Inspection Reports for
Livingston Post Acute Care
348 E Cedar Street, Livingston, NJ, 07039
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
134 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, 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, the circumstances under which health information may be used or disclosed, the rights of individuals to access and control their health information, and the department's legal duties and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The inspection was conducted based on complaints NJ00179449, NJ00179546, and NJ00181407 to investigate staffing ratio compliance at Livingston Post Acute Care.
Complaint Details
Complaint investigation based on complaints NJ00179449, NJ00179546, NJ00181407. The facility was found deficient in CNA staffing ratios on multiple days during the complaint period. No residents were identified as affected, but all had potential to be affected.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding staffing ratios, failing to meet required certified nursing aide staffing levels on multiple day shifts. No residents were identified as affected, but all residents had the potential to be affected.
Deficiencies (1)
Failed to ensure staffing ratios were met for 6 of 28 day shifts reviewed, specifically CNA staffing was deficient on multiple days.
Report Facts
Census: 134
Sample size: 7
Deficient CNA staffing days: 6
Staffing ratios: 8
Staffing ratios: 10
Staffing ratios: 14
CNA counts on specific days: 15
CNA counts on specific days: 14
CNA counts on specific days: 14
CNA counts on specific days: 14
CNA counts on specific days: 15
CNA counts on specific days: 14
Inspection Report
Re-Inspection
Census: 124
Deficiencies: 21
Date: Sep 20, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Deficiencies were cited for this survey.
Complaint Details
Complaint numbers NJ#167713, #167973, #171148, #171923, #174669, #175244, #175260, and #176352 were investigated during the survey.
Findings
Deficiencies were cited related to notification of changes, accuracy of assessments, services meeting professional standards, discharge planning, pressure ulcer care, mobility, nutrition and hydration, respiratory care, pain management, drug regimen review, medication labeling and storage, food safety, facility assessment, infection prevention and control, dining and activity rooms, life safety code compliance including means of egress, fire alarm system, elevator maintenance, and other regulatory requirements.
Deficiencies (21)
Failed to notify resident's representative and physician of a significant change in a timely manner for one resident.
Failed to accurately code the Minimum Data Set (MDS) for three residents.
Failed to ensure services provided meet professional standards including monitoring and documentation of resident condition and medication administration.
Failed to develop and implement an effective discharge planning process including obtaining physician orders and documenting acceptance of referrals.
Failed to provide a discharge summary including recapitulation of stay and final status for one resident.
Failed to provide care and services consistent with professional standards for a resident with pressure ulcers.
Failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease.
Failed to ensure monthly and quarterly weights were done, documented, and monitored; failed to notify physician of significant weight changes; failed to clarify duplicate physician orders.
Failed to administer respiratory care according to physician orders and facility policy for five residents.
Failed to ensure pain management was provided consistent with professional standards and care plans for one resident.
Failed to ensure dialysis communication records were maintained and completed for residents receiving hemodialysis services.
Failed to provide one or more rooms designated for resident dining and activities according to regulation and facility policy.
Failed to maintain minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Failed to ensure means of egress was continuously maintained free of obstructions.
Failed to ensure delayed-egress doors functioned properly to release after 15 seconds without use of a code.
Failed to ensure stairways serving 3 or more stories were provided with stairway identification.
Failed to ensure exit signage was displayed with continuous illumination.
Failed to ensure kitchen suppression system was inspected semi-annually and exhaust hood cleaned semi-annually.
Failed to ensure fire alarm system was inspected semi-annually and tested in accordance with NFPA standards.
Failed to ensure annual inspection and testing of fire door assemblies.
Failed to ensure medical gas system had a documented maintenance program including inventory and testing.
Report Facts
Census: 124
Staffing ratio: 15
Call bell wait times: 25
Fire door inspection: 1
Delayed egress door: 1
Stairway identification: 3
Fire alarm inspections: 1
Elevator emergency operations: 4
Elevator phone: 1
Kitchen sanitation test: 0
Call bell audits: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA#1 | Certified Nursing Aide | Observed removing gloves without hand hygiene |
| CNA#2 | Certified Nursing Aide | Observed improper mask use |
| RN#1 | Registered Nurse | Observed improper medication administration infection control |
| RN#2 | Registered Nurse | Educated on wound care infection control |
| DA#1 | Dietary Aid | Observed food safety violations in kitchen |
| DA#2 | Dietary Aid | Observed food safety violations in kitchen |
| LPN#1 | Licensed Practical Nurse | Observed improper mask use and documentation issues |
| LPN#2 | Licensed Practical Nurse | Observed improper mask use and documentation issues |
Inspection Report
Original Licensing
Census: 120
Deficiencies: 1
Date: May 13, 2024
Visit Reason
Initial inspection for licensure of long term care facilities to add 10 beds conducted on 05/13/2024.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to failure to maintain required minimum direct care staff to resident ratios for the day shift on all 7 day shifts reviewed.
