Careone at Livingston

Inspectors wroteComplaint NJ # 2599517 Based on interview and review of medical records, it was determined that the facility failed to ensure there was no delay in implementing a physician recommendation for a burn treatment, and failed to ensure the treatment was ordered for the physician recommended frequency. This deficient practice was identified for 1 of 2 residents reviewed for treatment orders (Resident #1) and was evidenced by the following:On 10/23/2025 at 10:00 AM, the surveyor reviewed the closed Electronic Medical Record (EMR) for Resident #1 which revealed the following: The admission Record (an admission summary) Resident #1 was admitted with diagnoses which included, but were not limited to; alcohol abuse with intoxication, anxiety disorder, bariatric surgery, burns, skin grafts on 79% total body surface area (TBSA) for 2nd and 3rd degree burns. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a) a resident who was identified as being at Low Risk for developing pressure ulcers did not develop a pressure ulcer, and b) upon the identification of a facility acquired pressure ulcer, a documented wound assessment was completed and new interventions were implemented to prevent further skin breakdown. The deficient practice was identified for 1 of 2 residents reviewed for wounds/skin treatments (Resident #3) and was evidenced by the following:On 10/23/25 at 10:00 AM, the surveyor reviewed the Electronic Medical Record for Resident #3 which revealed the following: A Nursing Progress note dated 7/28/25 at 15:02 (3:02 PM), documented Resident #3 had blanchable thick hard indurated skin on the Left buttock. The skin was not open and no pain was present. [...]

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI manual), the facility failed to ensure that three residents out of three resident (Resident (R) 28, R50 and R67) out of 22 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one out of 22 sampled residents (Resident (R)4) was provided with a meaningful, individualized activity program. R4 was not further assessed when the Minimum Data Set (MDS) triggered and indicated she had little interest/pleasure in doing things. The MDS indicated a care plan would be developed to address the care area of activities; however, this was not completed. R4's interests were not fully assessed and she did not have an activity program in place based on her interests and needs. This created the potential for R4 to have a decreased quality of life.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one out of five residents (Resident (R)70) reviewed for nutrition out of a total of 22 residents was provided with a therapeutic minced and moist diet texture as prescribed by the Physician. R70 was served regular texture food which created the potential for choking or aspiration (accidentally inhaling food or liquid into the airway).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of six residents (Residents (R) 72) reviewed for medication administration out of a sample of 22 residents received medications from the pharmacy as ordered by the physician for administration. This failure had the potential to cause residents to have unmet care needs.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure medical records were accurate for two out of two residents (Resident (R)4 and R71) reviewed for activities of daily living (ADLS) out of a total sample of 22 residents. Neither R4 nor R71 had received a tub bath or shower since admission; their medical records indicated they had received tub baths and/or showers. This created the potential for residents not to receive necessary care because their records indicated they had already received the care.

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to a.) electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 3 of 24 residents (Resident #25, 26, and #39), and b.) complete the discharge assessment for 1 of 24 residents (Resident #48) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. On 3/4/24 at 10:30 AM, the surveyor observed Resident #25 out of bed in a wheelchair, alert and oriented, sitting in the activity room. The surveyor reviewed Resident #25's medical record. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring administration of a medication, (Procrit)(an injectable medication used to stimulate bone marrow to produce more red blood cells), according to a physician's order. This occurred for one (1) of five (5) residents, (Resident #21), reviewed for medication management. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 3/6/24, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 25 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 12%. This deficient practice was identified for two (2) of six (6) residents, (Resident #26 and an unsampled resident), that were administered medications by two (2) of four (4) nurses that were observed. The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteC: #NJ00166633 Based on interviews, record review, and review of other pertinent facility documents on 11/8/23, 11/9/23, 11/13/23, it was determined that the facility failed to implement the facility's policy titled, admission Agreement (AG). This deficient practice was identified for 1 of 6 (Resident #3) residents reviewed as evidenced by the following: According to the facility admission Record (AR), Resident #3 was admitted on [DATE], with diagnoses that included but were not limited to: Spinal Stenosis, Dementia, Type 2 Diabetes. Resident was discharged on 8/11/2023. The facility was unable to provide Resident #3's AG. On 11/9/23 at 11:59 a.m., the surveyors interviewed the facility's admission Director (AD) who stated, AG for Resident # 3 can't be found. On 11/9/23 at 1:23 p.m., the surveyors interviewed the Administrator (LNHA) and AD. [...]

