Inspection Reports for Harmony Village at CareOne Valley

300 Old Hook Rd, Westwood, NJ 07675, United States, NJ, 07675

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 4.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

13% better than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

12 9 6 3 0
2020
2021
2022
2023
2024
2025

Census

Latest occupancy rate 95% occupied

Based on a June 2024 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

40 60 80 100 Nov 2020 Jul 2021 Aug 2022 May 2023 Jun 2024

Notice

Deficiencies: 0 Date: Nov 19, 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
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for the notice

Inspection Report

Annual Inspection
Census: 88 Capacity: 93 Deficiencies: 6 Date: Jun 10, 2024

Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Complaint investigations were also completed during this survey.

Complaint Details
Complaint investigations NJ173161, NJ173099, NJ169020 were completed during this survey.
Findings
Deficiencies were cited related to accuracy of assessments, respiratory care, pharmacy services, staffing ratios, emergency lighting, and cooking facilities. Plans of correction were provided and follow-up audits scheduled.

Deficiencies (6)
Facility failed to accurately code the Minimum Data Set (MDS) for 1 of 21 residents.
Facility failed to follow physician orders related to respiratory care for 1 resident.
Facility failed to properly store controlled and noncontrolled medications securely involving two residents.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law.
Facility failed to ensure emergency lighting was provided at the emergency generator enclosure and hardwired into the transfer switch.
Facility failed to ensure fusible links for the kitchen's fire-extinguishing system were replaced semi-annually as required.
Report Facts
Census: 88 Total Capacity: 93 Deficiency count: 6 Staffing Deficiencies: 11

Employees mentioned
NameTitleContext
Director of Clinical ReimbursementProvided re-education to MDS staff regarding accurate coding
Director of NursingProvided re-education on oxygen administration and conducted audits
Licensed Practical Nurse #2LPNInterviewed regarding medication administration error
AdministratorLicensed Nursing Home AdministratorDiscussed staffing ratio concerns and corrective actions
Director of Environmental ServicesEnsured emergency lighting and fire-extinguishing system corrections and conducted audits

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: Jun 10, 2024

Visit Reason
The inspection was conducted to investigate complaints regarding inaccurate Minimum Data Set (MDS) coding, improper oxygen administration, and medication storage issues at Careone at Valley nursing home.

Complaint Details
The complaint investigation substantiated issues with inaccurate MDS coding for Resident #69, improper oxygen administration for Resident #3, and medication storage violations involving Residents #122 and #123.
Findings
The facility was found to have failed in accurately coding the MDS discharge status for one resident, failed to administer oxygen at the prescribed rate for one resident, and failed to properly secure controlled and non-controlled medications, including a Class II controlled substance, in the medication cart.

Deficiencies (3)
Failed to accurately code the Minimum Data Set (MDS) discharge status for Resident #69.
Failed to follow physician orders related to the use of continuous oxygen for Resident #3; oxygen was set at 3.5 LPM instead of the ordered 4 LPM.
Failed to properly store controlled and non-controlled medications securely; Doxycycline and Oxycodone IR 5 mg tablets were found unsecured in a medication cart.
Report Facts
Residents reviewed for MDS coding accuracy: 21 Oxygen flow rate ordered: 4 Oxygen flow rate observed: 3.5 Doxycycline capsules found: 1 Oxycodone IR 5 mg tablets removed: 2 Oxycodone IR 5 mg tablets administered: 1 Oxycodone IR 5 mg tablets delivered: 30 Oxycodone IR 10 mg tablets delivered: 30

Employees mentioned
NameTitleContext
LPN #2Licensed Practical NurseInterviewed regarding improper destruction of extra Oxycodone 5 mg tablets not administered to Resident #122.
Clinical Reimbursement CoordinatorMDS CoordinatorConfirmed the MDS discharge coding error for Resident #69.
Licensed Practical NurseLPNAcknowledged oxygen setting for Resident #3 was incorrect and adjusted it to 4 LPM.
Assistant Director of NursingADONInvestigated medication storage issues and provided policy information.
Director of NursingDONStated oxygen should be administered according to physician orders and participated in medication storage investigation.
Licensed Nursing Home AdministratorLNHAProvided facility policies and participated in discussions regarding deficiencies.

Inspection Report

Routine
Census: 81 Deficiencies: 0 Date: Feb 10, 2024

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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 to prepare for COVID-19.

Report Facts
Sample Size: 6

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Feb 10, 2024

Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.

Findings
No health deficiencies were found during the inspection.

Inspection Report

Complaint Investigation
Census: 75 Deficiencies: 0 Date: May 10, 2023

Visit Reason
The inspection was conducted as a complaint survey based on Complaint # NJ00155826.

