to accidents, failure to document catheter care and urine output, failure to ensure timely physician visits, failure to maintain required staffing ratios, failure to obtain certificate of occupancy for renovated areas, and multiple life safety code violations including obstructed egress doors, hazardous storage areas without self-closing doors, fire alarm and sprinkler system maintenance issues, elevator firefighter service testing deficiencies, ventilation system failures, and generator transfer time certification.

The facility failed to provide written notice for cognitively impaired residents' room changes, failed to report and thoroughly investigate resident-to-resident abuse, failed to develop appropriate care plans for residents with aggressive behavior, failed to follow physician orders for psychiatric consultation, failed to assess and document resident code status, failed to prevent a fall resulting in fractures due to inadequate assistance, failed to document catheter care and urine output, failed to ensure timely physician visits, and failed to maintain required minimum direct care staffing ratios.