Inspectors wroteCOMPLAINT # NJ00166633 Based on interviews, and review of medical records (MR) and other facility documentation on 11/8/23, 11/9/23, and 11/13/23, it was determined that the facility failed to provide the resident's representative (RR) a 30-day written notice in advance of an impending discharge prior to the facility-initiated discharge. In addition, the facility failed to follow their policy on Discharging the Resident and admission Agreement who was discharged on 8/10/23 and 8/14/23 for 2 of 6 residents (Residents #3 and #4) reviewed for discharge. This deficient practice is evidenced by the following: The surveyor reviewed facility 8/1/23 to 11/8/23 Discharges on 11/8/23. The 8/2023 Discharges revealed that Residents #3 was discharged from the facility (F1) to another facility (F2) on 8/10/23 and Residents #4 was discharged from the facility (F1) to another facility (F3) on 8/14/23. [...]

Inspectors wroteBased on interviews, record review, and review of other pertinent facility documents on 11/8/23, 11/9/23, 11/13/23, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one 1 of 6 (Resident #3) residents reviewed. This deficient practice was evidenced by the following: According to the admission record (AR), Resident #3 was admitted to the facility on [DATE] and was discharged on 8/10/23, with diagnoses that included but were not limited to: Dementia and Difficulty in Walking. A review of Resident #3's care plan documented Resident #3 is a long-term care (LTC) resident, initiated on 4/29/21. A review of the Progress Notes (PN) dated 5/3/23 at 11:08 a.m. documented under Care Conference Note, Resident #3 remains appropriate for LTC. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to maintain accountability for oxygen therapy for 1 of 1 resident reviewed for respiratory care, Resident # 32. The deficient practice was evidenced by the following: On 12/13/21 at 10:39 AM, the surveyor observed Resident #32 sitting in the hallway in a wheelchair by the window looking out. The resident was wearing oxygen via a nasal cannula (a tube in the opening of the nostrils that delivers oxygen). The surveyor was unable to see the setting on the portable oxygen concentrator. On 12/14/21 at 10:04 AM, the surveyor observed Resident #32 in the doorway of their room, seated in a wheelchair, without the nasal cannula on, it was hanging off one ear. The surveyor asked the resident if they needed help putting it on. The resident said no, I can do it, it just takes time. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store medication at the appropriate temperature and failed to store controlled substances in a manner that would prevent loss or diversion. This was found with 1 of 2 medication refrigerators inspected. The deficient practice was evidenced by the following: On 12/14/21 at 11:31 AM, the surveyor inspected the Medication refrigerator in the med room on the Sub Acute unit with Licensed Practical Nurse #1 (LPN #1). There was an unopened box that contained one single dose pre-filled syringe of Invega Sustenna (an extended-release injection used to treat schizophrenia). On the box the storage instructions read: Store at room temperature 77 degrees Fahrenheit. The temperature in the refrigerator was 42 degrees. LPN #1 confirmed that the Invega should not have been stored in the refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs. The deficient practice was identified for 1 of 2 residents (Resident #136) reviewed for hospice/end of life care and was evidenced by the following. On 12/13/21 at 11:47 AM, the surveyor observed Resident #136 awake and alert in bed. A review of the resident's hybrid medical record revealed the following information: According to the admission Record the resident was admitted with diagnoses including but not limited to esophageal cancer and status post feeding tube insertion. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection. This deficient practice was observed with 1 of 1 Lab Technician and 1 of 1 dietary aide and was as evidenced by the following: On 12/14/21 at 9:10 AM, the surveyor observed a Lab Technician (LT) enter a resident's room wearing two surgical masks and no eye protection. The LT placed a large bag which contained her supplies on the bed next to the resident. The LT put gloves on her hands with no hand hygiene first and then drew the resident's blood. The LT then took her cell phone out of her pocket with her gloved hand and put it to her face to answer a phone call. The LT placed the phone back into her pocket and removed her gloves. The LT did not perform hand hygiene when she removed her gloves. [...]