Complaint Details
Complaint # NJ00155826 was investigated and found to be unsubstantiated as the facility was in compliance.
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.

Report Facts
Sample Size: 4

Inspection Report

Plan of Correction
Census: 91 Deficiencies: 1 Date: Dec 19, 2022

Visit Reason
The inspection was conducted to assess compliance with New Jersey state staffing requirements for nursing homes, specifically evaluating the facility's adherence to minimum direct care staff-to-resident ratios.

Findings
The facility was found not in compliance with the New Jersey minimum staffing requirements, failing to maintain the required certified nursing assistant (CNA) staffing ratios on all 14 day shifts reviewed between 11/27/22 and 12/10/22. The facility submitted a plan of correction detailing measures to address staffing shortages and improve recruitment and retention.

Deficiencies (1)
Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Residents present: 91 Certified Nursing Assistants required: 11 Certified Nursing Assistants present: 7 Deficient day shifts: 14

Employees mentioned
NameTitleContext
Certified Nursing Assistant (CNA#1)Interviewed and acknowledged staffing shortages
Licensed Nursing Home AdministratorMet with surveyor team to discuss staffing concerns

Inspection Report

Routine
Census: 77 Deficiencies: 12 Date: Aug 17, 2022

Visit Reason
Standard Survey conducted on 8/17/22 to assess compliance with long term care facility regulations including infection prevention and control, staffing, and life safety code requirements.

Findings
The facility was found not in substantial compliance with several regulatory requirements including infection prevention and control practices, minimum staffing ratios, and multiple life safety code deficiencies related to fire separation, exit discharge, emergency lighting, exit signage, hazardous area enclosures, fire alarm system installation, sprinkler system coverage, portable fire extinguisher placement, corridor door smoke resistance, and emergency generator remote stop station.

Deficiencies (12)
Failure to appropriately put on PPE and handle contaminated items in COVID-19 isolation rooms, leading to infection control deficiencies.
Failure to maintain required minimum direct care staff to resident ratios for day shift.
Failure to provide a two-hour fire separation between new construction and existing nonconforming building.
Failure to provide stable, hard packed all-weather exit discharge paths free of obstructions.
Failure to provide emergency illumination that operates automatically along means of egress.
Failure to provide illuminated exit signs in four locations to clearly identify exit access paths.
Failure to ensure hazardous areas are protected by fire barriers and self-closing doors.
Failure to install fire alarm system wiring in metal conduit and lack of smoke detector in Magnolia room.
Failure to provide proper fire sprinkler coverage in all areas including outside exit discharge door and recessed sprinkler head not level with ceiling.
Failure to install portable fire extinguishers within required mounting height in two locations.
Failure to ensure corridor doors resist passage of smoke due to gaps and inactive door leaves.
Failure to install remote manual stop station for emergency generator.
Report Facts
Census: 77 Day shift CNA staffing: 7 Day shift CNA staffing: 7 Day shift CNA staffing: 8 Day shift CNA staffing: 8 Day shift CNA staffing: 7 Day shift CNA staffing: 8 Day shift CNA staffing: 8 Day shift CNA staffing: 8 Day shift CNA staffing: 7 Day shift CNA staffing: 8 Day shift CNA staffing: 8 Day shift CNA staffing: 6

Employees mentioned
NameTitleContext
Regional Environmental Services DirectorInterviewed and provided facility layout, confirmed findings during inspection
Housekeeper #1Observed failing to wear gloves properly in COVID-19 room and handling contaminated items
CNA #1Certified Nursing AssistantObserved carrying meal trays improperly from COVID-19 room
CNA #2Certified Nursing AssistantObserved carrying meal trays improperly from COVID-19 room
Licensed Practical Nurse Unit ManagerLPN/UMInterviewed about proper meal tray transport procedures
Director of NursingDONRe-educated staff on infection control and monitored corrective actions

Inspection Report

Routine
Deficiencies: 3 Date: Aug 5, 2022

Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control practices, specifically related to COVID-19 precautions and handling of potentially contaminated items.

Findings
The facility failed to properly implement infection prevention and control measures, including improper order of cleaning rooms with COVID-19 positive residents, failure to wear gloves while mopping in COVID-19 rooms, and improper handling and transport of meal trays from COVID-19 rooms by staff.