Deficiencies (1)
Facility failed to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey, deficient in CNA staffing on 7 of 7 day shifts.
Report Facts
Residents present: 120
Certified Nurse Aides (CNAs) required: 15
Certified Nurse Aides (CNAs) present: 14
Deficiency correction completion date: May 17, 2024
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 2
Date: Feb 12, 2024
Visit Reason
The inspection was conducted based on complaints NJ00169866 and NJ00165595 to investigate compliance with regulatory requirements for long term care facilities.
Complaint Details
Complaint numbers NJ00169866 and NJ00165595 triggered the visit. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance due to failure to develop and implement comprehensive care plans for residents, specifically Resident #2, and failure to maintain required minimum staff-to-resident ratios on 21 of 28 day shifts.
Deficiencies (2)
Failure to complete comprehensive care plan for Resident #2, including interventions related to fall risk and other needs.
Failure to ensure staffing ratios met minimum state requirements for Certified Nurse Aides on 21 of 28 day shifts.
Report Facts
Census: 123
Deficient day shifts: 21
Sample Size: 4
Required CNAs: 15
Actual CNAs: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Documented progress notes regarding Resident #2's fall and care | |
| Assistant Director of Nursing (ADON) | Interviewed regarding care plan updates and incident reviews | |
| Director of Nursing | Responsible for auditing care plans and providing staff education |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: Aug 21, 2023
Visit Reason
The inspection was conducted as a complaint survey identified by complaint number NJ00166481.
Complaint Details
Complaint #: NJ00166481. The facility was found compliant based on the complaint survey.
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
Annual Inspection
Census: 105
Deficiencies: 7
Date: Aug 15, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint numbers NJ00157193, NJ00155196, NJ00153898, NJ00153555, NJ00153472 triggered the recertification survey.
Findings
Deficiencies were cited related to failure to complete and transmit Minimum Data Set (MDS) assessments timely, inaccurate MDS coding, failure to meet professional standards in medication administration, failure to obtain weekly weights as ordered, failure to monitor enteral feeding administration, and failure to act on pharmacy consultant recommendations. The facility also failed to maintain required minimum direct care staff-to-resident ratios.
Deficiencies (7)
Failure to complete and transmit Minimum Data Set (MDS) Entry Reporting Assessments timely for 2 of 38 residents.
Failure to accurately code MDS assessments for 3 of 22 residents.
Failure to provide services meeting professional standards related to medication administration for 1 of 22 residents.
Failure to obtain weekly weights as ordered for 1 of 5 residents.
Failure to monitor enteral feeding administration to assure it was in accordance with physician's orders for 1 of 3 residents.
Failure to act upon pharmacy consultant recommendations within an acceptable timeframe for 1 of 38 residents.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Report Facts
Census: 105
Deficient CNA staffing days: 6
CNA staffing shortfall: 1
Inspection Report
Life Safety
Census: 104
Capacity: 124
Deficiencies: 1
Date: Aug 10, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health on 08/10/2023 to assess compliance with fire safety regulations under 42 CFR 483.90(a) and NFPA 101 Life Safety Code (2012 Edition).
Findings
The facility was found to be in noncompliance due to stairway exit doors being equipped with panic hardware that violated the listing of the rated fire door assembly, potentially affecting all 104 residents. The facility has planned corrective action to install approved fire exit hardware by September 8, 2023.
Deficiencies (1)
Failed to ensure fire rated door assemblies for stairway exit doors were equipped with approved fire exit hardware in accordance with NFPA 101 Life Safety Code (2012 Edition) Section 7.2.1.7.2.