Deficiencies (3)
Housekeeper cleaned COVID-19 positive rooms first instead of last, contrary to infection control guidance.
Housekeeper mopped floor in COVID-19 room without wearing gloves.
Certified Nursing Assistants improperly handled and transported meal trays from COVID-19 rooms without proper containment.
Report Facts
Residents Affected: 3

Employees mentioned
NameTitleContext
Regional Environmental Services DirectorExplained proper cleaning order and PPE use; stopped housekeeper from entering red room without proper training
Director of NursingDONInterviewed regarding policy and procedure for well to ill flow when entering rooms
Licensed Practical Nurse Unit ManagerLPN/UMInterviewed about proper transport of meal trays from COVID-19 rooms
HousekeeperObserved and interviewed regarding PPE use and cleaning practices
Certified Nursing Assistant #1CNAObserved and interviewed regarding handling of meal trays from COVID-19 rooms
Certified Nursing Assistant #2CNAObserved and interviewed regarding handling of meal trays from COVID-19 rooms

Inspection Report

Abbreviated Survey
Census: 78 Deficiencies: 1 Date: May 4, 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 infection control.

Findings
The facility was found not in compliance with infection control regulations, specifically failing to practice appropriate hand hygiene for 3 of 7 staff observed, contrary to CDC guidelines. Immediate corrective actions including staff inservice and competency observations were implemented.

Deficiencies (1)
Failure to practice appropriate hand hygiene for 3 of 7 staff observed, including inadequate handwashing duration and improper technique.
Report Facts
Sample size: 5 Handwashing duration: 10 Handwashing duration: 8 Handwashing duration: 17 Audit frequency: 10 Audit frequency: 10 Audit frequency: 10

Employees mentioned
NameTitleContext
CNA #1Certified Nursing AssistantNamed in hand hygiene deficiency finding
CNA #2Certified Nursing AssistantNamed in hand hygiene deficiency finding
LPN/Unit ManagerLicensed Practical Nurse/Unit ManagerNamed in hand hygiene deficiency finding

Inspection Report

Complaint Investigation
Census: 83 Deficiencies: 0 Date: Jul 9, 2021

Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ143129 and NJ145579.

Complaint Details
Complaint numbers NJ143129 and NJ145579 were investigated and found to be unsubstantiated as the facility was in compliance.
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.

Report Facts
Sample Size: 5

Inspection Report

Original Licensing
Deficiencies: 0 Date: Jan 19, 2021

Visit Reason
Initial inspection for licensure of renovated long term care facilities including new construction of 10 private resident bedrooms and a renovated Physical Therapy gym converted from 3 resident rooms.

Findings
No deficiencies were noted during the inspection of the new construction areas. The noted areas may not be occupied until formal notification by the Certificate of Need and Licensing Division has been received.

Report Facts
New private resident bedrooms: 10 Resident rooms converted: 3

Inspection Report

Complaint Investigation
Census: 65 Deficiencies: 0 Date: Dec 10, 2020

Visit Reason
The inspection was conducted as a complaint survey based on Complaint #NJ00132680.

Complaint Details
Complaint #NJ00132680 was investigated and found to be unsubstantiated as the facility was in compliance.
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.

Report Facts
Sample Size: 4

Inspection Report

Abbreviated Survey
Census: 56 Deficiencies: 0 Date: Nov 18, 2020

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.

Inspection Report

Routine
Deficiencies: 1 Date: Feb 26, 2020

Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident nutrition and weight monitoring, specifically focusing on the failure to identify and address significant weight loss in a resident.

Findings
The facility failed to timely identify and address significant weight loss in Resident #21, with no documented re-weighs or notifications to the physician or dietitian despite substantial weight loss. The multidisciplinary team did not assess or analyze the weight changes, and the resident was not included in monthly weight meetings or reports.

Deficiencies (1)
Failure to identify and address weight loss in a timely manner for Resident #21.
Report Facts
Weight loss: 20.8 Weight loss: 23.1 Weight measurements: 284.6 Weight measurements: 263.8 Weight measurements: 240.7 Weight change thresholds: 5 Weight change thresholds: 2 Weight loss thresholds: 5 Weight loss thresholds: 7.5 Weight loss thresholds: 10

Employees mentioned
NameTitleContext
Director of NursingDirector of Nursing (DON)Stated CNAs would get weight list and re-weigh residents with significant weight changes
Registered DietitianRegistered Dietitian (RD)Responsible for reviewing weekly weights and requested re-weight for Resident #21 that was not done
Registered Nurse Unit ManagerRN/UMResponsible for reviewing resident weights and re-weighing if discrepancies found
CNA #1Certified Nursing AssistantDescribed process for weighing residents and reporting weight changes
RN #1Registered NurseDescribed process for weight documentation and reporting weight changes to physician
CNA #2Certified Nursing AssistantDescribed importance of re-weighing residents with weight loss and reporting to nurses
RN #2Registered NurseDescribed nurses' responsibility to review weights and report weight loss to nursing supervisor and RD
RN #3Registered NurseStated staff would obtain re-weight and report true discrepancies to nursing supervisor and RD
AdministratorFacility AdministratorStated facility did not have signed RD job description but provided unsigned copy

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