Report Facts
Occupied beds: 104
Total licensed capacity: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed stairway exit doors were equipped with panic hardware |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Date: Feb 4, 2023
Visit Reason
The inspection was conducted as a complaint survey based on Complaint #: NJ160852 to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
Complaint #: NJ160852. The facility was found compliant based on the complaint survey.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Report Facts
Sample Size: 7
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
Date: Jan 28, 2022
Visit Reason
The inspection was conducted as a complaint visit to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance with the requirements.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this complaint visit.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Oct 28, 2021
Visit Reason
The inspection was conducted based on complaint NJ00147022 to determine compliance with infection prevention and control requirements in a long term care facility.
Complaint Details
Complaint NJ00147022 was substantiated based on observations, interviews, and record review indicating deficient infection control practices.
Findings
The facility failed to ensure proper infection control practices were implemented for one of three residents observed during care and treatment, specifically related to hand hygiene and glove use during wound and incontinence care.
Deficiencies (1)
Failure to implement proper infection control practices including hand hygiene and glove use during resident care and treatment.
Report Facts
Census: 60
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Observed performing care with improper glove use and hand hygiene. | |
| Licensed Practical Nurse (LPN #1) | Observed performing wound care with improper glove use and hand hygiene. | |
| Infection Control Preventionist (ICP) | Interviewed regarding infection control practices. | |
| Director of Nursing (DON) | Interviewed regarding infection control practices. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ141520, NJ138921, NJ141540, and NJ141802.
Complaint Details
Complaints NJ141520, NJ138921, NJ141540, and NJ141802 were investigated and the facility was found compliant.
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: 22
Inspection Report
Routine
Census: 65
Deficiencies: 3
Date: Jun 21, 2021
Visit Reason
The inspection was a standard survey conducted to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with requirements related to accident hazards and supervision to prevent falls, proper labeling and storage of drugs and biologicals, and staffing ratios. Specific deficiencies included failure to consistently implement fall prevention interventions, improper labeling and dating of medications in medication carts, and failure to meet minimum staffing ratios for several shifts.
Deficiencies (3)
Failure to consistently implement interventions to prevent falls for a resident identified as a fall risk.
Failure to properly label and date medications in 3 of 6 medication carts inspected.
Failure to meet minimum staffing ratios for 7 of 24 shifts reviewed.
Report Facts
Census: 65
Sample Size: 19
Deficiency counts: 3
Staffing ratios: 1
Staffing ratios: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in fall prevention deficiency for being observed asleep on duty while assigned to a fall risk resident. |
| LPN #1 | Licensed Practical Nurse | Assigned to medication cart with improperly labeled medications. |
| LPN #2 | Licensed Practical Nurse | Assigned to medication cart with improperly labeled medications. |
| LPN #3 | Licensed Practical Nurse | Observed medication bottles not dated properly. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staffing shortages and fall prevention policies. |
| Regional Registered Nurse | Regional Registered Nurse | Provided facility investigation and information on medication delivery dates. |
| Staffing Coordinator | Staffing Coordinator | Interviewed about staffing shortages and reporting procedures. |
Inspection Report
Life Safety
Deficiencies: 4
Date: Jun 21, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 06/21/2021 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for the Atrium Post Acute Care of Livingston.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including delayed-egress door locking systems, illumination of means of egress, emergency lighting, and elevator inspection/testing. Specific deficiencies included malfunctioning delayed-egress locks, insufficient exit discharge lighting, lack of battery backup emergency lighting above the emergency generator transfer switch, and missing documentation of monthly firefighter elevator service tests.
Deficiencies (4)
Exit doors with delayed-egress locks were not engaged, could not be manually reset, and failed to emit audible alarms.
Two of five exit discharge paths lacked at least two sources of illumination.
Battery backup emergency light was not provided above the emergency generator transfer switch.
Elevators were not inspected and tested monthly as required; no documentation of Firefighter's Monthly Service Test was available.
Report Facts
Number of exit doors tested with delayed-egress locks: 4
Number of exit discharge paths lacking two sources of light: 2
Number of elevators: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged findings related to delayed-egress locks, exit discharge lighting, emergency lighting, and elevator service testing. | |
| Facility Administrator | Informed of all findings during Life Safety Code survey exit. | |
| Regional Representative | Present during observations and interviews related to deficiencies. |
Inspection Report
Routine
Census: 55
Deficiencies: 0
Date: Feb 24, 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 COVID-19 practices.
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: 8
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